Cardiology Coding Alert

You know you shouldn't report nonselective catheterization in addition to selective catheterization during peripheral vascular procedures, but now NCCI is making it official.
 
The latest National Correct Coding Initiative (NCCI) edits, which went into effect Oct. 1, bundle certain nonselective codes into selective cath procedures.
 
Specifically, the edits designate nonselective cath code 36200 (Introduction of catheter, aorta) as a component of selective cath codes 36215-36217. So, you shouldn't bill 36200 with 36215-36217 for selective catheterization of first-, second-, and third- order thoracic or brachiocephalic branch arteries.
 
The edits also indicate that you should not report 36140 (Introduction of needle or intracatheter; extremity artery) with 36245 (Selective catheter placement, arterial system; each first-order abdominal, pelvic, or lower-extremity artery branch ...) when the cardiologist performs selective catheterization procedures below waist level. NCCI bundled 36140 into 36215-36217 prior to version 9.3, so this edit further limits your reporting of nonselective extremity-artery cath insertions with selective extremity-artery placements, coding experts say.
 
Although the edits bundle 36200 into 36215-36217, and bundle 36140 into 36245, the status indicator for both edits is "1," which means you can append a modifier, such as modifier -59 (Distinct procedural service), to the nonselective and selective cath codes to override the edit, if appropriate.
 
For example, a cardiologist may perform a nonselective study such as abdominal aortography through the right femoral artery, and an unrelated selective study such as a carotid angiogram, through another puncture site, such as the brachial artery, says Jerome Williams Jr., MD, FACC, a cardiologist with Mid Carolina Cardiology in Charlotte, N.C.
 
In this situation, you would report 36200-59 separately for the nonselective study through the femoral artery puncture site and 36215 for the selective placement in the carotid artery through the brachial insertion site.

Coronary Interventions Include Selective Caths

Intervention codes for coronary stents, angioplasties and atherectomies now include even more selective cath procedures.
 
In general, these new edits bundle a collection of 10 cath placement codes (36120, 36140, 36160, 36200, 36215, 36216, 36217, 36245, 36246 and 36247) into each of the base intervention codes (92980, 92982 and 92995), says Jim Collins, CHCC, CPC, a cardiology coding consultant and president of Compliant MD Inc.
 
Specifically, selective catheter placement codes 36215-36217 and 36245-36247 are now components of 92980 (Transcatheter placement of an intracoronary stent[s]), 92982 (Percutaneous transluminal coronary balloon angioplasty; single vessel) and 92995 (Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; single vessel).
 
The edits also bundle 36160 (Introduction of needle or intracatheter, aortic, translumbar) into 92980, 92982 and 92995. Codes 92982 and 92995 include 36120 (Introduction of needle or intracatheter; retrograde brachial artery). And 36140 (... extremity artery) is a component of 92995 alone.
 
All of these edits have a "1" status indicator, which means you can override the edit, as appropriate, with an NCCI-approved modifier.
 
Even so, using modifier -59 to override the selective studies edits will likely attract increased Medicare scrutiny, says Christie Okoro, billing supervisor for Island Wide Medical Associates, a multi-cardiologist group in Mineola, N.Y. Medicare requires specific medical necessity for extra vessel study interventions, she says. So you should look carefully at the report to ensure that the ordering physician documents the reason for extra vessel studies with a cardiac catheterization, she adds.
 
You will not be able to override another group of injection code edits, which all have a "0" status indicator: Stent code 92980 now includes injection codes 90782-90784, and both 92982 and 92995 incorporate 90782-90783.
 
Indeed, these edits indicate an NCCI trend toward moving more and more secondary procedures, such as selective caths and additional balloon angioplasties, into initial intervention codes such as 92980 for coronary stent placement.
 
In July, NCCI version 9.2 also bundled several intervention codes such as 92984 for additional-vessel percutaneous transluminal coronary angioplasties (PTCA) into initial procedure codes 92980, 92982 and 92995. (See "Initial Coronary Interventions Bundle Additional Vessel Work: What You Need to Know" in the August 2003 Cardiology Coding Alert.)
 
Expect these new edits to increase your administrative burden when billing for situations in which cardiologists perform coronary and selective peripheral studies during the same session, Collins says.

Watch for Fluoro, Pacer Repositioning Bundles 

Keep an eye on how you bill pacers and cardioverter defibrillators: You won't be able to report some fluoroscopy or electrode repositioning codes with most pacer/cardioverter-defib procedure codes. 
 
Fluoroscopy codes 76000-76001 and 33215 (Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator [right atrial or right ventricular] electrode) for lead repositioning became components of virtually all pacemaker and implantable cardioverter defibrillator procedure codes (33200-33224 and 33233-33249).
 
The fluoro codes are also bundled into 26 other cardio codes, including each of the three base coronary intervention codes (92980, 92982 and 92995), many heart cath codes, and almost every electrophysiology code, Collins says. You can bill 76000-76001, however, with the following seven pacemaker procedure codes: 33222-33223, 33236-33238 and 33240-33241.  
 
Code 33207 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; ventricular) includes 76001 but not 76000, Collins says.
 
Cardiology practices are using 71090 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation) rather than 76000-76001 for pacemaker procedures, so these fluoro edits shouldn't significantly affect your coding for these services, Collins says. The fluoro edits have a "1" indicator, so you can use a modifier to override them.
 
And, the new repositioning code (33215) is now a component of nearly all the pacemaker and defibrillator implant codes, with only three exceptions: You can report 33215 with 33212 for pulse generator insertion or replacement, 33213 for dual-chamber pulse generator insertion or replacement, and 33226 for left ventricular lead repositioning, Collins says.
 
And 33215 becomes mutually exclusive with 33226 (Repositioning of previously implanted cardiac venous system [left ventricular] electrode). As of NCCI 9.2, code 33215 was already mutually exclusive with several codes for pacer or defibrillation procedures - 33206, 33207, 33208, 33214, 33216, 33217, 33234, 33235 and 33249.

Pacer Edits Exclude Modifiers

Don't expect to override most of the repositioning edits with a modifier. All but two codes have an indicator of "0," which means the 33215 edits can't be bypassed, Collins says. You can use a modifier to unbundle 33215 with new left ventricular pacing codes 33224 and 33225, which have a "1" indicator.