Cardiology Coding Alert

Experts explain how to recoup your practice's ultrasound pay
 
When cardiologists perform intravascular ultrasounds (IVUS) to diagnose lesions or to help guide therapeutic interventions in the coronary or peripheral vessels, make sure you've got a grip on the primary intervention procedure - this must be crystal- clear to report the IVUS study.
 
Cardiologists use IVUS in coronary and peripheral arteries to diagnose problems such as the amount of plaque burden and the amount of calcium in the vessel wall, and as a quantitative aid to determine the degree of coronary stenosis.
 
Physicians may use intravascular ultrasound during cardiac catheterization, interventions (such as percutaneous transluminal coronary angioplasty [PTCA], atherectomy or stent placement), and to assess treatment results. During an IVUS, the physician places a special ultrasound catheter in the vessel to visualize its structure.
Although an intravascular ultrasound has obvious diagnostic applications, some carriers may be reluctant to pay for this study, restricting coronary ultrasounds for therapeutic procedures only or rejecting peripheral ultrasounds altogether.
 
Some insurance carriers will try to deny IVUS codes, especially when the cardiologist performs a diagnostic procedure only, says Terri Davis, CPC, cardiology coder and coding supervisor at the University of Oklahoma College of Medicine
 
Even so, if you demonstrate appropriate medical necessity for the visualization service with a primary procedure, you may have an easier time convincing payers to reimburse.
 
For instance, a physician may note that an angiography study does not clearly reveal whether plaque is significantly narrowing a vessel and may document that the IVUS yields a more accurate assessment of the degree of narrowing, says Jerome Williams Jr., MD, FACC, a cardiologist with Mid Carolina Cardiology in Charlotte, N.C.
 
In addition, IVUS can give more information about plaque pathology, such as the presence of significant calcium, a thrombus or dissection within the artery, Williams says. These details can be used to guide the appropriate interventional therapy, so coders should look for this information in the procedure note.
 
Experts offer three tips for improving your IVUS reporting:

1. Pair IVUS With Primary Procedures

Both the coronary and peripheral IVUS codes are add-on codes, so don't try reporting them without the accompanying primary service, or you'll face denials, Davis says.
 
When cardiologists perform IVUS with coronary interventions, including stenting (92980) and PTCAs (92982), report +92978 (Intravascular ultrasound [coronary vessel or graft] during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel [list separately in addition to code for primary procedure]) for the initial vessel ultrasound and +92979 for each additional vessel.
 
Similarly, add peripheral vessel IVUS codes +37250 (... [non-coronary vessel]; initial vessel [list separately in addition to code for primary procedure]) and +37251 (... each additional vessel), as appropriate to peripheral interventions. If you're not sure which peripheral vessel the cardiologist performed the IVUS in, ask the physician, because this must be in the notes for insurers to pay, Davis says.
 
For example, a cardiologist places a stent in the left anterior descending artery, performs a PTCA in the left circumflex artery, and performs IVUS in both the left anterior descending and left circumflex coronary arteries. You would report 92980-LD (Transcatheter placement of an intracoronary stent[s] ...; left anterior descending coronary artery) for the stent in the left anterior descending artery, +92984-LC (Percutaneous transluminal coronary balloon angioplasty; each additional vessel [list separately in addition to code for primary procedure]; left circumflex, coronary artery) for the PTCA in the left circumflex artery, 92978 for the IVUS in the left anterior descending and 92979 for the IVUS in the left circumflex artery.
 
Append the HCPCS Level II coronary modifiers (-LD and -LC) to the intervention codes to designate the procedure location, Davis says.
 
You would report 92984 in this instance because the physician performs a PTCA on a second coronary vessel. You cannot report two "initial vessel" interventions (92980, 92982 and 92995) during the same session.
 
You can use the base IVUS code (92978) only once per operative session. Similarly, you can use the "each additional vessel" code (92979) only once for each of the other recognized coronary arteries, the American College of Cardiology (ACC) states. For instance, if the cardiologist places three stents in one coronary artery and uses IVUS to assess each stent placement, you can report 92978 only once, even though he inserted the ultrasound catheter three times.

2. Report Peripheral Interpretation Separately

Unlike the coronary codes, peripheral IVUS codes 37250 and 37251 do not include imaging supervision, interpretation (S/I) and report.
 
So, if the cardiologist interprets peripheral IVUS images, bill 75945 (Intravascular ultrasound [non-coronary vessel], radiological supervision and interpretation; initial vessel) for the initial vessel interpretation with 37250, and add +75946 (... each additional non-coronary vessel [list separately in addition to code for primary procedure]) to 37251 for additional vessel interpretation.

3. Convince Payers That IVUS Is Necessary
 
Carriers will likely pay for ultrasounds performed with a coronary intervention, but they're reluctant to reimburse for ultrasounds in non-coronary vessels. Many, such as Blue Cross Blue Shield of Arkansas, consider the study "investigational" and do not cover it. So, what's a coder to do?
 
Davis says that as long as she submits the documentation and includes the anatomic modifiers on the claim for IVUS with coronary artery interventions, "We get reimbursed by Medicare and others."
 
"We're getting paid for IVUS in the coronaries without an intervention, so I guess we're lucky," says Belinda Inabinet, CPC, technical support manager and head of a coding team at South Carolina Heart Center, a 28-physician practice in Columbia, S.C.
  
The local Part B carrier (Palmetto Government Benefit Administrators) does not have a policy, Inabinet says. "In some ways, the lack of a policy can be a good thing," Inabinet says. "Without a policy, your Medicare carrier has less ammunition to use to deny the claim." She notes that there are no edits in the National Correct Coding Initiative for IVUS and heart catheterizations, "so they should be payable if your carrier has not issued an LMRP [local medical review policy] stating otherwise."
  
Inabinet also stresses that if the physician documents medical necessity for the IVUS scan, you should appeal Medicare denials.
 
The same is true for peripheral ultrasounds. The Medicare Physician Fee Schedule indicates that 37250-37251 are covered services. Unless the carrier specifically rules out paying for this service in a medical review policy, the procedure should be paid, she says.