Cardiology Coding Alert

Hint:  You'll need to pay more attention to your 2-D reconstruction CT scan documentation

You've got only a short time before you'll have to implement CPT's 2006 changes on Jan. 1--especially since there's no grace period--so here are the five major changes likely to affect your cardiology practice that you should learn now.

1. Good News for Thrombectomy Procedures

Right now, you can bill for mechanical thrombectomy only if the physician performs it in a coronary vessel or arteriovenous fistula. But starting in January, you'll be able to bill for mechanical thrombectomy in peripheral vessels as well.

Break it down: New codes cover primary mechanical thrombectomy for noncoronary, arterial or arterial bypass graft for the initial vessel (37184) and each additional vessel (37185). Another new code covers secondary thrombectomy (37186). And a third covers percutaneous mechanical transluminal thrombectomy, including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance (37187) and a repeat treatment on a subsequent day (37188).

"These new thrombectomy codes are wonderful. We've added a new physician who specializes in peripheral vascular disease, so this is a biggie for us," says Jennifer Kelchen, MA, CCS-P, manager of the coding department for Cardiologists P.C. in Cedar Rapids, Iowa. "There's nothing worse than having to use the dreaded 37999 (Unlisted procedure, vascular surgery) code--it just delays your payments and creates a lot of extra paperwork."

2. Central Line Patency Check Gets CPT's Attention

If you've been billing for a central venous access device assessment, known as a central line patency check, your troubles may be over.
 
The new way: Until now, you've had to bill for this procedure using an unlisted code plus a fluoroscopy code, says Cheryl Schad, BA Ed, CPC, ACS-RA, owner of Schad Medical Management in Mullica Hill, N.J. But now CPT 2006 will add a new code for this procedure (36598, Contrast injection[s] for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report). "We might actually see some reimbursement for this procedure," Schad predicts.

You'll use 36598 when your physician injects contrast to see if there's a problem with a venous access device (such as fibrin around the ends) or a change in position, says Jackie Miller, RHIA, CPC, senior consultant at Coding Strategies in Dallas, Ga. The cardiologist checks to see if the contrast is able to pass through the device to determine if it continues to provide access.

3. 76375 Becomes Two New Codes

Those of you who have been billing 76375 for two-dimensional reconstructions of CT scans, MRIs or other imaging scans, will have to change your ways starting in January.

CPT 2006 deletes 76375 and replaces it with two new codes. Important: Both new codes specify that the rendering must be 3D, unlike 76375, which said rendering could be 3D or holographic. These two codes cover reconstruction with (76377) and without (76376) image postprocessing on an independent workstation.

Upshot: This change will make billing for reconstruction more difficult unless your physician is really using a machine that has 3D capabilities, experts say.

"The reconstruction was being billed by so many providers with every CT service, and they were starting to bill it with ultrasounds," Miller says. Now, if you take an axial scan and reconstruct it into the sagittal, coronal or other plane, you won't be able to bill 76376-76377 because the scan will only be two-dimensional.

Careful: If a technician performs the reconstruction on the main machine, you'll use 76376. But if the physician performs the reconstruction on an independent workstation, use 76377, says Bruce Hammond, CRA, CMNT, chief operating officer with Diagnostic Health Services in Addison, Texas. "It's going to force the doctor to change the dictation" to clarify who did the reconstruction and where.
 
Missed opportunity: The AMA should have incorporated 3D reconstruction into the existing CT imaging codes, Schad argues.

Because 3D reconstruction is a separate code, cardiologists have to go back and seek an order from the treating physician if they decide to perform a reconstruction after a CT scan. Often, cardiologists won't know until after the initial CT scan whether they'll need to do a 3D reconstruction to clarify their diagnosis.

The HHS Office of Inspector General has gone after cardiologists who lacked documentation of a separate order for 3D reconstruction after a CT scan, Schad notes. The AMA missed a chance to solve this problem by making 3D reconstruction part of CT scans.

4. Toss the Confirmatory Consult Codes

You'll have to be careful when you're preparing to report a consultation because your consultation coding choices just got narrower. In 2006, you'll no longer have the option of reporting confirmatory consultations (99271-99275).

But that doesn't mean that this deletion should be unwelcome. "You couldn't use confirmatory consultation codes when counseling or coordination of care dominated the visit," says Melanie Witt, RN, CPC, MA, an independent coding consultant in Guadalupita, N.M., "even though such consultations normally involved face-to-face counseling with the patient rather than a physical examination."

Important: As of Jan. 1, if your cardiologist sees a patient for a confirmatory consultation, you should report an inpatient or outpatient E/M code, not a consultation code.

How it works: When a patient presents to your cardiologist for a second opinion, generated by herself or her family, you'll report a standard E/M code (99201-99215) in 2006. "The reason is a confirmatory consultation is requested by the patient, rather than at the request of a qualified healthcare provider," Witt says.
 
Don't forget: If a third party requests this second opinion to confirm, for example, that the cardiologist's recommendation for surgery was medically indicated, you should add modifier 32 (Mandated services) to the E/M code.

5. Strike Out Follow-Up Inpatient Consults Too

Along the same line as the confirmatory consult deletion, you'll also discard the follow-up inpatient consultation codes (99261-99263). CPT guidelines now instruct the physician to report the subsequent hospital care codes (99231-99233) if the patient requires a follow-up visit after the initial inpatient consultation.

Good news: "This change is a positive one for cardiologist practices because the relative value units (RVUs) for the hospital care codes are slightly higher than the follow-up consultation codes were," Witt says.
 
Note this comparison for 2005 RVUs: 

Inpatient subsequent care    Follow-up consultation     
99231--0.90                            99261--0.59  
99232--1.47                            99262--1.20  
99233--2.09                            99263--1.78 

Heads up: Don't forget the new Category III codes for coronary CT angiographies (CTA). Read up on how to use them in the article, "News You Can Use: Reporting Unlisted Codes for Coronary CTA? Read This First," featured in the September 2005 Cardiology Coding Alert.

Note: For a PDF chart of new CPT codes that will affect your cardiology practice (including those discussed in this article as well as others, such as lippoprotien codes 83695-83704 and education and training for patient self-management codes 98960-98962), email the editor at Suzannel@eliresearch.com.