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Cardiology Coding Alert

2002 Fee Schedule Clarifies Impact of New and Revised CPT Codes

Published on Sat Dec 01, 2001

The 2002 Physician Fee Schedule, published in the Federal Register on Nov. 1, notes that the relative value unit (RVU) conversion rate has been cut from 38.2581 to 36.1992. Although this cut will seriously impact reimbursement for most physicians, cardiologists may find that they come out ahead when changes in CPT Codes 2002 that cover brachytherapy, AngioJet, electrophysiology studies and other cardiology-specific matters are considered.
 
Coding and billing staff for all specialties, meanwhile, will be pleased to find that CMS has removed "transitional" payment columns from the Fee Schedule , bringing the number of payment columns down to six, mainly to avoid the confusion that two sets of fees and 10 payment columns caused. 

Brachytherapy and AngioJet

CPT 2002 introduces 92974 (transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy [list separately in addition to code for primary procedure]) as an add-on code to the following:

  • 92980 transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel

  • 92982 percutaneous transluminal coronary balloon angioplasty; single vessel
  • 93508 catheter placement in coronary artery(s), arterial coronary conduit(s), and/or venous coronary bypass graft(s) for coronary angiography without concomitant left heart catheterization.

    • Note: A radiation oncologist is typically present when the cardiologist performs brachytherapy. CPT 2002 links 92974 with 77781-77784 (remote afterloading high intensity brachytherapy) "for intravascular radioelement application."
     
    The fee schedule sets the value of 92974 at 5.44 RVUs. If the cardiologist uses brachytherapy to treat the restenosis of a previously stented vessel and places a second stent, for example, the operative session is valued 21.84 (for the stent) + 5.44 (for the brachytherapy) = 27.28 RVUs.
     
    Although 92974 is listed in CPT 2002 and the fee schedule, Medicare carriers still may not cover the procedure. The fee schedule lists brachytherapy as a status A (active) code, which CMS defines as follows: "These codes are paid separately under the Physician Fee Schedule , if covered. There will be RVUs for codes with this status. The presence of an 'A' indicator does not mean that Medicare has made a national coverage determination regarding the service; carriers remain responsible for coverage decisions in the absence of a national Medicare policy." Ask your Part B carrier (and third-party payers) whether they consider brachytherapy a covered service.
     
    Note: Code 92974 assumes ZZZ global days, which means it assumes the number of global days of the primary procedure.
     
    Code 92973 (percutaneous transluminal coronary thrombectomy [list separately in addition to code for primary procedure]) developed out of the increased use of the AngioJet Rheolytic Thrombectomy System (Possis) to remove coronary blood clots. Although 92973 is also a new add-on code classified as status A with ZZZ global days, it differs from 92974 in that it is valued at 4.82 RVUs and may be billed only in conjunction with 92980 and 92982, not 93508. If the cardiologist performs balloon angioplasty and removes a blood clot using the AngioJet system, for example, CMS will reimburse both procedures as follows: 16.14 (for the percutaneous transluminal coronary thrombectomy) + 4.82 (for the AngioJet thrombectomy) = 20.96 RVUs.
     
    Like 92974, Medicare carriers may not cover 92973 even though it appears in CPT 2002 and the fee schedule. Unless CMS formulates a national coverage policy, payment for percutaneous thrombectomy is not guaranteed. Ask your local carriers about their policies on this increasingly used service.
     
    Contact carriers for preauthorization and billing instructions if AngioJet is performed on its own, because CPT states that add-on codes such as 92973 cannot be billed on their own.

    Electrophysiology

    The following codes will convert from stand-alone to add-on status in 2002, hopefully ending any confusion over how to list these codes in combination:

  • 93620 comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia

  • 93621 ... with left atrial pacing and recording from coronary sinus or left atrium (list separately in addition to code for primary procedure)
  • 93622 ... with left ventricular pacing and recording (list separately in addition to code for primary procedure).

    • When a left atrial study, a left ventricular study or both are performed in conjunction with right-side studies, some physicians bill 93620 in addition to 93621 or 93622. It is redundant to bill for 93620 in these cases, because 93621 and 93622 are component codes of comprehensive code 93620, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. "Changing 93621 and 93622 into add-on codes means they can now be appropriately billed," Callaway says. "As of Jan. 1, if the physician performs, for example, left atrial pacing and recording in addition to the comprehensive electrophysiology study described by 93620, both 93620 and 93621 may be billed."
     
