Cardiology Coding Alert

When billing cardiac catheterizations (heart caths), coders should make sure they bill for all the codes that apply, according to the operative report. This can be difficult, because the steps to gainful billing involve three separate components and many codes may apply to the situation.

In addition, even though heart caths are among the most common procedures performed by cardiologists, they are often difficult to understand. This is particularly true since some heart caths do not require injections and supervision and interpretation (S&I), and because the codes for this procedure actually describe more than one service.

Since 1994, when CPT reorganized the coding for cardiac catheterizations, a combination of codes from the following three categories has been used for most (but not all) heart caths:

1. Catheter placement
2. Angiography procedures
3. S&I of angiography

These codes are found in the medicine section of the CPT manual and range from 93501 to 93556. Cardiac catheterization usually is billed using only one code from the catheter placement section (93501-93536). Coding is based on the appropriate number of injections (angiograms) performed, the anatomical area being studied, and the appropriate S&I codes, which are determined according to the number and location of angiograms performed, says Terry Fletcher, BS, CPC, CCS-P, a cardiology coding and reimbursement specialist in Laguna Beach, Calif.

When selecting the codes for any particular cardiac catheterization, coders need to carefully examine the op report to determine which procedures from each component were performed. The coder must also be familiar with the differences among the various code descriptions.

Note: In some situations, more than one catheter placement code can be billed. The American College of Cardiologys (ACC) Guide to CPT cites the case of a 45-year-old male who receives a left heart cath, including left ventriculography and coronary angiography. The results of the study necessitate immediate emergency aortocoronary bypass, which is preceded by the insertion of a Swan-Ganz catheter and an intra-aortic balloon catheter. These additional services, both catheter placement codes, are reported together as 93503 (insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes) and 93536 (percutaneous insertion of intra-aortic balloon catheter).

The following three guidelines will help the coder make the best heart cath coding choices:

Guideline No. 1:
Check Op Report Before Coding the Cath Insertion

CPT 2000 lists 17 distinct coronary catheter placement codes. Of these, cardiologists commonly use the following five:

93501 right heart catheterization

93503 insertion and placement of flow directed
catheter (e.g., Swan-Ganz) for monitoring purposes

93508 catheter placement in coronary artery(s),
arterial coronary conduit(s), and/or venous
coronary bypass graft(s) for coronary
angiography without concomitant left heart
catheterization

93510 left heart catheterization, retrograde, from the
brachial artery, axillary artery or femoral
artery; percutaneous

93526 combined right heart catheterization and
retrograde left heart catheterization

These codes describe the placing of the catheter into the arteries, veins, or chambers of the heart.
According to the ACCs Guide to CPT, these codes cover the introduction, positioning and repositioning of the catheters, the recording of intracardiac and intravascular pressures, the acquisition of blood samples to measure blood gases and/or dye or other dilution curves, and measurement of cardiac output.

Cardiology coders may encounter several problems when trying to select the code that best describes what the cardiologist performed. These include:

Defining a Right Heart Cath and Flow Directed Cath

Right heart caths typically are performed to measure pressures in the right atrium, right ventricle, pulmonary artery, and also indirectly in the left atrium. In addition, the procedure can measure other factors, such as oxygen saturation. The patient undergoing a diagnostic right heart cath (93501) may receive conscious sedation during the procedure.

Code 93503, on the other hand, usually is performed in the intensive care unit (ICU). CPT 2000s descriptor for code 93503 adds to the muddle, because it specifically refers to the Swan-Ganz catheter, which could lead an unwary coder to conclude that if such a catheter is used, 93503 should be billed. In fact, says Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in Seattle, this is not so. The key words in the 93503 descriptor are for monitoring purposes, Yakovlevitch says.

Swan-Ganz or similar types of catheters are used in most right heart caths. What differentiates the 93503 procedure from the 93501 is what the catheter is being used for, he says, adding that the location of the procedure is another factor that should be considered.

The implication of code 93501 is that once everything is measured, the catheter will be removed, Yakovlevitch says. With 93503, the patient (who likely is in the ICU) has his or her intra-cardiac pressures measured over a period of time.

If the procedure began in the cath lab with the intent of removing the catheter once the measurements were taken, but the cardiologist decided to monitor the patient, 93501 not 93503 should be coded, even though the patient may subsequently be moved to the ICU for monitoring, Fletcher says.

