Cardiology Coding Alert

Presented by Jim Collins, CPC, CHCC

The following supplement to Cardiology Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and download the current issue, and the slides will be contained therein. If you're not sure how to use the Online Subscription System or need help downloading the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Jim Collins, CPC, CHCC is the Chief Executive Officer of the Cardiology Coalition, a professional society dedicated to advocacy efforts for cardiologists and the billing proficiency of cardiology practices.  Mr. Collins has over twelve years experience as a physician reimbursement consultant and limits his practice to cardiology related issues (procedural auditing, E&M auditing, revenue cycle optimization, staff training and physician training.) He is the Consulting Editor of Cardiology Coding Alert and is a seasoned national speaker on cardiology documentation and reimbursement.

Thank you.  Good morning to everybody that is calling in today, and thank you for attending.  We are going to cover pretty much everything that you need to know as far as diagnostic heart catheterization and coronary interventions and also information specific to - what I am sure everybody is seeing as a growing trend - limited peripheral vascular studies at the same time as the heart catheterization.  In working in this field, I am sure that a lot of you have been contradicted by historical coding methodologies, and the current ones and how we are seeing the clinical side of everything change, so this is really going to be a conference that is geared exactly towards where you are.  We will cover everything that you need to know not on the basic level, but kind of at an intermediate and higher level. 

The first thing that I want to do, just to make sure that the people who are with us who may not be too seasoned at coding heart catheterizations, is to take a few minutes to cover what a heart cath consists of, because I know a lot of times understanding these procedures and understanding why we are doing these procedures actually helps to go through an operative report and pull out the appropriate codes to bill them accurately.  This stuff is really intimidating when you first get into it so, on the bottom of page 1, I have got a brief summary of what the circulatory system is, and this is of course specific to the human anatomy.  First off, the circulatory system basically brings blood around the human body and it brings nutrients to where they need to go to, and it brings oxygen for living tissues, and it also eliminates certain kinds of wastes from our body as well. 

The blood we can really pick up at any point in the body, we will start at the upper right chamber of the patient's heart.  The heart has essentially four different chambers, when blood comes into the top right chamber, it is going to be returning to the body from the venous system.  The blood is going to move from the right top chamber of the patient's heart, which is called the atrium, and then it is going to be pushed down into the right ventricle.  When it goes down there, the majority of the blood actually just passively goes from the top to the bottom, and it is somewhat stimulated by gravity.  Once enough blood gets dumped into the top right chamber of the patient's heart, the pressure inside of that chamber is going to increase every drop of blood that goes into it, and at some point the pressure inside the top chamber of the heart is going to be greater than the pressure in the bottom chamber of the heart and the valve that separates the two is going to open and allow that blood to fall down into the right ventricle.  The blood is also actively pushed down there and that is when the right atrium is actually going to constrict and it is going to make the chamber smaller in size, which will effectively push the blood down into the right ventricle.  Once the blood goes into the right ventricle, it gets pushed off into the lungs and it goes to the lungs to the pulmonary artery.  When the blood goes off in the pulmonary artery, it is going to essentially carry it down into smaller and smaller pathways until it gets to a point inside of the lungs where carbon dioxide is actually released from the blood cells and oxygen is going to be attached to the individual blood cells.  At that point, the blood is going to be what we call oxygen-rich, and it is going to move from the lung back into the heart, but this time, it is going to go to the left atrium of the patient's heart.

The left atrium, just like the right atrium, is going to actively and passively move it down into the left ventricle.  The left ventricle is really the main working horse of the heart.  This has the thickest muscular chamber in the whole patient's heart.  From this left ventricle, once it fills with blood, it is going to squeeze very aggressively and push that blood out through the aortic valve.  Once it crosses the aortic valve, it is going to be in the aorta.  The aorta is actually the largest artery inside of the body.  All the different pathways the arteries go down in our bodies, the first place that they go through is that aortic valve.  The aorta carries the blood down this very extensive network of arteries, the arteries are going to continue to get smaller in size as the blood cells travel, regardless of where the blood cells are going to.  They could be going on to the patient's brain, down to their arms, down to their legs, down to their kidneys.  Where the blood travels away from the heart, the arteries are going to get smaller to the point that we actually have an exchange between the arterial system and the venous system at a point where we actually have cellular exchange where the oxygen gets delivered, and then gases such as carbon dioxide, carbon monoxide are picked up from the tissue.  Then it goes back into the venous system where the veins carry the blood back up into the right chamber of the heart through either the inferior or superior vena cava, which are just the biggest veins in the patient's body.  And of course, once it dumps back into the upper right chamber of the patient's heart, that is where we start this whole cycle again.
 
Now, what causes this blood to move continuously throughout this rather extensive network is what we call the heart's pumping action.  On top of page 2, you will see that the heart actually drives blood around a course that is actually about 60,000 miles long inside of every human being that is out there.  In addition to the pumping chamber of the heart, there are a lot of different physiologic changes, such as how the arteries can dilate and expand and constrict to regulate blood pressure.  Within the venous system there are a number of different valves that keep the blood flowing in the right direction.  If the blood tries to go backwards, these valves will actually shut and stop that from happening.  So there are a whole lot of different things that help the heart, but the main driving force behind this circulatory process is the heart itself.  In order to keep the blood moving through the heart and therefore through the body, we have to have a whole lot of different things working appropriately.  One of the things is that the heart chambers actually have to be timed very precisely.  What I mean by this is that if we have the heart beating out of sequence, any one of the four chambers beating when it should not be beating, it is going to have a dramatic impact on the amount of cardiac output, which is just a measurement of how much blood is actually moving from that left ventricle out to the aorta every minute.  In order to keep the blood flowing at maximal appropriate rates, we need to have the ventricles essentially relaxing at the same time that the top chambers of the heart - the atriums - are contracting, so that the blood can smoothly go across the appropriate valves and down into the ventricles.  And then we want the ventricles to be squeezing at approximately the same time.  The main reason for this is that there is a wall that separates the two bottom chambers of the heart, just like there is a wall that separates the two top chambers, called the septum, and if we have the two bottom chambers of the heart beating at different times, the wall that goes in between them is actually going to move back and forth from the left to the right, that is going to have the effect of reducing the cardiac output.  Because some of the force that is created by the ventricular contraction is actually going to be exhausted pushing that septum back and forth.  So this is one of the things that we are starting to really be able to tweak on patients, and this what you might hear frequently referred to as biventricular pacing or left ventricular pacing, where we actually time those two chambers so that they contract at the same time, keep that septum nice and straight and push the blood out of the patient's heart. 

When we look at what makes up the heart, what makes it contract, there are a whole lot of different things, but what we are mainly looking at with a heart cath is how the heart is functioning, we want to look and see if the walls are contracting in a nice and even fashion?  Are the valves that separate the heart from the other circulatory parts of the patient's body working appropriately or are they allowing the blood to flow in the wrong direction?  We are also looking at how the heart receives its oxygen, basically the energy that it uses itself.  The heart chambers themselves are made up primarily of muscle, this muscle is always contracting and relaxing day and night, whether we are awake or asleep.  A normal healthy patient's heart beats somewhere in the range of 60 - 80 beats a minute.  Slightly above or below that range is of course not considered abnormal; but when you get considerably below, that is when you have patients with what we call bradycardia, and considerably above is called tachycardia or even what we call fibrillation which is where the heart is not even contracting effectively, it is just kind of quivering.  Because the heart muscle is always contracting 60-80 times a minute which is more than once a second essentially, it has got a high demand for energy, and it gets this energy from the oxygen and the nutrients that are being supplied to it from what we call the coronary arteries.
 
The coronary arteries are actually the first take offs from the aorta.  Like I mentioned earlier, every blood cell that goes to our body that is oxygen rich, is going to go through that aortic valve before it goes to any tissues.  If you look at the middle diagram on page 2, you will see that the coronary arteries actually branch right off the aorta immediately after it leaves the heart.  The coronary arteries are marked in a darker color there, and you can see there are different names for the different branches.  We have essentially got two different coronary systems, there is a left system and a right system.  The left system of course splits into what we call the left circumflex artery, and the left anterior descending, which is just two different terms that you will see doctors reference a lot in their reports; and of course our billing structure is set up to adjust for that too which we will talk about.
 
The reason why we want to look inside the coronary arteries to see what is going on in there is that the coronary arteries will frequently have calcium and plaque build-up inside of these arteries.  As the calcium and plaque builds up inside of these arteries, what they do is they create these little places called stenotic areas which essentially act like roadblocks.  If we have a roadblock inside of this tubular pathway the blood is traveling down, that roadblock is going to keep blood from flowing effectively through it, and if that area of blockage is substantial enough, it is going to deprive the heart muscle of the oxygen and the nutrients that it needs to keep functioning.  Of course that is going to become problematic for the patient, if it comes to a point where the obstruction inside of the vessel is completely 100% blocked, then what we are going to have is what we call a myocardial infarction.  'Myo' references the muscle, 'cardio' references the heart, so we are talking bout an infarction which is just a blockage of the blood that is flowing to the heart muscle.  That is essentially what a myocardial infarction is.  An MI can be triggered by just the area of build-up just keeps building up and building up over a period of time to the point that it is 100% blocked.  Or, it can be building up and building up to the point that it may be 98 or 99% blocked and then all of a sudden we have a small piece of debris that goes flowing through the bloodstream and actually goes and becomes lodged in an area and it creates blockage, just like you stick a finger in a dike, it is going to completely stop the flow of blood.

On page 3, we have an idea of what we are doing when we try to do an assessment of the coronary arteries with a heart cath.  First off, what we need to do is get inside of the patient's arterial system.  Like we mentioned earlier, all the different arteries in the human body are all connected on this very extensive network, so what we are essentially doing is obtaining vascular access by puncturing through the patient's skin into an artery, we are going to then use a series of guidewires and catheters to help manipulate our way upstream through the arterial system and actually engage the left and right coronary system so that we can get inside of them with the tip of the catheter.

