Cardiology Coding Alert

While performing cardiac catheterizations or coronary interventions (i.e., angioplasty, stent and atherectomy), cardiologists must deal with the possibility of coronary thrombi blood clots in the coronary arteries that could cause a myocardial infarction (MI).

To minimize the chance of coronary blood clots, the cardiologist may inject the patient with one of several kinds of drugs. The method of delivery can vary, depending on whether the injection is preventive (to inhibit clot formation) or is administered to dissolve an existing clot.

Coding these services can be difficult, because thrombolysis may be bundled with other procedures that could be performed at the same time, such as left heart catheterizations and coronary interventions.

For example, if the cardiologist performs intracoronary thrombolysis during a cardiac catheterization or a percutaneous transluminal coronary angioplasty (PTCA), the thrombolysis is separately billable using 92975 (thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography), says Sueanne Bicknell, RRA, CPC, CCS-P, compliance administrator for CPR/Heart Place, an 80-physician practice in Dallas that includes 60 cardiologists and five electrophysiologists. The correct diagnosis to justify the thrombolysis is 411.81 (coronary occlusion without myocardial infarction).

If a stent (92980, transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel) is inserted, however, 92975 cannot be coded because it is bundled with 92980 in the national Correct Coding Initiative (CCI).

Note: Code 92980 should not be used if the occlusion is the result of atherosclerosis without associated thrombus.

According to the American College of Cardiologys (ACCs) Guide to CPT, 92975 includes selective coronary angiography. Many coders have taken this to mean that if intracoronary thrombolysis is performed during a heart catheterization, the injection portion of the catheterization (for example, 93545, injection procedure during cardiac catheterization; for selective coronary angiography [injection of radiopaque material may be by hand]) would not be separately billable.

Bicknell disagrees: The diagnostic injection 93545 is performed to identify the blockage, which is then treated by thrombolysis (92975). Therefore, 92975 should be separately payable. She adds, however, that if the blockage had been diagnosed and identified during a previous catheterization or other procedure, 92975 should not be coded, because it is part of the procedure (i.e., the catheterization) being performed to correct or treat an already identified problem.

Intravenous or Intracoronary Injection?

Although some cardiologists continue to use intracoronary injections to deliver clot-dissolving medication to the site of the thrombus, other drugs may be injected intravenously, either as a preventive measure or because the medication is able to seek out the clot and therefore does not need to be targeted.

According to the ACC, however, intravenous coronary thrombolysis (92977) although a covered service for Medicare beneficiaries has been assigned zero physician work units in the Medicare fee schedule. HCFA maintains this service is most often performed by hospital personnel at the patients bedside, and the physician work of monitoring a patient who receives intravenous thrombolytic therapy is captured in the evaluation and management (E/M) service provided to the patient.

Occasionally, however, cardiologists may perform coronary thrombolysis during a procedure. In those situations, Bicknell says, 92977 should be billed with modifier -59 (distinct procedural service) attached, and the operative report should also be sent to the carrier to indicate that the injection was performed during a procedure and not at bedside.

Coding ReoPro Used for Thrombolysis

Although ReoPro (or abciximab) is most frequently used to reduce the likelihood of thrombosis during interventions, it can also be used in some patients with acute coronary syndromes to reduce platelet adhesion and facilitate dissolution of thrombi, says Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in Seattle. This dual role may confuse cardiology coders, because policy guidelines for covering the infusion of ReoPro vary, depending on its purpose.

Generally ReoPro is used in two ways, Yakovlevitch notes. The first is as an adjunct to PTCA for the prevention of acute cardiac ischemic complications in patients at high risk for sudden closure of the treated coronary vessel. In addition, he says, ReoPro is also used for patients with unstable angina. In these patients, a clot is already present, but the traditional thrombolytic drugs used to treat acute MI are not indicated, because the risk of bleeding complications, including hemorrhagic stroke, exceed the anticipated benefit of therapy. ReoPro, on the other hand, may play a role in the care of these patients, Yakovlevitch says.

When ReoPro is used to reduce the chance of thrombosis during or after a PTCA, the service should not be coded, because it is considered part of the intervention. The cardiologist does not have to perform a significant level of additional work to infuse the drug during the catheterization.

If ReoPro is used as an adjunct for treatment of a thrombotic coronary syndrome, however, it should be coded and billed the same way as other medications used in this way (see section on intracoronary vs. intravenous infusions above), depending on the intervention performed and how the ReoPro is administered.

For example, if a specific lesion was targeted, 92975 would properly describe the work of finding the clot and injecting the ReoPro directly to its location. But if ReoPro is injected intravenously while the patient is in the emergency department or at bedside, the supervision of the administration (92977) is considered a facility service. Therefore, there is no separate physician service other than the appropriate E/M code for the encounter. If the ReoPro is injected intravenously during the procedure, however, it can be billed separately with modifier -59 attached (just as with the thrombolytic drugs discussed above).

All these variables make knowing which service to code extremely complicated. Aside from being able to distinguish between intracoronary and intravenous infusion of ReoPro, cardiology coders need to determine whether the ReoPro was injected to prevent thrombus formation or to remove an existing clot. This can be difficult, because cardiologists may have different ways of describing what they did in the operative report, and the descriptions may not always be clear to their coders. As a result, using ReoPro to facilitate clot dissolution can easily be confused with the medications other functions, and vice versa.

Therefore, Bicknell warns, coders who are uncertain about which service was provided should be prepared to ask their cardiologist whether the ReoPro was used to facilitate the removal of a clot, or as a preventive measure.

Avoid Problem Codes

Because the medications used in thrombolysis are delivered via injection or infusion, some coders may inadvertently use the wrong codes to describe these services. Among the most commonly misused codes are:

90780 IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour;

90781 . . . each additional hour, up to eight hours (list separately in addition to code for primary procedure);

90784 therapeutic, prophylactic or diagnostic injection (specify material injected); intravenous;

37201 transcatheter therapy, infusion for thrombolysis other than coronary; and

37202 transcatheter therapy, infusion other than for thrombolysis, any type (e.g., spasmolytic, vasoconstrictive).

None of these codes appropriately describe the infusion of thrombolytic drugs or related agents such as ReoPro for clot dissolution. Codes 90780, 90781 or 90784 may be appropriate when other medications such as nitroglycerin are injected to prevent coronary spasm; however, when the services described by these codes are performed in conjunction with cardiac catheterization or coronary interventions, they are always bundled and should not be separately billed, Bicknell says.

Code 37201, meanwhile, does describe the infusion of a thrombolytic medication by transcatheter. But the code descriptor clearly states for thrombolysis other than coronary. Code 37202, on the other hand, presumably may be used for infusions anywhere, including coronary vessels. According to the code descriptor, however, the infusion may be for any reason other than thrombolysis. To accentuate the point, CPT includes a note below 37202 directing physicians to use 92975 or 92977 when performing thrombolysis of coronary vessels.

When ReoPro or other medications are infused to reduce the chance of thrombosis during or after an intervention or catheterization, none of these codes should be billed because the service is inclusive, Bicknell says.