Cardiology Coding Alert

Watch out for edits with modifier indicators of '0'--you can't separate them

You'll have to modify the way you've been reporting electrophysiology (EP) procedures, intravascular stents and 3-D imaging codes thanks to a slew of edits included in the National Correct Coding Initiative (NCCI), version 12.0.

Be Cautious When Reporting 93501 With EP Codes

NCCI 12.0, effective Jan. 1 through March 31, bundles the right heart catheterization code (93501) into many intracardiac electrophysiological procedure/study codes (93600-93603, 93610-93612, 93615-93619, 93624-93652).

All of these edits have a modifier indicator of "1," meaning you can add a modifier to separate them (such as 59, Distinct procedural service) if your cardiologist performs the services during separate sessions or on separate sites.

"This makes sense because the cardiologist needs to place multiple electrode-tipped catheters into the area to perform an electrophysiological procedure," says Sandy Fuller, CPC, compliance officer at Cardiovascular Associates of East Texas in Tyler.

Follow CPT Advice for New Endovascular Repair Codes

The CPT manual provides great guidance in the new section for "Endovascular Repair of Descending Thoracic Aorta" about which codes 33880-33891 do and don't include, so any NCCI edits that re-emphasize this guidance aren't a huge surprise, says Rhena Burge, a cath lab coding and billing analyst at North Oaks Medical Center in Hammond, La.

Example: CPT says that you cannot report 33880 (Endovascular repair of descending thoracic aorta [e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption]; involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension[s], if required, to level of celiac artery origin) or 33881 (... not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension[s], if required, to level of celiac artery origin) along with 33886 (Placement of distal extension prosthesis[es] delayed after endovascular repair of descending thoracic aorta).

NCCI 12.0 adds this edit to reaffirm this advice. Code 33886 is now a component to both comprehensive codes 33880 and 33881. You'll see that the modifier indicator is "0," meaning that you cannot separate this edit with a modifier--even if your cardiologist performs the services on distinctly different anatomic regions or during separate sessions.

Similarly, each of these codes (33880 and 33881) now include 35452 (Transluminal balloon angioplasty, open; aortic) and 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). These edits, however, have a modifier indicator of "1," meaning that you can separate them with a modifier--as long as you have the supporting documentation.

The same goes for the edits that make 35452 and 76942 components of the other endovascular repair codes 33883-33886. They also have a modifier indicator of "1."

Note: For more information, see "CPT 2006 Update: Start Your Year Ready to Code Endovascular Repairs" in the January 2006 Cardiology Coding Alert.

Stop and Consider When Coding Stents

The intravascular stent codes 37215 (Transcatheter placement of intravascular stent[s], cervical carotid artery, percutaneous; with distal embolic protection) and 37216 (... without distal embolic protection) now have an array of component procedures, care of NCCI 12.0.

You'll have to be extra cautious if you're reporting 37215 along with therapeutic, prophylactic and diagnostic injections and infusions (90760, 90765, 90772, 90774 and 90775). In the case of 37215, you should also think twice before reporting it alongside 37184 (Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection[s]; initial vessel).

A cardiologist may not always perform all these procedures together--the stent (37215), the thrombectomy (37184), intravenous infusion (such as 90760, Intravenous infusion, hydration; initial, up to 1 hour), or therapeutic injection (such as 90774, Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; intravenous push, single or initial substance/drug)--but "it does happen," Fuller says. "We had to use an unspecified-procedure code (37799, Unlisted procedure, vascular surgery) until now."

In this case, you should report only the stent code to cover all the other services--unless you have documentation supporting the use of a modifier. Example: If your documentation states that the cardiologist places a stent in a vessel (37215) and performs the thrombectomy in a different vessel (37184), you should report both codes with modifier 59 attached to 37184.

Take Note of These 3-D Edits

You have several new "0" modifier indicators to worry about when you're reporting the 3-D imaging codes 76376 (3-D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation) and 76377 (... requiring image postprocessing on an independent workstation).

NCCI include codes 76376 and 76377 in the work of:

• 75635--Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, radiological supervision and interpretation, without contrast material(s), followed by contrast material(s) and further sections, including image post-processing

• 75945--Intravascular ultrasound (non-coronary vessel), radiological supervision and interpretation; initial vessel.

NCCI 12.0 states that you should include these codes in other services as a standard of medical/surgical practice--and you cannot separate them out by using a modifier, no matter what.

These two imaging codes are also components of:

• 93924--Non-invasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study 

• 93965--Non-invasive physiologic studies of extremity veins, complete bilateral study (e.g., Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography).

In both of these cases, however, a "1" modifier indicator allows you to separate these codes if you have the supporting documentation.