In the middle of page 3, you can see a kind of a picture of where we typically will go in into the common femoral artery and be going upstream through the aorta to the point that it actually reaches up just before where the aorta goes into the left ventricle, that is where those coronary arteries take off.  So we will just get up into that position, take a sharp right hand turn, and go off into the right coronary system, and a sharp left hand turn and go off in the left coronary system.  Once we get the catheter selectively positioned inside of these arteries that we want to assess, the catheter is essentially then going to act like a hose.  What we are going to do is inject a contrast agent through this hose, it is going to travel from outside the patient's body up along the hose and right into the coronary artery that we want to assess.  This contrast agent is essentially going to flood the whole coronary artery that we are looking at. This agent is kind of like a liquid metal, that is how I like to think about it; It is something that when we look at it with an x-ray outside of the patient's body, it is going to show up nice and crisp and clean just like if we were to have a piece of metal in our luggage and we tried to put it through the screening area at the airport.  So we cannot put a knife in there, we cannot put anything metal in there because it is going to show up on the x-ray cameras there.  So by injecting this liquid metal, we are able to see exactly what the inside of the coronary artery looks like.  If there is an area of blockage inside of there, it is going to allow us to see exactly what that shape looks like because it is going to be a completely flooded vessel.  Once we go in and do this type of an assessment, we are able to get images that will tell us what it looks like in there and it is going to help guide our interventions in the future, whether we want to go ahead and do some sort of a surgical procedure or percutaneous procedure to fix the patient, to help open up those areas of blockage. 

On the top of page 4 on the bottom left hand corner of slide 10 you will see there is a kind of a drawing that shows you what an area of blockage looks like inside that left main coronary artery, and then that the image that is behind is an actual angiographic image that kind of shows you where we are placing the tip of the catheter, it is kind of off to the left hand side there , inject the contrast, and it is going to flow downstream with the flow of blood and that will show you exactly what it looks like inside of the artery that we are looking at.  If this patient has chest pains, this patient has electrocardiographic findings that suggest a myocardial infarction, we want to go in there, we want to do a diagnostic assessment to see if there is a blockage to find out where it is, to find out how extensive it is, and that is going to help us keep the patient alive and living for the future.  Of course, 20 or30 years ago this type of a study was not available and we could not intervene on these patients without actually opening up their chest; now we can do all these procedures essentially through a small venipuncture in the patient's groin area. 

Once we do imaging inside a patient's coronary arteries, that is going to give us an idea what they look like, and of course at the time of the heart cath, that is one of the studies we do.  Another study we are doing is what we call intracardiac assessment.  Intracardiac just means we are looking inside of the heart itself to evaluate how the different chambers are functioning and how the different valves are functioning.  On the left patient's heart, what we are going to do is basically take the catheter from that position where we went into the coronary arteries, and we are typically going to use a different type of catheter called a pigtail catheter.  The tip of the pigtail catheter actually has a little curly q that looks like a pig tail essentially, that is going to allow us to push it across the aortic valve.  As soon as we cross that aortic valve, we are going to be inside the left ventricle of the patient's heart.  Inside of here we are going to obtain pressure measurements so that we can see how strong the heart is working, and how good it is relaxing; to have effective blood movement through these different chambers of the patient's heart, we want to make sure that those ventricles are relaxing enough so that the atrium can contribute their full load to them, because we want the blood to go from the top chambers down to the bottom chambers and then out.  Another thing we want to make sure is happening is that the left ventricle is squeezing hard enough to actively push the blood out through the aorta, and is creating enough force to keep that blood moving in the right direction.  When we get inside of the heart one of the things we do is take pressure measurements, another thing we do quite frequently on the left side is what we call ventriculography or left ventriculography.  In here, we are taking the same type of contrast agent that we used to do the coronary system, inject a large bolus of that inside of the patient's left ventricle, and what that is going to do is flood the whole left ventricle so that we can see what it looks like inside of there.  A couple of main things we are doing that for is; one is so that we can see how the contraction is, if there is a portion of the wall that is not working effectively, we will be able to identify that.  The reason why is because if we have a myocardial infarction, we have one of the major coronary arteries that is completed blocked, so any of the heart muscle that is downstream from it is going to die within a relatively short period of time, we are talking minutes to maybe an hour; but typically in 5,10,15 minutes you might start to see myocardial damage on these patients.  Once the heart muscle is dead, it is not going to ever be able to rejuvenate itself.  So if it is a dead piece of muscle, if you think about how the muscle is going to be responding after it essentially dies, it is just going to be a flaccid piece of flesh that is inside the patient's body.  So if we do a contrast injection inside of the ventricle in a normal healthy patient, we are going to see the whole circumferential area within the ventricle itself is actually going to be effectively squeezing blood out.  If a segment of it is dead, it is not going to be moving; one of the terms doctors reference quite frequently is that 'dead meat does not beat,' that just means if we have a major myocardial infarction, there is a going to be a portion of that ventricular wall that is not effectively squeezing. 

So we are looking at the wall motion inside there, we are also looking at the ejection fraction of the heart by seeing how effectively the heart moves the blood from the ventricle out through the aortic valve into the circulatory system.

On the right side of the patient's heart, we are looking at primarily the pressure measurement and we are also going to be going off into the pulmonary artery to take the pressure measurements there to see how effectively the right side of the heart is pushing the blood out.  Sometimes you will see ventriculography on the right side of the patient's heart but it is not nearly as frequent as we see it on the left side.  With some patients, instead of just doing a right heart cath or just a left heart cath, we are actually be going ahead and doing a combined heart cath.  That just essentially means we do a right heart cath and a left heart cath during the same operative session.  Almost all the time these types of catheterizations are done by two different punctures into the patient's body.  The left heart cath is going to be done in the arterial system.  We are going to go upstream, once we get into the patient's body to the point we cross the aortic valve. For the right heart cath, we actually go with the flow of blood into the right side of the patient's heart.  These are referenced as 'flow directed catheters,' because they actually get the tip of the catheter inside of the patient's venous system, inflate a small balloon on the tip of the catheter, and that balloon is going to go with the flow of the blood, kind of like if you threw a fishing bobber into the river, it is just going to go with the flow of the river downstream.  In the venous system we are going with the flow of the blood, in the arterial system we are going against the flow of the blood to get up into the heart.
 
When we start billing for these services, we have got to look at the code that I started to summarize at the top of page 5, there are actually a couple of different distinct components of these services that we are going to be billing for.  The first is what we call catheter placement.  Actually obtaining vascular access and manipulating the catheter so that it gets up into those coronary arteries, it will go up into any bypass vessel that happened to be in place, also go in the left ventricle in most cases. Just the positioning of that catheter to do these studies is a separately billable service.  The code that we are going to be using here is 93510, and this 93510 is what we typically refer to as a full left heart catheterization.  We do not have a 93510 until we get to the point that the tip of the catheter actually crosses the aortic valve.  This is important because sometimes the doctors will do an assessment of the coronary arteries or assessment of bypass vessels, but choose not go into that left ventricle for a number of different reasons.  For example, the patient might have a calcified aortic valve.  If we have a patient with a calcified aortic valve, what could happen if we go trying to go poke around there with that pig tail catheter, we could break off a chunk of that calcium build-up, and it could go flowing through the patient's arterial system and there is a chance that the chunk of calcium could actually flow up into one of the arteries that supplies our brain with blood, the carotid artery and the vertebral artery.  And if it were to do that, it is going to come to a point that it lodges inside that system and causes a major stroke to the patient.  So for some patients we will choose not to go in and do a full left heart cath, we will just look inside the coronary artery itself. 

If we are doing this assessment of the coronary artery only, instead of billing 93510, what we are going to be billing for is this code 93508 which essentially says we are doing a left heart cath, we are doing assessment of the coronary arteries but we are not actually going into the left ventricle of the patient's heart, we are not crossing over that aortic valve.  It is important to make this distinction and there are going to be a lot of different ways you can determine if the doctor did a left heart cath, or if the doctor only did an assessment of the coronary arteries.  Sometimes they will actually say why they chose not to do a left heart cath and will explain that calcified aortic valve or prosthetic aortic valve or whatever other contraindications the doctor feels are in play.  There are also definitive things that you can see in the operative report that will tell you that the doctor did do a left heart cath even if they do not specifically say they crossed the aortic valve.  The two main ones are of course, left ventriculography, and also assessment of intracardiac pressure measurements.  So you need to be looking at the reports, because these are two things that the doctor has to cross the aortic valve to do.  They are going to get the tip of the catheter across the aortic valve to take the pressure measurements and come on out in some cases, and this is going to be a definitive establishment that the patient did receive a full left heart cath, and you could bill a 93510.  Also for the left ventriculography, even if the doctor does not say, 'I crossed the aortic valve,' they are not going to be able to do a full left ventriculogram without getting the tip of the catheter inside of the ventricle so that they can flood it with this contrast agent.  Now if the doctor is actually doing just assessment of the coronary arteries, 93508 is going to be your code. 

One of the things that is really out of whack as far as our relative value units and our reimbursement rates is the actual difference between these two services.  From a physician's perspective there is only a small difference in doing a 93508 and a 93510 for just the catheter placement; it really is just the difference of maybe a half an inch or so of actual catheter manipulation.  If you look at the reimbursement differences between these codes, you can see that the 26 modifier (on slide 14, middle of page 5) is of course what the doctor is going to be doing if he or she is doing these coronary assessments and heart catheterizations in a facility setting.  This is just based on the North Carolina region and the actual dollar amounts will vary from carrier to carrier but proportions are going to be pretty much identical because they are all based on relative value units.  The modifier 26 shows that for the 93508 which is just catheter placement into the coronary arteries, the doctor will get $234.71.  If the doctor does the full left heart cath, including pressure measurement and going across the aortic valve, the reimbursement is only $247.06.  This is a difference of about $12.35 for the physician's work.  On the facility side, which is the TC, the technical component, you can see that the 93508 is going to generate $457.46 and the 93510 generates over a $1000.  There is actually $893 difference between the 93508 and the 93510 on the facility side, which proportionally is really out of whack because the equipment which is being used by the facility is exactly the same equipment.  There are no additional expenses, and if we wanted to argue and we could say that the majority of that difference was due to the amount of physician's work that was going into these things; however the facility will get 72 times the difference of what the doctor gets for these services.  So this is just an example of one of the places where the reimbursement structure is considerably out of proportion, and it of course is in disfavor of the cardiologists.  There are a lot of other places which are similar to that, but it is one of the things that is really important to understand so that you do not bill a 93510 if your doctor is only doing a 93508, it is only a $12 difference in reimbursement but it could of course, have a substantial impact on the facility side, and if the physician is the one that triggered the inappropriate billing, there could be the chance of a refund or a penalty in a worst case scenario.