    One problem with billing these codes was that 93621 and 93622 paid only marginally better than 93620. In 2001, 93620 was valued at 19.41 RVUs, 93621 at 21.20 RVUs and 93622 at 21.32 RVUs. The slight difference in reimbursement for much more extensive procedures was blamed, in part, for generating erroneous coding options. The 2002 fee schedule provides much more, Callaway says, noting that even though the RVUs for 93621 and 93622 have been slashed 3.13 and 5.07 RVUs, respectively, the physician is reimbursed even more compared to billing correctly under the 2001 fee schedule using only 93621 or 93622. However, she cautions, this should be balanced against the fact that the value of comprehensive code 93620 has been cut significantly, from 19.41 to 17.01 RVUs. This and the reduction in the overall RVU conversion factor mean that in 2002 physicians are likely to receive only 83 percent of the amount that Part B carriers paid for 93620 in 2001.
     
    Note: If left atrial and ventricular pacing and recording are performed while a comprehensive right-side study is performed, 93621 and 93622 may be reported. Reimbursement for any of the procedures should not be cut, as they are add-on codes. In such cases, the total reimbursement should be 17.01 + 3.13 + 5.07 = 25.21 RVUs.
     
    Another big RVU reduction involves 93609 (intraventricular and/or intra-atrial mapping of tachycardia site[s] with catheter manipulation to record from multiple sites to identify origin of tachycardia [list separately in addition to code for primary procedure]), which, like 93621 and 93622, will be an add-on code, says Nikki Vendegna, CPC, a cardiology coding and reimbursement specialist in Overland Park, Kan. The American College of Cardiology (ACC) lists intracardiac mapping with ablations; she notes that many carriers, however, continue to pay separately for mapping. As a result, the impact of 93609 becoming an add-on code with RVUs decreased from 14.93 RVUs in 2001 to 7.34 RVUs in 2002 depends on the carrier. "If the carrier followed ACC guidelines in 2001, 93609's 14.93 RVUs were payable only when mapping was performed on its own," Vendegna says. "With 93609 an add-on code, ACC guidelines should soon change."
     
    CPT 2002 notes that 93609 may be reported in addition to 93620, 93651 (intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination) or 93652 ( for treatment of ventricular tachycardia). Despite the RVU decrease, as of Jan. 1, 93609 will provide some payment (7.34 RVUs), whereas previously it provided none. If the carrier already paid for mapping separately, expect reimbursement for mapping to be cut by half, Vendegna says.
     
    Note: CPT 2002 introduces 93613 (intracardiac electrophysiologic 3-dimensional mapping [list separately in addition to code for primary procedure]). Although CPT instructs physicians to bill 93613 when performed in conjunction with 93620, 93651 and 93652 (like 93609), the fee schedule has not assigned any RVUs to the new code describing 3-D mapping. The fee schedule lists 93613 as a status C (carrier-priced) code, defined as follows: "Carriers will establish RVUs and payment amounts for these services, generally on an individual-case basis following review of documentation such as an operative report."
     
    Changes to the electrophysiology section are substantive enough that coders should alert physicians to the changes and update lab encounter sheets, suggests Savannah Siens, CPC, CCS-P, a cardiology coding and reimbursement specialist in Kansas City, Mo. "Coding is not taught to physicians in medical school, and it is usually up to coders to keep the doctors informed about the new codes available to them, and any other code changes," Siens says.

    Thrombin Injection

    Thrombin injection is often the first treatment for a pseudoaneurysm, which Dorland's Medical Dictionary defines as "dilatation and tortuosity of a vessel, giving the appearance of an aneurysm." No code specifically describes this treatment; reimbursement for the injection was considered part of the appropriate  E/M code.
     
    CPT 2002 rectifies this situation with 36002 (injection procedures [e.g., thrombin] for percutaneous treatment of extremity pseudoaneurysm). The fee schedule assigns the new code values of 4.99 RVUs (nonfacility) and 3.07 RVUs (facility). Code 36002 comes with instructions; for example, physicians are instructed to report imaging guidance separately using one of the following:

  • 76003 fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)

  • 76360 computerized axial tomographic guidance for needle biopsy, radiological supervision and interpretation
  • 76393 magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

  • 76942 ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation.

    • Note: A separate radiology report is not required when these codes are used. As always, the cardiologist should document the appropriate imaging guidance used, the location of the pseudoaneurysm, and the injection itself.
     
    If ultrasound-guided compression repair is required to treat the pseudoaneurysm, CPT instructs physicians to use 76936 (ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae [includes diagnostic ultrasound evaluation, compression of lesion and imaging]). Physicians should not report 36002 for vascular sealant of an arteriotomy site.

    Balloon Pump

    CPT 2002 replaced 93536 (percutaneous insertion of intra-aortic balloon catheter) with 33967 (insertion of intra-aortic balloon assist device, percutaneous). Both codes describe essentially the same thing the placement of a balloon catheter to assist temporarily the patient's circulation. The fee schedule has cut payment for this service: Whereas 93536 was valued at 8.16 RVUs (both nonfacility and facility) in 2001, 33967 is valued at 7.13 RVUs (nonfacility) and 7.08 RVUs (facility).

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