Cardiology Coding Alert

CPT 2000 lists a number of important changes for cardiologists, including new codes for event recording, a number of changes in the pacemaker/defibrillator section, and a significant change in the wording of critical care codes that will allow cardiologists to bill these services more often.

In CPT 1999, codes 99291-99292 were to be used for the critical care, evaluation and management of the unstable critically ill or unstable critically injured patient, requiring the constant attendance of the physician. (Code 99291 is for the first hour, defined as between 30-74 minutes, and 99292 is used for every subsequent 30-minute period.) Cardiologists may have understood this to mean that caring for a critically ill or injured patient did not in itself fully meet the criteria of the code. The patient also had to be unstable, meaning that he or she had to have a life-threatening, immediate problem that required stabilization.

In CPT 2000, the situation has been greatly clarified. The revised terminology now reads, critically ill or critically injured patient. Thus, there is now no requirement that the patient be unstable in all instances. This means that if the cardiologist has a patient listed as critical in the ICU or critical care unit and is directly involved with that patient (by performing, for example, ventilator management, interpretation of cardiac output measurement, blood gases, ECGs, temporary pacemakers, etc.), he or she now can code critical care time of total duration on a given date more than 30 minutes.

Note: If the critical care takes less then 30 minutes, it should be billed as 99233 (subsequent hospital care).

These clarifications indicate that the codes have been softened, says Susan Callaway-Stradley, CPC, CCS-P, an independent reimbursement and coding consultant in North Augusta, SC.

Yet, valuable as this change is, cardiologists should note that the critical care guidelines, which are found just before the two codes in the E/M section, instruct that the critical illness or injury must acutely impair one or more vital organ systems such that the patients survival is jeopardized. In other words, services for a patient who is not critically ill but has been placed in a critical care unit should be reported using other E/M codes for hospital visits. Thus, the mere fact that the patient physically resides in the ICU or CCU does not in itself qualify the case for critical care codes. It is the patients condition that must be critical

New Codes for Patient-Activated Loop Recorders

Previously, unlisted codes had to be used for the implantation and removal of patient-activated loop recorders. But CPT 2000 has added two new codes33282 (implant of patient-activated event recorder) and 33284 (removal of patient-activated event recorder)for these procedures, Callaway-Stradley says, adding that 33282 includes programming. For any subsequent reprogramming, another new code93727 (electronic analysis of implantable loop recorder system)should be used.

Defibrillator Code Changes and Deletions

In addition, many of the pacemaker/defibrillator (electrophysiology) codes have revised terminology, meaning the definition of the code and what it includes or may be bundled with, has changed.

Most important, code 33247 (insertion or replacement of implantable cardioverter-defibrillator lead[s], by other than thoracotomy) has been deleted. Instead, CPT code 33216 (insertion or repositioning of a transvenous electrode; [15 days or more after initial insertion]; single chamber [one electrode] permanent pacemaker or single chamber pacing cardioverter-defibrillator) should be used.

Codes 33240, 33241, 33243, 33244, 33245 and 33246 have been amended to include dual-chamber defibrillators. In CPT 1999, these codes simply referred to defibrillators.
Code 33249, which used to be a tagalong code for 33247 (now deleted), has been reworded to include the repositioning of leads for defibrillators.

The wording of the introduction to the pacemaker/defibrillator section also has been modified to clarify how and where subcutaneous pockets are placed, Callaway-Stradley says.

Other Changes

Two new procedure codes35879 (revision, lower extremity bypass arterial bypass without thrombectomy, open; with vein patch angioplasty); and 35881 (with segmental vein interposition)have been added, along with instructions to guide cardiology coders about when to use these codes instead of 35876 (thrombectomy of arterial or venous graft [other than hemodialysis graft or fistula] with revision of arterial or venous graft).

If youre using vein patch angioplasty or segmental vein interposition techniques, or if youre doing an open position of a graft threatening stenosis, you use the new codes, but if youre using thrombectomy with revision of a non-coronary graft, 35876 should be used, according to Callaway-Stradley. For direct repairs of a lower extremity blood vessel, 35226 (repair blood vessel, direct; lower extremity) should be used, while repairs using a vein graft should be coded 35256 (repair blood vessel with vein graft, lower extremity).

Other new codes include:

92961: (internal elective cardioversion). In the past, the only code that described cardioversion was for external use.

93741: (electronic analysis of pacing cardioverter defibrillators, without reprogramming);

93742: (with reprogramming); 93743 (dual chamber,
without reprogramming); 93744 (with reprogramming).

Modified codes in CPT 2000 include 35500 (harvest of upper extremity vein, one segment, for lower extremity or coronary artery bypass procedure [list separately in addition to code for primary procedure), which now includes the harvest of upper extremity vein for coronary bypass procedures. Previously, 35500 was used just for lower extremity bypass procedures.

Codes 37250 (intravascular ultrasound [non-coronary vessel] during diagnostic evaluation and/or therapeutic intervention; initial vessel [list separately in addition to code for primary procedure]) and 37251 (each additional vessel) were changed to include diagnostic evaluation. Previously, both codes only included therapeutic intervention. The same change was made to 92978 (intravascular ultrasound [coronary vessel or graft] during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel [list separately in addition to code for primary procedure]) and 92979 (each additional vessel).

Finally, a note and symbols have been added to all intracardiac electrophysiological procedure codes (93600-93660) to indicate that modifier -51 (multiple procedures) no longer should be appended to these codes. And 93737 has been reworded to address electronic analysis of single or dual chamber pacing cardioverter defibrillators. Previously, the code made no mention of pacing.