Cardiology Coding Alert

If you've got coronary computed tomographic angiography (CCTA) questions, we've got answers. Check out this breakdown of what codes 0144T-0151T represent, how you should report them, and whether carriers are starting to pay for these procedures.

"Because the application of CT imaging for the purpose of coronary and cardiac purposes is relatively new, we are witnessing an evolution of the related reimbursement issues: the code structure, coverage guidelines, provider credential requirements, reimbursement rates, and over-read protocols," according to the April 2007 Cardiology Coalition Membership Newsletter.

Why CCTA is worthwhile: Although CCTA images are slightly less accurate than images obtained from catheter-based angiographic studies (heart catheterization), CCTA is a desirable diagnostic testing modality.-This is because it is much less invasive than heart catheterization, requiring only an injection of contrast and possibly a medication to help lower the patient's heart rate. Consequently, CCTA has replaced and will continue to replace many diagnostic heart catheterizations.-

In the past: When you reported the work associated with CCTA, you would use either chest CTA code 71275 (Computed tomographic angiography, chest, without contrast material[s], followed by contrast material[s] and further sections, including image postprocessing) or unlisted-procedure code 76497 (Unlisted computed tomography procedure [e.g., diagnostic, interventional]), says Terri Davis, CPC, CIC, a coding supervisor at The University of Oklahoma College of Medicine in Oklahoma City.

What you should use now: You should use Category III codes 0144T-0151T, Davis says. You can find these codes in the 2007 CPT manual, just before appendix A.-These codes are temporary, indicating that the AMA considers CCTA an "emerging technology."-Although these codes were effective in January 2006, they did not make their debut in the official CPT book until the 2007 edition.

Coverage: Most payers didn't cover CCTA because they deemed it "investigational" technology. Now payers do cover this form of testing for certain symptoms, but you still need to confirm coverage and coding with your individual payers.

The first code in this range, 0144T (Computed tomography, heart, without contrast material, including image postprocessing and quantitative evaluation of coronary calcium), is a diagnostic test that measures the amount of calcium that has built up in coronary arteries.-

What calcium is: Calcium is a mineral that circulates throughout the body and is necessary for many cellular functions, including bone strength. Calcium is frequently deposited in arterial walls, where it stiffens the blood vessels and causes them to harden.-This calcium buildup contributes to the formation of plaque and the eventual blockage of blood flow.-

Did you know? Because calcium is a marker of coronary disease, many physicians use calcium scoring to predict coronary disease in asymptomatic patients.-Since most payers do not cover this form of testing, many facilities offer it on a cash basis to the general public.-

Differentiate 0145T-0150T

You should use 0145T-0150T to report diagnostic tests that include images obtained "without contrast material," "with contrast material," "further sections," and "cardiac gating and 3D image post processing."-

Key: When you analyze the code definitions, you'll see two categories:

• those performed primarily for coronary artery assessment (0146T-0147T) and

• those physicians perform to assess "cardiac structure and morphology," whether this is the full scope of the study (0145T and 0150T) or whether this is in addition to coronary assessment (0148T-0149T).-

Cardiac structure and morphology: According to the American College of Cardiology (ACC) Coding and Nomenclature Committee, the structure and morphology code was specifically designed for the detailed imaging required prior to electrophysiologic testing (e.g., atrial and pulmonary vein evaluation prior to atrial fibrillation ablation or coronary sinus and venous anatomy prior to implantation of a biventricular pacemaker) and not for chamber size, dimensions, and so on.

ACC's "CPT Guide 2007" echoes this guidance when it states, "Codes 0145T, 0148T and 0149T specify 'structure and morphology' in the descriptor, these codes are specific to a pre-electrophysiology CT study."-

Bottom line: You should use these codes only when the physician does the CCTA at the request of an electrophysiologist to anatomically map the coronary sinus or pulmonary veins in preparation for a procedure.-

Remember: You cannot separately report the work associated with 3D image construction (such as 76376 and 76377).-Also, as described later, the work associated with the evaluation of "further sections" is an inherent part of each service description.-

Don't Overlook 0146T-0147T

You'll use the remaining two codes (0146T and 0147T) for coronary artery assessment studies.-Both of the code descriptors contain the terminology "computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts)."

