Cardiology Coding Alert

Read the following five cath coding problems, keeping in mind whether the interventions are planned or unplanned, and then decide on a solution.

Tackle This Transfer Situation

Scenario 1: Greenwich Hospital in Greenwich, Conn., sometimes has to send patients to its affiliate, Yale New Haven Medical Center, for cardiology interventions, writes Carl DeRosa with Cardiovascular Services of Greenwich.

That's because Greenwich Hospital's Certificate of Need (CON) license with the state doesn't allow it to perform some cardiac interventions in-house, he explains.

So Greenwich Hospital performs the initial catheterization on the patient and then sends the patient to Yale New Haven. But payers often won't cover the initial catheterization when the patient receives two catheterizations on the same day, DeRosa says. Greenwich Hospital is also having trouble obtaining payment for E/M services on the same date, even with modifier 25.

How should you code this scenario?

Evaluate This Elective Intervention

Scenario 2: A patient with non-Q wave myocardial infarction transfers from a rural hospital for elective intervention of a mid-LAD critical stenosis diagnosed on diagnostic heart catheterization. The cardiologist performs the PTCA and drug-eluting stent placement in the LAD.

How should you code this scenario?

Figure Out This Stent Scenario

Scenario 3: A patient presents with a history of angina, CAD, and history of CABG to the diagonal, LAD, and obtuse marginal branch. The cardiologist performed a cardiac catheterization two weeks ago, which showed severe diffuse disease of the distal right coronary artery. The cardiologist schedules elective stenting, during which he places a drug-eluting stent on the RC.

How should you code this scenario?

Try This Unstable Coronary Syndrome Situation

Scenario 4: A patient presented a few weeks ago with an unstable coronary syndrome. The patient had undergone diagnostic heart catheterization, stenting of the LAD and stenting of the first diagonal arteries at that time. The patient did well but had a residual 90 percent stenosis in the mid-right coronary artery. The cardiologist advised the patient to schedule an angioplasty and stenting of that particular lesion. The cardiologist performs the PTCA and places drug-eluting stents on the proximal, mid and distal areas of the RC at the time of the second procedure.

How should you code this scenario?

Secure Your Seldinger Technique Coding

Scenario 5: Your cardiologist's op report states he performed a heart catheterization and interventional procedure. He used the Seldinger technique to insert a guiding catheter into the right femoral artery.

Here is a section of the op report: "Positioned a guiding catheter into the left main artery where I performed initial injections in different projections, revealing a 90 percent stenosis 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."

How should you code this scenario?

Find Out How Confident You Are Coding Cath Procedures

Did you make the mistake of reporting a repeat cath?

Did you conquer the cath coding challenge? Read on to find out.

Tackle This Transfer Situation

Solution1: Most payers "will never pay for a second cath when the problem has been identified with the first cath," says Jan Rasmussen, CPC, AGS-GI, ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis.

You can bill the second procedure as an intervention only--without any diagnostic catheterization or angiography. The CPT manual clearly states that if there is a prior diagnostic study and the patient's condition has not changed, the physician should only bill for the intervention, experts say.

Heads up: If a cardiologist decided to perform the intervention at the initial encounter (at the transferring facility, Greenwich Hospital), the cardiologist performing the intervention should not bill an E/M service. Any pre-op work he does is part of the interventional global service package.

Watch out: That means modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) shouldn't even cross your mind. Modifier 25 is the most overused modifier, says Christopher Felthauser, medical coding instructor for Orion Medical Services in Eugene, Ore. "No wonder it's under investigation so much." Some payers are denying all modifier 25 claims and making people appeal them because it's so frequently abused.

Evaluate This Elective Intervention

Solution 2: You would only report 92980 (Transcatheter placement of an intracoronary stent[s] ...). Because a cardiologist at another facility diagnoses the stenosis prior to the transfer, the interventionalist would not bill for a repeat heart catheterization.

Figure Out This Scheduled Stent Scenario

Solution 3: Again, you should report only 92980 because this service was a planned intervention.

Try This Unstable Coronary Syndrome Situation

Solution 4: You should report 92980 only. Scenarios 2, 3 and 4 are good examples of planned scheduled interventional procedures. In all of these examples, the cardiologist would code the highest-valued procedure performed on the LAD or RC.

Secure Your Seldinger Technique Coding

Solution 5: You should report 93508 (Catheter placement in coronary artery[s], arterial coronary conduit[s] ). You should also report the following codes: 93545 (Injection procedure during cardiac catheterization ); 93556-26-59 (Imaging supervision, interpretation and report for injection procedure[s] ...; professional component; distinct procedural service); and 92980 (Transcatheter placement of an intracoronary stent[s], percutaneous ).

Why use modifiers 26 and 59? Understand that 93556 represents the supervision and interpretation of the diagnostic portion of this procedure. You should attach modifier 26 to demonstrate that you are only billing for the professional portion of the service the cardiologist performed in a facility setting.

You have to include modifier 59 because the NCCI bundles this diagnostic code with the interventional code (92980). Modifier 59 tells the payer that the imaging study was truly diagnostic, not a guiding or road-mapping study to help facilitate the intervention. Note: Remember to add modifier 26 to 93508 also.

A cardiologist typically uses percutaneous puncture to place an introducer sheath in the  femoral artery (such as the 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").