Case Study:
Billing for Multiple Stents in the Same Vessel
Published on Wed Sep 01, 1999
Coding for cardiology procedures that include multiple stents in the same vessel can be complicated. Bundling issues abound, not only because the procedures typically make up only part of a longer surgical session that may include diagnostic as well as other interventional services, but also because for billing purposes, CPT codes 1999 considers the placement of stents in a single vessel as a single procedure, regardless of the number actually placed.
Complicating the issue further is that both Medicare and the American College of Cardiology (ACC) group all cardiac blood vessels into one of the three (in the case of the ACC, four) large cardiac blood vessels. So even if the stents were placed in different vessels anatomically, if they are in the same group they would be considered the same vessel, which makes reimbursement for the extra vessel(s) difficult.
Case Description
Take, for example, the case of a 40-year-old patient with known coronary disease who already has had a stent placed in the circumflex coronary artery (CLX). More recently, the patient suffered a non-Q wave infarction and was admitted to the hospital. Diagnostic studies were suggested, and the patient requested same-setting revascularization.
The patients preoperative diagnosis was unstable angina pectoris with non-Q wave myocardial infarction, posterolateral, while the post-op diagnosis was coronary heart disease.
A number of procedures were performed on the patient. The case was submitted to the insurer with the following CPT codes:
Diagnostic procedures:
93510: left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery;
percutaneous.
93543: injection procedure during cardiac catheteri-
zation; for selective left ventricular or left atrial
angiography.
93545: injection procedure during cardiac catheteri-
zation; for selective coronary angiography [injection of radiopaque material may be by hand].
93555-59: imaging supervision, interpretation and report for injection procedure[s] during cardiac catheteri-
zation; ventricular and/or atrial angiography; distinct procedural service.
93556-59: imaging supervision, interpretation and report for injection procedure(s) during cardiac
catheterization; pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits [whether native or used in
bypass]; distinct procedural service.
Interventional procedures:
CPT 92980 transcatheter placement of an intracoronary
stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel.
Note: CPT code 92982 (percutaneous transluminal coronary balloon angioplasty [PTCA]) is bundled into 92980.
There were complications during the procedure that necessitated the placement of additional stents. According to the operative report, stenting across an obtuse marginal resulted in transient total occlusion of this vessel with ST segment elevation and complaints of chest pain.
ReoPro intracoronary nitroglycerin and intravenous nitroglycerin were able to abate the patients symptoms complex.
According to Medicare bundling guidelines, intracoronary nitroglycerin cannot be billed because it is considered part of the heart catheter [...]
