Cardiology Coding Alert

CMS ranks injections for coronary x-rays in the top 10 most performed cardiology diagnostic procedures, but that doesnt mean that these routinely used angiography codes dont present coding challenges. Correctly coding coronary x-ray injections depends on the origination site for the initial injection during cardiac catheterization, advise coding experts.

When documenting injection procedures, physicians shouldnt forget to include specifics on catheter placement, says Sandy Fuller, CPC, a cardiology coding and reimbursement specialist in Abilene, Texas. For instance, if the cardiologist injects into a venous bypass graft (93540), the documentation must show where the catheter went in, she advises. All too often, the notes for this procedure summarize the studys findings without stating directly that the vein bypass graft was injected.

Coders should also remember that they can report each injection code (93539-93545) only once per cardiac catheterization service, according to the American College of Cardiologys Guide to CPT 2002.

The key to proper injection coding is having access to documentation that clearly reports the exact catheterization insertion site, coding experts stress.

For instance, when reporting injections into the internal mammary arteries, you should apply 93539 (Injection procedure during cardiac catheterization; for selective opacification of arterial conduits [e.g., internal mammary], whether native or used for bypass).

Typically, you would use this code if the cardiologist performs the procedure to check the viability of the internal mammary artery prior to bypass surgery, Fuller explains. Technically, the physician does this by manipulating the catheter through the subclavian artery to the internal mammary where he or she performs the selective injection.

If the procedure includes both left and right internal mammary artery imaging, you would use 93539 only once, emphasizes Krista Dauphinee, CPC, coding and compliance coordinator with Northeast Cardiology Associates of Bangor, Maine.

Code 93543 (... for selective left ventricular or left atrial angiography) is part of the basic left heart catheterization procedure. The cardiologist would use the procedure to diagnosis a variety of heart problems, including left ventricular dysfunction, such as ventricular fibrillation and flutter (427.4).

You should report 93544 for aortography injections when imaging the aortic arch, Fuller observes. This procedure is helpful in locating saphenous vein grafts (33510-33516) and visualizing the ascending arch for possible aneurisms.

When injecting radiopaque material by hand in coronary angiography, use 93545. Texas carriers, such as Trailblazer, may allow you to report this code twice because the catheterization procedure involves switching catheters when changing from the coronary arteries on the left side of the heart to those on the right side, Fuller notes.

Even so, you should be careful to limit your use of 93545 to procedures that include left heart catheterization. For instance, if a patient has an electrode lead placed in a coronary sinus during an electrophysiological study (EP), the physician may inject dye to guide the lead to the correct location. Angiography performed for guidance is not separately payable because it is not considered medically necessary, coding experts advise.

CPT 2003, like the 2002 edition, specifies that you should use 93508 (Catheter placement in coronary artery[s], arterial coronary conduit[s], and/or venous coronary bypass graft[s] for coronary angiography without concomitant left heart catheterization) with angiography that does not also include left heart catheterization.

To code for a left heart catheterization (93510), the catheter must cross the aortic valve and go into the left ventricle. If the procedure does not include left ventricle entry, then you should apply 93508.

If after catheterization and injection a patient develops problems, such as chest pains, on the same day and needs another coronary injection, you would bill 93508 for reinjecting the coronary arteries, Fuller advises. You can bill 93508 more than once per day if there is an event that necessitates it, she confirms.

Use 93555 for imaging during both ventricular or atrial aortography and 93556 for imaging during all other injections, Fuller emphasizes.

Because injection codes 93539-93545 are physician work codes (the physician does the injection), you would not append modifier -26 (Professional component), Fuller explains. In addition, you should not add modifier -51 (Multiple procedures) to 93539-93545, according to CPT 2003.

However, situations can arise that require appending modifiers to 93539-93545. If a patient has to return to the catheterization lab on the same day after having a catheterization procedure, you would add modifier -76 (Repeat procedure by same physician) to the appropriate injection code if the same physician does the catheterization again, Dauphinee instructs. Add modifier -77 (Repeat procedure by another physician) to the appropriate injection code if another physician performs the repeat catheterization on the same day.

Some carriers also want you to append modifier -59 (Distinct procedural service) to 93545 (for selective coronary angiography) if the physician performs any intervention during the procedure, Fuller says. Often, insurers dont understand that you have to do catheterizations to identify problems, such as blockages, before you can fix them, and they tend to bundle catheterizations with intervention procedures, she notes. If youre encountering this problem, you should make clear to payers that catheterizations are separate diagnostic procedures and should not be considered part of the intervention. If youre not sure about appending modifiers, you should contact your payer, Fuller advises.