Cardiology Coding Alert

If you're wondering whether you can report diagnostic angiograms separately, we'll untangle the NCCI angiogram knots and show you when and how you can earn extra reimbursement by ethically reporting a diagnostic angiogram code in addition to other services.

The National Correct Coding Initiative (NCCI) limits your angiogram coding options. Some edits are "no-brainers," says Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga.

Example: You can't get paid for both a bilateral renal angiogram (75724, Angiography, renal, bilateral, selective [including flush aortogram], radiological supervision and interpretation) and a unilateral renal angiogram (75722, Angiography, renal, unilateral, selective [including flush aortogram], radiological supervision and interpretation) on the same day. The modifier indicator status is "0," meaning you can never separate this edit with a modifier.

But other edits are less clear-cut. You have to be certain that you can use a modifier and that the documentation supports using one.

Example: NCCI bundles a unilateral extremity angiogram (75710, Angiography, extremity, unilateral, radiological supervision and interpretation) into a bilateral extremity angiogram (75716, Angiography, 'extremity, bilateral, radiological supervision and interpretation). Unlike renal angiograms, however, you can override this edit.

For instance, if your cardiologist performs the extremity angiograms during different encounters, you can add modifier 59 (Distinct procedural service) to 75710 -- the lesser-valued code. Also, if your cardiologist exams three extremities (both legs, 75716, and one arm, 75710), you can add modifier 59 to 75710, says Sandy Fuller, CPC, compliance officer at Cardiovascular Associates of East Texas in Tyler.

Remember: Anytime you use modifier 59, you must have documentation to support its use, says Rehna Burge, billing analyst at North Oaks Medical Center in Hammond, La. For example, your cardiologist must document that he performed these services at different encounters or different locations.

"You can also bill 75716 two times, one for upper extremities and one for lower extremities, but you'll have to appeal it to get paid because most carrier systems will deny it as duplicate," Fuller adds. "But we've been successful on getting these paid upon appeal."

If you use modifier 59 to override angiogram edits, you should know the rules for using it backward and forward.

NCCI bundles 75710 with endovascular repair (75952-75954), stent placement (75960), foreign-body retrieval (75961), peripheral angioplasty (75962), transcatheter biopsy (75970), and atherectomy (75992).

Similarly, NCCI bundles 75722 (Angiography, renal, unilateral, selective [including flush aortogram], radiological supervision and interpretation) with endovascular repair (75952-75953), stent placement (75960), foreign-body retrieval (75961), renal/visceral angioplasty (75966), transcatheter biopsy (75970), and renal/visceral atherectomy (75994-75995).

With both code situations, you can use modifier 59 to separate these edits.

First, you can use modifier 59 if your cardiologist performs the services during different encounters or on different anatomical sites.

Also, you can use modifier 59 when the angiogram represents an initial diagnostic exam that served as the basis for your cardiologist's decision to perform the intervention.

If your cardiologist performs an intervention due to a diagnostic exam, you'll need to tread carefully.

According to Fuller, CPT instructions state that you should separately report a diagnostic angiography at the time of a transcatheter procedure if:

--no prior catheter angiogram is available; and

--the cardiologist performs a full exam; and

--the cardiologist bases his decision to intervene on the current exam.

"Again, you must append modifier 59 and include documentation of the decision to intervene in the op report," Burge says.

Example: Your cardiologist performs a lower- extremity arteriogram due to claudication. He has no prior films. He diagnoses superficial femoral artery (SFA) stenosis, so he decides to perform an angioplasty. Because the diagnostic exam indicated the SFA lesion and was the basis for his decision to perform the angioplasty, you should charge for both the arteriogram (75710-59) and the angioplasty, Miller says.

Red flag: If your cardiologist had a prior catheter angiogram available, you should not report another diagnostic angiogram, Burge says. Keep in mind: You don't need to worry about a specific timeframe for the prior angiogram.

However, if the prior catheter angiogram meets one of the following three exceptions, you can report a second angiogram.

Exception 1: The patient's condition has changed since the prior study. For example, two months ago, an angiogram showed moderate arteriosclerosis in the legs. The patient now returns with the new onset of rest pain and loss of pulses. Because the condition has changed, you can report a new diagnostic angiogram.

Exception 2: The cardiologist has inadequate visualization on the prior study. For example, the patient transfers from another facility with poor-quality films. The cardiologist cannot make a treatment decision without performing additional imaging. In this case, you can report a new diagnostic angiogram.

Exception 3: The cardiologist detects a clinical change during the procedure that necessitates new evaluation outside the target intervention area. For example, imaging during a renal artery stent placement suggests severe stenosis of the superior mesenteric artery (SMA) not seen on prior exam. The cardiologist performs a selective exam of the SMA, which you can separately report.

Note: Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga., provided this information during her "Ins and Outs of CCI Edits for Peripheral Procedures" presentation at The Coding Institute's 2006 National Cardiology and Radiology Coding and Reimbursement Conference. Look for information regarding 2007's cardiology coding conference at www.codingconferences.com.