Cardiology Coding Alert

The 2007 physician fee schedule raises your 93571-93572 reimbursement dollars

If your cardiologist takes coronary blood flow measurements during coronary angiograms or cardiac catheterizations and you're not separately reporting it, you could be letting extra reimbursement slip away.

Did you know? The 2007 physician fee schedule raised the average payment for +93571 (Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement ... initial vessel) by 7.4 percent to $99.29, and the payment for +93572 (... each additional vessel) rose 6.8 percent to $77.31. But this good news won't mean much if you're missing out on ethical opportunities to bill these codes.

Tackle This Terminology

What happens: When a cardiologist takes a coronary blood flow measurement, he measures the difference in blood flow when the patient is resting and then when the patient is at pharmacologic exercise, which simulates physical exercise. 

In a normal patient, those coronary arteries will expand considerably to make a larger-caliber vessel. This allows more blood to flow from the aorta into the heart muscle so more oxygen and more nutrients are going to the heart muscle itself. If the patient has a ring of plaque inside of the coronary artery, that plaque ring won't allow that area of vessel to open up.

Thus, the cardiologist will go in and measure the amount of blood flowing through an area of stenosis when the patient is resting and then she will induce pharmacologic stress by injecting adenosine. That should trigger an immediate increase in the blood flow going through the artery, and by measuring how much the blood flow increases, the cardiologist can determine how much the blocked area has affected the patient.

What to look for: Physicians use various techniques that you can bill for using 93571-93572. Look for "slang terms" such as "pressure wire," "coronary flow reserve," "fractional flow reserve study" or "Doppler ultra-sonography" in your documentation. These all refer to a scan for coronary blood flow.

You can look for clues in your physician's documentation that he measured the coronary blood flow, says Cheryl Klarkowski, coding specialist with Baycare Health Systems in Green Bay, Wis. She keeps a list of the "slang terms" for coronary blood flow measurement in her CPT book next to 93571.

CMS Regularly Updates Primary Procedures

Get this: In the past, Medicare would pay for 93571-93572 only if the doctor repaired a coronary lesion in addition to scanning it. But since 2001, Medicare will pay for 93571-93572 with a coronary angiogram or cardiac catheterization, too.

Medicare regularly updates the list of "primary procedures" you can bill 93571-93572 with, Klarkowski says. You should keep a list of primary procedures for these codes.
"The payable list has changed since I originally started coding the flow wire," she says. "I would caution coders to keep the primary procedure list updated."

Good idea: Klarkowski sent information about these codes, along with a list of the primary procedures you can bill them with, to her cardiologists. The physicians are aware of the reimbursement, and they rarely, if ever, miss documenting this procedure, she says.

Get to the Bottom of These Guidelines

If your coronary blood flow coding wasn't confusing enough, the coding guidelines for 93571-93572 are unclear. The descriptor for 93572 refers to "each additional vessel." But whether each bifurcation or bypass is a new vessel (as would be the case with a peripheral intervention) or the whole coronary system only contains three "vessels" (as in coronary interventions) is not clear.

Solution: To bill for multiple coronary lesions, the physician should measure flow in different vessels. There are really only three separate coronary arteries and branches, says Christina Neighbors, MA, CPC, charge capture/reconciliation specialist with Franciscan Health System in South Puget Sound, Wash. But you won't find any identifiable CMS policies to substantiate this common rule of thumb.

Memorize this: The three vessels are the left anterior descending (LAD or LD), the left circumflex (LCX or LC), and the right coronary artery (RC), which includes the posterior ventricle branch, right posterior descending, acute marginal, right ventricle branch, conus and sinoatrial (SA) nodal.

Important: If you receive denials, you may need to try a different tactic. For instance, Klarkowski tried billing for 93571-93572 using the LC, LD and RC modifiers to indicate which primary vessel the cardiologist scanned. She received denials from her carrier for these claims. Now, she doesn't use a location modifier for the vessel scanned. Instead, she treats each vessel the cardiologist catheterized to measure flow velocity as either initial or additional.