Cardiology Coding Alert
VPs Recent Coronary History Makes Good Cardiology Coding Primer
In the latest episode (June 29-30), an electrophysiology (EP) study was performed that indicated the need for an internal cardioverter-defibrillator (ICD). The implantation was performed the same day.
The main events in Cheney's coronary history over the past year cover a wide range of procedures, including EP services, cardiac catheterizations, coronary interventions and other services.
The following timeline includes the main procedures performed on Cheney up to November 2000, along with associated signs and symptoms and/or diagnoses. Without operative reports from these sessions, which have not been released, it is impossible to know with certainty the correct CPT or ICD-9 codes. But based on information released by George Washington Hospital and the White House, most of the procedures appear readily identifiable:
1978: Cheney has first heart attack, age 37
1984: Cheney has second heart attack
1988: Cheney has third heart attack, followed by quadruple bypass surgery
1996: Cardiac catheterization reveals no change.
Nov. 22, 2000
Cheney checks into hospital, complaining of chest pain. An ECG is performed, after which he was taken to the cath lab for a left heart cath. Coronary angiography indicates that the diagonal branch off Cheney's left anterior descending artery had a 90 percent blockage. This leads to a percutaneous transluminal coronary angioplasty (PTCA), followed by stent placement to support the artery and prevent a recurrence of the blockage.
Subsequently, Cheney's physicians reveal that a small portion of myocardium, or heart muscle, had died due to lack of oxygen arising from the blocked coronary artery.
March 5, 2001
The vice president goes to the George Washington University Medical Center after two brief episodes of chest pain. He is taken to the cath lab, and a cardiac catheterization is performed. After coronary angiography reveals that the diagonal branch of the left anterior descending artery, which was stented in November, has a small area of significant (90 percent) restenosis, Cheney's cardiologist, Dr. Jonathan Reiner, MD, performs a PTCA to dilate the area.
In a news conference after the revascularization, Reiner noted that about 20 percent of patients who receive stents experience renarrowing or restenosis. "It's a different process than atherosclerosis, which occurs over a period of many decades. This is a specific response to injury from the stent," he said, adding that the risk of the stenosis returning was about 40 percent. Cheney's chest pain, or angina, was due to the restenosis.
Based on this information, the operative session would likely be coded as follows, says Terry Fletcher, BS, CPC, CCS-P, an independent cardiology coding and reimbursement specialist in Laguna Beach, Calif.:
Because PTCAs include supervision and interpretation (S&I), modifier -59 should be appended to 93555 and 93556 to let the carrier know that these services were performed with the left heart cath, not the PTCA, and therefore shouldn't be bundled. Modifier -26 should be attached to 93510, 93555 and 93556, but not to 93543 or 93545, to indicate that the procedure was performed in the hospital and the cardiologist provided professional services only.
Finally, as in the November stent procedure, appending the -LD modifier to the PTCA shows that it was performed in the left anterior descending artery (or, in this case, one of its branches), Fletcher says.
June 16, 2001
As a "proactive" measure, Cheney wears a Holter monitor for 34 hours, even though he reports no symptoms. The recording, however, reveals that the vice president had four separate 1- to 2-second episodes of abnormally fast heartbeats.
The correct code for the Holter monitor should be chosen from 93224-93237, depending on whether the cardiology practice (a) performs the entire service, which includes recording, microprocessor-based analysis and report, and physician review and interpretation or (b) provides review and interpretation only. Another factor is the type of Holter monitor used.
Without an operative report, it is difficult to determine the diagnosis, but the episodes of abnormally rapid heartbeat might be attributable to ventricular tachycardia (427.1). If the source of the tachycardia is unknown, ICD-9 code 785.0 (tachycardia, unspecified) might be appropriate. Because the vice president had no symptoms when the test was ordered, however, only his personal cardiac history (V12.50) may be used if the carrier only accepts pretest diagnoses. Some carriers may not consider the V code to be a payable diagnosis. Another possible ICD-9 is 412 (healed myocardial infarction, or past mycardial infarction diagnosed on ECG or other special investigation, but currently presenting no symptoms).
June 30, 2001
Electrophysiologist Sung Lee, MD, wished to determine the likelihood of a persistent, abnormal heart rhythm developing. An EP study was performed because of the four recorded incidences of abnormally fast heartbeat while Cheney was wearing the Holter monitor. The results of the EP study persuaded Cheney's physicians that the vice president required an ICD. This was done immediately after the EP study, with Cheney under conscious sedation. Sung implanted the GEM III DR, a dual-chamber ICD.
Although little technical information about the EP procedures performed was released, the following were likely, says Linda Laghab, CPC, chief coder with Foothill Cardiology/California Heart, a 46-physician practice in Los Angeles:
Note: CPT includes two conscious sedation codes: 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation), and 99142 (... oral, rectal and/or intranasal). The conscious sedation administered to Cheney is likely described by 99141. Medicare and many private carriers consider conscious sedation a component of the primary procedure and do not cover it. Some commercial payers pay separately for the service.
Code 93620 describes the most-often-performed EP study, Laghab says, adding that because Cheney had no symptoms "before, during or after" wearing the Holter monitor, it is unlikely a more elaborate study (i.e., the same study plus left atrial or left ventricular recordings, 93621 or 93622) was performed.
The implantation of the ICD should be coded 33249, Laghab says, noting that after an ICD is implanted, the electrophysiologist usually evaluates the ICD to ensure its leads and generator are working. This evaluation would likely be coded 93641. Because the national Correct Coding Initiative edits list 93620 and 93641 as mutually exclusive, modifier -59 should be attached to 93620 to indicate that both services are payable separately because the EP study led to the decision to implant the ICD.
Note: For more information on coding 93620 and 93641 together, see You Be the Coder on page 60.
Because both 93620 and 93641 are diagnostic services, modifier -26 should be attached to indicate that the electrophysiologist does not own the equipment and performed supervision and interpretation only.
The diagnosis for the EP study should be ventricular tachycardia -- if it is determined to be what caused Cheney's abnormally quick heartbeat while he wore the Holter monitor (the findings of the EP study were not released). Because this study was the main factor in determining that an ICD should be implanted, presumably it indicated a condition (such as ventricular tachycardia) that should be linked to the implantation of the ICD.
Cheney's cardiologist stressed that the EP study and ICD implantation were "preventive" and were unrelated to earlier coronary artery stenosis and restenosis. Further re-stenosis was thought likely (at least a 40 percent possibility).
At some point, Reiner indicated, brachytherapy -- using a radioactive-tipped catheter to effect a more permanent opening of the artery -- might be considered. This procedure, only recently approved, does not have its own code. When it is performed, use an unlisted-procedure code. Documentation should accompany the claim.
Note: Neither George Washington Hospital nor the White House released sufficient information to code the E/M visits, such as admissions, or some diagnostic tests (i.e., ECGs, stress tests). But tests were performed and E/M services were provided, both in conjunction with procedures referred to above and on their own.
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