The right heart cath placement on the bottom of page 5, of course 93510 is the code that we use here, and this again is positioning of the catheter and the taking of the different pressure measurements.  If we have a patient that is having a right heart cath for congenital problems which is just something that the patient was born with at birth, the 93530 is the code that we will use to obtain reimbursement.  There is a slight difference in the reimbursement rates for these, and it essentially just compensates the physicians for the fact that the patient with congenital anomalies might have a different anatomic structure, and reimburses the doctor for a little bit more cautious navigation within the patient's arterial system.
 
A Swan Ganz catheterization is coded 93503.  The doctors when they do a right heart catheterization or a combined right/left heart cath, a lot of times will reference the right heart cath as being a Swan Ganz catheterization.  When they are doing this, they are actually referencing the type of equipment that they are using, that is going to be that catheter I told you about, that has got a little balloon on the end of it that helps to kind of guide the tip of the catheter into the appropriate place.  When doctors are doing a right heart cath, they will use a Swan Ganz catheterization, but we are going to be coding it as a right heart cath, and there are really two distinctive features between the two services.  A Swan Ganz catheterization is typically going to be done at the patient's bedside in the hospital and it is going to be left in place for extended monitoring, which could be a series of hours or it could be essentially overnight.  We are getting that catheter tip into position in the pulmonary system and taking pressure measurements at regular intervals so that we can monitor how the patient's heart is functioning.  With a right heart cath, it is going to be the same exact equipment but it is typically going to be done in the cath lab, the doctors are going to go in, take the pressure measurements, they might do a right ventriculography, and then they are going to pull the equipment out of the patient, obtain hemostasis, and discharge the patient back to the floor.  Those are the two main distinctions between the two but if you do see the occasional placement of a Swan Ganz catheter at the patient's bedside, do not code that as a right heart cath; put it as a Swan Ganz.  But when you see the doctor do these procedures in the cath lab, even if they say they are doing a Swan Ganz catheterization, they are really not, they are just referencing the type of equipment they are using, and they are not just saying that it is a right heart cath, they are not saying they are placing it for monitoring purposes.

On the top of page 6 we have the 93526 code, this is one we use when we do a regular left heart cath and then a regular right heart cath.  So we actually have two different puncture sites.  The main thing here is that we are going to, instead of billing for two procedures and getting reimbursed for two preoperative and postoperative services, we bill this as one service and it is going to effectively reduce our reimbursement to adjust for the fact that we have economies of scale.  We only have to sedate the patient once, we are only going to have to prepare the patient once, and there is only one period postoperatively, so we cannot bill for two separate procedures in this specific situation. 

There are also other codes that are in the book now for different approaches of a left and right heart cath, whether we are going through an intact septum or puncturing across a septum that is in place, and those codes are all listed out on slide 16 on top of page 6.

When we start billing for these services, one of the things that we have to be cognizant of is that when we bill for catheter placement, we have got to use the 26 modifier.  This 26 modifier will actually apply to all the codes that we have talked about so far with the exception of that Swan Ganz, the one that the doctors will occasionally place at bedside, that one does not have a 26 modifier that goes along with it.  Other modifiers to be aware of is that if you are doing a right heart or a left heart cath - or even an interventional, which we will talk about a little bit - on the same day you made the decision to do this catheterization, your evaluation and management service should be reported with a 25 modifier; if you had diagnostic tests that preceded the catheterization on the same day such as an EKG, in a lot of cases it will be necessary to attach a 59 modifier to these diagnostic test codes.  Otherwise, carriers and payers will bundle those EKGs and the other diagnostic tests into the heart cath under the assumption that you are billing for routine intraoperative monitoring.  So, the patient comes into the emergency room, complaining of acute chest pain, the doctor does an EKG, interprets it and then says we need to move you immediately to a heart catheterization, if you just billed a EKG interpretation and then a heart cath, sometimes the payers and carriers are going to deny that because when you are doing these heart catheterizations on patients you are going to be monitoring the patient's heart rate with an EKG.  So you need to use that 59 that is saying this was not intraoperative monitoring, this was a diagnostic decision that helped us make the decision to do the heart cath itself. 

Once we get the catheters into position and we are talking about inside of the coronary arteries, instead of the bypass vessels, inside of the heart itself, what we are going to do is inject that contrast agent, inject this liquid metal, so that we can fully illuminate the areas that we are trying to study, whether it be a vessel or whether it be inside of the heart itself.  As you can see on the bottom of page 6, there is a series of different codes that we have to actually report the injection of this contrast agent, and they are all specific to the different areas that we are injecting the agent.  The most common ones of course are going to be the 93545, which is the first one I have listed there, and that is going to be injection of a contrast agent inside of the coronary arteries.  The other one which is very common is 93543 and that is going to be injection of contrast inside the left chambers of the patient's heart.  Those two are reported far more than any of the other injection codes on slide 18.
 
The other ones are specific to the injection of the right side of the patient's heart.  93539 is occasionally billed, that is when we do an injection inside of other arteries at the time of the heart cath, and this is typically going to be if we are looking inside of the internal mammary artery, if they are already used as a bypass vessel or if we are looking at those to see if they are suitable for using bypass in a future operation, and also if we have other arteries sewn into place with bypass vessels.  The 93540 is the same concept but this is if the patient has a venous bypass graft sewn into place.  Venous bypass is just going to be additional conduits such as the saphenous vein that gets harvested from the patient's leg, we are going to make a hole inside of the artery that is blocked, that is going to be downstream from the area of the blockage inside the coronary artery, sew one end of the saphenous vein to that hole, and then puncture another hole into the aorta and sew the other end of the saphenous vein to that.  Essentially we are going to make a bypass for the blood to flow from the aorta downstream from the blockage and re-perfuse the heart muscle that is downstream from it.  With these injection codes, even though there is a number of different ones on there, when we do injections inside of the coronary system or inside any of these different anatomic areas, we are only allowed to bill these codes one time.  This is one of the errors that I see quite frequently, going in and looking at heart cath reports for different practices.  Historically a lot of people were billing for two different 93545 codes.  They would bill one 93545 left and one 93545 right, with a RT and LT modifier on it to show that they are injecting the left coronary and then the right coronary system.  The way these codes are set up you should only be billing for these injection codes one time, and if you do not do that, Medicare is certainly going to deny your claim and other payers would, I would assume, at some point catch on to the fact that they have paid you inappropriately and demand that reimbursement back.  So that is one of the things you should kind of look at, pull a sample of your cath reports and see how they were billed, and make sure you are only billing these injection codes on the last slide of page 6, once per operative session.

After we do this injection of contrast, there is another service, a third service that actually has to get done to complete a full diagnostic heart catheterization, and that is going to be the interpretation of the images that are being created.  In this situation, what we have is that the injection of contrast agent is being made, the x-ray images are going to be projected onto a TV screen that the doctor is going to be able to look at, he will be able to freeze it, manipulate it, reverse it, just like they are looking at a videotape essentially, and that is where the doctor is doing what they call the 'radiological supervision and interpretation.'  The supervision part just means the doctor is essentially responsible for making sure the equipment is being used appropriately, determining the angles of the different projections that we want to take these images from.  The interpretation is actually looking at the images that are being created on the TV screen, interpreting those, making sense out of them and then recording them in their operative report.  So we have to document these services just like any other services before we can actually bill them out.  When we do radiological supervision and interpretation, there are two different codes that we are going to be able to bill for these: one is specific to anything inside of the patient's heart, and that is 93555, so whether we are doing injections inside of the upper right chamber of the patient's heart, bottom right chamber of the patient's heart, we could essentially do injections inside all four chambers of the patient's heart, the imaging of those injections are all going to be captured by billing 93555 one time.  So just like with the injections, if we do 10 or 15 different injections in the coronary system, we are only going to be billing the 93545 one time.  Similarly if we interpret 10 or 15 different images from the coronary system, we are only going to be billing this 93556 one time.  So the 93555 is anything inside of the patient's heart, the 93556 is anything inside of the vessels outside of the patient's heart, so this is going to include the coronary artery, any of the bypass vessels whether they are arterial or venous bypasses, injections inside of the aorta, and also the internal mammary injections.  That is another common mistake that I see: the aortic imaging code, 93544 code, a lot of times that gets billed inappropriately as well. 

On slide 18 on bottom of page 6, the 93544 has to be a diagnostic study before we can bill for it, and the aortic root is essentially the portion of the aorta immediately after the aortic valve, where the blood leaves the heart before it goes up to the aortic arch.  A lot of times the doctors will do an injection into that area just so that they can find either the opening of the coronary arteries, which of course is going to be to the immediate left and right after the aortic valve; or they are if they are trying to find one of those bypass vessels.  Because they do not know exactly where these bypass vessels were sewn into the aorta, what they will do is inject a small amount of contrast agent into the aorta, some of that is going to flow off into these bypass vessels and that will show the doctor on the camera where the tip of their catheter is in proportion to the opening of the arteries or venous bypass grafts and allow them to go in and selectively engage them to do a contrast injection.  A lot of times the doctor will refer to that as 'localizing the ostium' of these bypass vessels, just finding the opening is what it means in lay terms.  That is not a separately billable service.  The work that is necessary to get into these bypass vessels to get into the coronary vessels is inclusive in the codes for regularly going for the injection and imaging codes.  So unless the doctor is doing that aortic injection to assess for aortic stenosis, aortic aneurysm, aortic valve disease, there is a whole lot of different reasons why they would do a diagnostic aortic root injection. But unless they are documenting that as a diagnostic study, they should not be going with the 93544 code. 

