# Coronaries,Stent,IABP Report



## em2177 (Jun 19, 2012)

Need some assistance coding this scenario. 93454,92980RC,33967??

PROCEDURE(S) PERFORMED: Left heart catheterization, possible angioplasty and
stenting.

REASON FOR EVALUATION: Acute Ml

HISTORY OF THE PRESENT ILLNESS: This patient is a 39-year-old gentleman with
multiple cardiovascular risk factors, who awoke with the sudden onset of chest
discomfort and multiple symptoms. The patient had a 911 call.
Inferior-posterior ST elevations were diagnosed and code AMI was called. I
arrived to the emergency room. The patient was in shock. I explained the
risks, benefits, and alternatives of left heart catheterization and possible
angioplasty and stenting with the patient and the family, and the family agrees
to proceed.

PROCEDURE: The patient was brought to the catheterization lab emergently and
prepped and draped in a sterile fashion. Lidocaine was placed to the right
common femoral area, and a 7-French sheath was placed to the right common
femoral artery using Seldinger technique. Next a JL4 was used to engage the
left main with multiple-view angiography followed by 7-French JR4 with side
holes guide catheter. I engaged the right coronary ostium. Angiography was
performed.

At this time Angiomax was started per protocol. I increased the IV fluids due
to hypotension and started the patient originally on 5 of dopamine due to
hypotension. I was able to take a Luge wire across into the posterolateral
branch. Predilatation with a 2.0 x 15 Apex over-the-wire balloon was performed
and repeat angiography was performed. Posterolateral branch did not appear to
be an extremely large branch. However, there was now a large posterior
descending artery.
At this point the patient's blood pressure dropped further. He had continued
ectopy. His systolic blood pressure was in the 40-60 range. He had altered
levels of consciousness. Thus, we called anesthesia emergently for support of
intubation, and Dr.  immediately arrived to help control the airway. The
patient had significant nausea and vomiting and was suctioned. The patient did
have ventricular fibrillation cardiac arrest requiring 200 joules of shock with
reestablishment of sinus rhythm. The patient awoke at that time. However, due
to the complexity, the hypotension, and the shock, as well as his nausea and
vomiting, I felt that to control his airway was more prudent. Thus, Dr. Buese
sedated the patient and intubated per standard protocol without complication.
At this point the patient remained in cardiogenic shock. Thus, I used
lidocaine to the left common femoral area and put in a 6-French sheath. This
6-French sheath was then exchanged, per standard protocol, for an intraaortic
balloon pump, and this was placed under fluoroscopic guidance to the descending
thoracic aorta and hooked to 1:1. At this point the patient's blood pressure
only minimally improved with augmentation. He was on full IV fluids as well as
dopamine of 15.
At this point there were discussions regarding the need for emergent coronary
artery bypass grafting due to 3 vessel disease. We attempted to cali
cardiothoracic surgery. However, there was going to be a delay in care. Thus,
I felt more prudent at this time to stabilize the right coronary artery in this
distal segment and perform stenting with a 3.5 x 18 Integrity non-drug-eluting
stent. Status post stenting there was TIMI-3 flow and 0% residual stenosis.
There was now a large PDA which is widely patent with grade 2 collaterals,
filling a chronic total occlusion of the LAD. Multiple-view angiography was
performed. Wire and catheter were removed.
Next, at this point the patient remained in cardiogenic shock and was
hypotensive. I was worried about the high dose of dopamine, and the
intraaortic balloon pump was not supporting the patient. Thus, through the
right common femoral area we did angiography. This was followed by insertion
of the Impella device which was placed into the LV under fluoroscopic guidance
and prepped in standard protocol and reestablished adequate pressure. Then,
through the left common femoral artery we placed a wire through the intraaortic
balloon pump. The intraaortic balloon pump was removed and we placed a
9-French sheath to the left common femoral area. The patient was
hemodynamically stable. We were able to reduce dopamine. At this time he is
intubated and airway is controlled. He is in critical condition.


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## jewlz0879 (Jun 20, 2012)

He also removes the IABP -33968. Puts in an Impella. Now, The manufacturer suggests using 33975-52 for implant and 33977-52 for removal OR you can bill with unlisted code and use the above codes as comp codes to figure amount to bill. I always use the codes with the 52, well, be that's how my manager wants it done. 

