Cardiology Coding Alert

Poor documentation by cardiologists places limits on how well insurance carriers will reimburse for a procedure. With specific dictation and precise operative notes, however, cardiologists can expect higher payment rates.

In the following case study, the cardiologist performed a non-coronary procedure but combined an unusual format with an unclear procedure report. Because the operative note makes it difficult to know exactly what occurred during the surgery, some key reimbursement opportunities have been missed.

Operative Report

1. Occluded left common femoral artery successfully
treated by Angio-Jet thrombectomy and balloon
angioplasty.
2. Occlusion of the left superficial femoral artery.

Procedure: Left lower extremity angioplasty. Angio-Jet thrombectomy. Percutaneous transluminal angioplasty.

Method: Written informed consent was obtained. Modified Seldinger technique was used to place a 6 Fr sheath into the right femoral artery. A 5 Fig-TR catheter was used along with an 035 angled Glidewire to gain contralateral access. Angiography was performed of the left iliac artery. The patient received 5,000 units untravenous Heparin. The sheath was exchanged for a 6 Balkin sheath. A 14 BMW wire was then introduced but could not be advanced across the occlusion. It was exchanged for a V-18 control wire, which was successfully used in conjunction with this wire. Angiography was performed in the distal vessel, and Angio-Jet, E-train catheter was then used for thrombectomy.

The Angio-Jet was removed and a 4/2 Opta LP was used to perform balloon angioplasty after exchanging the wire for a Magic Torque. Additional inflations were performed using a 5x2 Opta LP at five atmospheres. Attempts were then made to traverse an occlusion in the left superficial femoral artery using both a multipurpose catheter and a variety of wires; none of these could be advanced into the occlusion in the superficial femoral artery. The sheath was withdrawn, adequate hemostasis was achieved and there were no complications.

Angiography: Initial angiograms demonstrated a normal appearing distal left external iliac artery. The common femoral artery was occluded. After treatment with the Angio-Jet and angioplasty, there was a 20 percent residual in the common femoral artery. The profunds was normal. The superficial femoral was occluded in its proximal position. There was distal reconstitution of the vessel through collateral flow. The popliteal had plaque disease. The anterior tibial appeared normal in its proximal portion, as did the posterior tibial and peroneal. The tibioperoneal trunk was normal.

Comment: Patient is a 49-year-old female who recently underwent coronary intervention using a left groin approach. An Angio-Seal closure was used. Shortly after the procedure, she experienced leg pain. She will return in approximately one month to have an attempt to open the superficial femoral artery from a popliteal approach.

Unclear Documentation Limits Pay Up

Although the operative note does not refer specifically to a pre- or postoperative diagnosis, the ICD-9 code 444.22 (arterial embolism and thrombosis, lower extremity) should be used. According to the report, the cardiologist performed three procedures: 36245 (selective catheter placement, arterial system, each first order abdominal, pelvic or lower extremity artery branch, within a vascular family); 35474 (transluminal balloon angioplasty, femoral-popliteal); and 75962 (transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation), says Kathleen Mueller, RN, CPC, CCS-P, a coding and reimbursement specialist in Lenzborg, IL.

Note: Typically, balloon angioplasty includes thrombectomy.

Because the documentation is unclear, determining if the physician actually performed a second-order catheter placement is difficult. If, indeed, such a placement was performed, code 36246 (initial second order abdominal, pelvic or lower extremity artery branch, within a vascular family) would have been used in addition to 36245 (selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family). This would have increased the cardiologists reimbursement by approximately $300. (According to Medicares 1999 National Physician Fee Schedule Relative Value Guide, 36245 has 8.30 relative value units [RVUs], whereas 36246 has 9.16). Because the second-order placement is not referred to clearly, it should not be billed. Coders always should remember this basic coding guideline: Not written, not done.

Report May Increase Reimbursement

The cardiologist who conducted the above procedure also failed to dictate a separate report on the angiogram. Some cardiologists refuse to bill for supervision and interpretation of angiograms to avoid stepping on radiologists toes. But they are missing out on payment to which they are entitled and should receive when a separate report on the interpretation of the angiogram is dictated that clearly indicates the date and time of the angiogram and that the radiologist was not present.

When angiography is performed, film is produced that is sent to the radiology department, where it is read, Mueller says. But Medicare guidelines state that the physician whose interpretation guides the further care and treatment of the patient is the one who should be paid. (The review of the film by radiology is for quality assay [i.e., quality control purposes] only, according to the Health Care Financing Administration [HCFA]).

Often, the radiologist reviews the film the day after the procedure, but the cardiologist cannot wait for the radiologist to read the report to provide proper care to the patient. In these circumstances, the cardiologist should get paid for the interpretation of the angiogram because he or she is directing the patients care.

To avoid conflicting reimbursement requests, the cardiologist and radiologist should work out an arrangement before they begin billing for supervision and interpretation to prevent two separate bills from being sent to the insurance carrier for the same procedure.

Even with an arrangement, however, the radiologists office inadvertently may bill for the interpretation, and the cardiologist will need to supply the carrier documentation to prove that he or she performed the interpretation that is guiding the patients care. Once Medicare determines who should be reimbursed for the supervision and interpretation, the other physician will need to return the payment. To ensure receiving and keeping the payment, a separate interpretation report should be written and filed in the patients record that includes the date and time the supervision and interpretation was performed, to indicate that the cardiologists interpretation guided the session, Mueller says.

Note: There is no separate payment, or any CPT or HCPCS codes, for Angio-Seals.