Cardiology Coding Alert

 Home in on where the intervention actually takes place

The more you practice coding for peripheral vascular procedure op notes, the less likely you'll be left in a daze when one lands on your desk. Learn the tricks of the trade to determine when a more complex procedure includes a lesser one and when you should use a modifier to report them separately.

Read the Full Procedure

History: A 73-year-old male with insulin-dependent diabetes and heart disease had a percutaneous transluminal coronary angioplasty (PCTA) three years ago. He now has drug-resistant hypertension, and testing indicates probable renal artery stenosis.
 
Op report: Physician draped and prepped right groin area and introduced a pigtail catheter to the aorta through a retrograde right common femoral artery puncture. Then performed a flush abdominal aortogram.
 
The initial study of the right and left renal systems revealed potential high-grade stenosis of the mid-left renal artery. The physician then performed both a left renal arteriogram using a curved catheter and a left renal artery cannulation. Selective diagnostic study of the left renal artery confirmed a high-grade occlusion suggestive of fibromuscular dysplasia (FMD). The right renal artery was only visualized from the flush abdominal aortogram. The artery and its branches were within normal limits.
 
The physician gave the patient 5,000 units of intravenous heparin. She then introduced PTA balloon catheter over the guidewire into the area of blockage in the left renal artery. She performed initial angioplasty with balloon. Upsized balloon; performed another dilation at the mid-vessel stenosis site in the left renal artery. Performed a final arteriography, which showed no residual stenosis and smoothly flowing contrast through left renal artery and parenchymal bed.
 
How should you report these procedures?

Break the Report Down

Coding from an op report doesn't have to be a daunting task. By breaking down each section, you can code step-by-step.
 
Part 1 of the op note: For example, look at "Physician draped and prepped right groin area and introduced a pigtail catheter to the aorta through a retrograde right common femoral artery puncture. Then performed a flush abdominal aortogram."
 
Solution: "Your catheter placement at this point is 36200 (Introduction of catheter, aorta)," says Anne Karl, RHIA, CCS-P, CPC, coding and compliance specialist at St. Paul Heart Clinic in Mendota Heights, Minn. Keep in mind: You won't report this code, because you have a selective renal catheter placement to follow.
 
Hint: You're going to include the flush aortogram (75625) in the selective renal study the cardiologist performs later, Karl adds.
 
Part 2 of the op note: "The initial study of the right and left renal systems revealed potential high-grade stenosis of the mid-left renal artery. The physician then performed both a left renal arteriogram using a curved catheter and a left renal artery cannulation. Selective diagnostic study of the left renal artery confirmed a high-grade occlusion suggestive of FMD. The right renal artery was only visualized from the flush abdominal aortogram. The artery and its branches were within normal limits."
 
Solution: "Here we have the selective left renal artery catheter placement 36245 (Selective catheter placement, arterial system; each first-order abdominal, pelvic, or lower extremity artery branch, within a vascular family) and selective unilateral renal study 75722-26-59 (Angiography, renal, unilateral, selective [including flush aortogram], radiological supervision and interpretation; professional component; distinct procedural service)," Karl says.
 
Code 36245 includes the catheter placement in the aorta (36200) thanks to a National Correct Coding Initiative (NCCI) edit, so you don't need to bill for this. Also, you don't need to code for the aortogram (75625) because this procedure is included in the selective renal study (75722). 
 
Heads up: You need modifier 59 appended to 75722 to signify that this procedure is a true diagnostic renal angiogram. In other words, the cardiologist had not performed a prior diagnostic study, and this was not a guiding shot to a planned intervention, Karl says.
 
Part 3 of the op note: "The physician gave the patient 5,000 units of intravenous heparin. She introduced PTA balloon catheter over the guidewire into the area of blockage in the left renal artery. She performed initial angioplasty with balloon. Upsized balloon; performed another dilation at the mid-vessel stenosis site in the left renal artery. Performed a final arteriography, which showed no residual stenosis and smoothly flowing contrast through left renal artery and parenchymal bed."
 
Solution: "The intervention takes place here," Karl says. You should report 35471 (Transluminal balloon angioplasty, percutaneous; renal or visceral artery) and the companion supervision and interpretation code 75966-26 (Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation).
 
Code 35471 is for the percutaneous transluminal balloon angioplasty (PTA) of the left renal. "This is sort of unusual because the usual treatment for renal artery stenosis is to stent (37205, Transcatheter placement of an intravascular stent[s] [except coronary, carotid, and vertebral vessel], percutaneous; initial vessel; and 75960, Transcatheter introduction of intravascular stent[s] [except coronary, carotid and vertebral vessel], percutaneous and/or open, radiological supervision and interpretation, each vessel)," says Sandy Fuller, CPC, compliance officer at Cardiovascular Associates of East Texas in Athens. However, patients with FMD (fibro-muscular dysplasia) are perhaps the most common exception to this standard. 
 
Code 75966 represents the radiological interpretation and report for the PTA. "You should not bill the post-procedure angiogram because it is included in the procedure," Fuller says.

Tally Up Your Codes

Finally, you should pull all of your codes together and rank them according to their relative value units (RVU).
 
Your final coding report should look like this:
  35471
  75966
  36245
  75722-26-59.

Don't forget: You should include your diagnosis codes based on what your cardiologist documents. "The diagnosis code I would use in this situation is 440.1 (Renal artery stenosis) because this is what the cardiologist found during the procedure, meaning it is the most specific diagnosis for this patient," Fuller says.
 
Here's your chance: Do you have a challenging op note that you are unsure how to code? We would love to see it and perhaps feature it as an upcoming article. Just send it to our editor, Suzanne Leder, CPC, at suzannel@eliresearch.com.