Cardiology Coding Alert

Peripheral interventions in the renal arteries are justified only in one instance

Suppose your cardiologist intends to perform angioplasty or atherectomy, but the intervention fails and he places a stent. Should you report the stent code only, or should you include the angioplasty or atherectomy code as well? If you meet three simple criteria, you may be able to collect for each.

According to Jim Collins, CCC, CPC-CARDIO, CHCC, president of CardiologyCoder.com in Saratoga Springs, N.Y., the physician's note must clearly illustrate each of these three items:

1. The doctor's intention to perform angioplasty as a primary intervention. In other words, "this is the procedure that is planned to be the ultimate solution to address the lesion," Collins says.
2. The angioplasty as a failed procedure or that it produced a suboptimal result. Note: Payers define what is suboptimal differently. However, a "30-percent residual stenosis or a flow-limiting dissection are very common standards," Collins says.
3. The decision to proceed with the stent placement after the cardiologist identified the suboptimal angioplasty result.

Keep in mind: The lesion must be of the type that is a viable candidate for primary angioplasty.
If you do not document each of these three factors, your payer will consider the angioplasty a predilatation of the lesion and the atherectomy a debulking of the lesion. In that case, both these services are not separately billable, Collins says.

Angioplasty or Atherectomy Must Be Primary Intention

The first hurdle your doctor's medical record must clear to bill multiple interventions of the same vessel in this fashion is to establish angioplasty (or atherectomy) as the physician's primary intention during the particular intervention. You will typically not be able to meet this criterion if the physician addresses lesions located at the origin of the renal arteries, industry experts say.

Why: One reason for this is that clinical studies have shown that the majority of percutaneous transluminal angioplasties (PTA) that physicians perform in the ostium of the renal arteries fail due to the lesions' pronounced elasticity.

Most interventional radiology coding experts agree that when physicians perform peripheral interventions in the renal arteries, the only time they are justified in performing primary stenting is when they treat orificial lesions (the most common lesions involving the renal arteries). If, before the physician even performs the procedure, he intends to stent for treatment of orificial lesions, you should report only the stent codes, not PTA.

"If a renal artery lesion (particularly one involving the renal artery ostium) is treated by angioplasty alone, re-stenosis is likely to occur," says Jackie Miller, RHIA, CPC, coding expert and senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga. "Stenting significantly reduces the likelihood of reoccurrence." Therefore, your cardiologist may perform primary stenting.

"You should report stenting of the renal artery with 37205 (Transcatheter placement of an intravascular stent[s], [except coronary, carotid, and vertebral vessel], percutaneous; initial vessel) and 75960 (Transcatheter introduction of intravascular stent[s], [except coronary, carotid, and vertebral vessel], percutaneous and/or open, radiological supervision and interpretation, each vessel)," Miller says. Because the cardiologist knows from the start that he will be stenting for treatment of orificial lesions, you should report only these codes. "Make sure to also report the appropriate code(s) for any preceding diagnostic study as well as catheter placement," Collins says.

Document 'Failed' PTA

Other than documenting the performance of both interventions and establishing the physician's intent, the medical record must establish that the primary angioplasty was unsuccessful based on your carrier's definition of a "failed" procedure.

Cigna Medicare of Tennessee defines a suboptimal or failed PTA as "a dilation judged by the physician to be suboptimal or failed due to the presence of unfavorable lesion morphology." If your cardiologist does not specifically note that the PTA failed, you may have to dig deeper. Check the operative report for the following terminology, which signals a failed PTA:

1. An inadequate angiographic and/or hemodynamic result as defined by a 30 percent or greater residual stenosis after PTA, lesion recoil, or intimal flaps.
2. Flow-limiting dissections post-PTA.
3. A 5-mm Hg or greater mean trans-stenotic pressure gradient post-PTA.
4. Acute occlusion of the vessel after PTA.

Many carriers, including Empire Medicare of New Jersey, publish policies that confirm that you should report both the angioplasty and stent procedure when your cardiologist places stents to treat suboptimal or failed angioplasty.

Value of Atherectomy Not Included in Angioplasty

"Some blockages are calcified, so the physician has to use a rotational atherectomy catheter, which has a burr on the end to grind away the blockage," says Rhonda Burge, CPC, coding and billing supervisor for Mid-Ohio Cardiology and Vascular Consultants in Columbus, Ohio. Although guidance for billing failed interventions with subsequent stent deployment appears specific only to failed PTAs, the same concept holds true for failed atherectomies (35490-35495).

"In peripheral cases, you should bill for all methods of intervention that your cardiologist performs," Burge says. "So if the physician performed an atherectomy, angioplasty, and stent, you would be able to bill all three."

Therefore, if the medical record reflects that (1) the physician performs an angioplasty of the superficial femoral artery as the primary intention and this provides suboptimal results, (2) the physician then proceeds with an atherectomy of the lesion and this also provides suboptimal results, and (3) the physician places a stent to treat the lesion, you can code each intervention and the accompanying radiological supervision and interpretation codes (PTA: 35474 and 75966; atherectomy: 35493 and 75992; and stent: 37205 and 75960).

Don't forget: You should also report catheter placement, which would typically be a first-order cath placement (36245 or 36246) with an ipisilateral, antegrade puncture, or a third-order (36247) with a contralateral puncture site, Collins adds.

Editor's note: Stay tuned to the Cardiology Coding Alert. The Correct Coding Initiative (CCI) instructions changed in October 2007 to prohibit billing for multiple interventions to address the same lesion. Medicare has temporarily repealed the restriction, however, with notification from Medicare officials that this billing provision will be revisited, Collins points out.