Cardiology Coding Alert

Additional payment may be obtained for any abdominal aortography performed during the same session as a left heart cath with aortography of the aortic root but only if documentation indicates that the intent of the abdominal aortography was to treat a different problem.

Procedure notes therefore need to document clearly and accurately (by including, for example, a second diagnosis) that the additional aortography was separate from the heart cath.

When a left heart cath is performed, aortography in addition to the more typical angiography of the left coronary chambers and the coronary arteries may be performed to obtain images of the aortic root (where the aorta joins the heart). For this procedure, 93544 (injection procedure during cardiac catheterization; for aortography) is reported with 93556 (imaging supervision, interpretation and report for injection procedure[s] during cardiac catheterization; pulmonary angiography, aortography and/or selective coronary angiography including venous bypass grafts and arterial conduits [whether native or used in bypass]).

Any images obtained from injections in the ascending aorta (the first section of the aorta, defined as the section from the left ventricle to the arch, or bend) are included in 93544/93556. According to the American College of Cardiologys Guide to CPT Coding, 93544 involves positioning the catheter in the ascending aorta above the aortic valve. It does not, however, describe abdominal aortography.

Abdominal aortography may be performed following a heart cath. For example, the cardiologist may have difficulty passing a guidewire and catheter from the access site (the femoral artery) to the aorta because the patient has tortuous arteries (defined as twisted and full of turns), says Martha Gerant, CPC, a coder with Cardiology Services, an 11-physician practice in Shawnee Mission, Kan.

If the coronary problem requires urgent attention, Gerant says, the cardiologist may perform the heart cath first. While the catheter is being removed via the aorta, another injection is performed to image the abdominal aorta or other arteries (such as the renal, iliac and femoral arteries).

Abdominal aortography and heart cath may also be performed simultaneously if the patient has an additional problem (such as hip pain or leg cramps) that the cardiologist wants to assess at the same time, Gerant notes.

Even if aortography of the aortic root (or elsewhere in the ascending aorta) has already been performed (and reported using 93544/93556), the supervision and interpretation of the abdominal aortogram (which reflects the manipulation of the catheter as well as the interpretation of the images) should be separately payable using either 75625 (aortography, abdominal, by serialography, radiological supervision and interpretation) if only the aorta is imaged, or 75630 (... plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation) if images of the iliac and/or femoral arteries are also obtained, notes Terry Fletcher, BS, CPC, CCS-P, an independent cardiology and vascular surgery coding and reimbursement specialist in Laguna Beach, Calif.

If the procedure was performed at the hospital, modifier -26 (professional component) should be appended to the appropriate code.

Because the same catheter used for the heart cath is also used in the abdominal aortogram, no additional catheter placement code (e.g., 36200, introduction of catheter, aorta) should be billed.

Second Diagnosis Required

When unrelated abdominal aortography is performed during the same session as a heart cath, documentation needs to indicate clearly where and why the additional angiography was performed, Fletcher says. Because angiography of the aortic root is performed far more often than abdominal aortography during a heart cath, the coder may not realize that an aortic flush (abdominal aortogram) has been performed, and could mistakenly code 93544/93556.

If the cardiologist took images of the abdominal aorta after images of the ascending aorta (and reported using 93544/93556), documentation should clearly state that an additional injection was performed as the catheter was exiting the aorta. The nature of the problem (i.e., tortuous artery) should also be noted. For example, the cardiologists procedure notes might include a short paragraph similar to the following:

The catheter then was withdrawn into the abdominal aorta, where aortography was performed to visualize the distal abdominal aorta and iliac arteries because problems were encountered initially when advancing the guidewire.

The paragraph should note the nature of the problem, which should also be reflected in the claim by linking a different diagnosis (for example, tortuous, atherosclerotic or arteriosclerotic arteries) to 75625 or 75630.

Some carriers may recognize only specific codes in such situations. For example, according to a draft policy by Empire Medicare Services, the local Medicare carrier in New Jersey and parts of New York, 75625 and 75630 with cardiac catheterization may be denied unless they are performed for specific conditions that warrant selective investigation. The draft also specifies, These services will be subject to special review.

The draft goes on to list acceptable ICD-9 codes, but does not mention atherosclerosis (or arteriosclerosis) of the femoral or iliac artery; only atherosclerosis of renal artery (440.1) is acceptable. Aneurysms of the aorta (441.00-441.9) and iliac artery (442.2) are also acceptable, as is embolism and thrombosis of the abdominal aorta (444.0).

Empire also accepts the following diagnoses to support extra-cardiac angiography:

404.00-404.93 hypertensive heart and renal disease

405.01 secondary hypertension, malignant, renovascular

405.11 ... benign, renovascular

405.91 ... unspecified, renovascular

433.1 occlusion and stenosis of precerebral arteries, carotid artery

435.2 transient cerebral ischemia, subclavian teal syndrome

435.9 unspecified transient cerebral ischemia

440.1 atherosclerosis of renal artery

442.1 other aneurysm, of renal artery

442.82 ... of other specified artery, subclavian artery

444.1 arterial embolism and thrombosis, of horacic aorta

447.3 other disorders of arteries and rterioles, hyperplasia of renal artery.

Note: These diagnoses provide medical necessity for several CPT codes, including aortography codes (75625-75660), angiography codes (75662-75724) and introduction of needles or catheters (36120-36248).

Other carriers (Medicare and private) are likely to include different acceptable ICD-9 codes in their own policies. Additionally, if the cardiologist is able to make a case for the medical necessity of the procedure in the patients record, the abdominal aortogram may be payable even if the reason for the service does not correspond to a diagnosis on the carriers list.