According to ACC guidelines, Code 93503 is distinguished from code 93501 in that the service described by code 93503 is not typically performed in the cardiac catheterization laboratory. Placement of a flow-directed catheter for monitoring in an intensive care setting is done to monitor critically ill patients, or pre-operatively to allow monitoring of hemodynamics during surgery. The right heart catheterization, described by code 93501, is diagnostic in nature and often performed in conjunction with other cardiac catheterization procedures.

For example, a 35-year-old man with a heart murmur is sent to the cardiologist for an echocardiogram and consult. The echo uncovers an atrial septal defect with mild right ventricular enlargement, but the echo images are sub-optimal, so the patient is scheduled for a right heart cath to assess pulmonary pressures and the degree of shunt across the defect.

This diagnostic procedure would be coded 93501 only, as it likely is performed in the cath lab and the catheter is removed once the measurements are taken. No injection or S&I codes are used, because all the cardiologist did was measure pressures and oxygen saturation.

Catheter placement for monitoring purposes, however, is indicated in the case of a 67-year-old woman who is brought to the emergency department (ED) intubated by medics, with evidence of pneumonia on a chest x-ray. The woman also is hypotensive and tachycardic, and is admitted to the ICU, where she is volume resuscitated with normal saline. After receiving five liters of saline, the woman still is hypotensive, so the cardiologist decides to place a Swan-Ganz catheter to monitor her hemodynamics and to assess whether she can continue to receive IV fluid, or whether she needs pressors. This procedure would be coded 93503 because the patient is being monitored in the ICU via catheter. Again, no injection or S&I codes apply.

Incorrectly Selecting 93510 Instead of 93508

Another problem for coding heart caths occurs when the cardiologist performs only a coronary angiogram without actually crossing the aortic valve and entering the heart itself (the definition of a true left heart cath). This procedure typically is performed before an intervention (i.e., angioplasty, stent or atherectomy) and in some cases may be payable (see the June issue of Cardiology Coding Alert, page 45-47, for more on this issue). Sometimes cardiologists describe the procedure as a left heart cath at the top of their operative report, so coders should read the procedure notes to determine if the aortic valve was, in fact, crossed. If not, 93508 should be billed. This typically will be reflected in the reporting of a left ventricular end-diastolic pressure.

Billing 93501 and 93510 Instead of 93526

Finally, if the cardiologist performs a combined left and right heart cath, coders should not bill these two services separately (i.e., 93501 and 93510). Instead, they should use 93526, which correctly describes such a joint procedure, says Stacey Elliott, CPC, business office manager with COR Healthcare Medical Associates, an 11-physician cardiology practice in Torrance, Calif.

Coders need to make sure they are coding what the doctor actually did. If the documentation in the operative report describes a combined left and right heart cath, but the note at the top refers only to the left heart cath, 93526 would be the appropriate code, Elliott says.

Guideline No. 2:
Bill as All Codes Warranted by Op Note

Seven coronary injection codes are listed in the CPT manual. Cardiologists commonly use the following five:

93539 injection procedure during cardiac catheterization; for selective opacification of arterial conduits (e.g., internal mammary), whether native or used for bypass

93540 for selective opacification of aortocoronary
venous bypass grafts, one or more coronary arteries

93543 for selective left ventricular or left atrial
angiography

93544 for aortography

93545 for selective coronary angiography (injection
of radiopaque material may be by hand)

As their descriptors indicate, these codes are distinguished by location. For example, code 93543 is used when dye is injected into the left ventricle or left atrium, whereas 93544 is used for the aorta. The angiograms are not bundled into each other or into the catheter placement codes. This means coders can bill for as many injection procedures as are warranted in the operative note, Fletcher says.

Coders should remind their cardiologists to document each location injected to avoid missing any reimbursement opportunities. Coders should not be afraid to code however many angiograms are indicated in the op note, Fletcher emphasizes, but adds that coders also should remember that not all catheter placements require angiography. Left heart caths are far more likely to require angiography than those performed on the right heart.

Note: The other two coronary injection codes, 93541 (for pulmonary angiography) and 93542 (for selective right ventricular or right atrial angiography), are rarely used.

