Cardiology Coding Alert

Prepare to change how you report blood imaging, MPI codes

When your cardiologist studies or scans a patient's heart, you'd better know how to report these codes in conjunction with other procedures. The National Correct Coding Initiative (NCCI) version 12.1 lays out dozens of new edits, and it's your responsibility to know whether you can use a modifier.

76350 Now Among NME Edits

NCCI removed any temptation you might feel to report 76350 (Subtraction in conjunction with contrast studies) with about 150 other codes, including cardiac MRI codes 75552-75555, aortography codes 75600-75790 and venography codes 75801-75891.

NCCI categorizes these edits as nonmutually exclusive (NME) and gives them a modifier indicator of "0," meaning that you may not use a modifier to break the edit and if you report a bundled pair together, payers won't reimburse 76350. 

These edits make sense, because you shouldn't be billing 76350 any longer, says Donna Richmond, CPC, RCC, a consultant with CodeRyte in Bethesda, Md.

Why? "Subtraction is a technique for removing images of bone and soft tissue so that all that remains in the picture is the vasculature," says Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga. Subtraction used to be a labor-intensive manual process, which is why CPT has a separate code for it, she says. Now, software performs subtraction, so your documentation is unlikely to support reporting 76350 legitimately. 

Common mistake: Many coders erroneously report 76350 for other types of image manipulation, such as CAD with a breast MRI, Miller says.

See How Your CT Coding Changes

If you're wondering about the new computed tomography edits, you're not alone. CT scan codes 71250-71275 all become components of new CT angiography codes 0144T-0150T, but you can override those edits with a modifier.

Rationale: "You're not supposed to be doing a CT of the chest as well as a CTA of the chest," says Jeff Fulkerson, BA, CPC, CMC, certified coder in the radiology department at Emory Health Care in Stockbridge, Ga. "Those should be few and far between."

But 71275 (Computed tomographic angiography, chest, without contrast material[s], followed by contrast material[s] and further sections, including image postprocessing) does reflect CTA of the chest (lungs, aorta, etc.)  In some cases, your cardiologist may have medical necessity to perform this study in addition to the new coronary CTA services (0144T-0150T). For this reason, these edits have a modifier indicator status of "1," meaning you can override the edit with a modifier (such as 59, Distinct procedural service).

Treat TEE as a Component to Cardio Surgery Codes

Transesophageal echocardiography code 93318 (Echocardiography, transesophageal [TEE] for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing [continuous] assessment of [dynamically changing] cardiac pumping function and to therapeutic measures on an immediate time basis) also becomes a component of 93600-93662, except for add-on codes. And 93318 becomes a component of all cardiovascular surgery codes from 33200 to 33261.
 
If, however, your cardiologist performs a TEE (93318) to assess a patient and later decides to upgrade the patient's pacemaker to a defibrillator, you can report the TEE separately. Be sure to apply modifier 59 to 93318 to demonstrate that the TEE was a separate study.

No Modifier Breaks Blood Imaging, MPI Edits

You won't be able to use a modifier to override edits bundling cardiac blood pool imaging codes 78472-78473, 78481-78483 and 78496 with myocardial perfusion imaging codes 78460-78465.

And you can't use a modifier to override edits that make multiple myocardial perfusion imaging studies code 78461 a component of multiple cardiac blood pool imaging studies codes 78473 and 78483.
 
Difference: Cardiac blood pool imaging (equilibrium) studies (78472-78473) are designed to image tagged red cells and evaluate the heart's function. The study normally yields ejection fraction and wall motion information.

With the first-pass add-on code (78496) you can also see right heart function, whereas the standard codes are for left heart function, Fulkerson says. In contrast, the MPI evaluates perfusion of the myocardium. With gated imaging, you can gather ejection fraction and wall motion information. You'd report this procedure with 78478 and 78480.

You shouldn't be reporting MPI codes (78464, 78465) together with equilibrium studies. The two tests are for differing information, Fulkerson says: "In fact, the only way you would be able to adequately do both on the same day would be to use Thallium 201 for the MPI imaging while using Tc99m-labeled compounds for the equilibrium studies. Since Thallium 201 is not routine, the preferred imaging agent to the tests would be less than optimum."

In a nutshell: If you're already injecting a radionuclide to see how it perfuses through the heart tissue, it doesn't make sense to inject a second radionuclide into the blood. You wouldn't be able to see anything, he says.