When we look at all the different things we have talked about so far we have got the placement of the catheter, the injection of contrast in different places whether it would be inside the heart or inside the arterial or venous pathway and then also the imaging of that.  When we really look at your bread and butter, what, 90 percent some odd of heart catheter are going to consist of, there is a package of codes which is listed on the top of slide #20.  93510 for the cath placement, then we are going to inject inside the coronary arteries 93545, we are going to interpret that inject of the coronary arteries which is 93556 with the 26 modifier on it; and then we are going to inject inside of the left ventricle specifically 93543, and also image that injection 93555.  So you can see these codes kind of go hand in hand with each other.  Placement of the catheter, injection, and then looking at the injection and then another injection, and then looking at another injection. 

One thing that practices will do which is another very common mistake is actually set up these explosion codes in their billing because they look like they save all these keystrokes.  You might have like an "ALT L" on your keyboard at data entry point and it is going to actually pull-up all 5 of these heart catheter codes, the 93510 through 93555 that I have listed on page 20 for you, and all those are going to get billed at one time.  The problem with that is that not all heart caths are going to be the same.  Maybe 9 out of 10 are going to be that combination, but not all of them.  And if you do that you are going to have a lot of false claims going out the door.  There are a lot of different variations.  Sometimes, for example, the doctors will go in and do a full left heart cath, the 93510, they will take pressure measurement, they will assess the coronary arteries but they will choose not to inject the contrast agent inside the left ventricle.  The main reason why they might not do that is if a patient is in endstage renal disease, the doctors will not want to inject that big bolus of contrast that is necessary to illuminate the intracardiac chamber because that contrast agent is going to flow down and that is going to be processed by the kidneys, and that is going to do some damage to the kidneys if they are already weakened.  So a lot of times you will see that being a contraindication, you will also see the disease or prosthetic aortic valve be a contraindication.  There are just a whole lot of differences that make it so that if you want to be compliant in your billing and want to obtain optimal accurate reimbursement, you really need to be reading through the operative report and only billing those services that are definitely documented.  When we have an idea of what the area of blockage is inside of these different arterial pathways, one of the things that we are going to do is try to fix these patients and that is what we call coronary intervention.
 
On the top of page 8 you will see the groundwork that we have to have in place before we start talking billing about these different services.  And the first thing is that there is a difference between human anatomy and billing anatomy.  Essentially the code structure and the reimbursement guidelines are not set up to provide cardiologists with accurate reimbursement for doing these heart caths and coronary intervention.  One other thing is that in the billing anatomy there are only 3 different coronary arteries.  Now one of the things that we talked about already is that there are really only 2 different coronary branches, a left and a right.  Now the left coronary system will bifurcate and split into the left anterior descending and a left circumflex artery, and that is what the coding regulation all refer to as the 3 main branches of the coronary system, or the only 3 branches: the left circumflex, the left anterior descending and the right coronary artery.  One of challenges with that, is that we have this certain segment of the left system, which is called the left main - that is essentially the part from the left coronary ostium to the point that it bifurcates into those 2 different branches and that is called the left main artery.  The billing system does not have a specific code or modifier that references that left main.  When we bill for these different services, we have to bill for the interventions as though they were done in one of the three recognized coronary branches, one of the recognized coronary arteries.  The first challenge is how we bill for intervention in the left main artery?  The main place that this is going to be defined is essentially at the payer level.  Because it is not addressed at CMS nationally, it is not addressed in the code structure.  What I have seen more carriers say than anybody else, is that you want to bill the left main as though it was the same artery of the downstream dominant branch.  So essentially your doctor has to be documenting the left anterior descending and the left circumflex as the dominant downstream branch, and that is going to dictate how you bill interventions that are done in the left main coronary artery. 

Another challenge is that you have different branches of these coronary systems.  As you can see on the diagram on slide 22, there are a lot of different branches and doctors frequently will go and place stents, do angioplasties inside of these different branches.  We are going to code any interventions done in a branch of a coronary system as though it was done in the main system that is feeding it, whether it be the LAD, the circumflex or the right coronary system.  We also have those bypass vessels that I told you about.  In this case, we are going to have an artery that is not a bypass vessel that is sewn into the aorta and then it is going to go from the aorta down to a branch of the coronary system.  These vessels are prone to become blocked over periods of time as well.  So when we do an intervention inside of one of these bypass vessels, the doctor is going to actually have to bill it as though it was part of the artery that it is feeding.  And what that means is that the blood is going to go from the aorta through this bypass vessel and into a branch of the coronary system.  If you do an intervention inside of the bypass vessel you are going to pretend that it is actually the same vessel as the one that is being fed by the bypass vessel.  They'll call that the 'coronary artery of distal anastomosis.'  Distal just means on the far side, anastomosis just means where it connects.  So these bypass vessels will connect proximally to the aorta distally to a bypass vessel.  So you are going to bill it as though it was part of the coronary artery of distal anastomosis. 

The final challenge that is presented by this human vs. billing anatomy is the ramus artery.  The ramus artery is just a small coronary artery that approximately 33% of the population has at the point the left main artery branches and bifurcates into the left circumflex and the left anterior descending.  There will be a third branch that kind of splits right out of the middle of those two and that is called the ramus artery.  About 33% of the population is going to have one of these ramus arteries.  When we do an intervention inside of those what I have seen, again this is going to be something dictated at the carrier level, what I have seen most carriers say is to bill it as though it was part of the coronary artery to which it is anatomically equivalent, which means which ones it leans closer to, which one it feeds, as far as the segment of the heart muscle that it feeds.  Bill it as though it is the one that is anatomically equivalent to.  Defining exactly how to bill the ramus and the left main is a challenge with most reports.  So it is something you probably want to make your doctors aware of so that they can document those things accurately.  When we start doing interventions, the main thing that we are trying to do is just restore the flow of blood so that it can get to that heart muscle.  The first intervention we are going to be doing is angioplasty, which we call PTCA or percutaneous transluminal coronary angioplasty for a 25 cent word.  There are different pictures on slide 23.  The top one shows you what that area inside of the artery looks like.  You can see there is an extensive 90 some-odd percent blockage of the opening of that coronary artery.  We are going to thread a specialized guidewire through the areas of blockage.  Over the guide wire, we are going to pass a deflated balloon.  Once the balloon gets into position we are going to inflate it and that is going to essentially smush that area of blockage up against the arterial wall so that makes a nice passageway through there.  At the place that we are doing these angioplasties, the blockages that are inside of these coronary arteries are of play-dough consistency.  They are something that is pliable, we can go at it and manipulate it and just like with a can of play-dough if you stick your finger in it and move it around it is going to create a hole that goes right through it.  That is essentially what we are doing with a coronary intervention, creating a hole that goes through the area of blockage.  Once that hole is in place that is going to allow blood to flow right through it and immediately the heart muscle that is downstream is going to be re-perfused. 

The next thing that we can do is go to an atherectomy and this just means that we are going in and we are actually scraping away or removing that area of blockage.  Anytime you see the ending of a word that says 'ectomy' that means that we are removing something.  So 'athero' refers to atherosclerotic plaque, 'ectomy' means that we are actually going in and removing that plaque.  Couple of ways that we will do this, one is with a directional atherectomy tool.  This way we just go in and scrape away the plaque from the inside of the coronary artery.  Another one what is called rotoblade, which I haven't seen, it has kind of decreased in frequency.  Five or six years ago this used to be done much more frequently than it has been lately.  This is essentially a very high-speed drill tip that they mount on the end of the catheter.  It is not a conventional drill tip like you might see in a workshop or something like that.  It has got little diamond chips on the outside of it, it just burs a hole through the area of obstruction.  Now the reason we want to do atherectomy instead of angioplasty on some patients is that as we leave that area of stenosis in place for an extended period of time, just like play-dough, it is going to become hardened over a series of months or years.  Once that area of blockage hardens, it becomes like flat plaque - very hard substance.  We cannot go in and push it around with a balloon catheter because it is simply too hard.  We are going to have to use too much pressure, it is going to do damage to the arterial wall.  So we actually just go in and scrape away the plaque. 

From a billing perspective the highest intervention that we can do is what we call stent placement.  That is on the top of page 9 for you.  Here we are actually going in, we have got a stent, which is like a small little piece of metal, it is like a tube that goes in.  We inflate the balloon, it inflates the stent that is riding over the top of it and that is going to act like a scaffolding inside of the arterial wall.  It is going to of course hold the area of obstruction open and that is also going to provide support to keep that arterial wall from closing back in on itself.  Nowadays, there are a whole bunch of different kinds of stents, whereas 5-10 years ago there was only a couple of choices out there to choose from and most of them were bare metal stents.  A bare metal stent is just what it sounds like, it is just the metal structure that we are going to be placing inside of the patient. 

