Cardiology Coding Alert

All new wording appears for RHC and EP.

The Correct Coding Initiative (CCI) manual has an updated version effective Jan. 1, 2016, and there are several changes that affect cardiology. Here’s what you need to know for endomyocardial biopsy and device services. Check back next month for analysis of additional updates.

Begin With a CCI Manual Background

Coders typically know to check for quarterly CCI updates, also called NCCI (National Correct Coding Initiative). New versions go into effect every January 1, April 1, July 1, and October 1.

“It’s really imperative that practices subscribe to the NCCI quarterly updates, either by the published printed version or electronically, through an IT source,” says Ray Cathey, PA, MHS, CMSCS, CHCI, president of Medical Management Dimensions in Stockton, Calif. “The quarterly changes can be drastic. I’d also suggest that providers review and check their NCCI source whenever they get a payment denial that is new or unusual from payers, as the payers that use NCCI, in addition to Medicare, can and do frequently misinterpret edits or aren’t using the most current version of the edits.”

Manual: In addition to the CCI code pair edits, there is a CCI manual, which you can download from www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. When this manual receives updates, you’ll find the changes in the file italicized in red font.

The two changes to the manual discussed below relate to Medicine codes and are in Chapter XI of the manual. Section I covers Cardiovascular Services.

#22: Abbreviated RHC With Biopsy Gets a Mention

An update to Chapter XI.I.22 offers advice on coding an abbreviated right heart catheterization (RHC) during endomyocardial biopsy. But you should approach this change with caution.

2015: Here is the 2015 wording: “Endoymocardial biopsy requires intravascular placement of catheters into the right ventricle under fluoroscopic guidance. Physicians should not separately report a right heart catheterization or selective vascular catheterization CPT^® code for placement of these catheters. A right heart catheterization CPT^® code may be separately reportable if it is a medically reasonable, necessary, and distinct service performed at the same or different patient encounter.”

2016: This year, you’ll find this sentence added at the end: “The right heart catheterization CPT^® code may be reported only if a complete right heart catheterization procedure is performed. If an abbreviated right heart catheterization is medically reasonable and necessary, it may be reported with CPT^® code 93799 (Unlisted cardiovascular service or procedure).”

Takeaway: It would be extremely “unusual for a cardiologist to perform an ‘abbreviated’ right heart cath because all of the information that is obtained is vital to determining the patient’s treatment. To do less than the normal would be rare, indeed,” says Cathey.

Additionally, there needs to be strong support in the documentation for why the cardiologist thought the minimal RHC (93799, according to the CCI manual) was medically necessary. Use 93799 cautiously and provide a description explaining what the cardiologist did, Cathey says. “I always advise practices to minimize the use of ‘unlisted’ CPT^® codes,” he adds.

Warning: Endomyocardial biopsy is a typical procedure following heart transplant. Experts advise that “post heart transplant” without further explanation is not sufficient to support reporting both the RHC and biopsy at the same session. Medically necessary RHC at the same session as endomyocardial biopsy is rare. Terms like elective, periodic, routine, and surveillance for the RHC suggest the RHC is not reportable as a diagnostic service. Also keep in mind that performing right atrial and ventricular pressures can be part of the standard protocol for the biopsy rather than being a true diagnostic RHC. See “Take Your RHC and Endomyocardial Biopsy Savvy Up a Notch” in this issue for more on RHCs and biopsy.

Bottom line: Don’t use the CCI manual’s language change as an excuse to start reporting RHCs that are not medically necessary diagnostic procedures.

#23: Look at the Limited EP Test Text

The next change we’ll look at is in Chapter XI.I.23. Here you’ll see all new language about coding a limited diagnostic electrophysiology (EP) test to determine whether a patient needs an electrode or device procedure.

2015: There was no related language in 2015.

2016: “CPT^® codes 93600 (Bundle of His recording), 93602 (Intra-atrial recording), 93603 (Right ventricular recording), 93610 (Intra-atrial pacing), and 93612 (Intraventricular pacing) should not be reported with a code describing insertion or replacement of an electrode or device (pacemaker, defibrillator) because they are integral to the procedure. If a physician performs a medically reasonable and necessary limited diagnostic electrophysiology test preceding the insertion or replacement of the electrode or device to determine the necessity to proceed with insertion or replacement of an electrode or device, the appropriate CPT^® codes describing the limited diagnostic electrophysiology testing may be reported with an NCCI-associated modifier. The limited diagnostic electrophysiology testing to determine the necessity to proceed with insertion or replacement of the electrode or device may be performed at the same or different patient encounter.”

Takeaway: Cathey notes that this new language should help support coding for testing performed before lead replacement: “It’s sometimes unclear to the physician whether the lead is malfunctioning or the device (pacemaker/ICD) itself is malfunctioning.” For example, you may be able to report 93600, 93602, 93603, 93610, or 93612 with device or lead replacement codes 33206-33208 for true diagnostic tests. Be sure to append modifier 59 (Distinct procedural service) to the diagnostic test code.

In current practice, it’s rare for a cardiologist or interventional cardiologist to perform a limited diagnostic EP test before an electrode or device procedure. You’re more likely to see an electrophysiologist, who specializes in this type of service, perform the test.