Q & A with Dr. Z: Arch Study (36221) Medical Necessity

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC

Question:
Hoping you can help us resolve a dispute over medical necessity for use of arch study code 36221. Because the code describes diagnostic imaging, I assume that we need documentation of indications and findings to use it. Without an indication, I assume it is just a guiding shot to find the orifice of the subclavian or innominate for angiography of the arm. Cath lab staff wants to apply this code without indications (i.e., trauma to the arm only). Is a history of PVD enough? What if there is no history of PVD or problem with the arch vessels? Could you please provide some examples of indications?

Answer:
An arch arteriogram is often performed to evaluate the orifices of the great vessels to determine if it is safe to select them (and not cause a stroke). It is never an issue with a carotid or vertebral angiogram, but then, it is bundled with 36222-36226. When done with an arm angiogram for arm evaluation (and not vertebral), it is reasonable to evaluate the arch for similar issues prior to an arm angiogram. If done, and then a selective arm angiogram is done, we do report 36221. Inflow and outflow is always important to document with vascular pathology.