Cardiology Coding Alert

When billing vascular procedures, coders need to be able to visualize the route the cardiologist took in the cardiovascular system, so clarity should be a top priority when describing these procedures in operative reports.

You need a clear picture when you code for vascular, says Rebecca Sanzone, CPC, assistant billing manager with Mid-Atlantic Cardiology, a 45-member cardiology practice in Baltimore. You need to be able to close your eyes and see where the cardiologist started, where they ended, and any bumps in the road. If you cant visualize what they did, you cant code it.

In the following op note, the cardiologist carefully and clearly describes a series of vascular procedures, including diagnostic angiography (pictures of the blood vessels) as well as interventional procedures to correct the circulatory function.

Operative Report

Procedures: Bilateral renal angiography, left subclavian angiography, angioplasty of the left subclavian artery, angioplasty of the left vertebral artery.

Conclusions: There is no evidence of renal artery stenosis bilaterally. There is 90 percent left subclavian artery stenosis and a 90 percent vertebral artery stenosis. The 90 percent stenoses of the left subclavian and vertebral arteries were successfully dilated, leaving behind good flow and a 40 percent gradual stenosis in the subclavian with brisk distal flow.

Protocol: After informed consent, the patient was brought to the cath lab in the fasting state. She has a history of recent uncontrolled hypertension in spite of medication. She also has a history of angioplasty in the left subclavian artery. She has been having symptoms of pain in the left arm as well as occasional dizzy spells. Non-invasive studies revealed subclavian steal consistent with subclavian stenosis.

Right femoral artery was cannulated with SF sheath. A right Judkins catheter was used to cannulate the renal arteries. Selective angiography was performed of the left and right renal arteries. There was no gradient at the ostium of the renal arteries.

The right Judkins catheter was then advanced to the aortic arch and the left subclavian artery cannulated. Digital angiography was performed in multiple projections to obtain an overview of the left subclavian artery stenosis.

After reviewing the angiograms, preparations were made for angioplasty. The 5F sheath was removed and replaced with a 6F sheath. We advanced a Terumo wire across the lesion without too much difficulty and placed it in the distal axillary artery. We then took an 8F ... sheath in place of the earlier sheath and positioned the tip of the sheath into the left subclavian artery.

An 8-mm-by-4-cm Meditech balloon was prepped and advanced over the Terumo wire. There was no significant difficulty crossing the lesion. The lesion in the left subclavian was dilated to two atmospheres. It seemed that the balloon was oversized, and we replaced it with a 6 mm balloon and dilated this to six atmospheres. There appeared to be spasm in the left vertebral artery, and we used a Choice CT wire to access this left vertebral artery. This design was then dilated with a 3.5 mm x 20 mm Ninja balloon. There was good dilatation and some recoil, but it was not significant. Multiple doses of intra-arterial nitroglycerin were administered to relieve vasospasm.

The left subclavian artery was once again dilated to six atmospheres with a 6-mm balloon as was the vertebral artery. Heparin was administered to keep the ACT above 200 seconds. The patient previously had been treated with aspirin and Plavix.

After angiograms were obtained, the sheaths were removed, and the right femoral artery repaired with a Perclose device.

Findings: The arterial systolic pressures are markedly elevated. The right renal artery is patent. There is mild atherosclerosis, but this is not critical. There is no gradient at the ostium of the right renal artery.

The left renal artery is patent. There is mild atherosclerosis noted in the intrarenal arteries. There is no gradient at the ostium of the left renal artery. There is no evidence of renal artery sclerosis.

The left subclavian artery has an eccentric stenosis just where the vertebral artery originates. The lumen is narrowed by 90 percent. It appears to involve the lumen of the vertebral artery.

After balloon dilatation, the subclavian artery is patent, but the vertebral artery has some snowplow effect narrowing the lumen and flow. This was relieved with the balloon dilatation on the vertebral artery along with intra-arterial nitroglycerin. Subsequent balloon dilatations in the subclavian were able to enhance the lumen without significantly impacting the vertebral artery.

The final angiogram showed a 40 percent residual stenosis with good flow in the vertebral and subclavian arteries. We did not stent this vessel because of concerns of spasm in the vertebral artery.

Coding the Procedures

The procedures are coded as follows:

35475 (transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel) times 2 units

75962 (transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation)

75964 (transluminal balloon angioplasty, each additional peripheral artery, radiological supervision and interpretation [list separately in addition to code for primary procedure])

36245-50 (selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family; bilateral procedure)

36215 (selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family)

75710 (angiography, extremity, unilateral, radiological supervision and interpretation)

75724 (angiography, renal, bilateral, selective [including flush aortogram], radiological supervision and interpretation)

To correctly code the surgical procedures, the first thing to determine is which vessels were accessed directly for diagnostic angiography, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

According to the op note, catheters were placed in both the left and right renal arteries (36245-50) and also in the left subclavian artery (36215), Callaway-Stradley says, noting that if the right subclavian artery also had been accessed, the code would be 36216 (selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family). Although the aorta was accessed as well, it would not be coded separately, she says.

Because there was no documentation to support that the cardiologist entered the vertebral artery for diagnostic pictures before performing the intervention of that vessel, the only procedure coded for the vertebral artery is the intervention itself. Had the vessel been accessed to take diagnostic pictures, 36216 could have been coded and would have included the pictures taken of the subclavian artery.

In addition to the angiography performed, the op note clearly states that angioplasty was performed on the left subclavian artery and the left vertebral artery, which should be coded 35475 with a 2 in the units box of the HCFA 1500 claim form to indicate the procedure was performed twice.

Supervision and Interpretation Codes

Because the cardiologist bills supervision and interpretation (S&I) codes, the coder also needs to consider all the procedures involving imaging. The S&I of the angiography of the renal arteries is coded 75724. Because the code includes the word bilateral in its descriptor, modifier -50 (bilateral procedure) should not be used.

The subclavian artery imaging requires 75710. The S&I of the angioplasty of the subclavian artery is coded 75962, and the additional vessel (the vertebral artery) is coded 75964.

Note: The injection of nitroglycerin is considered bundled into these procedures and would not be billed separately.

Whether or not to add modifier -51 (multiple procedures) to the subsequent surgical procedure should be determined by contacting your carrier because its use is payer specific, Callaway-Stradley says, noting that although Medicare does not require it, many commercial carriers may. She adds that modifier -26 (professional component) should be appended to all of the radiological S&I codes performed in a facility setting.

With all the surgical and imaging procedures involved, clarity on the part of the cardiologist writing the report is crucial. This particular operative report is straightforward, allowing the coder to clearly see where the cardiologist began and finished, as well as the bumps in the road (the renals), Sanzone says.

Still, she cautions that some carriers may see the two PTAs (subclavian and vertebral) and deny the vertebral angioplasty as an incidental duplicate, so she recommends including a text message that says: subclavian PTA and vertebral PTA. Depending on the carrier, she also suggests adding modifier -51 to the subsequent procedure if the carrier lets you. The operative report also should be sent to the carrier, Sanzone says.