Cardiology Coding Alert
Beat Coding Complexities of Congenital Heart Problems
The treatment of congenital heart disease often requires high technical skills and involves high risk, meaning the cardiologist must spend more time pre-operatively reviewing the patient's records, previous surgeries and cardiac catheterizations. "It's the loss of normal expected anatomy that makes these procedures much more complicated," says Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in private practice in Seattle. "With a routine catheterization, once the correct catheter is set up, it usually gets to where it needs to go relatively easily. But with congenital patients, the anatomy is so distorted you can't just go through the usual series of steps to get there. It's often much more difficult."
CPT 2002 covers cardiac catheterization procedures for patients with congenital anomalies, as well as echocardiograms performed on these patients.
Cardiac Catheterization
CPT offers the following for reporting treatment of congenital heart conditions:
This procedure differs from a typical right heart catheterization CPT 93501 (Right heart catheterization) in that the cardiologist measures pressures, takes blood samples for oximetry and may inject contrast to define the patient's anatomy. Blood samples are taken from the inferior and superior vena cava, as well as from sites in the right atrium, right ventricle and pulmonary artery, Yakovlevitch says. If a right ventriculogram is also performed, report it separately using 93542 (Injection procedure during cardiac catheterization; for selective right ventricular or right atrial angiography). Supervision and interpretation may also be billed separately using 93555 (Imaging supervision, interpretation and report for injection procedure[s] during cardiac catheterization; ventricular and/or atrial angiography).
Although the professional component of this procedure is similar to 93526 (Combined right heart catheterization and retrograde left heart catheterization) with modifier -26 (Professional component) appended, it reimburses at a higher rate 12.05 relative value units (RVUs) for professional services versus 8.8 RVUs for 93526-26 because there is a congenital anomaly. The higher reimbursement reflects the fact that the procedure may take much longer due to what the cardiologist may encounter and may be required to do, notes Yakovlevitch. Again, injection procedures and supervision and interpretation should be reported separately.
This procedure involves not only a right heart catheterization but also the puncturing of the septal wall to probe congenital anomalies in the left side of the heart. Tetralogy of Fallot, a relatively common combination of congenital cardiac defects that consists of pulmonary stenosis, interventricular septal defect, dextroposition of the aorta so that it overrides the interventricular septum and receives venous as well as arterial blood, and right ventricular hypertrophy, is one of the anomalies that the procedure described in 93532 can remedy. The procedure is similar to 93527 (Combined right heart catheterization and transseptal left heart catheterization through intact septum [with or without retrograde left heart catheterization]) with modifier -26 appended but reimburses more (14.64 RVUs for the professional component versus 10.69 RVUs for 93527-26). "There is a higher likelihood of complications in patients with congenital anomalies," Yakovlevitch says. "For example, if any clots were to form in the venous system, there is a risk that they could cross over into the arterial circulation."
This code is similar to 93529 (Combined right heart catheterization and left heart catheterization through existing septal opening [with or without retrograde left heart catheterization]), particularly since it is extremely unlikely a patient would have an existing septal opening except as a result of a congenital anomaly. The difference between the codes, Yakovlevitch speculates, relates to the reason the procedure is performed. If the catheterizations are performed to evaluate the congenital anomaly itself, 93533 should be reported; if the patient has a known anomaly (i.e., the septal opening) used to evaluate another problem, 93529 would be more appropriate. The procedure reported using 93529 does not involve taking pressures or blood samples for oximetry, he adds.
Echocardiography
Transthoracic Echocardiography (TTE). TTE can be used to identify many congenital heart conditions, especially when performed in conjunction with Doppler studies and color flow velocity mapping, and may preclude the need for cardiac catheterization. Much the same as cardiac catheterization, performing echocardiography on a patient with a congenital condition is more difficult than on a healthy patient or one with an acquired cardiac condition. As a result, CPT 2002 includes two codes that specifically describe TTE for congenital anomalies: 93303 (Transthoracic echocardiography for congenital cardiac anomalies; complete) and 93304 ( follow-up or limited study).
Reimbursement for either of these procedures is higher than that for a TTE performed on a heart with normal anatomy, mainly because of the added complexity involved in assessing a two-dimensional slice of a heart that does not have normal anatomic landmarks.
Note: If the patient's condition is stable, continual or serial, TTE assessment requires documentation of medical necessity if more than one evaluation per year is performed.
Transesophageal Echocardiography (TEE). TEE may be required when TTE does not yield sufficient results. TEE can display abnormalities that TTE may miss, because placement of the probe closer to the cardiac structures in TEE allows higher-resolution images to be obtained. CPT includes codes for TEE performed for congenital anomalies: 93315 (Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report), 93316 ( placement of transesophageal probe only) and 93317 ( image acquisition, interpretation and report only).
All the congenital codes listed above may be used even if the cardiologist does not know a congenital anomaly exists until the procedure is performed, says Linda Laghab, CPC, a practice coder with Pediatric Management Group, a multispecialty practice at Children's Hospital in Los Angeles, and a longtime cardiology coder. "If the cardiologist rules out a congenital defect, the congenital codes should not be used," she says. "However, if the defect is established, congenital codes should be used because the procedures are more difficult to technically perform and interpret."
Diagnosis Codes
When congenital cardiac procedure codes are used, there must be a corresponding congenital ICD-9 code associated with the claim, says Laghab. Medical necessity must be indicated when any procedure involving congenital cardiac conditions is reported.
Cardiac catheterization codes 93530-93533, for example, may only be permitted when linked to diagnosis codes such as 745.0-745.9 (Bulbus cordis anomalies and anomalies of cardiac septal closure), 746.00-746.9 (Other congenital anomalies of heart), 747.0 (Patent ductus arteriosus), 747.10-747.11 (Coarctation of aorta) or 747.20-747.29 (Other anomalies of aorta).
The same ICD-9 codes provide medical necessity for TTE and TEE, although additional medical necessity must be provided to justify using TEE rather than TTE. Some carriers may also consider a TTE medically necessary for other diagnoses, such as Down's syndrome (758.0).
Cardiology Coding Alert
- Modifier Is Key for Ablation with Transseptal Puncture Reimbursement
When an electrophysiological evaluation reveals an accessory pathway, the physician may decide to perform an [...] - Information Facilitates Coding of Pacemaker Surgery
Although CPT 2002 includes more than a dozen codes related to pacemaker implantation, replacement and [...] - You Be the Coder:
Kissing Balloon Angioplasty
Test your coding knowledge. Determine how you would code this situation before looking at the [...] - Beat Coding Complexities of Congenital Heart Problems
CPT Codes 2002 covers procedures performed on patients with congenital heart disease and [...] - Reader Question:
Vascular Angiography
Question: What is the correct supervision and interpretation code for selective superior mesenteric and celiac [...] - Reader Question:
Sestamibi Stress Tests
Question: Our office will soon perform nuclear stress tests using sestamibi. How should we bill [...]
