Cardiology Coding Alert

You do not have to settle for payment of a left heart catheterization with aortography of the aortic root when you also perform an abdominal aortogram as long as you provide documentation indicating the abdominal aortogram was used to image a separate problem.

When a cardiac physician performs a left heart catheterization, he or she may also do an aortogram to obtain images of the aortic root where the aorta joins the heart. The physician may also perform these procedures during the same session as the more typical angiography of the left coronary chambers and the coronary arteries.

In addition, the cardiologist may perform an abdominal aortography following a heart catheterization. For example, the cardiologist may have difficulty passing a guidewire and catheter through the access site the femoral artery to the aorta because the patient has an abdominal aortic aneurysm (441.4).

The cardiac physician may perform an abdominal aortogram and heart catheterization simultaneously if the patient has an additional problem (such as abdominal aneurysm or leg cramps) that the cardiologist wants to assess at the same time.

Generally, you should report the aortography of the aortic root using 93544 (Injection procedure during cardiac catheterization; for aortography) with 93556 (Imaging supervision, interpretation and report for injection procedure[s] during cardiac catheterization; pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits [whether native or used in bypass]).

Any images obtained from injections in the ascending aorta the first section of the aorta from the left ventricle to the arch are included in 93544/93556. According to the American College of Cardiology, 93544 involves positioning the catheter in the ascending aorta above the aortic valve. The code, however, does not describe abdominal aortography.

Even if aortography of the aortic root or elsewhere in the ascending aorta has already been performed and reported with 93544/93556, you should report the supervision and interpretation of the abdominal aortogram using either 75625 (Aortography, abdominal, by serialo-graphy, radiological supervision and interpretation) if only the aorta is imaged or 75630 (Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialo-graphy, radiological supervision and interpretation) if the images of the iliac and/or femoral arteries are also obtained. These codes reflect the cardiologist's manipulation of the catheter as well as the interpretation of the images.

If the cardiac physician performs these procedures in the hospital, you should append modifier -26 (Professional component) to the appropriate code (75625 or 75630) because the hospital provides the instruments and supplies for the procedure.

In addition, because the physician uses the same catheter for the heart catheterization and the abdominal aortography, you should not bill an additional catheter placement code, e.g., 36200, Introduction of catheter, aorta. "Even though you stopped and made a separate injection, you do not code the cath placement," says Sandy Fuller, CPC, a cardiology coding and reimbursement specialist in Abilene, Texas. "The only time you would code that is if that was the only imaging you did."

"When cardiologists perform unrelated abdominal aortography during the same session as a heart catheterization, their documentation must clearly indicate where and why they performed the additional aortography," says Judy Richardson, MSA, RN, CCS-P, a senior consultant at Hill and Associates Inc., a coding consulting firm in Wilmington, N.C. Cardiac physicians perform aortic root angiography far more frequently then abdominal aortography during a heart catheterization. Consequently, coders may not realize that the physician performed an aortic flush (abdominal aortogram) and mistakenly code only 93544/93556.

If the doctor took images of the abdominal aorta after images of the ascending aorta and reported 93544/93556 documentation should clearly state that he or she performed an additional injection. The cardiologist should also note the nature of the patient's problem, e.g., abdominal aortic aneurysm. For example, the physician's notes might include a short paragraph stating that he or she withdrew the catheter into the abdominal aorta and performed the aortogram to visualize the distal abdominal aorta and iliac arteries because problems were encountered initially when advancing the guidewire.

The paragraph should note the nature of the problem, which should also be reflected in the claim by linking a different diagnosis for example, abdominal aortic aneurysm (441.4) to 75625 or 75630.

Some carriers may recognize only specific codes in such situations. For example, according to the medical review policy of the Upstate Medicare Division of HealthNow New York Inc., the local Medicare carrier for upstate New York, it will deny payment for 75625 and 75630 with cardiac catheterization "unless there are specific conditions that warrant selective investigation."

The policy goes on to list examples of specific clinical syndromes that may require "selective investigation," including subclavian steal syndrome (435.2), transient ischemic attack (435.9), renal artery stenosis (440.1), hypertensive patients (401.x) with pulmonary edema (514) and renal failure (586). The HealthNow policy also states that the following diagnoses support "extra cardiac angiography":