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Cardiology Coding Alert

IVUS and Diagnostic-Procedure Codes Can Be Billed Together

Published on Mon Apr 01, 2002

Cardiologists should not assume that reimbursement for intravascular ultrasound (IVUS), whether coronary or peripheral, is simple. Code descriptors were modified in CPT Codes 2000 so the codes could be added to diagnostic as well as therapeutic procedures. However, carriers have yet to revise existing policies and may restrict coronary IVUS to therapeutic procedures only and reject peripheral IVUS altogether.
 
IVUS is an imaging technique whereby an ultrasound transducer and a rotational mirror are mounted on a catheter tip, which is then inserted directly into the blood vessel. Images of the vessel's internal structure during cardiac catheterization, intervention (such as percutaneous transluminal coronary angioplasty, PTCA), atherectomy or stent placement are then produced.
 
IVUS is used in coronary and peripheral arteries to provide diagnostic and other information, including location, quantity and type of atherosclerotic plaque. It is also used to facilitate deployment of stents and other therapeutic devices, and assess treatment results.

Coding the Service

IVUS codes include +37250-+37251 (used for peripheral vessels) and +92978-+92979 (used for coronary vessels).
 
Note that all four codes are add-on codes, which means IVUS is not considered a payable service when performed on its own. It also means that the fee for IVUS should not be reduced as a multiple procedure, because the fees for add-on codes already reflect the fact that the service is performed with a primary procedure.
 
The codes designating work on additional vessels (+37251 and +92979) should only be reported with the codes designating work on the initial vessel (+37250 and +92978). Use +92979 if IVUS is performed in a vessel in another coronary branch.
 
Note: If the cardiologist interprets the images obtained during peripheral IVUS, 75945 (Intravascular ultrasound [non-coronary vessel], radiological supervision and interpretation; initial vessel) and +75946 ( each additional non-coronary vessel [list separately in addition to code for primary procedure]) may be billed with +37250 and +37251.
 
For example, if a stent is placed in the left anterior descending artery, a PTCA is performed in the left circumflex artery, and IVUS is performed in both coronary vessels, the session would be billed as follows:
 
92980 (Transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel)
 
+92984 (Percutaneous transluminal coronary balloon angioplasty; each additional vessel [List separately in addition to code for primary procedure])
 
+92978
 
+92979

Note: Code +92984 is correctly used when a second PTCA is performed on a second coronary vessel. Two "initial" interventions (for example, 92980 and 92982) cannot be billed during the same session.
 
If the stent is placed in the LAD and the PTCA is performed in the diagonal branch (an offshoot of the LAD), both the PTCA and the second IVUS are bundled and the session is billed as 92980 and +92978.
 
Peripherals are different, notes Tamara Shy, RHIA, a cardiology coding data specialist at William Beaumont Hospital in Royal Oak, Mich.
 
"Multiple peripheral interventions are not bundled. If an angioplasty and a stent of a peripheral blood vessel are performed, both may be reported separately. The same is true for IVUS," Shy says. Noting that most peripheral vessels are relatively small in comparison to coronary arteries, Shy says that each IVUS scan on a separate vessel (even in the same vascular family) may be reported separately as long as the cardiologist's documentation clearly notes the vessels involved. "If the cardiologist does not document the specific vessels that were imaged using IVUS, the service should not be billed," she says. "If the cardiologist documents that two vessels were scanned but does not specify the names of the vessels, we don't give credit for that, even though IVUS codes do not require HCPCS coronary modifiers."
 
Note: If an intervention is performed, HCPCS coronary modifiers should be appended to the appropriate PTCA, stent or atherectomy code. These modifiers include -LC (Left circumflex, coronary artery), -LD (Left anterior descending coronary artery) and -RC (Right coronary artery).

Obtaining Payment for IVUS

IVUS performed with a coronary intervention is likely to be paid if the procedure is documented and a valid diagnosis demonstrates medical necessity.
 
This is not the case for IVUS performed during a diagnostic coronary procedure or for any peripheral vascular IVUS, where carrier payment policies vary considerably.
 
A review of Medicare carriers' local medical review policies (LMRPs) indicates that many carriers continue to cover IVUS when performed with therapeutic coronary interventions only. When IVUS images are obtained during a heart catheterization, many carriers do not cover the service. For example, Cahaba Government Benefit Administrators (Part B carrier in Georgia) states that, "The use of diagnostic intravascular coronary ultrasound without therapeutic interventions (e.g., balloon angioplasty) is considered investigational. CPT codes +92978 and +92979 will be payable only when done in conjunction with a therapeutic procedure." None of the other Part B carriers with published LMRPs on IVUS have revised them to include left heart catheterizations or other diagnostic procedures.
 
The situation is much the same for IVUS on peripheral vessels: Most carriers consider the service "investigational" and do not cover it. However, at least one Part B carrier (HGSAdministrators in Pennsylvania) has revised its LMRP to cover peripheral IVUS in one specific circumstance.
 
Policy S-115C states that "Effective for dates of service on or after May 13, 2001, intravascular ultrasound of non-coronary vessels (codes +37250, +37251, 75945 and +75946) is considered investigational and, therefore, not medically necessary with the following exception: Intravascular ultrasound of non-coronary vessels is covered in the restricted setting of abdominal aortic aneurysms undergoing endograft repair where either (i) an unsupported endograft is being used; or (ii) the patient has renal insufficiency or renal failure. The above scenario must be supported in the medical-record documentation, which should be submitted with the claim for this service."
 
Note: Most Part B carriers do not have published LMRPs on IVUS. Information may be available in carrier bulletins or obtained by contacting the carrier.
 
Aetna U.S. Healthcare (a private payer) instructs physicians that coronary IVUS may be reported when performed with diagnostic procedures. Aetna coverage policy bulletin 0382 states that IVUS is covered "to evaluate the need for an intracoronary interventional procedure in a symptomatic patient whose angiogram shows 50 to 70 percent stenosis(es)." However, the policy also states that "the clinical application of IVUS in screening for coronary artery disease and its use in other non-coronary arterial procedures has not been validated by clinical studies and is not covered."
 
Carrier IVUS policies are likely to change, and services such as peripheral studies are likely to be covered by more payers in the future. Now, however, cardiologists have little choice but to contact their payers individually, explain why the IVUS is necessary, and obtain precertification whenever possible before the procedure is performed.
 
Belinda Inabinet, CPC, technical support manager and head of a coding team at South Carolina Heart Center, a 21-physician practice in Columbia, S.C., reports that although a couple of private payers have reimbursed for IVUS when performed with a heart catheterization, most do not. The local Part B carrier (Palmetto Government Benefit Administrators) does not have a policy, she notes. 
 
"In some ways, the lack of a policy can be a good thing," Inabinet says. "Without a policy, your Medicare carrier has less ammunition to use to deny the claim." She notes that there are no edits in the Correct Coding Initiative for IVUS and heart catheterizations, "so they should be payable if your carrier has not issued an LMRP stating otherwise."
 
Inabinet also notes that if there is documented medical necessity for the IVUS scan, Medicare denials should be appealed.
 
The same is true for peripheral IVUS. The Medicare Physician Fee Schedule indicates that +37250-+37251 are covered services (valued at 3.06 and 2.24 relative value units). Unless the carrier specifically rules out paying for this service in a medical review policy, the procedure should be paid, she says.

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