Cardiology Coding Alert

Learn what good news you can apply to your E/M coding practices

The overriding trend for NCCI version 13.0 is bundling the new epicardial implant and operative tissue ablation codes into tons of cardiology procedures -- but you need to know which ones, and now. You have no grace period.

Tackle These Temporary Pacemaker Edits

If you use temporary pacemaker implant codes 33210 (Insertion or replacement of temporary transvenous single-chamber cardiac electrode or pacemaker catheter [separate procedure]) or 33211 (Insertion or replacement of temporary transvenous dual-chamber pacing electrodes [separate procedure]), you shouldn't miss this.
 
The National Correct Coding Initiative bundles both these codes into the new epicardial placement codes 33202 (Insertion of epicardial electrode[s]; open incision [e.g., thoracotomy, median sternotomy, subxiphoid approach]) and 33203 (... endoscopic approach [e.g., thoracoscopy, pericardioscopy]) as well as the new operative tissue ablation procedure codes (33255-33256, 33265-33266).

Heads up: You can use a modifier to separate these edits, except for the ones bundling 33210-33211 into the operative tissue ablation codes (33255-33256, 33265-33266) because these edits have a "0" modifier status.

Keep in mind: When an edit pair has a modifier indicator status of "1," this means you can separate it using a modifier (such as 59, Distinct procedural service) -- as long as you have supporting documentation. When the modifier indicator is "0," you cannot separate the edit under any circumstances.

Example: A patient presents to the emergency department with extreme symptomatic bradycardia. The cardiologist must place a temporary pacemaker until he can insert a pacemaker with epicardial leads later in the day. In this case, you should report either 33202 or 33203, depending on the cardiologist's approach, and 33210-59 for the temporary pacemaker. 

"If your documentation supports the physician doing services above and beyond, then I would use a modifier to bypass the edit and see if the claim will be paid. Appeal it if necessary," says Rebecca Lopez, CPC, certified coder for Bright Medical Associates in Whittier, Calif.

Educate Yourself on Epicardial Electrode Edit

Similarly, the new epicardial code 33202 now includes the work represented by 33215 (Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator [right atrial or right ventricular] electrode).

NCCI includes the rationale for this edit as "a standard of surgical practice," meaning that when your cardiologist implants an epicardial electrode, he'll also reposition the previously implanted pacemaker. This edit has a modifier indicator of "1," however, so you can separate it with an appropriate modifier.

Example: If your cardiologist repositions one electrode intracardiac but also places another epicardially, you should report both 33202 and 33215-59, says Jim Collins, CPC, ACS-CA, CHCC, president of The Cardiology Coalition in Matthews, N.C.

Watch out: If you don't have the documentation to demonstrate that these two procedures involved different placement methods, your payer will likely pay only 33202.

You Can Use Modifier for TEE Edit

The only echocardiography code affected by NCCI 13.0 is 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). This code is now a component of new epicardial electrode implant codes (33202-33203) and operative tissue ablation codes (33254-33256).

If you reported 33255 (Operative tissue ablation and reconstruction of atria, extensive [e.g., maze procedure]; without cardiopulmonary bypass) as well as 93318, your payer will only reimburse 33255. You can use a modifier to separate this edit, but you must have documentation to support the separate and distinct nature of the TEE service.

Get This Mutually Exclusive Pair Down Pat

You'll have to pause before trying to report thrombectomy (36870, Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft [includes mechanical thrombus extraction and intra-graft thrombolysis]) alongside a thromboendarterectomy code (35302-35305). NCCI characterizes these procedures as "mutually exclusive."

Did you know? "A thrombectomy is a removal of thrombus (or blood clot) from a blood vessel, while a thromboendarterectomy is a removal of thrombus (or blood clot) from a vessel with excision of the inner lining of the artery," says Jerome Williams Jr., MD, FACC, a cardiologist with Mid-Carolina Cardiology in Charlotte, N.C.

Heads up: Mutually exclusive edits pair procedures that a cardiologist would not reasonably perform at the same session, on the same anatomic location or on the same beneficiary. If you were to report both of these services, Medicare would only pay for the lesser valued of the two procedures.

But you can separate these edits with a modifier if you have the necessary documentation to support it.

New Operative Ablation Codes Get Slammed

You should be aware that NCCI 13.0 bundles the new operative tissue ablation codes (33254-33256) into a slew of open chest procedures. "This is in line with CPT's contradictory guidance to bill these procedures with an unlisted-procedure code when the cardiologist performs the procedure with another procedure requiring open chest access," Collins says.

According to CPT, when your cardiologist performs 33254-33256 "with a concurrent procedure that requires a median sternotomy or cardiopulmonary bypass, report the operative (nonthoracoscopic) electrophysiologic procedure with unlisted-procedure code 33999 (Unlisted procedure, cardiac surgery)."

All of these edits have a modifier indicator status of "0," meaning you cannot separate them using a modifier under any circumstances.

Infusion, Injection Procedures Not Spared

Code 36000 (Introduction of needle or intracatheter, vein) has a few more edits, thanks to NCCI 13.0. This code is a component of the new epicardial implant codes (33202-33203) as well as the new operative tissue ablation codes (33254-33256, 33265-33266). "This just appears to be business as usual," Collins says. All of these edits have a modifier indicator of "1," meaning you can separate them with a modifier if your documentation supports one.

Along similar lines, check out the new edits for 36410 (Venipuncture, age 3 years or older, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes [not to be used for routine venipuncture]). Like the edits for 36000, this code is a component of new epicardial implant codes (33202-33203) as well as the new operative tissue ablation codes (33254-33256, 33265-33266). These also have a modifier indicator of "1."

The same goes for 37202 (Transcatheter therapy, infusion other than for thrombolysis, any type). NCCI 13.0 applies the exact same edits and the exact same "1" modifier indicator.

Also affected by NCCI 13.0 is 36005 (Injection procedure for extremity venography [including introduction of needle or intracatheter]). This code is now the component of the entire Pacemaker or Pacing Cardioverter-Defibrillator section (33202-33249); 36550-36598; arterial codes 36600-36660, 36800-36870, 37201, and 37205; as well as a slew of common radiology procedures. Don't forget that 36005 is now a component to category III CTA cardiac codes 0145T-0150T. Without exception, all of these edits have a modifier indicator of "1."

NCCI 13.0 makes infusion and injection codes 90760-90775 components of the new epicardial implant codes (33202-33203), new operative tissue ablation codes (33255-33256, 33265-33266) and category III CTA cardiac codes 0145T-0150T. Without exception, all of these edits have a "1" modifier indicator.

In other words: If you were to report any two of these codes, such as one of the epicardial electrode implant codes (33202-33203) with 90760 (Intravenous infusion, hydration; initial, up to 1 hour), without a modifier and supporting documentation, Medicare would pay you only for the epicardial electrode implant code.

Don't Miss E/M Edits

If your cardiologist believes he can appropriately bill for ventilator assist and management (94002-94005) as well as an E/M code and receive reimbursement for both, then NCCI 13.0 is here to prove him wrong. Codes 94002-94005 are now components of all E/M codes -- and you can't use a modifier to separate them.

There's good news: Because of an NCCI 13.0 deletion, you can now bill initial nursing facility care (99304-99306) on the same day as attendance-at-delivery services (99431-99432) or newborn resuscitation (99440) and collect reimbursement for both services.