Cardiology Coding Alert

If coding right heart catheterizations -- particularly procedures that include Swan-Ganz catheters -- sets your heart aflutter, a few minutes brushing up on the basics could be just what you need to improve your cath coding acumen.

Here's how: Take a look at the following right heart cath procedure and see if you're on par with our expert- provided coding recommendations.

A 58-year-old male patient with myocardial infarction and cardiogenic shock received left heart catheterization, left ventriculography and selective coronary angiography through the right femoral artery in the cath lab and stenting in the left anterior descending (LAD) coronary artery. He also had intra-aortic balloon catheter placement. He had right heart catheterization through the right femoral vein with a Swan-Ganz catheter.

The physician recorded the patient's resting hemodynamics with a 7 French Swan-Ganz catheter. He completed left ventriculography and selective coronary angiography with a 6 gauge French catheter through the right femoral artery.

He traversed the total occlusion of the left anterior descending coronary artery with a 0.014 ostial wire. He performed predilatation with a 3.0-mm x 15-mm Maverick balloon. Next, he deployed a 3.0-mm x 33-mm velocity stent in the left anterior descending coronary artery.

The physician inserted an intra-aortic balloon catheter through the right femoral artery and initiated counterpulsation.

He took hemodynamic measurements in the right atrium, which were 0 mm of mercury; the right ventricle, 13/2 mm of mercury; pulmonary capillary wedge pressure, 2 mm of mercury; pulmonary artery, 15/3 mm of mercury; the central aorta, 85/50 mm of mercury; the aortic valve, 169/82/153 mm of mercury; and the left ventricle, 85/80 mm of mercury.

The procedure indicated severe three-vessel coronary artery disease and severe left ventricular dysfunction. The physician successfully completed an angioplasty and stenting of a totally occluded left anterior descending coronary artery and measured hemodynamics consistent with cardiogenic shock.

Step 1: Before you begin assigning any codes, read the note again to determine if the physician performed the procedure for diagnostic purposes, as in this case, or for monitoring, says Cheryl Klarkowski, RHIT, CPC, cardiology coding specialist at Baycare Health Systems in Green Bay, Wis.

Why this is important: "If the service is diagnostic, the physician needs to perform it before he can determine a definitive treatment (such as a stent). If this is merely a monitoring situation, you should count the service as inclusive of the definitive procedure," Klarkowski says.

Step 2: Start by reporting 93526-26 (Combined right heart catheterization and retrograde left heart catheterization; professional component) for the combined right and retrograde left heart catheterization. In this instance, the physician used a Swan-Ganz catheter to perform a diagnostic right heart catheterization to assess the patient's hemodynamic status.

The physician used these measurements to assist in medical decision-making.

Another indication that you should report 93526-26 for the combined left and right heart catheterization, rather than 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes) for the Swan-Ganz procedure, is that the physician inserted the catheter in the cath lab, with another cardiac catheterization procedure, rather than at the patient's bedside.

Step 3: For the dye injection in the left ventricle, report 93543 (Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography). Report 93545 (... for selective coronary angiography [injection of radiopaque material may be by hand]) for injection in the coronary arteries.

Remember that you should not append the professional (26) and technical (TC) modifier to 93539-93545 because CPT 2008's parenthetical note says these injections, usually performed by hand during cardiac catheterizations, do not include a technical component. Additionally, the Medicare Physician Fee Schedule describes these codes as "physician services," which you cannot split into separate components, says Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Step 4: Report 93555-59-26 (Imaging supervision, interpretation and report for injection procedure[s] during cardiac catheterization; ventricular and/or atrial angiography; distinct procedural service) for the supervision and interpretation (S&I) of the injections in the left ventricle.

Use 93556-59-26 (... pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits [whether native or used in bypass]) for the S&I of the coronary arteries.

Because "guiding angiograms" are an integral part of therapeutic procedures, append modifier 59 (Distinct procedural service) to indicate that these services were a part of a diagnostic catheterization that led to an intervention, which in this case was stenting. Without modifier 59, a carrier could deny your claim for unbundling.

Step 5: Notice also that the physician inserted a balloon pump during this procedure (33967-26, Insertion of intra-aortic balloon assist device, percutaneous). Typically, physicians use IABP (intra-aortic balloon pump) as an abbreviation for this procedure, so you should be on the lookout for this to fully capture all billable services. Another phrase to watch for in reports for patients with cardiogenic shock is "diastolic augmentation," which indicates that the physician has administered counterpulsation.

Step 6: For the stent placement in the left anterior descending coronary artery, you should bill 92980 (Transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel) and append modifier LD (Left anterior descending coronary artery) to illustrate which vessel the physician stented.

The stent placement bundles the predilatation (also known as PTCA, percutaneous transluminal coronary angioplasty), so you would not code this separately. You should always report the stent placement first on the claim form as the most extensive procedure to get the full payment the cardiologist deserves, Klarkowski says.

Final order: On the claim, you should report in descending value order the following codes:

• 92980-LD

• 93526-26-51

• 33967-26-51

• 93543-51

• 93545-51

• 93555-59-26

• 93556-59-26.