Cardiology Coding Alert

Coronary angiograms performed before therapeutic interventions PTCAs (angioplasties), atherectomies and stents are payable procedures. A second angiogram, however, is usually considered part of the therapeutic procedure and shouldnt be billed, coding experts say.

Although some cardiologists routinely bill for a coronary angiogram and are reimbursed by many payers (including some local Medicare carriers), it is correctly billed and paid only when the medical necessity for performing the procedure is documented.

After a cardiologist performs a left heart catheterization, he or she may determine that the patient requires therapeutic intervention, and a PTCA, atherectomy or stent often is performed during the same session. But sometimes, the patient may have to return for the therapeutic intervention later the same day or on a different day. This can occur, for example, if the patient has an adverse reaction to the original procedure, or if the cardiologist who performed the cath doesnt perform therapeutic interventions during the initial operation.

When the patient returns for the therapeutic intervention, a second coronary angiogram routinely is performed. Unlike the earlier procedure, this catheter typically will not cross the aortic valve into the left ventricle; when that is the case, it is not considered a left cardiac catheterization.

In 1997, CPT Codes introduced a new code for this procedure: CPT 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: Code 93508 is considered a component of code 93510 (left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous) code 93511 (by cutdown), code 93524 (combined transseptal and retrograde left heart catheterization) and code 93526 (combined right heart catheterization and retrograde left heart catheterization) and is not reported if any of these procedures were performed. As with these left heart cath codes, injection procedures 93539-93545 and supervision and interpretation codes (93555, 93556) are separately reportable.

This procedure should be billed only if there is a significantly different problem, or the cardiologist suspects a separate lesion in another vessel or a second lesion in the same vessel, says Gay Boughton-Barnes, CPC, MPC, CCS-P, a cardiology coding and reimbursement specialist at the Tulsa, Okla., office of CPA firm Baird, Kurtz & Dobson.

For example, during the course of a pre-op for an angioplasty, the interventional cardiologist determines the patient is having a recurrent episode of chest pain. For diagnostic purposes, the cardiologist performs a second coronary angiogram (without crossing the aortic valve). Because this procedure has been prompted by a patient indication (the chest pain), the coronary angiography can be billed in addition to a stent, as follows: 93508-26, 93545, 93556-26-59, 92980 (stent).

Note: Because stent procedures already include supervision and interpretation, modifier -59 is added to the 93556 to indicate this is for the angiography, not the stent.

The diagnosis of chest pain provides the medical necessity for the coronary angiogram, which then should be billed.

As with heart caths, Medicare reimburses 93508 at 50 percent when it is performed before a therapeutic intervention, says Terry Fletcher, MS, CPC, CCS-P, a cardiology coding and reimbursement specialist in Laguna Beach, Calif. But, she adds, the medical necessity has to be documented.

A clinical, diagnostic reason is required for the procedure to be considered medically necessary and not just a component of the stent, Fletcher says.

When a heart cath is performed and the patient then has a therapeutic intervention, there is obvious medical necessity because you need to perform at least one coronary angiogram (typically, a left heart cath) to do the primary procedure. Showing medical necessity for a second, usually routine angiogram after a heart cath already has been performed, however, is not as straightforward.

The second angiogram may be medically necessary in an unusual situation, or due to a problem that could not be anticipated, Boughton-Barnes states. For example, the patients lesion may have progressed in a way that requires stenting, rather than balloon angioplasty, and a second angiogram was required to determine that a stent was needed.

In this case, the cardiologist would use a medical or mechanical complication code as the diagnosis, which would allow the 93508 to get paid, Boughton-Barnes says. Or the cardiologist may decide not to perform the stent on the basis of the data from the second coronary angiogram; again, the 93508 would be payable.

Correctly billing and getting paid depend on the nature of the patients problem and how comprehensive the cardiologists notes are, Boughton-Barnes emphasizes.
(See sidebar, page 47).

Routine Angiograms Should Not be Billed

In the above scenarios, the secondary coronary angiogram can be billed. In most others, however, its considered a convenience to the physician and is not payable.

Even though some cardiologists report that they regularly bill and receive payment for performing routine second coronary angiograms, these should not be billed separately, Boughton-Barnes says. After all, the insurer always can request a refund when performing an audit for medical necessity of procedures billed.

Catheter placement is included in the primary procedure, Boughton-Barnes notes. It is considered the diagnostic portion of the therapeutic intervention. In essence, Boughton says, the second angiogram in this situation simply allows the cardiologist to view the problem and determine how to fix it. As such, it is part of the procedure and cannot be billed separately.

This can be confusing, especially as some local Medicare policies indicate that 93508 is a separately payable procedure. For example, Adminastar Federal, the Medicare carrier in Indiana and Kentucky, outlines:

Diagnostic coronary angiography with or without heart catheterization can be covered by Medicare, when it is performed on the same day that percutaneous interventional procedures are performed on the coronary arteries (e.g., CPT codes 92980, 92981, 92982, 92984, 92995, 92996).

However, the policy goes on to state that the medical necessity for concomitant diagnostic angiography with or without heart catheterization must be documented at least in the catheterization report.

Regular reimbursement, by private or Medicare carriers, is no guarantee that the payment is correct or will not become an auditing issue in the future, says Fletcher. A routine coronary angiogram after a heart cath was performed probably would not withstand a Medicare audit. And if Medicare decides the angiograms shouldnt have been billed or paid, theyll take all the money back, with interest.