Guideline No. 3:
Use Each S&I Code Only Once Per Operative Session

Two supervision and interpretation codes are used in conjunction with heart caths, and these are integrally linked to the injection codes described above.
Depending on the type of angiography performed, one or both may be used. S&I is what the cardiologist actually did, whereas the injection is how the cardiologist was able to do it, Fletcher explains.

There are two S&I codes:

93555 imaging supervision, interpretation and report for injection procedure(s) during cardiac
catheterization; ventricular and/or atrial
angiography, and

93556 pulmonary angiography, aortography, and/or
selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass).

For example, if the cardiologist performed a left ventricular angiography, code 93555 should be billed. If, in addition, selective coronary angiography, pulmonary angiography or an aortogram were performed, code 93556 also should be included.

The key when billing for these services is that each of the two codes may be billed only once per operative session, Fletcher says. If, for example, the cardiologist performed aortography and selective coronary angiography, 93556 can be billed only once. If ventricular or atrial angiography also was performed, 93555 may be billed in addition to the 93556, she concludes.

Note: If a radiologist interprets the angiograms, the cardiologist cannot bill for any S&I.

Correctly Using the Components

Once the three components of cardiac catheterization are understood, the procedures are relatively easy to code. One typical coding scenario is a left heart cath with left ventricular angiography as well as selective coronary angiography. This means that all the coronary vessels the left anterior descending artery, the left circumflex artery, and the right coronary artery as well as the left ventricular chamber of the heart, are injected with dye.

The cardiologist performs the S&I for all the angiograms taken. For example, a 58-year-old diabetic man is referred to the cardiologist for evaluation of chest pain. The cardiologist has the patient do a treadmill test; however, after five minutes, the patient develops retrosternal chest pain with 3 mm anterior ST segment depression and a drop in blood pressure. The study is immediately stopped, and the patient is sent directly to the hospital for a left heart cath. A coronary angiogram reveals a 95 percent proximal LAD stenosis and an 80 percent mid-right coronary stenosis in a large right dominant system. At that point, a left ventriculogram also is performed. It shows anterior wall hypokinesis with moderately depressed ejection fraction, which means the patient will likely require bypass surgery.

This operative session would be coded as follows: 93510, 93543, 93545, 93555, 93556.

Note: Modifier -26 (professional component) should be appended to 93510 and to 93555/93556 when the catheter placement is performed in the cath lab and/or hospital setting.

The left heart cath is coded 93510. The left ventriculogram is coded 93543, and the selective coronary angiogram takes a 93545 code. Both S&I codes are used (once only) because both the ventriculogram and selective coronary angiography were performed.

In another example, a 74-year-old man who had a three-vessel bypass graft surgery 15 years ago has refractory heart failure. He gets a myocardial perfusion study that shows a moderate ischemic defect in the inferior wall. The right ventricle is reasonably well visualized and appears to be dilated and hypokinetic. The patient is given a right and left heart catheterization to assess filling pressures and the condition of his bypass grafts. His native coronary arteries are injected first, then the cardiologist proceeds to look for his bypass grafts. Two of the grafts are identified, but the third cannot be located. An aortogram then is performed to locate the third graft.

Because a left and right heart cath was performed, 93526 should be billed, not 93501 and 93510. The cardiologist also performed an aortogram, which means that 93544 and 93556 are billed, while the identification of the bypass grafts by angiography is coded 93540. Because atrial and/or ventricular angiography was not performed, S&I code 93555 cannot be billed.

Note: Again, modifier -26 should be appended to the 93526 if the hospital owns the equipment used for the catheter placement.

Other Procedural Regulations

Many procedures, such as temporary pacemakers (33210, insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter [separate procedure]) and non-coronary selective catheter placements (for example, 36215, selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family), cannot be used in conjunction with a cardiac catheterization.

The national Correct Coding Initiative (CCI) bundles 33210 to 93510, for example, while CPT guidelines preclude billing 36215 or other intra-arterial vascular injection codes during the same session as a heart catheterization.

When a cardiac catheterization is followed by an intervention, such as an angioplasty (92984), stent (92980) or atherectomy (92995), during the same operative session, most carriers will automatically reduce the cardiac cath by 50 percent, citing multiple procedure guidelines, Elliott says.

Because such interventions bundle S&I, to get paid for the S&I performed during the heart cath, modifier -59 (distinct procedural service) must be attached to any S&I codes claimed, Fletcher adds.