Cardiology Coding Alert

If the notes reference such details as the radiation dwell time, for instance, this helps confirm for carriers that the cardiologist actually performed the catheter radiation procedure, says Sheldrian Wayne, CPC, a cardiology coding specialist with Coding Strategies Inc. of Powder Springs, Ga.

Usually, cardiologists perform left heart catheterizations before brachytherapy to diagnose restenosis. When this occurs, report 93510 (Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous) for the left heart catheterization.

If the physician performs a left heart catheterization with bypass graft angiography, report 93540 (Injection procedure during cardiac catheterization; for selective opacification of aortocoronary venous bypass grafts, one or more coronary arteries).

Once the physician identifies the restenotic site, he will likely perform an angioplasty to reopen the site and then administer brachytherapy, says Happiness Miller, RN, an auditor with the cardiac catheterization lab in Central Baptist Hospital in Lexington, Ky.

If this is the case, report 92982 (Percutaneous transluminal coronary balloon angioplasty [PTCA]; single vessel) for a single vessel PTCAand add +92984 ( each additional vessel [list separately in addition to code for primary procedure]) for each additional vessel.

Next, add +92974 (Transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy [list separately in addition to code for primary procedure]) for the brachytherapy.

For instance, a 56-year-old male with a previously placed coronary stent comes in because of chest pain (786.50). The cardiologist first performs a left heart catheterization (93510) and detects restenosis in the stent. He next performs a PTCAin the stent (92982) and places a brachytherapy catheter across the lesion and delivers radiation therapy to the site (92974). The cardiologist would then bill for the left heart catheterization, angioplasty and brachytherapy treatment.

If the cardiologist administers intracoronary nitroglycerin during the angioplasty procedure, you should report 37202 (Transcatheter therapy, infusion other than for thrombolysis, any type [e.g., spasmolytic, vasocon-strictive]) for the nitroglycerin therapy.

For example, a patient comes in for recurrent chest pain three months after stent placement. During the heart catheterization procedure, the cardiologist finds 95 percent stenosis in the previously stented vessel. After administering 200 micrograms of nitroglycerin, he detects no change in the stenosis. In this case, you should report 37202 in addition to the codes for the left heart catheterization, the angioplasty and brachytherapy.

Many Medicare carriers, such as the National Heritage Insurance Company (NHIC), which provides coverage in several states, including Maine, Massachusetts, New Hampshire and Vermont, have recently issued local medical review policies specific to coronary brachytherapy.

Local carriers and third-party payers still consider the procedure experimental or investigational and may not have established payment guidelines yet, Wayne says.

Typically, Medicare carriers limit coverage to management of patient symptoms, such as chest pain (786.50) attributable to in-stent restenosis, confirms Cynthia Swanson, RN, CPC, a cardiology coding consultant with Seim, Johnson, Sestak and Quist in Omaha, Neb.

For instance, NHIC posts diagnoses supporting medical necessity for intracoronary brachytherapy, including the codes for acute myocardial infarction (410.00-410.92), other acute and subacute forms of ischemic heart disease (411.xx), old myocardial infarction (412), angina pectoris (413.x) and other forms of chronic ischemic heart disease (414.xx), and mechanical complication of unspecified cardiac device and graft (996.00).

Coders should check with their carriers and research information regarding Medicare claims on the LMRP Web site (www.LMRP.net) to verify coverage, Swanson says. If necessary, provide other carrier LMRPs to recommend revisions to existing local carrier medical policies, she adds.

If your state has intracoronary brachytherapy guidelines, "share the information with all applicable physicians and staff in your practice and bill according to the guidelines," Swanson emphasizes.