I think you could also bill for the cardioversion 92960. 

HTH


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## jtuominen (Jun 20, 2012)

I agree with your codeset 93454, 92980-RC, 33967 and the 33968 for the IABP removal.
I have billed for impella for a while and would use 33999, as if you examine the FIs out there with policies on cardioassist devices I have only seen them reccomend using the unlisted code. Our FI where I live indicates we should put the phrase 'Impella" in form locator position 19 on the CMS 1500, so you might want to coordinate that with your business office too.

I would not use 92960 for this emergency defibrillation, because 92960 is meant for elective, planned, consented cardioversion. This was an emergency defibrillation and I would consider it a component of the other charges encompassing the services.

Good luck,
Jayna RHIA, CIRCC, CCC


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## jewlz0879 (Jun 21, 2012)

You wouldn't bill for 92960 even if it's not bundled as per CCI? 

And where can I find FI's? Forgive my igorance I hadn't heard of that but I'd like to show my manager. When I worked at Baylor we billed the unlisted code as well for Impella and used an internal modifier to identify it, but like I said, where I'm at now, she wants to follow suggestions made by ABIOMED. I know it's because unlisted code will net too many denials.  

This is from ABIOMED:

Physician Services
CPT® Procedure Codes
The relevant Current Procedure Terminology (CPT®) Codes that describe the Impella 2.5 insertion and removal procedures are listed below.
Options for CPT coding of placement of Impella 2.5 catheter
CPT Code
Description
2011 National Average
Medicare Reimbursement*
*33999 w/crosswalk to 33975
Unlisted procedure, cardiac surgery or reduced services
Use freeform field 19: “33999 comparable to 33975, payment of $XXX.XX expected”
Varies by carrier
$0 - $1180
**33975 - 52
Insertion of ventricular assist device; extracorporeal, single ventricle. Requires payer approval.
Varies by carrier
Options for CPT coding of removal of Impella 2.5 catheter
CPT Code
Description
2011 National Average
Medicare Reimbursement*
*33999 w/crosswalk to 33977
Unlisted procedure, cardiac surgery or reduced services
Use freeform field 19: “33999 comparable to 33977, payment of $XXX.XX expected”
Varies by carrier
$0 - $1300
**33977- 52
Removal of single extracorporeal ventricular assist device. Requires payer approval.
Varies by carrier
*Freeform field 19: “33999 comparable to 33975, payment of $XXX.XX expected”
**To facilitate electronic claims processing, many CMDs may elect to support and grant permission to report “modified” existing codes in lieu of the use of a generic, unspecified unlisted code. With CMD approval, an existing code may be reported with use of either modifier -52 (Reduced Services).


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## jtuominen (Jun 25, 2012)

No, I wouldn't bill 92960, there is a good CPT assistant on when to bill 92960 that highlights that it is an elective procedure. Its CPT Assisatnt November 2000, Page 9: Coding Communication: Elective Cardioversion. here is an excerpt:
   "Code 92960 specifically describes elective (nonemergency) external electrical cardioversion"

These are my rules for 92960 that I give to my docs:
A billable external cardioversion is one that is:
--elective, pre-planned, consented
--nonemergency
--not performed to cardiovert a patient developing an arrhtymia due to a cardiac catheterization procedure (ie. "tickling the aortic valve" with a pigtail)
--Is billable when performed immediately before or after a cath lab procedure has concluded (not intraprocedural)


The FIs are the Fiscal Intermediaries. They are companies that CMS has contracted to provide payment and payment guidelines to you for your geographic area for Medicare patients. When an FI lays out a guideline, it is known as a Local Coverage Determination (LCD). Alot of times LCDs are the basis for third party commerical insurance carrier policies too, or they usually follow suit close to the LCD.
The FI in my region (Minnesota) is Noridian and WPS. Noridian has a bulletin out there that specifically states how they want impellas billed. Here is the link to it for an example: https://www.noridianmedicare.com/cg...n&tmpl=part_b_viewnews&style=part_ab_viewnews

I would not use the 33975-52 or 52 on any of those codes that Abiomed suggests. Think about what modifier 52 means--reduced procedure. I think using a code with modifier 52 just to try to find a code that is a  "close match" isn't a good standard of practice.


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## jewlz0879 (Jun 26, 2012)

Thank you so much!


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