Cardiology Coding Alert

Are your peripheral vascular (PV) coding methods out of date? Changes are coming down fast, and if you're still reporting nonselective catheter placement codes 36140 and 36200 with certain selective catheter placement codes, you'll experience denials. Here's how to avoid reimbursement losses.

Look to CPT Guidelines

CPT specifies under "Vascular Injection Procedures" that "selective vascular catheterization should be coded to include introduction and all lesser order selective catheterization used in the approach." This is a basic peripheral vascular coding convention, but many coders don't follow it and continue to report nonselective studies along with selective studies, coding experts say.

Examine Your Bilateral Studies Coding

Here's an illustration: Often, during PV studies, the cardiologist will image vessels with the catheter in both selective and nonselective positions. One common scenario is when the cardiologist performs a bilateral lower-extremity study from a femoral puncture site with the catheter tip positioned in each of the lower extremities.
 
Until now, you may have reported the nonselective catheter placement on the ipsilateral side (the punctured side) with 36140 (Introduction of needle or intracatheter; extremity artery), along with the appropriate selective catheter placement code (36245-36247) for the cath placement on the contralateral side (the extremity artery opposite the access point).
 
This coding approach had widespread acceptance, says Deb Ovall, CMA, CCS, CIC, lead coder and data quality analyst with Medical College Hospitals of Ohio at Toledo. Ovall, who trained two years ago on PV billing, says, "At that time, they stressed that it was OK to report the ipsilateral cath placement this way, and that 36140 ... should be used to indicate that the nonselective vessel was selected." But "the logic actually feels a little weak now," she says.

Review NCCI 9.3 PV Changes

By now, you know that the National Correct Coding Initiative (NCCI) edits, version 9.3, effective Oct. 1, 2003, bundled certain nonselective catheterization codes into selective catheterization codes, which changes the way you report these nonselective catheterizations performed with selective cath services, coding experts say. (See "Get the Lowdown on New Coronary Intervention, Pacer Bundles" in the November 2003 Cardiology Coding Alert for more on NCCI, version 9.3.)
  
Specifically, the 9.3 edits bundle 36140 into 36245 (Selective catheter placement, arterial system; each first- order abdominal, pelvic, or lower-extremity artery branch, within a vascular family), and 36200 (Introduction of catheter, aorta) into 36215 (Selective catheter placement, arterial system; each first-order thoracic or brachiocephalic branch), 36216 (... initial second-order thoracic or brachiocephalic branch), and 36217 (... initial third-order or more selective thoracic or brachiocephalic branch). These bundles close the gaps in NCCI that would permit billing nonselective catheterization codes with selective catheterization codes without a modifier, coding experts say.
 
Certain associations are challenging the edits. "We did receive a letter from CMS indicating that new NCCI edits were being created regarding this issue," says Dawn R. Hopkins, senior manager for reimbursement, Society of Interventional Radiology (SIR). "SIR and the ACR (American College of Radiology) will be opposing these edits and CMS' position regarding this issue," she says.

Append Modifier -59 With Caution

If you're routinely appending modifier -59 (Distinct procedural service) to your claims with selective and non-selective cath placements to override the edits, be careful. Although each of the edits listed above has an indicator of "1" (which means that NCCI-related modifiers will bypass the edits), in many cases appending modifier -59 is inappropriate and could expose you and your practice to liability.
 
Use modifiers in two situations: Specifically, you can use an NCCI-related modifier, such as modifier -59, to report NCCI column-one selective arterial catheterization codes and column-two code 36140 under two circumstances, according to a Dec. 10, 2003, letter from a CMS official to Cardiology Coding Alert:
 
1. The provider performs the nonselective catheterization and selective catheterization through two separate catheters introduced into two separate arteries.
 
2. The provider performs the nonselective and selective catheterizations at two separate patient encounters on the same date of service.
  
"CMS also thinks that if a provider performs a procedure along the path of a nonselective catheterization, followed by further advancement of the catheter to perform a selective catheterization, the provider should not bill for the nonselective catheterization since the catheter passes through the vessel in order to perform the selective catheterization," the CMS official adds.
 
In short, you can continue to apply modifier -59 when the physician performs selective and nonselective catheterizations from separate puncture sites or during separate operative sessions.