What we see a lot of times been used these days is what we call a drug-eluting stent.  What a drug-eluting stent does is it is going to decrease the chances of inflammation, it is going to decrease scab growth, it is going to decrease the rate of restenosis.  When we go inside of a patient's coronary artery and starts scraping away things, start inflating balloons and placing metal objects inside of there, the arterial wall is a living piece of flesh and it is going to react just like any other piece of human flesh.  It is going to inflame itself, it is going to become scabbed over and the problem with that is that inside of a coronary artery that is going to essentially create another area of stenosis which the doctors will reference as a 'restenosis'.  So these drug-eluting stents, they cost quite a bit more money than the bare metal stent but in the long run they cost the health-care system considerably less because if they use the bare metal stent, often these patients are going to have to come back in months or years to have another angioplasty performed on them.  From a billing perspective, when we do interventions we are going to bill them as though they were done in one of the three recognized coronary arteries.  Within each of the recognized coronary arteries, we can only bill for one intervention.  So a lot of times we will doctors addressing two different areas of lesion, but when we code them out we ask, which of the 3 coronary arteries is this considered to be done in?  You will find that there will be 2, maybe even 3 or 4 interventions done within 1 coronary artery.  From a billing perspective we only could bill one intervention inside of each of these coronary arteries.  The one that we want to be billing is of course the one that is going to reimburse us the most.  So the angioplasty, the PTCA reimburses the least; atherectomy is in the middle and then the stent is the one that pays the most.  The reason for that logic is that a lot of patients that have a stent placed are going to have angioplasty and atherectomy performed before they actually receive the stent.  So the reimbursement rate reflects that with each of the different interventions that we have talked about, they kind of include the reimbursement for the preceding intervention plus the additional amount of money for the additional work that is involved.
 
When we bill for these services ,if we find that we actually did interventions in more than one of the coronary arteries, we are going to bill for the highest reimbursing intervention within each of the three coronary arteries, but we have got to distinguish them by the codes that are in the middle of page 9 and slide 26.  We have got one set of codes that are called base set of codes and then another set that says we are doing each additional vessel.  So within even the most complex operative report when we are talking about doing coronary intervention, we should only have one code that is listed from the base series of codes, because that code is going to reimburse us for obtaining the vascular access, manipulating our equipment up into the coronary system and actually doing the intervention.  It also includes the postoperative and the preoperative work that is associated with it.  If we were to do angioplasty in one coronary artery and then go on and do angioplasty in another one, it is not going to be appropriate to get reimbursed for all that work twice.  That is kind of why they have set up a base code.  The base code says we are doing all of this work and then each additional vessel code says, at the same time we had the patient in operating room at the same time we had vascular access, we went ahead and did this other intervention in the coronary system as well.
 
One of the errors I see happening quite a bit is that we will see multiple interventions being done in different coronary arteries and we will bill two of these base codes at one time, the 92982, 92995, 92980, which are on the top of slide 26 - that actually is going to trigger an immediate denial.  Because you can only bill one of these base codes per operative session and if you don't do that it is going to be problematic.  Then the each additional vessel codes at the bottom.  One of other reimbursement challenges that are currently addressing is the fact that the base codes and each additional vessel code inaccurately reduce the reimbursement for doctors.  With any other code in the CPT Book, when we do multiple procedures, the first procedure will get paid at 100%, 2nd procedure will get paid at 50%.  So we have essentially a 50% reduction on the 2nd procedure.  Within these coronary interventions, this is the only place where the CPT Book varies from that.  And in these cases, when we do stents in two different vessels or angioplasties at two different vessels, the 1st one gets paid at 100%, the 2nd one is going to have a 73% reduction in reimbursement, which is considerably more.  That is almost half as much more as any other procedure.  So this is another area where the reimbursement rate and coding methodology is kind of stacked  against the cardiology.  When we bill for these services on the top of page 10 we have got the different modifiers that we need to utilize; just like there are three different arteries that we can do these interventions in, there are three different modifiers to distinguish which of the different arteries we did the intervention in: the right coronary, the left anterior descending and the left circumflex.  When we do more than one coronary intervention we actually have to attach the appropriate modifier onto the appropriate base code and the each additional vessel code.  And if we don't do this, this is going to trigger an automatic denial.  This is another areas where we see a lot of claims being inappropriately denied.  The reason why we have to attach these modifiers is first off, to make them understand that we are not billing for two interventions at the site of the same coronary artery because some providers were abusing this.  They actually established a set of nine different correct coding initiative edits last year and actually bundled each of these base codes into each of the additional vessel codes so that, unless we use the modifier saying that these are two different coronary arteries, it is going to trigger denial of the cheaper paying on as being inclusive into the more expensive ones, essentially.
 
On slide 29 - a lot of times we will do a diagnostic cath and proceed immediately to an intervention.  This is going to be a patient that comes in in acute patin, we do a diagnostic cath and then we identify that we need to do an intervention immediately; it is appropriate to bill for the full diagnostic heart cath, for example those five codes we talked about, and also bill for your stent placement.  Now carrier by carrier, payer by payer, they might require you to use a different set of modifiers, typically if you put the 59 modifier on the imaging codes, your 93555, 93556, that is going to work more times than not.  Sometimes you will also have to put on a 51 modifier on the heart cath.  I have seen a couple of payers require that even though the heart cath, the 93510, is marked as a 51 modifier exempt code in the CPT Book.  So you really need to figure out how your main payers, how your Medicare carrier wants those billed because they are separately reimbursable.  You are going to get a 50% reduction on your diagnostic heart cath code, which again is technically inappropriate, because it is modifier 51 exempt. 

When we do interventions, another error that we see happening a lot is that the billing staff will try to bill for another diagnostic study at the time of a planned intervention.  Typically if we have a patient that we do a diagnostic study on one day and then we are going to plan to do an intervention -whether it be the same doctor or another doctor who is an interventionalist - and that is going to be on a subsequent day, a scheduled intervention, it is not going to be appropriate to bill for the catheter placement, any angiographic studies or any injections that are performed.  So if you are doing those things there has to be a medical necessary reason to do it.  One of those is that a patient could be scheduled for an intervention on Thursday and they present to the emergency room acutely on Wednesday, and we are going to of course have to do another diagnostic study then to find out how their physiology has changed and the pathology of the lesions; something has obviously changed to trigger an acute event like that.  Other times, a certain amount of time could have elapsed between the diagnostic study and the planned intervention necessitating a reassessment of the arteries so we can plan the intervention out.  But in a typical scenario, if you are doing a planned intervention, all you are going to be billing for is the interventional code.  So if you are planning to do a right coronary stent placement your claim is going to have the stent placement code on there, the 92980 and nothing else on it.  No catheter placement and no imaging service. 

On top of page 11 it is conscious sedation.  Conscious sedation is something that a couple of years or probably last year even some practices were having limited success getting paid for it.  Effective with 2005 CPT code, conscious sedation is bundled into these codes.  So you cannot bill conscious sedation at the same time. 

Temporary pacing of the patient's heart.  When we go in and start poking around the coronary arteries and start putting a pigtail catheter inside of the left ventricle of the patient's heart, sometimes we are going to be triggering arrhythmias, which just means that the heart is beating out of the appropriate rhythm.  Some doctors will anticipate this and they will place a temporary pacemaker inside of the patient, which is just another catheter that is going to have a pacing electrode on the end of it which will allow the doctor to pace the patient's heart to keep that from happening.  If the doctor is placing a temporary pacemaker for what they call prophylactic reasons, which means we are trying to prevent an arrhythmia, it is not going to be separately billable in most cases.  This is referenced in several different local coverage determinations that are available on the Internet and from your individual carriers.  If, however, the doctor is doing a diagnostic heart cath and the patient goes into an arrhythmia such as ventricular fibrillation or atrial fibrillation, at that point they are going to have the indications to do temporary pacing and in most cases they will able to bill for it and get separately paid for it.  But you are going to first have your claim reviewed in a lot of those cases so make sure the documentation is appropriate.
 
Embolic protection is a service that we are starting to see a lot more frequently than we were used to.  Embolic protection is just preventing against a small myocardial infarction.  If we go in and we do interventions inside the coronary system and we inflate these balloons and scrape away plaque and what not, it is going to be dislodging areas of plaque and thrombus, which is essentially a clot, and that clot or that plaque is going to flow downstream it is going to come to a point that it occludes the vessel that it is in and that is going to cause a small myocardial infarction.  There are two different types of embolic protection.  The one that has been out the longest is what we call distal embolic protection.  This is a strainer that gets deployed downstream from the interventional tip of the catheter and it essentially acts like a pasta strainer that is going to catch any of debris that breaks loose.  So that way we can pull it out of the patient body before it does any damage. 

What is coming out in the market now is a couple of different proximal embolic protection devices.  In these cases we go in and actually inflate a balloon upstream from the area that we were working on.  Inflating the balloon is actually going to stop the flow of blood.  It is going to completely occlude the vessel and allow us to pass distal embolic protection through the area of stenosis and capture anything before it goes out.  With the proximal embolic protection, we are going to essentially do the intervention, do whatever we need to do and then suck out the debris before that is allowed to flow downstream.  When we look at billing for embolic protection you are going to find different payers and different carriers across the country are going to have different policies on these, both in what they will pay, if they will pay and how much they will pay.  There is no code that represents it.  We have to use 93799 regardless of if we are going to be billing that at all.  We have to use the unlisted code currently until there is a code that is listed that comes out.  Some payers I have seen will pay $200, some actually even more than $200 for it.  Other ones have flat out came out with policy that says, embolic protection is an included part of the procedure.  So with those payers it is not going to be appropriate to bill separately for it.
 
Coronary flow reserve is another service that doctors will do occasionally.  This is where they are measuring the difference in blood flow when the patient is resting and then when they are at maximal pharmacologic exercise, which stimulates physical exercise.  In a normal patient what we are going to see happening when the patient gets up to the optimal heart rate, is that those coronary arteries are actually going to expand considerably to make a larger caliber vessel to allow more blood to flow through them from the aorta off into the heart muscle, so that more oxygen and more nutrients are going to the heart muscle itself.  If we have a ring of plaque inside of the coronary artery, that ring of plaque is going to not allow that area of vessel to open up.  so one of things doctors will do is they will go in and measure the amount of blood flowing through an area of stenosis when the patient is resting and then they will induce pharmacologic stress by injecting adenosine inside of the patient.  That should trigger an immediate increase in the blood flow going through the artery, and by measuring how much the blood flow increases we can determine how substantial of an effect the area of blockage is having on the patient.  This is a separately billable service.  The doctors typically will call this a coronary flow reserve, there are a whole lot of other measurements such as total flow reserve and fractional flow reserve; the doctors are essentially making these different calculations from the data they are obtaining.  When we bill for coronary flow reserve 93571 is going to be the code for the first vessel, 93572 is each additional vessel.  Now the way that these codes are set up now, there is no clarification as far as do we code these per vessel in the same way that we bill the coronary interventions, or we bill them as though we would be billing a peripheral intervention, which is going to be each time a vessel bifurcates it basically becomes a different vessel.  Right now what most people are doing is billing those as though they are the same type of structure as the coronary intervention, in which there are only three vessels inside of the whole coronary system regardless of bifurcations and bypasses, left main and ramus and all these other things.  But that is an area that is gray right now and it has not definitively been clarified.
 
