Cardiology Coding Alert

Question: Has anyone else been noticing the rise in various commercial carriers starting to bundle the cath charges 93510, 93508, etc., when you perform a stent? They will pay on the angiography charges but not the cath. We add modifier 59 to the supervision and interpretation portion of the angiography codes, but we shouldn't have to on the cath. Do they not understand that we can't do the angiography or stent without that cath? We have to appeal with modifier 59 on the cath placements AND the injections, but they say it is a system error and we only get them hit or miss now.


Arkansas Subscriber

Answer: This happens because the insurance companies think all interventional procedures are planned. You should add modifier 59 (Distinct procedural service) and appeal when this happens if the cardiologist did not plan the intervention.

When a patient is scheduled for an interventional procedure on a different date of service after a diagnostic catheterization with no new indications/symptoms, you would code the interventional procedures only. The planned interventional procedure includes the catheter placement, coronary angiography and coronary imaging S&I. If new indications/symptoms occur and the degree of stenosis has changed, then you can bill the catheter placement, coronary angiography, and coronary imaging S&I separately.

Example 1: A patient with non-Q wave myocardial infarction transfers from a rural hospital for elective intervention of a mid-LAD critical stenosis diagnosed on diagnostic heart catheterization. If the cardiologist performs the PTCA and drug-eluting stent placement in the LAD, you would only code 92980 (Transcatheter placement of an intracoronary stent[s] ...). Because a cardiologist at another facility diagnoses the stenosis prior to the transfer, the interventionalist would not bill for a repeat heart catheterization.

Example 2: A patient presents with a history of angina, CAD, and history of CABG to the diagonal, LAD, and obtuse marginal branch. The patient presents with symptoms of angina. The cardiologist performed a cardiac catheterization two weeks ago and showed severe diffuse disease of the distal right coronary artery. The cardiologist schedules elective stenting. If the cardiologist performs a drug-eluting stent on the RC, you would code 92980 only. 

Example 3: A patient presented a few weeks ago with an unstable coronary syndrome. The patient had undergone diagnostic heart catheterization, stenting of the LAD and stenting of the first diagonal arteries at that time. The patient did well and had a residual 90 percent stenosis in the mid-right coronary artery. The cardiologist advised the patient to schedule an angioplasty and stenting of that particular lesion. If the cardiologist performs the PTCA and places drug-eluting stents on the proximal, mid, and distal of the RC at the time of the second procedure, you would code 92980 only.

All three examples above are good examples of a planned scheduled interventional procedure. In all of these examples the cardiologist would code the highest valued procedure performed on the LAD or RC.