Cardiology Coding Alert

Cross the aortic valve? Then set your sails for 93510

Don't rock the boat when you're deciding between diagnostic cath codes CPT 93508 and CPT 93510. Although 93510 has only a slightly higher relative value unit (RVU) than 93508, your practice could still be caught up in fraud allegations for upcoding.
 
Key idea: When you'll report 93508 or 93510 depends on the cardiologist's documentation--specifically whether he crossed the aortic valve with the catheter's tip. 

Determine the Difference

 You'll find the difference between these two diagnostic cath codes in their definitions. Code 93510 (Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous) is a full diagnostic left heart cath that includes catheter placement into the left ventricle and usually into the coronary arteries.

On the other hand, 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) is the same procedure--with the exception that the catheter did not enter the left ventricle, which would require the catheter to cross the aortic valve.
 
Strategy: You should look for proof that the cardiologist crossed the aortic valve in his documentation, says Jim Collins, CPC, ACS-CA, CHCC, CEO of The Cardiology Coalition. For example, the following indicators show that the cardiologist provided a full left heart cath (93510):

• the description of his advancing the pig tail catheter across the aortic valve

• the measurements of intracardiac pressures (which require the catheter to be inside of the heart)

• the performance/findings of a left ventriculogram (which also requires the catheter to be placed inside the heart).

Any of these factors will establish the diagnostic study as a full left heart cath (93510) rather than catheter placement in the coronary arteries (93508).

Learn by Example

How you'll report 93508 and 93510 relies heavily on your cardiologist's op report. Word of caution: Because of the nature of unexpected interventions, you may find hints to the wrong code right at the beginning, so make sure you read the entire report before making your diagnostic cath selection.

Case study: Your cardiologist performs a heart cath and intervention procedure. Using the Seldinger technique, he inserts a guiding catheter into the right femoral artery. His op report reads: "Positioned a guiding catheter into the left main artery where I performed initial injections in different projections, revealing a 90% occlusion of the circumflex artery and sub-total occlusion of the obtuse marginal branch. I attempted for several minutes to cross the obtuse marginal occlusion without success. At this point, I decided to proceed with angioplasty and stenting of the circumflex artery."

Warning: You might be tempted to report 93510. But the op report does not support this code because your cardiologist did not state he advanced the catheter across the aortic valve. 

Answer: The correct code is 93508. A cardiologist typically uses percutaneous puncture to place an introducer sheath in the femoral artery (such as, Seldinger technique). He advances an angiography catheter through the sheath to the opening of the artery, conduit or venous coronary bypass (such as, "positioned guiding catheter into the left main artery"). Finally, the cardiologist injects contrast material or dye through the artery while recording a cineangiogram (such as, "I performed initial injections in different projections"). For these reasons, you should report 93508.

Another reason is that 93510 includes passing the catheter through the aortic valve into the left ventricle and then performing blood samples as well as pressure and electrical recordings. Code 93508 does not include blood samples and pressure and electrical recordings.

Don't forget: You should also report the following codes:

• 93545--Injection procedure during cardiac catheterization; for selective coronary angiography (injection of radiopaque material may be by hand)

• 93556-26--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); professional component

• 92980--Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel.

Explanation: You should always include an injection code (93545) with the left cath series. And 93556-26 represents the supervision and interpretation in a facility setting. Code 92980 represents the stenting of the circumflex artery. Note: Remember to add modifier 26 to 93508 as well.

Caution: You won't report the injection code you typically use for left ventriculography (93545, ... for selective coronary angiography [injection of radiopaque material may be by hand]) or the corresponding supervision and interpretation code (93555, ...ventricular and/or atrial angiography) because a cardiologist can perform these services only from inside the heart. In other words, you should never report these codes with 93508.

Hunker Down for Repeat Diagnostic Caths

You won't typically report a repeat diagnostic study at the time of a planned intervention, regardless of who did the initial diagnostic. This also includes pre- and post-procedure imaging, Collins says.

Collins says, however, that you should never say never. Some local coverage policies outline exceptions, such as:

• The patient presents with new symptoms necessitating documentation workup.

• A long time exists between the two procedures (for example, 30-60 days).

You may also report a repeat diagnostic cath if your cardiologist transfers the patient for the intervention and the films did not arrive, or the films are of such poor quality the cardiologist could not determine the area needing the intervention, says Sandy Fuller, CPC, a compliance officer at Cardiovascular Associates of East Texas in Athens. "Remember, the reason must be dictated in the procedure report."

Ask your carrier for what it might deem an exception for reporting repeat diagnostic catheterizations.