Percutaneous thrombectomy.  Thrombus is just an area of clot.  When we have these different areas of obstruction inside of a coronary artery, sometimes blood clots will form on those.  These blood clots, we cannot go in and place a stent over the blood clot because it is going to cage the clot up against the wall of the coronary artery and between that and the stent.  So what the doctors will do is go in and suck the clot out through a specialized catheter tip.  This thrombectomy, the removal of the clot is a separately billable service, 92973, and this code can currently be billed with either stent placement or angioplasty, but not with the arthrectomy, which really isn't that big of a concern.  Typically if the doctors are doing an arthrectomy, they are going to be placing a stent as well.  And I think the logic behind that is if you are really only going to do an atherectomy, your attention is just to go in and remove the areas of stenosis.  So if you are going to be removing the clot as well, you don't have to bill separately for it.  That is how I try to make sense out of it, you could go either way with the logic behind that very easily. 

Intravascular ultrasound which we frequently refers to as IVUS.  This is really where we are able to go in and look to see what makes up an area of stenosis.  We have an area of stenosis that we identify with coronary angiography, sometimes we are not actually sure if it would be best to treat this with angioplasty, atherectomy or stent?  Can we go in and do brachytherapy?  If there is an area of restenosis we want to figure out exactly what that restenotic area is made up of, and to do that we cannot just do angiography.  Angiography is just going to show us how big the lumen is that is going through the area of obstruction but it does not tell us what it consists of.  So IVUS is actually going in with a specialized catheter tip.  It is going to shoot ultrasound all the way around through the inside of the lesion and show us the denseness and what constitutes the area of obstruction that we are looking at.  This is really considered the gold standard of identifying what makes up these areas of lesion and telling us exactly how to go ahead and treat this patient.  This is a separately billable service of course 92978 is the first vessel code, the 92979 is each additional vessel code.  These are per vessel codes but there is no definitive clarification that has been out by CMS, by any other Medicare carriers -and I looked at every single one of those coverage determinations that are out there - there is nothing that definitively says you have to bill these per vessel and that there is only three vessels.  This is something again I am trying to clarify through the coalition to try to get this definitively clarified.  There is a considerable difference in reimbursement if we are to do IVUS or thrombectomies in different branches of the same coronary tree. 

The final thing that we will talk about with the diagnostic heart cath is what we call brachytherapy, and this is actually a therapeutic procedure that is being done to help reduce the restenosis rate.  When we go in and do interventions inside a patient, like I said earlier there is going to be an inflammatory process that happens immediately after we do the intervention.  There is a chance of restenosis, whether it be from clotting or just from building up that puts like a speed bump there; low density cholesterol can build up on it and actually re-stenose the area.  One of the things that doctors have done recently is what we call brachytherapy.  This is where the cardiologist, the interventional doctor is actually going to be going in placing the tip of the catheter exactly where it needs to be so that the tip of it is right where the area of stenosis is, and then another doctor, a radiation oncologist, will come in and pass a radioactive source to it, whether it be a pellet or some other type of a delivery source.  This is a separately billable service with code 92974.  It is an add-on code so of course there is not going to be any reduction in reimbursement.  We are going to be billing that.  In a lot of cases, when we go in and we place stent inside a patient's body we are going to want to use this brachytherapy to help reduce the restenosis rate.  Of course with these drug-eluting stents, some of these v brachytherapy patients that 5-6 years ago might have been treated by brachytherapy, now these drug-eluting stents may make it so it is not as necessary to do the brachytherapy.
 
One other thing that we are seeing a lot in cardiology groups across the country is this increasing amount of doctors that are doing peripheral vascular studies.  This is the focus of page 14.  One of the things to understand is that this is something that is going to continue and we are going to start seeing a lot more of peripheral vascular procedures being performed by cardiologists.  There are three main reasons for it.  One is that is a natural fit.  Cardiologists have huge patient bases - any of you that have paper-based medical records, go into your file room and every one of those files is essentially a different patient that has coronary disease that you are managing.  When we look at what causes coronary disease which is just different types of substances and ingredients inside of the patient's blood and their family history that causes the coronary arteries to become blocked; the same factors that cause coronary disease cause peripheral vascular disease.  The whole arterial system, whether it be coronary arteries, renal arteries or arteries that go to the brain or arteries that go the lower extremities, these arteries are all interconnected and the same blood that goes to the coronary arteries, that same blood could go off to the carotid arteries or the vertebrals or the renals or the iliacs or anything downstream.  So if something is inside of the patient's blood or in their family history that causes coronary disease they have got a very increased chance of having peripheral vascular disease as well.  So one of the reasons why we are seeing peripheral vascular come in to cardiology a lot is just because they are our patients, essentially.
 
Another reason is that the service, whether it be diagnostic studies or the intervention, are going to require the same exact skill and the same exact equipment that is being utilized.  So if the cardiologist is capable of using this tool, the catheter, these guidewires and different types of devices that they are using, and they are capable to go into the patient's body to go all the way up to the source of the arterial system through that aortic valve, diagnose inside of the patient's heart and then go off into different branches of the coronary system and do interventions, why would not this doctor also do the same type of studies in the renal arteries or the lower extremity arteries or the arteries that go up to the brain?  These doctors are the ones that invented the equipment, they have mastered its use, they are actually going into coronary arteries, which wrap around a beating human heart.  Like I said earlier, it is beating 60-80 times a minute, sometimes considerably faster than that at the time that these patients are having an intervention performed.  So if they can do this work inside of a coronary artery that is wrapped around in beating human heart, then it is really kind of a cakewalk to go into a renal artery to do the same type of a study or even a lower extremity artery.
 
In addition to the natural fit between the peripheral and a coronary intervention we have monetary reasons.  If we can diagnose the patient with suspected peripheral vascular disease at the same time we are diagnosing their coronary disease, this is going to allow us to basically get the same diagnostic imaging from one procedure as opposed to potentially having the patient come back for multiple procedures in the future.  So it is going to be fewer hospital admissions, there is going to be less consultation fees, because we are not going to have to send this patient off to some other specialty to have a full head to toe physical performed with lab studies and noninvasive imaging, and then proceed to the point to actually have an angiographic study of these different peripheral vessels performed.  So it is going to be less expenses on the medical system, less expense to the patient; and also if we can diagnose these patients with peripheral disease before they progress to a point of causing permanent damage, it is going to save the patient a ton of anguish, physical pain, and it saves the system a ton of money.  For example if we are doing a heart cath on a patient, we do a nonselective renal study and find that the patient has substantial renal artery disease we can go ahead and treat the patient immediately as opposed to allowing the patient to just get discharged.  They can perhaps go on with life for a year or two until the point that they actually become acutely ill, and at that point their renal arteries could be so severely damaged that they are actually starting endstage renal disease, which of course is going to be a substantial expense and a substantial hardship to the patient.  This is something that, if we can catch the disease earlier, it allows us to take care of the patient better because we can treat them percutaneously which is through a small incision or a small puncture in the patient's groin area, as opposed to going in and actually having to open the patient's abdomen up to do these procedures or to actually replace a kidney. 

Now when we start looking at the first level of peripheral vascular studies on patients, the common one that we see being done at the time of heart cath are these nonselective renal and iliac artery angiographies at the time of the heart cath.  These codes G0275, G0278 are specific only to Medicare patients, only if they are having a heart cath done and only if they are having a nonselective renal or iliac study performed at the same time.  When these G codes were first introduced they were really ambiguous.  Their definitions could be interpreted to apply to both selective and nonselective studies.  The code definitions were changed immediately after about 4-5 months of extensive rambling and political angling and what not.  They were changed to clarify that they work for nonselective only.  The 2005 HCPCS Book came out and it brought the code definition back to what you see at the top of page 15, which is essentially ambiguous again.  They don't say whether they are selective or nonselective.  This is something I became aware of back in November.  I immediately started talking to officials at CMS, and I kind of worked my way up the ladder the hard way.  What we were able to clarify is first off, in talking to CMS, it became clear that CMS feels that cardiologists should be doing peripheral studies and they were somewhat shocked to hear that the doctors would be going in and doing selective peripheral vascular studies and that a cardiologist would be suited to place a carotid stent and different types of lower extremity studies as well.  So one of the things that I have done is really clarify to the government that cardiologists are very well gifted and exceptionally suited to do these peripheral studies whether it is in a carotid artery, renal artery or what not.  By using the same clarification I just presented to you about being able to go into an artery that is wrapped around the beating human heart as opposed to going into a renal artery, it is really not that much of a challenge to the doctor.  It is still a very technical procedure.  There is a lot of enhanced risk, but if you can do it inside of a coronary artery, chances are you can do it inside of a renal artery much easier.  So one of the things that we educated CMS about is the fact that cardiologists are going to be doing these procedures.  We have shown them that these G codes should be made nonselective in nature because financially it would just be highway robbery if these G codes, which pay about $13 or $14 depending upon your carrier, were the reimbursement rates for a selective study as well.  And a proposal has been made - and this is something that they haven't stated anything on yet, but a proposal has been made that they make these codes covered for any patient with documented coronary artery disease based on the logic that if a patient has coronary disease, they are at increased rate of having peripheral vascular disease.  If we can catch these things before the disease progresses to the point that it shows up in renal hypertension or abnormal lab values, we will be able to save the Medicare system just a ton of money and save patients just a ton of anguish and physical harm.  So that is something that I have been personally involved in since November 2004.  The status right now is that CMS has clarified that these G codes are for nonselective studies only.  They are currently looking at the different proposals that have been submitted to them and there have been other people that have submitted proposals as well.  What they have said is that until they rule on that, it is okay to bill these as though they were crafted last year as nonselective studies.  If we are doing a selective catheterization, peripheral vascular study on a patient at the time of the heart cath, we go ahead and bill for the appropriate selective codes such as the ones on the top of page 16, which I have got listed, just like a 36215, which would a first-order catheterization above the diaphragm, like if we were going to do the left carotid study.  And then also bill the imaging code such as 75722, which is a unilateral selective renal study. 

