Cardiology Coding Alert

Cardiology billers should always make sure the procedures listed at the top of an operative report correspond to the description of the operative session in the procedure notes. Sometimes, cardiologists list procedures performed at the top of the op note, but the cardiologists notes make no mention of the procedure. Alternatively, the procedure notes may describe a procedure that hasnt been listed at the top. Both examples will cause confusion for the person coding the procedures.

The first scenario is far more serious if a procedure hasnt been described, it is as though it hasnt been performed because there is no record of it in the patients chart. When coders spot this sort of discrepancy, they should talk to the cardiologist involved to determine if the procedures actually were performed. If the listed procedures were performed, the cardiologist should be asked to write an addendum describing the procedures in question before the claim is submitted.

Cardiologists are prone to omit such critical data inadvertently because the services they perform often involve several procedures and associated codes. For example, intervention procedures such as percutaneous transluminal coronary angioplasties (PTCAs), stents or atherectomies usually involve cardiac catheterization and associated injection procedures as well as supervision and interpretation (S&I), and may also include injections of thrombolytics or nitroglycerin. Such procedures are often bundled, but the cardiologist may list them separately with the expectation of reimbursement.

In the following case study, the cardiologist lists two interventions, a cardiac catheterization (and its associated injection and S&I procedures) and a Reopro injection. The procedure notes, however, tell a different tale.

Operative Report

Date of Service: 8/17/00 10:00 a.m.

Procedures:
1. Left heart catheterization
2. Left ventriculography
3. Selective coronary angiography
4. Percutaneous transluminal coronary angioplasty of right coronary artery (RCA) stenosis
5. Deployment of stent into RCA stenosis
6. Administration of Reopro in cath lab to dissolve blood clot

Indications: Increasing angina, shortness of breath, abnormal stress test indicating myocardial disease.

Description of Procedure: Informed consent was obtained and patient was brought to cath lab ... After satisfactory local anesthesia was achieved, the right femoral artery was cannulated ... and a 6-French arterial sheath was placed and flushed. Left heart catheterization, left ventriculography and selective coronary angiography were then performed ... At the end of angiography, catheter was removed, sheath was flushed and findings were reviewed. Left ventriculography demonstrated a mildly enlarged left ventricle with global hypokinesis and severe left ventricular dysfunction. Left ventricular ejection fraction is calculated at 30 percent. Selective coronary angiography demonstrated right coronary artery damage. The RCA gave rise to a posterior descending (coronary) artery (PDA) and posterolateral left ventricular branches. The mid-portion of the right coronary artery had a long tubular stenosis. The mid-portion of this tubular stenosis has a high-grade 80 percent to 90 percent lesion. The distal right had minor disease.

The operative session described above should be coded as follows, says Terry Fletcher, BS, CPC, CCS-P, an independent cardiology coding and reimbursement specialist in Dana Point, Calif.:

93510-26 left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous-professional component;

93543 injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography;

93545 ... for selective coronary angiography (injection of radiopaque material may be by hand);

93555-26 imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography-professional component; and

93556-26 ... pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass)-professional component.

Note: Modifier -26 is attached to the cardiac catheterization and any associated S&I codes when the procedures are performed using equipment not owned by the cardiologist or his or her practice.

Noticeably absent from the list of billable codes are 92980 (stent) and 92982 (PTCA). These are the two highest-paying procedures listed at the top, but neither is billable because the cardiologist neglected to include descriptions of either procedure in the notes. The administration of Reopro, similarly, was noted at the top but omitted in the body of the op report.

In this situation, the patient developed complications later the same day and required a rescue PTCA and stent. As a result the coder knows that the original stent and PTCA were performed. Therefore, before billing, the coder should talk to the cardiologist and ask for an addendum that includes descriptions of the missing procedures, Fletcher says. Otherwise, the procedures should not be billed, following the coders maxim, not written, not done. Although the claim may well be paid because charts and documentation normally are not required when bills are first submitted, in the event of an audit the absence of supporting documentation would elicit serious suspicions.

The administration of Reopro also is not listed and should not be billed. Even if the administration of Reopro had been described, however, it would only have been billable if the interventions (stent, PTCA) had not been performed, because the administration of thrombolytics or anti-platelet agents such as Reopro is bundled into interventions (but not to cardiac catheterizations).

Had the Reopro been adequately described without the stent and PTCA, it may have been billable, depending on why it was administered, says Sueanne Bicknell, CPC, CCS-P, coding specialist with Heart Place, an 80-physician practice with 60 cardiologists and five electrophysiologists in Dallas.

If Reopro is injected to dissolve an actual thrombus that was discovered as a result of the heart cath, it is billable using 92975 (thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography). If, on the other hand, the report indicates that the Reopro was injected to relax the blood vessels or for another preventive purpose, it should not be billed.

It also is important to note that even though 92975 includes angiography, the initial diagnostic angiogram (93545) associated with the heart cath is still separately billable if no intervention is performed, Bicknell says.

Note: Intravenous coronary thrombolysis (92977) has been assigned 0 physician work units in the Medicare fee schedule. According to the Health Care Financing Administration (HCFA), this service is most often performed by nursing personnel in the hospital setting.

Had both interventions and the Reopro injection been described, the procedures would be coded 93510-26, 93543, 93545, 93555-26-59, 93556-26-59 and 92980 (transcatheter placement of intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method, single vessel).

The angioplasty of the RCA (92982, percutaneous transluminal coronary balloon angioplasty, single vessel) could not be billed, Fletcher says, because the PTCA was performed on the same vessel as the stent, and CPT and HCFA guidelines do not allow multiple interventions to be billed on the same vessel during the same session. The Reopro also could not be billed, because it is bundled to the stent in the national Correct Coding Initiative.

In addition, says Fletcher, modifier -59 (distinct procedural service) should be attached to the S&I codes, because both 93555 and 93556 are bundled to the stent. By attaching modifier -59, you are indicating to the carrier that these S&I codes are linked to the cardiac cath, not to the stent, and therefore are separately payable.

Preview Note: Six hours after this operative session ended, the patient was rushed back into the cath lab for an emergency angiography that was followed by rescue angioplasty and stenting of the RCA. In a future issue of Cardiology Coding Alert, we will examine how these emergency procedures should be coded and modified, given that both sessions took place on the same day and involved repeating many of the same procedures.