Cardiology Coding Alert

Case Description/Op Report

A 79-year-old man undergoes percutaneous transluminal coronary angioplasty (PTCA) and stenting.

Using the Seldinger technique, the cardiologist inserts a guiding catheter into the right femoral artery. The op report reads:

A guiding catheter was positioned into the left main artery where initial injections were done in different projections. Over this, a long attempt was made to cross the subtotal to total occlusion of the obtuse marginal branch of the circumflex artery without success. At this point, it was decided to proceed with angioplasty and stenting of the circumflex artery. All-star wire was inserted and crossed the lesion without difficulty. Over this 3.0 balloon insertion, inflations were carried out in mid and proximal segment. After this, 3.5 x 8mm length, two multi-length stents were deployed in the mid and proximal circumflex artery. Intracoronary nitroglycerine was given, final pictures recorded, guiding catheter and wire was removed and femoral sheath was sutured. Patient was transferred in satisfactory condition.

Results

Prior to angioplasty, the patient had moderate 75 to 89 percent stenosis of the circumflex artery. After angioplasty and stenting, there was no residual narrowing of the circumflex artery. There was an unsuccessful attempt to cross the wire across the subtotal occlusion of the obtuse marginal (OM) branch. The obtuse marginal branch has slow flow identifier at the end of the procedure because of the deployment of the stenting in the circumflex artery for which the OM branch was coming.

Coding Dilemma

Actually, there are two coding dilemmas here which are beyond the coders control: poor physician documentation and variations in the patients anatomy that prevent completion of the procedure. But you can minimize the chance of a denial or upcoding by a thorough reading of the op report, says Nancy Reading, RN, BS, CPC, president of Reading Reimbursement Consultants, a multispecialty coding and reimbursement consulting firm in Salt Lake City, UT.

Never code from the name of the operation, she stresses, explaining her staunch take on this philosophy: Often physicians will list every little procedure performed because it is medically correct and prudent to do so. However, it is not always technically correct to code each and every procedure as they are listed due to bundling and other reimbursement issues.

She adds that medical language is not reimbursement language. In order to be accurate translators, coders must be able to extract charges from the op report, she says.
And that means reading the note to see what is actually documented as well as having a sound knowledge of cardiovascular anatomy and procedures themselves.

Lets look at each procedure listed as name of operation and compare it to the documentation.

1. Left heart cath and hemodynamic pressure study. If you were coding directly from the name of the operation, you would select 93510 (left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous). However, the note itself does not support the billing of a left heart cath. It only says the cath was placed and injections performed, but nowhere does it indicate that the heart was entered and studied. By CPT definition, a left heart cath includes passing the catheter through the aortic valve into the left ventricle and then performing blood samples, pressure and electrical recordings.

The correct placement code is 93508 (catheter placement in coronary artery[s], arterial coronary conduit[s], and/or venous coronary bypass graft[s] for coronary angiography without concomitant left heart catheterization) Therefore, at a Relative Value Unit (RVU) of 48.11, it would be considered upcoding to bill 93510 instead of 93508, which has an RVU of only 20.15.

Code 93508, which was introduced only two years ago, is not clearly understood by many cardiology codersand thus may be underused, says Sueanne Bicknell, RRA, CCS-P, reimbursement and compliance specialist, Cardiovascular Provider Resources-Heart Place in Dallas, TX.

Code 93508 differs from 93510 in that blood samples, pressure and electrical recordings are not done as with a left heart cath, she explains.

For example, in 93508 the cardiologist typically uses percutaneous puncture to place an introducer sheath in the femoral artery (i.e. Seldinger technique). An angiography catheter is advanced through the sheath to the opening of the artery, conduit or venous coronary bypass (i.e., guiding catheter was positioned into the left main artery). Finally, contrast material is injected through the artery while the cineangiogram is recorded. (i.e., initial injections were done in different projections.)

Thus, the procedure described in the op report is not a 93510 but a 93508.

Note: When you use 93508, be sure to also code supervision and interpretation (93555-93556) as well as injection codes (93539-93545), just as with the left heart cath series.

2. Selective coronary angiogram study. In this instance the name of the operation does represent the procedure that was performed: 93545 (injection procedure during cardiac catheterization for selective coronary angiography).

3. PTCA of proximal co-dominant circumflex artery. If you had coded directly from the operation name, you would be unbundling. When a PTCA (92982) is performed at the same session in the same vessel as a stent, the work RVU (10.98) is built into the stents RVU (14.84) code. Therefore, you should bill only for the stent (92980).

4. PTCA of mid-circumflex artery. The same coding conventions apply as in #3.

5. Deployment of 3.5 multi-length stent in proximal circumflex artery. If you coded from the operations name and billed 92980 (transcatheter placement of an intracoronary stent[s] percutaneous, with or without other therapeutic intervention, any method; single vessel) you would be correctin this particular case. But in the next case, if you relied only on the operations name, you might be wrong.

6. Deployment of multi-length stent in mid circumflex artery. But if you code 92981 (each additional vessel) for this second stent because of the different description (proximal circumflex vs. mid-circumflex artery) you would be upcoding. Even though two stents were placed, you cant charge for the second one because, for coding purposes, the circumflex artery is one major vessel. Only one intervention can be coded for each major artery per session, no matter how many blockages are treated in that artery or its branches, says the American College of Cardiology Guide to CPT 1999.

7. Unsuccessful angioplasty of the obtuse marginal branch of circumflex artery. This notation that angioplasty was unsuccessful has no bearing on coding. Modifier -53 (discontinued procedure) would not be appended to 92982 because the PTCA is considered included in stenting. Even if the angioplasty followed by a stent in the obtuse marginal branch had been successful, 92981 in the obtuse marginal (OM) branch could not be billed because the OM is still considered part of the circumflex artery.

8. Interpretation of results. Either billing from the op note or the operation name would produce similar results: 93556 (imaging supervision, interpretation and report for injection procedures.) Append modifier -26 (professional component) if the cardiology practice is using hospital equipment.

9. Intracoronary nitroglycerin injection. This service is included in the 93508 and 92980; therefore, it should not be billed.

Coding Solution

Despite the nine procedures listed in the op report as the name of the operation, only four can actually be coded:

1. 92980-LC (left circumflex)
2. 93508 (this code is modifier -51 exempt)
3. 93556-26
4. 93545

Terminology

Concomitant: Accompanying.
Seldinger technique: A method by which a catheter reaches the target site. After a needle is inserted through the blood vessel, a guide wire is passed thorough the needle and advanced to the target site. Next, the needle is removed and the catheter is passed to the desired area. Then the guide wire is removed.
Left main coronary artery: One of the hearts two coronary arteries. Comes off the aorta, then divides into other increasingly smaller arteries, or branches.
Circumflex artery: One of the branches of the left main artery. Branches off into multiple smaller branches that supply blood to the left margin of the ventricle. Since this margin is obtuse angled, these branches are also called:
Obtuse Marginal (OM) branches: A patient may have one to seven OM branches; but for coding purposes all are considered part of the circumflex artery.