Cardiology Coding Alert

Think you've got interventional coronary procedure coding beat? Think again. A dozen new National Correct Coding Initiative (NCCI) edits bundle additional vessel procedures, such as PTCAs and atherectomies, into primary coronary interventions.

But take heart: If you pay attention to these crucial new edits - which went into effect July1 - and remember your vessel-coding basics, you should receive the pay you deserve for your interventional coronary claims. 

Primary Stent Placement Includes 92981

When the physician places two coronary stents in separate coronary vessels, you should bill 92980 (Transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel) for the initial stent placement and +92981 (... each additional vessel) for stent placement in the additional vessel, according to CPT instruction and established coding methodology. One of the new edits, however, bundles the additional vessel code (92981) into 92980, which means that you would not report additional vessel stent procedures with the primary code. (For a synopsis of these new interventional procedure edits, see the chart on page 59.)

The remaining 11 edits may also surprise you, coding experts say. For instance, initial stent placement (92980) now includes +92984 for additional vessel percutaneous transluminal coronary angioplasties (PTCA), as well as +92996 (... atherectomy; each additional vessel [list separately in addition to code for primary procedure]), says Christie Okoro, billing supervisor for Island Wide Medical Associates, a multi-cardiologist group in Mineola, N.Y. She adds that she learned about the edits when she reported these codes to her local Medicare carrier.

The edits include all of the PTCA and atherectomy codes (92982, 92984, 92995 and 92996) as component codes of 92981 for additional vessel coronary stent placement. For example, if the physician places a stent in the left anterior descending artery (LAD) and performs a PTCA or atherectomy in an additional vessel, which is subsequently stented, you cannot bill for the PTCA or atherectomy in that vessel.

Code 92982 for PTCAs in initial coronary vessels now includes the work of 92984 - the add-on code that CPT specifies you should report for each additional vessel PTCA. Code 92995 (Percutaneous transluminal coronary atherectomy ... with or without balloon angioplasty; single vessel) for initial vessel atherectomies now includes 92984 for additional vessel PTCAs and 92996. Code 92996 for additional vessel atherectomy now includes the work of 92982 for initial vessel PTCAs and 92984 for additional vessel PTCAs.

Append Vessel Modifiers to Avoid Edit Violations
 
Although these coronary intervention edits may seem alarming, coding experts advise that the edits do not change CMS coding or payment policy. The bottom line: Don't forget vessel modifiers if you want to navigate these edits successfully.

Indeed, the key to accurately reporting multiple interventions, such as PTCAs and atherectomies, in separate vessels and avoiding edit violations is appending the appropriate HCPCS Level II coronary modifiers -RC (Right coronary artery), -LD (Left anterior descending coronary artery) and -LC (Left circumflex, coronary artery) to the procedure code to designate which vessels have interventions, says Jim Collins, CHCC, CPC, president of Compliant MD Inc. and compliance manager for several cardiology groups nationwide.

For instance, a cardiologist places a stent in the left anterior descending artery (LAD) and performs an atherectomy in the first septal perforator (a branch of the LAD). In the same session, he could perform another atherectomy in the left circumflex artery.  The most extensive procedure the physician performed would be the stent placement in the LAD, so you would report this with the base code 92980 and append the anatomic modifier
-LD, Collins says.

You would not report the atherectomy (92995) the physician performed in the branch of the LAD because the vessel is in the same main coronary branch, Collins says. You would separately report the atherectomy the physician performed in the left circumflex with 92996 and append the anatomic modifier -LC.  Even though this coding combination (92980 and 92996) unbundles one of the new NCCI edits, the anatomic modifiers -LD and -LC will allow carriers to adjudicate the claim, he adds.   

Note that 10 of the 12 interventional coronary edits have a "1" modifier indicator, which means that you can append an NCCI-approved modifier, such as -LC, -LD and -RC, to these codes and bill them without violating the edits.

But two edits have an indicator of "0," which means that you cannot report these codes together, even with a modifier. Specifically, you cannot report 92981 for additional vessel stent placement with 92982 for initial vessel PTCA. Also, you cannot bill 92981 with 92995 for initial vessel atherectomy. These two edits prevent the improper reporting of lesser-valued initial vessel codes (92982 and 92995) with a higher-valued additional vessel code (92981).

Instead, CPT guidelines specify that you should report the highest-valued intervention (stent placement) with the initial vessel intervention code (92980) and lesser-valued intervention (PTCA or atherectomy) with the code for each additional vessel intervention (92984 or 92996, respectively), Collins says.

Substitute Vessel Modifiers for Modifier -59

So what about using modifier -59 (Distinct procedural service) - the modifier most cardiology coders use when seeking payment for bundled services? "You should apply modifier -59 only when none of the other modifiers apply, and with coronary interventions this is simply not the case," Collins says.

For instance, you would append an anatomic modifier rather than modifier -59 when the physician performs coronary interventions in vessels - such as the left main coronary or the ramus - which are not one of the three main coronary vessels.

Be sure to follow the appropriate guidelines for assigning the intervention to one of the three recognized vessel modifiers (-LD, -LC, or -RC), Collins says. Specifically, if the physician performs the intervention in the left main coronary artery (which is located before the bifurcation that gives rise to the left circumflex and left anterior descending) you should report the intervention as being performed in the dominant of those two arteries, he says. In this case, the dominant artery is the left anterior descending.

When the physician performs an intervention in the ramus (a coronary vessel between the left anterior descending and the left circumflex in only a minority of patients), report the ramus intervention as if the physician actually performed it in the artery to which the ramus is most proximal, which could be the left circumflex.

For comprehensive instruction on billing diagnostic heart caths and coronary interventions, see the May 2003 Cardiology Coding Alert Extra.