Cardiology Coding Alert

Cardiology practice coders accustomed to reporting 92980 and 92981 for the insertion of all stent types could be using two new HCPCS codes G0290 and G0291 after April 1 when interventional cardiologists insert drug-eluting stents.

Specifically, drug-eluting stents (DES) are designed to release immunosuppressive agents such as Sirolimus that inhibit smooth muscle cell proliferation, which is the leading cause of restenosis within stented coronary arteries, says Susan M. Hull, RHIA, CCS, practice manager for coding products and services with the American Health Information Management Association (AHIMA) in Chicago. The stent delivers or elutes"" the active drug over a period of 30 to 45 days through a polymer coating that remains on the stent after all the drug has been released she says.

Coders should expect to see an increase in DES use in interventional procedures and subsequent changes in operative reports that could impact reimbursement in the near future.

Indeed in the next two years the use of drug-eluting stents could reduce bypass surgery by almost 50 percent cause significant reductions in the need for medical therapy and increase the frequency of interventional procedures for coronary artery disease says Joseph D. Babb MD FACC FSCAI professor of medicine at East Carolina University School of Medicine in Greenville N.C. and moderator of a debate on drug-eluting stents sponsored by the Society for Cardiac Angiography and Interventions (SCAI).

Drug-eluting stents cost as much as three times more than conventional stents. However there should be no significant financial impact on physician practices because these procedures are performed in hospital settings Hull says.

Even so physicians will want to use the new stents and will press hospitals to invest in the most costly devices Hull predicts.

Moreover the reduced rate of restenosis should in turn reduce reoperation rates and may lead physicians to use DES in smaller and smaller coronary vessels that were previously not amenable to revascularization by stenting Hull says. In effect coders could see more of these procedures and will need to master the complexities of small coronary vessels for correct DES coding.

Indeed coders are used to reporting 92980 (Transcatheter placement of an intracoronary stent[s] percutaneous with or without other therapeutic intervention any method; single vessel) when the physician places a standard (bare-metal) intracoronary stent and adding 92981 for stent insertion of any type in each additional vessel.

But stent coding will change on April 1 the implementation date for two HCPCS level II codes for drug-eluting stent insertion Hull says.

For all stent placement procedures including DES insertion prior to April 1 report 92980 and 92981 as appropriate says Sheldrian Wayne CPC a cardiology coding specialist with Coding Strategies Inc. of Powder Springs Ga.

After April 1 report G0290 (Transcatheter placement of a drug eluting intracoronary stent[s] percutaneous with or without other therapeutic intervention any method; single vessel) when the physician inserts a DES into a single coronary vessel and G0291 ( each additional vessel) for DES insertion in each additional vessel Hull says.

Remember that in general only Medicare accepts G codes so you should consult with private payers before billing these codes.

Codes G0290 and G0291 replace G0NNN and G0OOO which are ""place-keeper codes"" that CMS developed for the preliminary rule (Federal Register Aug. 9 2002) Hull says. Codes G0NNN and G0OOO should not be used she clarifies. G0290 and G0291 include the cost of both the device and its insertion she says.

You should continue to use 92980 and 92981 after April 1 when the physician inserts a bare-metal or a ""coated"" stent but not a DES. Indeed DES should not be confused with ""coated stents"" such as heparin-coated stents Hull says. ""These stents which are usually coated with heparin to prevent clotting during the insertion procedure are not DESs and their placement should be reported with the regular CPT stent codes"" rather than G0290 and G0291 she says.

For example if a physician inserts a standard stent in a patient's right coronary artery and another in the left anterior descending coronary artery (LAD) you would report 92980-RC and 92981-LD Hull says. If the stents are drug-eluting report G0290-RC and G0291-LD.

If the physician places multiple stents in one or more arteries you could append modifier -22 (Unusual procedural services) to the standard stent or drug-eluting stent codes to illustrate the additional time and skill required Hull adds. Remember that modifier -22 is not approved for hospital use she says.

Report G0290 and G0291 once per vessel regardless of the number of drug-eluting stents the physician places in the vessel Hull says. Report 92980 and 92981 only once per vessel for standard and heparin-coated stents.

Also you should append the appropriate HCPCS level II modifiers to G0290 and G0291 to identify which coronary arteries have drug-eluting stents such as -RC for the right coronary artery -LC for the left circumflex coronary artery and -LD for the left anterior descending coronary artery Hull says. Likewise append these modifiers to 92980 and 92981 to identify arteries stented with standard or heparin-coated devices.

Coders should encourage physicians to document the specific type of stent they're using and the reason for stenting Wayne says.

Because a DES is more expensive than a bare-metal stent the risk for restenosis should be documented if known to support reimbursement Hull says.

Coronary artery disease of either native arteries or bypass grafts is the only indication for stent placement Hull says. If the patient has a prior history of restenosis of a stented artery that should be documented in the health record she says.

Possible diagnosis codes to link to G0290 may also include V15.89 (Other specified personal history presenting hazards to health; other) and V15.1 (Surgery to heart and great vessels) Hull says. Check carrier policies before billing V codes since some payers do not view V codes as demonstrating medical necessity.

Note: For more information concerning drug-eluting stents visit the Society for Cardiac Angiography and Interventions Web site at www.scai.org. To learn more about the American Health Information Management Association see www.ahima.org.