Cardiology Coding Alert

You're up to speed on reporting percutaneous transluminal coronary angioplasties (PTCA) but a little shaky on the coding when the cardiologist performs an angioplasty in a peripheral (noncoronary) vessel.
 
Sound familiar? If so, learning a few basic guidelines offered by cardiology coding experts will make percutaneous transluminal angioplasties (PTA) in noncoronary vessels seem much less daunting and result in better pay for your provider's services.

Learn the PTA Components: Cath Placement + Vessel + S&I

Typically, peripheral PTA coding has three basic parts a code for the selective catheter placement, the angioplasty (PTA) code assigned according to the location of the vessel, and the radiological supervision and interpretation (S&I) code for the PTA. Accurate PTA coding depends on including all three, coding experts say.
 
Unlike cardiac catheterization and coronary intervention codes, which are bundled to include catheter placement and S&I services, you should report peripheral procedures, including PTAs, using component (separate) codes, according to the Society of Interventional Radiology's (SIR) CPT user's guide and the American College of Cardiology's (ACC) Guide to CPT Codes 2003. This means you code the angioplasty, the radiological S&I, and the catheterization separately.
 
For peripheral interventions, such as PTAs, you can bill the S&I and catheter placement codes with the angioplasty code for each angioplasty the physician performs, says Terry A. Fletcher, BS, CPC, CCS-P, CCS, CMSCS, a healthcare coding consultant based in Laguna Beach, Calif., and American Academy of Professional Coders (AAPC) National Advisory Board member. Indeed, the CPT description for PTA states that you should report the S&I and the catheter placement in addition to the therapeutic aspect of the procedure or PTA, she says.

Catheter Coding: Report Highest Level of Selectivity

 PTAs in peripheral vessels require selective catheter placements, so you'll need to understand the fundamentals of selective catheter coding.
 
Selective catheterization indicates that the physician moves the catheter into another part of the arterial or venous system, beyond the initial puncture/access site (such as from a left common femoral access catheter movement to the right renal artery or common iliac), according to the SIR's manual and ACC's coding guide. You choose the correct selective catheterization code depending on "how many bifurcations" the physician must  guide the catheter through, in one direction or another, "before it reaches its most distal or final destination," the ACC's guide says.
 
You should use a code in the 36215-36218 range for catheter placement in the carotids, head/neck or brachiocephalic vascular family and 36245-36248 for catheterization of the abdominal, pelvic or lower-extremity vessels. Remember: Report codes according to the highest-level vessel selectively catheterized in each vascular family. Do not code to "pass through" a vessel to get to another vessel. (See "Apply What You've Learned: 3 PTA Coding Scenarios" for examples.)
 
Angiography: Determine Diagnostic or Follow-Up

To bill the angiography correctly, you must be able to determine from the procedure notes that the radiological S&I was diagnostic.
 
When a diagnostic angiogram precedes the therapeutic intervention, you should code the diagnostic components separately, says Anne C. Karl, RHIA, CCS-P, CPC, coding and compliance specialist with the St. Paul Heart Clinic in Mendota Heights, Minn.
 
Typically, the physician performs a diagnostic angiogram on a patient before the PTA to evaluate the problem area (lesion) in the vessel and to determine the need for any further treatment, Fletcher says. These patients usually have peripheral vascular indications, such as leg cramping, edema and thrombosis of lower extremities, she says. Once the physician has identified the lesion, he or she will place a catheter selectively into a vessel, or just beyond the area to be treated, and then "balloon" (PTA) the lesion, she adds. Report the S&I for peripheral PTAs using a code from the 75962-75964 range.

 Keep in mind that for you to bill for the S&I portion prior to a PTA, the radiological supervision and interpretation must be for diagnostic purposes, Fletcher says.
 
According to SIR, the ACC and CMS, you should not code for "quick looks," Fletcher says. "Angiography that is diagnostic is medically necessary, whereas a follow-up angiogram is for the physician to check the success of the procedure and would not be separately billable," she says.
 
So, for instance, you would not use a code such as 75898-26 (Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion; Professional component) to bill for additional angiographies after a peripheral PTA, says Belinda Inabinet, CPC, technical support manager and head of a coding team at South Carolina Heart Center, a 21-physician practice in Columbia, S.C. 

