Cardiology Coding Alert

Get the lowdown on coding native vessel intervention followed by a graft service.

If you want to see what’s new in the Jan. 1, 2013, Correct Coding Initiative (CCI) policy manual, all you have to do is look for the red text marking the changes. One of the revisions sure to draw your eye features guidelines for the new percutaneous coronary intervention (PCI) codes. Below is a review of this new policy’s main points.

1 Code Is All You Need for Same-Vessel Services

The new CCI policy manual entry begins by explaining the services included under the term PCI. It also explains that the new codes may include multiple PCIs in a single code.

CCI Excerpt 1: “Percutaneous coronary artery interventions (PCI) include stent placement, atherectomy, and balloon angioplasty. There are CPT® codes describing various combinations of these PCI procedures.”

The “combinations” concept is an important one for proper use of the new codes. For instance, if you compare the two codes below, you’ll see that CPT® clearly defines which PCI procedures are included in the codes (bold added):

·         92924, Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed …

·         92933, Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed …

As the code definitions show, a single code is sufficient to report multiple PCI services. This was a point stressed in the “Medicine: Cardiology Procedures/Services” presentation by Kenneth P. Brin, MD, PhD, FACC, of the American College of Cardiology and CPT® Editorial Panel Vice Chair, at the CPT® and RBRVS 2013 Annual Symposium: “All interventions in a major vessel itself (including proximal, mid, and distal vessel) are reported with one PCI code (report the highest service level of intervention performed).”

Add LM and RI to Your Coronary Modifier Arsenal

The next sentence in the CCI policy addresses a noteworthy development for PCI coding. In 2013, CMS recognizes five major coronary arteries. In 2012, only three were recognized for coding and payment purposes.

CCI Excerpt 2: “There are five major coronary arteries (left main, left anterior descending, left circumflex, right, and ramus intermedius).”

To clarify, in 2012 CMS recognized the left anterior descending (LAD), the left circumflex (LCX), and the right coronary (RCA) arteries for payment purposes. To identify these vessels on your claim, there were three modifiers to choose from:

·         LD, Left anterior descending coronary artery

·         LC, Left circumflex coronary artery

·         RC, Right coronary artery.

Consequently, in 2012 there was not a way to code and bill separately for the left main and ramus intermedius. You typically had to use modifier LD or code based on the closest vessel, says Marchelle Cagle, CPC, CPC-I, CMOM, PCS, of Alabama-based Cagle Medical Consulting. For instance, if the LAD was the dominant downstream branch for the left main, you would have appended modifier LD for a stent in the left main.

In 2013, CMS recognizes the left main and the ramus intermedius as major coronary arteries, in addition to the LAD, LCX, and RCA. As a result, you have two additional modifiers to choose from:

·         LM, Left main coronary artery

·         RI, Ramus intermedius coronary artery.

So now you can code and bill LM and RI services in addition to services on the other major vessels, such as the LAD, says Cagle. The new HCPCS modifiers take “a lot of guess work out of coding for these procedures and give more clarification on the use of the modifiers,” she adds. And because the new coding scheme is a better match to clinical practice, you should have fewer problems with denials.

Smart move: Work with your physicians to be sure their documentation supports the more specific PCI codes, says Cagle. For instance, the physician should document the termination points for catheters and be specific about which interventions are performed in which vessels and branches. For coding purposes, “there are two coronary branches of the left anterior descending (diagonals), left circumflex (marginals), and right (posterior descending, posterolaterals) coronary arteries. For reporting purposes, there are no recognized branches of the left main and ramus intermedius coronary arteries,” the CCI manual states.

Give Graft Services Separate Code

The next excerpt from the CCI manual addresses reporting PCI on a second vessel segment through a graft.

CCI Excerpt 3: “Only one PCI code may be reported for all PCIs of a major coronary artery through the native circulation. However, PCI treatment of a different second segment of a major coronary artery through a bypass graft may also be reported with a different PCI code for revascularization treatment through a coronary artery bypass.”

Excerpt 3 repeats the point made in Excerpt 1 that you need only one code to represent multiple PCI services in a major coronary artery. But Excerpt 3 goes further and explains that you may report a second code if additional PCI is performed in the same vessel through a bypass graft.

CPT® 2013 guidelines offer additional guidance: “If one segment of a major coronary artery and its recognized branches is treated through the native circulation, and treatment of another segment of the same vessel requires access through a coronary artery bypass graft, an additional base code is reported to describe the intervention performed through the bypass graft.”

Example: The physician performs angioplasty of one segment of the LAD. He then approaches a separate LAD segment through a left internal mammary artery graft and again performs angioplasty. You should report 92920-LD (Percutaneous transluminal coronary angioplasty; single major coronary artery or branch) for angioplasty in the native circulation and then for the service via graft access, you should report 92937-LD (Percutaneous transluminal revascularization of or through coronary artery bypass graft [internal mammary, free arterial, venous], any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel).

Note that both codes are base codes, rather than a base code and add-on code. This is important because, as explained in the “MPFS” box in this issue, Medicare will not reimburse you for the new add-on codes.

Start the CCI Manual Review in Chapter 11

The CCI manual version that’s effective Jan. 1, 2013, is available from the Downloads section at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. To locate the new PCI policy, open the PDF for Chapter 11, which features policies for codes in the 90000 range. Then scroll through the pages until you reach section I.14.