# heart cath/ptca with 15 cardioversions HELP!



## csorensen21@yahoo.com (Apr 24, 2016)

My physician performed an emergent cardiac catherization with multiple cardioversions exceeding 15. Am I able to bill that many cardioversions?



PROCEDURES:

1. Emergent cardiac catherization
2. Emergent temporary pacemaker placement, 5-french with balloon tipped under fluoroscopy for asystole.
3. Primary PCI PTCA to the right coronary artery in cardiogenic shock set up and multiple ventricular fibrillation, cardiac arrest with multiple cardio versions exceeding 15 times.
4. Endotracheal intubation, which was complex, but successful.
5. Intraarotic balloon pump placement for cardiogenic shock.

Indication:

1. ST elevation acute inferior STEMI
2. Cardiac arrest, asystole followed by VFIB
3. Severe hypotension

The patient was brought into the ER for acute myocardial infarction. He was severely hypotensive and Brady cardiac being prepped on the table. The patient had developed this asystole, emergent temporary pacemaker was placed. Then, a 6 French sheath was placed via right femoral artery and angiography was attempted and performed in the right coronary artery during that event and it was interrupted multiple times due to ventricular fibrillation arrest. The patient was cardioverted more than 15 times. ACLS protocol was performed. He received 150 of amiodarone, 100mg of lidocaine. finally, we were able to balloon the artery with 2-0 then within a 3-0 20 balloon and PTCA rate of the RCA and multiple levels to remove thrombus and restore flow and TIMI 0 flow at the beginning followed by TIMI 3 flow. There were 40% residue in the mid RCA and some residue of thrombus in the left ventricular branch, but with TIMI 3 flow, which was restored. 

Angiography of the left coronary system afterwards was performed revealed patient left main and LAD and circumflex artery. Unfortunately, during the procedure, we had table and we had to perform the procedure on 1 angle, which is LAO and we were unable to reset the equipment till the end of the procedure. After the vessel recanalized, Intraarotic balloon pump was placed successfully via the right femoral artery and under fluoroscopic monitoring, 40mL, a balloon pump was placed and it went very well. The patient has done relatively well and the subsequently the patient appear to be stable, we withdrew the temporary pacemaker as he was maintained on rhythm, we used a 5-french sheath for the venous access and he was given dopamine, potassium, magnesium in addition to fluids. 

Findings:

1. NO LV gram done though LVEDP measured, which was elevated during that time, patient was asystole, so catheter was withdrawn and no further attempt was done due to ventricular irritability. 
2. Left main 50%
3. Left anterior descending artery, patent.
4. Circumflex artery, moderate size and patent.
5. Right coronary artery, heavily calcified and multiple stents and occlusion appeared to be within ostial with a proximal occlusion 100%
6. Successful PTCA of the right coronary artery, restoring TIMI 3 flow from original TIMI 0 flow and 40% residue and lesion type C. 
7. Delayed PCI to primary PCI is recurrent cardiac arrest and multiple cardioversion and CPR and intubation of the patient. 

Even though LVEDP measured I don't see a complete LHC here so I'm uncertain of what to code especially with 15 cardioversions.
Should I code
93454
92920 RC
33967
33210
92960


Thanks!


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## jvilla (Apr 24, 2016)

csorensen21@yahoo.com said:


> My physician performed an emergent cardiac catherization with multiple cardioversions exceeding 15. Am I able to bill that many cardioversions?
> 
> 
> 
> ...




I would code for 93458, per CPT: "... left heart catheterization _including_ intraprocedural injection for left vetriculo.."

Also, per EncoderPRO for payers lay description: "The catheter passes through the aortic valve into the left ventricle. Intracardiac and intravascular pressures are recorded. Left ventricular injections _*may *_ be performed for left ventriculography.."

The use of 'may,' instead of 'shall,' indicates that the additional component of the LV gram is not necessary to report this code; though, it is included if performed.

I'd give your physician a 93458 for his/her work.

Also, in regard to 92960, I don't think I would even report this code at all. 
Per CPT description: "92960 Cardioversion, *elective*, electrical conversion of arrhythmia; external"
This is not an elective circumstance, this is an emergency. Also, the CMS Medically Unlikely Edit for 92960 is 2 units for 3 Date of Service. 

I would consider using 92950, cardiopulmonary resuscitation, for reasons as follows:
1. Per CPT Assistant (2012/07 issue), "... it is not required that the physician performs the actual chest compressions and/or mouth-to-mouth resuscitation or bagging in order to report code 92950."
2. Per EncoderPRO 92950 lay description, "... An electronic defibrillator may be used to shock the heart into restarting..."

Of course, you cannot report this 15 times, this would all be included in the CPR effort.

Also, I assume you also know to use your appropriate X[EPSU] modifiers to override the edits in your code set, along with your informational modifiers [RC, etc..]

I hope this helps.

Jacob A. Villa, CCA, CPC
Kaiser PSCII


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## espressoguy (Apr 25, 2016)

Couple of comments:

I agree that 92950 is appropriate, not because of the cardioversions, though. There is no code for emergent cardioversion. Cardioversion is a component of 92950. So, if CPR had not been documented, then nothing could be billed.

I also agree with 93458. All that's needed is for the LVEDP to be measured. LV gram is optional. 

33210 hits a CCI edit as not allowed with either 93458 or 92920.

Lastly, the notes indicate that this was an emergent case with acute MI. This would be coded as 92941, not 92920. There is sufficient information on the interwebs from credible sources to support this code in spite of the CPT description of, "any combination of. . ."


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## Misty Dawn (Apr 25, 2016)

I agree with  L. Mark Kozu response ..Mi/92941 is correct

Misty Sebert CPC, CCC, CCVTC


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## csorensen21@yahoo.com (Apr 26, 2016)

espressoguy said:


> Couple of comments:
> 
> I agree that 92950 is appropriate, not because of the cardioversions, though. There is no code for emergent cardioversion. Cardioversion is a component of 92950. So, if CPR had not been documented, then nothing could be billed.
> 
> ...



I completely overlooked the 99241 due to acute MI. You are correct. Ok I understand the logic of all this. I was just making sure because my doctor insisted that another physician had recieved payment for multiple cardioversions. Also am I able to also bill the intraaortic balloon pump insertion as well in addition to all these codes?

Thanks for the help!


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## Misty Dawn (Apr 27, 2016)

Yes you can code for the balloon pump-33967 for the cardiogenic shock.


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## megg1100 (Jul 21, 2016)

csorensen21@yahoo.com said:


> I completely overlooked the 99241 due to acute MI. You are correct. Ok I understand the logic of all this. I was just making sure because my doctor insisted that another physician had recieved payment for multiple cardioversions. Also am I able to also bill the intraaortic balloon pump insertion as well in addition to all these codes?
> 
> Thanks for the help!




You can't report CPR 15 times, but 92950 has an MUE value of 2 so I would think it could be reported with up to 2 units.


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