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Cardiology Coding Alert

Correct Injection Code Simplifies Billing for Cardiac Catheterizations

Published on Mon Apr 01, 2002

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Cardiac catheterization, particularly left heart catheterization (LHC), is a three-step process: Place the catheter, inject dye for imaging, and supervise and interpret images that the angiograms produce.
 
Although there are considerably fewer injection codes than catheterization codes and even fewer supervision and interpretation (S&I) codes, some of the injection code descriptors might confuse anyone not yet strong on cardiac anatomy and medical terminology.
 
Clear and accurate documentation greatly simplifies code selection. The cardiologists notes should document the number of injections, the arteries or heart chambers receiving injections, and the type of heart catheterization performed.
 
Injection codes differ based on the anatomic area injected. Although the cardiologist can report injections in more than one location, each code can be billed only once, regardless of the number of injections made, says Nikki Vendegna, CPC, a cardiology coding and reimbursement specialist in Overland Park, Kan.
 
For example, injections are typically made in two locations during an LHC (93510, Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous), each of which may be reported separately. These are CPT 93543 (Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography) and CPT 93543 ( for selective coronary angiography [injection of radiopaque material may be by hand]).
 
Both 93543 and 93545 may be reported separately. Even if more than one angiogram of the coronary arteries is taken, however, 93545 may be reported only once. Separate payment should not be sought for separate injections of different coronary arteries, such as the left anterior descending (LAD) artery and right coronary artery (RCA).
 
Five of the seven injection codes are used with LHC only (93539, 93540, 93543, 93544 and 93545); the other two (93541 and 93542) are used with right heart catheterization (RHC, 93501) only. 
 
Cardiologists may take pulmonary pressures during a right heart catheterization, but this does not necessarily mean that pulmonary angiography was performed, notes Sandy Fuller, CPC, a cardiology coding and reimbursement specialist in Abilene, Texas. An injection must be performed to report 93541, so coders must ensure the cardiologist documents actually injecting and imaging the pulmonary artery, she says.
 
The other injection codes are used as follows:

  If arterial conduits such as the left and right internal mammary arteries or radial arteries are imaged, use 93539 ( for selective opacification of arterial conduits [e.g., internal mammary], whether native or used for bypass]). Although it has been suggested that 93539 should be used only for bypass grafts, the descriptor makes it clear that 93539 is also meant to report imaging of native arterial conduits, Fuller says.

  For bypass grafts of coronary arteries, report 93540 ( for selective opacification of aortocoronary venous bypass grafts, one or more coronary arteries).

  Aortic angiograms performed with LHC are reported as 93544 ( for aortography).
 
 
Note: When aortography is performed and there is no accompanying heart catheterization or coronary angiography, neither 93544 nor 93556 (the corresponding S&I code) should be reported. Instead, use 36200 (Introduction of catheter, aorta) and the appropriate radiology code (75600-75630).
 
Although the main code covers introduction of the catheter, changing the catheters position is included in the appropriate injection code. CPT states that injection procedures do not include introduction of catheters but do include repositioning of catheters when necessary.
 
Finally, carriers recognize each code in the Cardiac Catheterization section of CPT as a multiple-procedure code that should be reimbursed in full when reported on its own. If you append modifier -51 (Multiple procedures) to any of these codes, you risk a carriers computer misreading the code and automatically reducing reimbursement 50 percent.
 
Note: If a heart catheterization is done with an intervention, some carriers (including Part B payers) reduce its payment 50 percent.

S&I Codes
 
 
Cardiologists routinely supervise and interpret the images obtained through injection procedures. The two codes that describe these S&I services are used with all of the injection codes: 93555 (Imaging supervision, interpretation and report for injection procedure[s] during cardiac catheterization; ventricular and/or atrial angiography) and 93556 ( pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits [whether native or used in bypass]). 
 
Location of the injections determines which of the two codes to use, Vendegna says. If the injection is made into any of the heart chambers, 93555 should be reported. This is the correct S&I code for the two injection codes that involve heart chambers, namely 93542 and 93543, she notes. Code 93556, meanwhile, is used for all the other injection codes, including 93541 for pulmonary angiography during a right heart catheterization, as long as the cardiologist documents performing the S&I.
 
The two S&I codes may be billed separately, Vendegna says, but each code may be billed only once per session.

Combining the Codes
 
Heart catheterization codes are divided into three categories, increasing the number of possible coding combinations. Some typical scenarios follow:
 
LHC with left ventriculography only. Report 93510, 93543 and 93555. Only one injection code and one S&I code may be reported because angiography was not performed anywhere but in the left ventricle.
 
LHC with left ventriculography and angiography of the left circumflex artery (LCX), the LAD and the RCA. Use 93510, 93543, 93545, 93555 and 93556. This is a routine heart catheterization scenario. Even though three angiograms were obtained for the three coronary arteries, 93545 and 93556 may be reported only once.
 
RHC with pulmonary angiography. Use 93501, 93541 and 93556. The only injection code that applies to an RHC is 93541. No angiography inside the heart is performed; therefore, 93556 is the only S&I code that may be reported.
 
LHC and RHC with angiography of arterial conduits, coronary angiography and left and right ventriculography. Report 93526, 93539, 93542, 93543, 93555 and 93556. A combined LHC/RHC is billed using one code (93526). Several separately payable injection procedures were performed both inside the heart chambers and in coronary and other nearby blood vessels, so 93555 and 93556 may be billed. The three injection codes listed may each be reported only once, regardless of the number of injections performed in each anatomic area that the code describes.
 
Coronary angiography, LAD, LCX and RCA. Use 93508, 93545 and 93556. Code 93508 is used when the aortic valve is not crossed; thus, codes used for injections in the heart (e.g., 93543 and 93555) cannot be reported.
 
Note: When the cardiac catheterization is performed in the hospitals catheterization lab, modifier -26 (Professional component) must be appended to the appropriate catheter placement code and to 93555 and 93556. The injection codes do not require modifier -26. When the heart catheterization diagnoses a problem that requires same-session intervention, modifier -59 (Distinct procedural service) must be appended to 93555 and/or 93556 to indicate that these services are linked to the earlier heart catheterization and not the subsequent intervention (stent, percutaneous transluminal coronary angioplasty or atherectomy).
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