Cardiology Coding Alert

Find out how cath and US changes affect your EPs

If you think you've got the whole story for this latest round of National Correct Coding Initiative updates, you'd better think again. As of April 1, you need to make sure you've got your stent, electrophysiology and moderate  sedation coding practices down pat--or you could find yourself landed with a denial.

1. Implement These Stent Changes

You'll have to be cautious when reporting intravascular stent codes because NCCI version 12.1 tacks on several new edits for codes 37215 (Transcatheter placement of intravascular stent[s], cervical carotid artery, percutaneous; with distal embolic protection) and 37216 (... without distal embolic protection).

For instance, 37207 (Transcatheter placement of an intravascular stent[s] [non-coronary vessel], open; initial vessel) now includes the work represented by both 37215 and 37216. If you try to report 37207 with either of these codes, you'll only be paid for 37207.
 
If you've got supporting documentation, you can separate this edit with a modifier (such as 59, Distinct procedural service). This would be appropriate, for example, when you are billing for peripheral vascular studies/interventions in vascular families that are distinct from the vascular family in which the cardiologist is placing the carotid stent.  

Bonus: You'll also find that 37215 is now a component of 37216. In most cases, your cardiologist will use distal embolic protection (37215) alone. But when the cardiologist stents both carotid arteries, you may have a situation in which he treated one with distal embolic protection (37215) and the other without distal embolic protection (37216).

In that case, report both codes with modifier 59 attached to 37215 to bypass the NCCI edit. Remember: If your cardiologist treated both carotid arteries with the same approach, you should list the same code (either 37215 or 37216) on your claim with a unit measurement of 2.

NCCI also includes the peripheral procedures 34812, 34820, 34834, 35201, 35261, 36620, and 36625 into 37215-37216. You can also separate these codes with a modifier, should your documentation warrant the use of one.

2. Electrophysiology Not Immune to 12.1

Your electrophysiology codes did not pass unnoticed under NCCI 12.1's radar.

Cardiac catheterization codes 93508-93533 and 93541-93556 all become components of every code in the Intracardiac Electrophysiological Procedures/Studies section (93600-93662), except for add-on codes and evaluation code 93660.

Rationale: This makes sense because "most of the listed heart catheterization codes occur on the left side of the patient's heart, while the EP study codes listed take place on the right side of the patient's heart," says Jim Collins, ACS-CA, CHCC, CPC, CEO of the Cardiology Coalition in Matthews, N.C.

Also, a slew of edits bundle ultrasound guidance codes 76986 (Ultrasonic guidance, intraoperative) and 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) into various implant procedures. 

For example, 33200 (Insertion of permanent pacemaker with epicardial electrode[s]; by thoracotomy) now includes the work of 76986. Your cardiologist would probably never perform these procedures in conjunction, because Medicare lists these edits under "Misuse of column 1 with column 2 code."

But if you cardiologist does perform these procedures and they are during separate sessions or on different sites from one another, you can separate the edit with a modifier (such as modifier 59 on 76986). Make sure your documentation backs up this modifier.

3. How NCCI Handles Moderate Sedation Codes
 
So far, no Medicare carriers have decided to pay for the new moderate sedation codes (99143-99149). That hasn't stopped NCCI 12.1 from applying new edits to 99143-99149 just in case.

For instance, you need a modifier to bill for moderate sedation along with any E/M codes. Remember: You should append a modifier (such as 25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, not the moderation sedation code, when your cardiologist sees the patient for an unrelated condition, such as sleep disorders.

"These edits are really no surprise because they are all listed in Appendix G of your CPT book. Also, each code has a symbol next to it that indicates it includes moderate sedation," Collins says. The only tricky part is making the distinction between those with a "0" status indicator and those with a "1."

A status indicator of "0" means that the bundle cannot be broken under any circumstances, says Paula Okano, CPC, a medical biller for Retina Associates of Hawaii in Honolulu.

For example, you cannot under any circumstances use a modifier to separate edits such as the one that includes 99143 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological  status; under 5 years of age, first 30 minutes intra-service time) with the insertion of a pacemaker (33206, Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial). This edit has a modifier indicator of "0."

But if your cardiologist performs the work represented by 99149 (Moderate sedation services [other than those services described by codes 00100-01999], provided by a physician other than the healthcare professional performing the diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 minutes intra-service time) at a different session on the same day as an ECG (93000, Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report), you should append a modifier (such as 59, Distinct procedural service) onto code 93000.