The differentiating terminology between these codes is that 0146T is "without quantitative evaluation of coronary calcium" while 0147T is "with quantitative evaluation of coronary calcium."-

Pitfall 1: Although you can accurately represent the work of quantifying calcium scoring by itself using 0144T, you should not report 0144T in addition to 0146T because 0147T accurately describes the full service.-

Pitfall 2: Don't assume if your cardiologist documents coronary calcium that you should report 0147T rather than 0146T.-The calcium evaluation must be "quantitative" to definitively support 0147T.-Some studies may include only a "qualitative" analysis of coronary calcium, which means you should use 0146T instead.-To support 0147T, make sure you can identify a numeric "calcium score" in the report.-

You May Not Use Add-on Code 0151T

When your cardiologist manipulates data obtained by CCTA imaging and assesses the wall motion and ejection fraction of the heart's ventricles, you should report this with add-on code +0151T (Computed tomography, heart, without contrast material followed by contrast material[s] and further sections, including cardiac gating and 3D image postprocessing; function evaluation [left and right ventricular function, ejection-fraction and segmental wall motion] [list separately in addition to code for primary procedure]).

Note: "Some providers may opt not to invest the additional time necessary to assess wall motion and ejection fraction if this assessment has been made by other reliable imaging modalities: MUGA studies, first-pass imaging, echocardiography, or myocardial perfusion imaging," The Cardiology Coalition Newsletter says.

Some carriers, such as National Government Services Inc., specify that you shouldn't bill 0151T when the cardiologist determined ejection fraction by other techniques.

A CCTA takes diagnostic images from adjacent portions of the patient's chest in addition to those structures that were the procedure's primary intent.-These "further sections" typically include the lungs, the mediastinum and the spine.-Bottom line: If your cardiologist examines the heart and coronary arteries, he should be the same physician who looks at these further sections.

Report excerpt: If your cardiologist interprets other abnormalities seen in the field of view, his documentation should look like this, according to the AMA and the American College of Radiology publication Clinical Examples in Radiology (Vol. 2, Issue 1):

"Imaged central airways of the lung parenchyma as well as pleura are unremarkable.-Also within the imaged chest, no pleural or pericardial effusions are seen. No adenopathy is present.-Soft tissue density with triangular shape anterior to the ascending aorta may represent residual thymic tissue.-Imaged osseous structures unremarkable."

Good advice: Because you need to have assessments of these further sections, you should establish a separate section in CCTA report templates that summarizes the cardiologist's data interpretation, The Cardiology Coalition Newsletter recommends.-Otherwise your claim may not stand up under an audit.

Watch out: If the cardiologist's report says, "This study is limited to the coronary arteries and cardiac function, please refer to the radiology report for interpretation of non-cardiac structures," an auditor might assert that the cardiologist did not provide full definition of the CCTA code.-Then you would need to apply modifier 52 (Reduced services), according to The Cardiology Coalition Membership Newsletter.

If your cardiologist does send the report to a radiologist, a statement like "radiology over-read is pending" in addition to an initial interpretation of the entire study would support the full CCTA code definitions. The reason is this means the cardiologist fully interpreted and reported on all of the data before sending the images for an over-read.-In other words, the radiologist would not provide the initial data interpretation, but he would provide a quality assurance over-read to confirm that the cardiologist did not miss something clinically significant.

Team approach: The "team approach" to interpreting CCTA data is extremely common.-In fact, the Medicare carrier policies applicable to Rhode Island, Arkansas, New Mexico, Oklahoma, Northeast Missouri, South Missouri and Louisiana specify that "a team approach for reading cardiac and non-cardiac computed tomography of the chest is suggested. This team-based approach assures that the beneficiary receives the newest in technology in the most competent hands."

Once again, applicable guidelines continue to evolve. Make sure to stay current on your payers' policies.