Cardiology Coding Alert

Hint: Policies you create for your practice should include growing technologies.

Technology is ever changing, which means you have to be ready to adapt your coding, too. Consider the example of catheter-based angiography and the advances of computed tomography angiography (CTA). Do you know how to capture this futuristic service? Find out.

Follow CCI Edits Manual and CPT^® Guidance for CTA

The CCI Edits manual specifically references both fluoroscopic and CT diagnostic angiography when it talks about how to report diagnostic and interventional intravascular procedures.

“If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology,” says the CCI Edits manual in Chapter 9, Section D, “Interventional/Invasive Diagnostic Imaging.”

Also, if the medical documentation proves that the second angiogram was medically necessary, the same cardiologist performs the diagnostic angiography on the same date of service as the intervention, and the service meets the criteria as specified in the CPT^® guidelines, you must append modifier 59 (Distinct procedural service) or CMS modifier XU (Unusual non-overlapping service) to the diagnostic and radiological supervision codes you report, according to both CPT^® and the 2017 CCI Edits policy manual. You must add modifier 59 or XU to override the edits with the interventional service and mark the diagnostic service as distinct.

CPT^® adds that if the cardiologist has to repeat only a part of the angiogram, you would append modifier 52 (Reduced services), in addition to modifier 59 or XU.

Breakdown: The CCI manual says, “If the prior diagnostic angiogram (fluoroscopic or computed tomographic) was complete, the provider should not report a second angiogram for the dye injections necessary to perform the percutaneous intravascular interventional procedure.” This idea essentially restates CPT®’s rule that you shouldn’t report a diagnosis code for angiography related to the therapeutic service.

You can read the CCI Edits policy manual in its entirety here: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/.

See Need for Clear Policy Regarding Growing Technologies

Practices should write a policy procedure stating when it’s appropriate to code both a diagnostic angiogram prior to the intravascular intervention after the cardiologist performed a CTA, according to Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions, Coding Quality & Education Department. You should be sure to include catheter-based angiography in your policy, as well.

“Many facilities have begun to provide non-invasive diagnostic procedure prior to invasive diagnostic/interventional procedures,” says Neighbors.

Neighbors also advises including magnetic resonance angiogram (MRA) in your policy because doctors are ordering the test with increasing frequency.

You should apply the same rule to MRA as CT or a previous angiogram, agrees Jim Pawloski, BS, MSA, CIRCC, R.T. (R)(CV),  interventional radiology technologist/coder at William Beaumont Hospital in Royal Oak, Mich., and coder at Adreima in Phoenix, Ariz.

According to Neighbors, oftentimes, the history and physical (H&P) plan of care, discussion, or order contradicts the medical necessity, because the physician documents statements like ‘Heart catheterization with possible intervention,’

‘Mesenteric arteriogram with possible intervention,’ or ‘Abdominal and bilateral lower extremity arteriogram with possible intervention,’ these statements provides probability of a catheter-based arteriogram prior to the possible intervention,” says Neighbors.

“Other examples are: When the H&P specifically states a pre-operative CT angiogram was provided with finding of a.,

b., and c. Then under the discussing/summary, the physician states, ‘The patient had a CT angiogram, which identified a.,
b., and c. with a statement of repeat coronary arteriogram or heart catheterization is recommended with possible intervention’ without new indications or reasoning to support an additional diagnostic arteriogram.”

Takeaway: The policy you create for your office should say that if the physician has angiography (catheter-based, CTA, MRA, etc.) with specific findings and goes on to recommend repeat angiography, there needs to be documentation of new indications or a reason the repeat needs to be performed. If no indications support doing the repeat, the policy should state that the coder cannot report the repeat.

Check Out This Sample Policy Checklist

Your practice’s ideal policy should meet certain requirements, according to Neighbors:

“We need the physicians to specifically state the following criteria,” says Neighbors:

• No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, or
• A prior study is available, but as documented in the medical record: The patient’s condition with respect to the clinical indication has changed since the prior study, or
• A prior study is available, but as documented in the medical record: There is inadequate visualization of the anatomy and/or pathology,” or
• A prior study is available, but as documented in the medical record: There is a clinic change during the procedure that requires new evaluation outside the target area of intervention.

“It really doesn’t matter what modality was used,” says Pawloski. “If you have a diagnostic exam, you cannot bill for a second diagnostic exam, unless there is documentation that a change has occurred.”