Cardiology Coding Alert

Watch out: You will still have problems with the reinstated policy, experts say

No more will you have to limit your cardiologist's peripheral vascular (PV) intervention to one vessel, when the initial intervention (for instance, stent, atherectomy and angioplasty) failed.

Many societies, including the American College of Cardiology, protested Medicare's bundling policy, and persistence paid off -- literally.

Niles Rosen, MD, Correct Coding Initiative (CCI) medical director, announced the change in an Aug. 6th letter to the Society of Interventional Radiology (SIR), AMA and coding consultant Stacy Gregory, RCC, CPC, of Tacoma, Wash.-based Gregory Medical Consulting Services, in response to letters about the controversial policy.

"This response is extremely significant because it provides an answer to the question many of us were left asking after Oct. 2007: Do we continue to bill for these services despite Medicare's revised guidelines in the hopes they will be reversed, or do we eliminate billing for angioplasty/atherectomy/stent in the same peripheral vessel as a result of this CCI policy?" Gregory says.

CCI Plugs In Old Verbiage

CCI will temporarily reinstate old language in the next release (version 14.3, published on Oct. 1, 2008). It will state:

"When percutaneous angioplasty of a vascular lesion is followed at the same session by a percutaneous or open atherectomy, generally due to insufficient improvement in vascular flow with angioplasty alone, only the most comprehensive atherectomy that was performed (generally the open procedure) is reported (see sequential procedure policy, Chapter I, Section M)."

Note: The change is retroactive to Oct. 2007. However, Gregory recommends a "wait and see" approach to following up and re-billing of claims.

"First, the change won't be effective until Oct. 1, so you need to wait to resubmit claims until after this date," Gregory says. "Also, I get the impression we have not heard the last about this issue from CMS and CCI, as the letter says CMS will temporarily reinstate the new paragraph. It seems like they are still in the process of finalizing their decision."

Indeed, the Aug. 6th letter indicates, "CMS remains concerned about this issue and has encouraged national healthcare organizations to work with other interested parties to address coding for reporting atherectomy, angioplasty and stenting in non-coronary arteries." Translation: Make sure to keep reading the Cardiology Coding Alert for updates.

You Won't Find All Good News

Be forewarned: This old policy remains problematic. In a sense, "we are back where we started; we have a vague policy that people will interpret in numerous ways," says Jim Collins, CPC-CARDIO, ACS-CA, CHCC, president of The Cardiology Coalition in Saratoga Springs, N.Y.

Like before, "this policy excerpt fails to address the deployment of stents; it only suggests you should not separately report an angioplasty if followed by percutaneous or open atherectomy," Collins points out.
 Even if the CMS policy fails to explain what to do for an angioplasty and stent placement of the same lesion, you still have standards to follow. "The medical record must establish that angioplasty was the the physician's primary intent," Collins says. "According to SIR, an angioplasty is not a viable primary intervention for the treatment of ostial renal lesions. The report must also establish that a sub-optimal result was identified and that it is what led to the doctor's decision to treat the lesion with a stent. These restrictions prevent us from billing for multiple interventions more times than not."