Cardiology Coding Alert

Plus: Find out whether you should use -50, -RT, -LT and/or  -59 for catheter placement

When your cardiologist fails to document specifically whether an angiogram was selective, you could take your best guess at the correct code - but you'd be making a big mistake. Here's the correct way to handle these tricky situations.

1. Locate the Problem's 'Origin' With This Scenario

When you receive an op note for an angiogram, you may find one vague word that could potentially throw you off the right track and lead you to an audit situation.

Scenario: Your cardiologist's op notes say the following: "We went up with a  5 French internal mammary (IM) catheter to the origin of the right renal and did an angiogram of that system."

So now you're left holding the bag. Would you consider the angiogram selective, because the cardiologist said "origin," which means the point in which something begins?

2. Look for 'Selective' Terminology

Although the cardiologist mentioned the origin of the renal arteries, he gave no indication that there was selective advancement of the IM catheter.

Look for keywords: Your cardiologist has to use one of the "magic words" that allow you to report the selective placement, such as "... the renal artery was selectively engaged ..." or "... the renal artery was cannulated with ...," says Karen Salowitz, RN, CPC, billing coordinator at Heart and Vascular Center in Phoenix. In this case, you only have "to the origin" to work with.

"I wouldn't code this as selective," says Deborah Ovall, CMA, CCS, CIC, lead coder and data quality analyst with Medical College Hospitals of Ohio at Toledo. "To me, 'to the origin' means that the cardiologist is at the entrance but still in the aorta."

You should ask your cardiologist to document clearly whether he actually engaged the renal artery(s) with the catheter and performed a selective renal angiogram. If the study was nonselective, you should report the catheter placement with CPT 36200 (Introduction of catheter, aorta) and the imaging with CPT 75625 (Aortography, abdominal, by serialography, radiological supervision and interpretation) - codes that are a far cry from those you would use for a selective renal angiogram. In fact, you'll find about a $100 difference between the nonselective and selective renal angiograms, based on national averages.

3. Pinpoint the Proper Way to Bill Selective Renal Angiograms

Because you know the importance of reporting the correct procedure, you must ask your cardiologist for more specification. Your questions may have uncovered that this procedure was, in fact, a selective renal angiogram and the only diagnostic study he performed.

The proper way to report this depends to some extent on carrier/payer instructions. "You can code selectively engaged renal arteries in different ways but with the same codes, depending on regional carrier issues," Salowitz says.

Generally, the correct way to bill for the radiologic component of a bilateral selective renal study would be with 75724-26 (Angiography, renal, bilateral, selective [including flush aortogram], radiological supervision and interpretation; professional component).

You should report a unilateral selective renal study with 75722-26 (Angiography, renal, unilateral, selective [including flush aortogram], radiological supervision and interpretation; professional component).

For the catheter placement in one of the renal arteries, you should report 36245 (Selective catheter placement, arterial system; each first-order abdominal, pelvic, or lower-extremity artery branch, within a vascular family).

However, when both renal arteries are selectively engaged you may need to check with payer policy to identify the proper code/modifier combination. Many prefer you to report 36245 with modifier -50 (Bilateral procedure). Others prefer you to list the code twice on separate lines with anatomic modifiers, such as 36245 with modifier -LT (Left side) and 36245 with modifier -RT (Right side), says Stacy Gregory, RCC, CPC, charge capture and reconciliation specialist with Franciscan Health System's Imaging Support Services in Tacoma, Wash. Also, some payer policies may require you to attach modifier -59 (Distinct procedural service) to one of the catheter placement codes.

Example: "Noridian, my regional Medicare administrator, prefers 36245-50 for bilateral selective renal artery catheter placement, with 75724-26 (and -59 if done with another procedure) for the angiogram portion for the procedure," Salowitz says. "For unilateral catheter placement, they want 36245 (with -RT and -LT as appropriate) and 75722-26 for the unilateral angio."

Despite the "standardized transactions and code sets" requirement of HIPAA (the Health Insurance Portability and Accountability Act), the correct way to code this common procedure varies by payer.

Learn This Lesson: Never Assume

You should make "never assume" your creed. If you don't have the documentation, you cannot code the procedure.

Rule of thumb: Whenever you're dealing with something that's vague or pushing a rule, ask yourself, "Could I defend my billing in court?" If not, you should go to your physician for more information.

"You should always ask the physician for clarification on anything that you don't understand or that looks incomplete. Coders are never to assume anything," Ovall says.

What to say: One way to approach this is by telling your cardiologist, "Look, I really can fight this and get reimbursement if you just clean up your dictation in this area," Salowitz says. "Communication with your physicians and accurate, precise documentation are vital to coders and a physician's practice."