When we bill heart catheterization and these peripheral studies at the same time, be cognizant of the different CCI edits that are in place because a couple of them don't make sense.  If you look on the middle slide on page 16, you see that these are the codes that are currently bundled into the 93510, the heart cath.  And the ones that I have got in bold don't make any sense, like 36245 which is a first order catheter below the patient's diaphragm, is bundled as being part of and inclusive of a heart cath; the coronary arteries are arteries that are above the diaphragm, so if anything, 36215 should be bundled into them as opposed to 36245, which I don't see why they would possibly say that that is inclusive of a heart cath. 
The other ones that are involved are of course the unilateral and bilateral selective studies.  CMS and individual carriers have said time and time again, if you are doing a selective renal study at the time of the heart cath you can bill separately for it.  So there is really no need for correct coding initiative edits there.  All three of those do allow to circumvent the edits but they require us to put a modifier on it.  Whether it be the left, right or the 59 modifier. 

One of the reimbursement challenges that I am facing right now as well is if you look on the bottom of page 16, consider the procedure of a left heart and the bilateral selective renal study.  If you look at them there are a lot of similarities and a lot of differences that you can draw.  The similarities are that in both of these procedures, we are obtaining vascular access, selectively catheterizing two different vascular families performing angiography.  When we start to see them differentiate is that the end organ of a heart cath, which is actually the organ that will be damaged if we screw up the procedure - that is kind of how I think about the end organ - is the heart.  In worst case scenario if we shred a coronary artery, that patient's heart could essentially be impacted to the point that it kills the patient.  The end organ with the renal study is the kidney.  As you know we have got two kidneys.  We only really need one of them, so if the doctor just shreds a renal artery, the worst case scenario is that it is going to kill one kidney, the patient still has another kidney to live.  And even if we accidentally destroy both of the renal arteries and both kidneys in the worst case scenario die, these patients can still have a kidney transplant and they can go on dialysis but still live.  So the end organ is much more delicate with a heart cath.  Look at where the vessels are.  The renal arteries just branch off at the abdominal aortic area.  They pulsate of course with the different blood pressure changes, but they are not moving substantially.  When we look at the coronary arteries, these things are again wrapped around a human heart beating at about 60-80 times per minute.  In a left heart cath in addition to doing the catheter placement and the injections, we are going to be taking pressure measurements inside of the heart and doing the angiography inside of the heart as well as the angiography in the various vessels, which could be 5, 6 or 7 different injections inside the different branches of the coronary system.  If you look at the reimbursement rate, in my mind, the left heart cath should pay substantially more than a bilateral selective renal study.  Actually the renal study will pay 20% more than a left heart cath, which is just another place where the reimbursement rates right now are stacked against the cardiologist, which is a considerable concern in my mind considering how much work it takes to become an interventional cardiologist and the delicacy of these procedures. 

If you look at the reimbursement rates, for example for a left common carotid vs. a right internal mammary study at the time of the heart cath on top of page 17. Similarly we have got a left common carotid artery study is the first order selection.  The right internal mammary is actually a 3rd order selection.  We are doing angiography inside of both of them.  When we look at the reimbursement rates, if we are doing the right internal mammary at the time of a heart cath, which is a 3rd order selective we get $21.  If we do a left common carotid study, whether it would be at the time of heart cath or not we are going to be able to bill the 36215 and 75676 with the 26 modifier on to get $187.  This is about 8 times the difference.  So we get paid 8 times more for doing this left common carotid than the right internal mammary, even though by any measure the right internal mammary includes a heck of a lot more work.  It is a 3rd order selection, we have to navigate the catheter selectively through three bifurcations.  We leave the aorta, it becomes first order, and then we have to select two different orders to get to this third order selective.  We get 8 times more money for the left common - there is no logic to be had there whatsoever.

When we look at diagnosis coding for procedures.  When we do a left heart cath or when we do a peripheral study, these are diagnostic services Medicare requires us, because of HIPAA, to report that findings for a positive diagnostic study report the indications of the study as normal.  This is really a very, very common place where I see errors happening.  We will see a patient have a heart cath done, the doctor documents multiple vessel extreme coronary artery disease, the diagnosis code that gets put on the claim is chest pain or angina.  This is inappropriate.  We need to bill any diagnostic test.  If it is a positive study we report the findings, if it is a negative study that is when we report the indications.  This is something that has been mandated by HIPAA effective January 1, 2002 and I still see practices doing it to this day on an almost routine basis.  Even in office diagnostic tests like your echocardiograms, your EKGs, different studies that you are doing internally, a lot of times you will see these things billed out with indications for the study before the doctor even interprets the study and then the study is of course positive, so we have essentially submitted a claim that is inappropriate.  Report the findings not the indications for these services.

In the next couple of pages, I just have more information about the diagnosis codes you can bill for.  What I will let you read over is basically just referencing how to use the GA modifier to show that you don't feel that the diagnostic study that you are performing is indicated, and also just some idea as to why it is important to get these diagnosis codes accurate.  There are different excerpts from local medical review policies in the backside of your paper,  CMS 1500 or HCFA 1500 depending upon how updated your form is.  I would like to focus just briefly on the top of page 19.  I will skip to this just because I have pretty much presented all the information that you need.  It will just allow us to have a couple of more questions and answers here at the end.
 
When we look at doing these different procedures, heart catheterizations, we look at right heart cath, left heart cath and also the combined right/left heart cath, when we look at how we bill for these services one of the things we have to be aware of is the different diagnosis codes that will cover these services.  Right now there are a lot of payers that are starting to develop what we call a 'split cover policy', which means they might have a diagnosis code that will cover a left heart cath, but it would not cover right and the left heart cath.  This is really a challenge because a lot of times that we could be doing a right and left heart cath for two different reasons. and if we put the wrong reason on there the claim is going to be denied even though the service is totally medically necessary.  What I did was went ahead and pulled each of the different local coverage policies that are available right now, and on the bottom of page 19 is a listing of the most common ones where we will see the diagnosis codes will cover a left heart cath but it will not cover the combined left/right heart cath.  These are ones that you really need to be aware of because when you are doing a right/left heart cath a few claims are getting denied all the time because we put one of these diagnosis codes on there.
 
What happens occasionally is summarized on top of page 20.  This is where we have a patient that comes in to have a left and right heart cath done during the same operative session.  We start looking at billing for these services and when we look through office visit notes or consult notes preceding the procedure, we look at the diagnostic findings, we have a diagnosis that covers a left heart cath but not the right/left heart cath.  What a lot of practices will do is to call up and say, is it okay to just bill this as a left heart cath and forgo the reimbursement difference between a right/left?  Technically it is not.  I mean, if you did a right/left heart cath then the 93526 is going to be the right code to bill; if you were to down code your service through a 93510 just to cure reimbursement, that is technically a false claim.  Basically what you are doing is you are billing a lower level service so you can obtain reimbursement whereas the service that you should be billing for would not obtain reimbursement based on the findings or the indications for the study.  This is something where it is much better for you to go ahead and file the claim and then appeal it and fight for your reimbursement that way.  Because if you down code it that is technically a false claim and you could get in trouble for it. 

Finally I will tell you about upcoming conferences that we have and then we will open the floor up for a few questions and answers.  We have got EP study, peripheral vascular we have actually got 120 minutes dedicated to peripheral vascular.  As you know, these peripheral vascular services, the reimbursement rules and the coding guidelines that are out there are rather complex; the reimbursement rates are way out of whack with where they should be.  This is an area that I am really actively involved in, in getting the regulations clarified making it more fair for cardiologists so that they get reimbursed appropriately for the different services that they are doing.  And this 120-minute teleconference is going to just be world renowned as far as clarifying the appropriate way to bill for these services and you will walk away from the conference call knowing exactly how to bill even the most complex PV report.
 
We also have an ICD and CPT update, two different conferences.  Then we have an evaluation and management teleconference coming up and you want to have your doctors and your auditing team sitting in on that.  There have been 4-5 major clarifications that I have got from CMS as far as how we should applying evaluation and management rules as they really rocked my world.  When I got the clarification I just could not believe that we have been applying a much higher requirement on physicians' documentation and using much stricter audit standards than we really need to be applying.
 
Again, my name is Jim Collins.  I have got contact information on the slide of page 20; I am with the cardiology coalition which is just a specialty society that is dedicated towards making sure that we get these different reimbursement rates, get theses code structures, get the correct coding initiative edits, all these different things that are stacked against cardiologists, addressed head-on.  And as illustrated by the G0275, G0278, we are making a lot of headway.  In this E&M conference you will find even more headway that has been made through the coalition.  It is also dedicated to the proficiency of your physicians documentation and your billing staff to make sure that you get paid appropriately for services.
 
Contact information for me is on the bottom of slide 59.  At this I am going to open up the call back to Mandy and Mandy will be open up the conference to you folks so you can ask a few questions before we adjourn. 

Thank you Mr. Collins.  Ladies and Gentlemen, I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time, please press the *1 key on your touchtone telephone.  If your question has been answered or you wish to remove yourself from the queue, please press #.  Please limit yourself to one question at a time so that everyone may have a chance to participate.  If you have another question, you may reenter the queue by pressing the *1 key. 