Vessel Coding: Know the Lesion Location

When the physician "balloons" (performs a PTA) on a peripheral vessel, report the procedure using a code from the 35470-35476 range, depending on the location of the peripheral vessel, Fletcher says.
 
Code selection is based on the location of the lesion, Karl says, so having a clear understanding of vessel branches is vital.
 
If the physician treats more than one lesion in the same vessel, you should report the appropriate PTA code only once per vessel, Karl says. In other words, you code only one dilation per vessel, even if the physician performed multiple dilations in that vessel. Although you cannot code multiple dilations in the same vessel, you can code multiple PTAs in the same vascular family, Fletcher says.
 
For example, if the physician performs a PTA in the right iliac artery and the right superficial femoral artery (SFA), you can code for both of the procedures, Fletcher says. Because these codes are in the surgical section of the CPT book, you should follow the rules specified there for reporting these services. Specifically, you should list the highest-valued procedure first the SFA angioplasty using 35474 (Transluminal balloon angioplasty,  percutaneous; femoral-popliteal) for the PTA of the femoral-popliteal artery and 75962-26 (Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation) for the S&I, she says.
 
Then you would report the right iliac PTA with 35473 (Transluminal balloon angioplasty, percutaneous; iliac) and report +75964-26 (... each additional peripheral artery) for the additional-vessel S&I.
 
You will only have one catheter placement (for the most distal placement of the catheter), and in this example, it would typically be the SFA, Fletcher says. If done from a contralateral femoral puncture, the cath placement code would be 36247, she says.
 
When the physician performs a PTA on two vessels during a single balloon inflation, you code the intervention of the most distal vessel, Karl says. For example, if the patient's lesion covers the external iliac and common femoral area, you should code the angioplasty to this lesion to the femoral angioplasty, using 35474 (Transluminal balloon angioplasty, percutaneous; femoral-popliteal), she says. You would also report 75962-26 (Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation) for the S&I, she adds. 

Is the PTA the Only Procedure?

Make sure that the PTA was the "intent" of the treatment, Fletcher says. Often cardiologists use PTAs to dilate narrow or occluded vessels prior to another interventional procedure, such as stent placement. In such situations, many physicians will list "PTA/stent" on their fee tickets, but you cannot bill for both procedures in the same vessel in all scenarios, she says.
 
If the physician intended to stent the vessel and he or she performed the angioplasty for predilation only, you would not report the PTA, Karl says. Any pre- or post-dilation is included in the stent, she says. Instead, you would report codes for the percutaneous transcatheter stent placement (37205-37206) for a noncoronary vessel, along with the stent S&I code (75960-26).
 
Look for key terms such as "predilation" in the documentation, Inabinet says. If the physician uses that term in the report, the PTA is not separately billable.
 
You can bill for both a PTA and a stent placement in the same vessel, however, when the PTA is the original intent but the physician deploys a stent because the angioplasty fails or the result is suboptimal, for reasons such as lesion recoil or 30 percent or greater residual stenosis, Fletcher and Inabinet say. Make sure you check your local medical review policies (LMRP) on this subject of billing both procedures together, Fletcher says. Many states give you exact wording that must be documented for both procedures to be covered at the same setting.

Check Carriers for Peripheral PTA Indications

Be sure to link the appropriate diagnosis code to the PTA (35470-35476) because many states have specific indications for peripheral angioplasties in LMRPs, Karl says.
 
For instance, Empire Medicare Services, New Jersey's Medicare carrier, specifies that it covers peripheral (non-coronary) PTAs for management of patients with a range of hypertensive heart and renal disorders, including malignant hypertensive heart and renal disease with renal failure (404.02) and malignant hypertensive heart and renal disease with heart and renal failure (404.03). Palmetto, Ohio's Medicare carrier, covers peripheral PTAs for such indications as peripheral vascular disease unspecified (443.9), atherosclerosis of the extremities unspecified (440.20), with intermittent claudication (440.21), with ulceration (440.23), and with gangrene (440.24).