Q & A Session:

Our first question comes from Linda Everfeld of Lebanon Cardiology, please state your question.

Question:  When a physician is attempting to do a combined right and left heart cath and the physician cannot cross the aortic valve for the left heart portion how would you code this?

Answer:  The best way is going to be to bill with the 93508 and then also bill the right heart cath by itself.  If they are not able to cross, some people say you could bill that with a discontinued service modifier and there is certain logic in that.  The challenge with that is it is going to create substantial delay in getting your reimbursement for the service.  A lot of times the doctors will specifically say that we cannot cross the aortic valve because of this or that reason.  That is really a contraindication as opposed to they are attempting to do a service and discontinue it.  You would want to bill the 93508 assuming that you are going in to assess the coronary arteries, and then the 93501, which is going to say we are doing a right heart cath as well.  Unless you actually cross that aortic valve you should be billing for those services separately as opposed to the 93526 which is your combine left/right heart cath.

Question:. Would you need a modifier on that or they in the CCI edits to bill them?

Answer:  I don't believe you need a modifier, but if you would need one, that would be the reason why, I do not know off the top of my head; but I do not believe that there is a CCI edit in place there.  If you would need one, just put the 59 modifier on it.

Comment:  Okay, thank you.

Comment:  You are welcome.

Our next question comes from Juana Torreo of Premier Healthcare.  Please state your question.

Question:  My question is, sometimes my physician injects nitroglycerin when doing his catheterization and I have not been able to find a code to bill separately for that.  Is there a code or is that just part of the catheterization?

Answer:  It is going to be inclusive of the cath.  It is another error that I see a lot.  Some practices will try to bill that as an infusion service which is a really high reimbursing, extensive procedure.  What your doctor is actually doing is when they go into these coronary arteries, like I said earlier with triggering an abnormal heart rhythm, sometimes what they will trigger is those coronary arteries to spasm and they will start squeezing non-stop and that makes it very hard for the doctor to do a diagnostic study then.  They inject this nitroglycerin and it is kind of like just a mellowing drug that helps smooth those arteries down so that they are not constricting and spasming.  It is something that is necessary to do a lot in these different coronary studies and it has been defined as being inclusive of the heart cath itself.  So it is not separately billable. 

Comment:  Okay, thank you.

Our next question comes from Rosemary Brookhart of HPV Heart.  Please state your question.

Question:  Yes, we would like to know how to bill for a LIMA and RIMA bypass grafts during a cardiac cath? And then also address modifier with that please.

Answer:  As far as RIMA and LIMA, those are going to be your 93539 codes, it is what you are going to be billing for your injection of those codes.  And then when you do the imaging it is going to be the 93556 code.  Typically the 93556, you are already going to be billing for your coronary study so it is not going to be really be billed twice.  So the only way it is going to impact your billing is if you are going to add-on a 93539, in most cases.  As far as modifiers go, there is not going to be a different modifier and you can only bill those codes one time as well, the 93539.  So even if you do just the LIMA you are going to be billing the 93539 one time, but if you did the RIMA and LIMA, it does not increase your reimbursement; but if you look at a diagram of the great vessels you will see that it really is a lot more work.  And this is probably one of top 20 places where cardiologists are not reimbursed appropriately for the work that they are doing.  It is a really great question.  There is a lot more work if you do a right and a left internal as opposed to doing this one or the other, but the cardiologist does not get an additional penny in reimbursement.  There are also no modifiers that are necessary.

Comment:  Okay, thank you, we just want to clarify that we could only bill once.

Answer:  You have got it right, it does not seem right but that is the way that it is set up. 

Our next question comes from Janette Freemont of Longmark Clinic.  Please state your question.

Question:  Yes, hi, you have put on here the most common diagnoses that cover a left heart cath, what about the ones that cover a right and left cath?

Answer:  What this study was, the ones on the bottom of page 19, what I looked at to figure it out for your carrier, what you want to do is look at your specific carriers' coverage determination.  It is going to either be called an LCD or an LMRP depending on how updated your web page is.  Look and see that they have got different collection of diagnosis codes for 93510 and then 93526.  93510 is your left heart cath, 93526 is your combined.  What this page summarizes is all the different coverage policies currently in effect and this is probably 3-4 weeks that this study was done.  We looked from diagnosis code to diagnosis code, if it is covered for a left heart cath, it is also covered for a right heart cath?  And this collection of diagnosis codes on the bottom of page 19 shows those ones that are covered for a left heart cath but are not covered for a right heart cath.  The study was quite extensive to do just to get that information.  But to do it for your own carrier, it is probably be the best way to go.  It might take 30-40 minutes to do it for one carrier. 

Comment:  Okay.

Our next question comes from Dennis Stormer of Hilton Head Heart.  Please state your question.

Question:  I just wanted to know, you talked about getting that clarification on G codes, renals and iliacs that are done in conjunction with the heart cath, did you happen to get that in writing from CMS?

Answer:  Yes I did, but it is in writing in an e-mail, and when you receive information from CMS in e-mail form, they typically will put a disclaimer at the bottom that says you cannot pass it along; but they have told me that it is going to be published in the Federal Register and they are going to open it up to the public comment.  The reason they are doing that I think primarily is because of that proposal that I made to them to try to get this thing covered for any patient with documented coronary artery disease.  I think that would be a huge difference in coverage policies, but one that is really, really indicated and would be really beneficial to both the Medicare trust fund and to the patients that cardiologists are serving.  They are going to publish it soon.  They have said that they are going to publish a letter to carriers that should be on the internet some point in the near-future, so maybe within a couple of weeks there will be a public document that is out there.  It is going to be addressed in the next edition of Cardiology Coding Alert and it has also been out there now for just a couple of weeks of clarification.  We are still in the infancy of it getting dispersed but it will be out there.  You can trust me.

Comment:  All right, thanks.
 
Answer:  Thank you.

Comments:  Good bye.

Our last question, due to time constraints comes from Chris Balis of Northern Heart Institute.  Please state your question.

Question:  I am really new to cardiology and international cardiology coding, and I have one doctor that consistently will document that a femoral angiogram is done during a left heart cath procedure when he has also done an LV gram and a coronary angiogram.  In looking at your slide #47, I am assuming that 75710 code means that the left femoral angiogram or the femoral angiogram is excluded from being bundled.  Is that correct?

Answer:  That is partially correct.  It is a wonderful question and what your doctor is doing more times than not - I would bet - is that they are doing a femoral angiogram or even an iliac angiogram that might represent to see exactly where the access site is.  So they are going to be making a puncture in the patient's groin area.  It is going to go into one of the arteries in that area and then they are going to thread the catheter through it.  What they are doing is that after they do the heart cath they will come back just above the point where they made that puncture into the patient's arterial system and do a small injection of contrast to help illustrate exactly where they are and to see if they are able to use what we call a closure device.  There are a couple of different closure devices on the market and these devices are just like collagen plugs that they are placing inside of the arterial wall that will help the patient become ambulatory much quicker than if they were to just obtain hemostasis with like a sandbag which is just stopping the flow of blood so it does not come out of that artery.  When the doctors are doing femoral angiograms to assess the access site and to see if they can use one of these closure devices, that is not separately billable.  Sometimes however, the doctors will do a diagnostic lower extremity study at the same time the heart cath and in those cases sometimes it is going to be appropriate to bill for both catheter placement and the imaging; but if it is on that same side that they made the access it is typically going to be captured by the G0278.  But again it has to be a diagnostic study not something that they are doing just to identify if they can use a closure device. 

Question:  Now usually they are doing it for diagnostics, because this doctor is a peripheral vascular specialist.

Answer:  Then if it is truly diagnostic, then you bill it out depending upon what is supported by the codes, and if it is an injection that they might do from the aortoiliac bifurcation, which is just where the aorta splits to go down both of the patient's legs, then that is going to be clearly a G0278.  If they do it on the ipsilateral side, the same side as the access site that is still going to be a G0278 because it is nonselective.  You are nonselective until you actually either go into the aorto and leave it to go down a different vascular family, or if you go through a bifurcation moving antegrade with the flow of blood.  So on the ipsilateral side it is still going to be considered a nonselective and you would bill a G0278.  If they crossover the horn and go off into the contralateral leg then that would actually be a selective peripheral study.  You are going to be billing for that with the appropriate code whether it is first, second or third order catheter placement, and also your imaging which would be that 75710 code that is listed.  That 75710 is listed as a CCI edit, but it does have an indicator of 1 so you can get around it by putting a 59 modifier on it.

Question: The 75710? Okay.

Answer:  Right.  That is going to be a unilateral lower extremity study.

Comment:  That was what I was curious, what about the 59 modifier that indicates that it is separate.

Answer:   That is a wonderful question, thank you.

Mandy, are you there? 

At this time due to time constraints we will conclude the question and answer session.  Would you like me to go ahead and wrap up the conference Mr. Collins or do you have more closing comments?

Yes Mandy.  The different studies that we talked about, the different teleconferences coming up.  We have got an electrophysiology peripheral vascular study that is a 2-hour conference so pack a lunch for it.  Diagnosis coding CPT update for 2006 and also the E&M coding which is going to be just a wonderful conference where you want to get as many of your doctors and your auditing staff in the room for that as humanly possible.  You are going to get some clarifications that doctors just might actually do cartwheels on their way out of the room.  To find the information, go to the Coding Institute web page.  It is all out there now as far as the dates and the times and how you can sign up.  All these conferences would be great for you.  Other than that Mandy I am ready for you to close it up. 

This is the conclusion of "Biggest Mistakes and Best Strategies for Heart Cath Coding Revealed" national teleconference.  We hope you enjoyed this session.  Please complete you teleconference evaluation form and return it to the Coding Institute at the address listed on the form.  Mr. Collins, the Coding Institute and I would like to thank you for your attendance.  To end this call, simply hang-up your phone.  Goodbye.

To view slides, see pdf of issue.