Cardiology Coding Alert

CPT 1999 contains a useful group of codes that can be hard to find because the names assigned to these procedures do not match the common descriptions used by physicians or their staffs, and are not indexed very well.

Most CPT catheter codesfor example, 93503 (insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes)are diagnostic. But in some procedures, catheter procedures are therapeutic. CPT 1999 lists these procedures in a different section and refers to them as transcatheters, an unfamiliar term for many that makes the codes hard to locate in the CPT index.

Terminology Confusing

The main problem with these codes is that a lot of people arent even aware they exist. When you are looking them up in CPT 1999, quite often the descriptions in the book dont match what you are looking for, says Susan Callaway-Stradley, CPC, CCS-P, senior healthcare consultant with Elliott, Davis and Co., LLP, an accounting and consulting firm in Augusta, GA.

For example, stent placements for the lower vessels and transcatheter removal of a foreign body are both difficult to find in the CPT index.

When referencing stent, CPT offers indwelling insertion ureter, placement bronchoscopy, and urethra insertion, but nothing related to cardiovascular procedures.

Using cardio or vascular also leads to a dead end in the CPT index. However, if you are lucky enough to have your physician use the words intravascular stent, CPT will lead you to the radiologic supervision code, 75960. That code references procedures 37205 through 37208.

When searching for the code for the removal of a fractured or broken catheter, the terms catheter, catheterization, foreign body, removal, and fracture all lead nowhere in the search for a correct code.

The key difference between transcatheter and typical catheter procedures is that they are treatment, not diagnostic, procedures.

Typically, interventional procedures, where the physician goes in and takes photographs of blood vessels to determine blockages or other disease processes are represented by the codes 36000-36248. But these codes are inappropriate when billing for procedures aimed at treating the problem diagnosed by the interventional procedure, in this case, the first catheter.

The problem is that because the transcatheter codes are indexed poorly, or not named in accordance with typical usage, they are difficult to find. So physicians and coders sometimes end up using the diagnostic catheter codes, unlisted codes or codes for open procedure, all of which are incorrect.

In most offices, a transcatheter stent placement is referred to as Stent to femoral artery. So some physicians search for a stent placement code that doesnt exist, instead of using the correct code (37205-37208), labeled transcatheter placement.

Inexperienced coders may have little formal training. While they are able to look up procedures in the CPT index, many have never read the sections that pertain to cardiology.
Coding classes, meanwhile, may teach how to use the CPT index, but often do not tell coders that if they are unable to locate their procedure in the index, they must pick up the book and take the time to actually read through the code descriptions, Callaway-Stradley says.

Transcatheter codes that apply to cardiology include:

37200- Transcatheter biopsy. A needle is inserted through the skin and into a blood vessel, and a guidewire is threaded through the needle into the vessel. After the needle is removed, a catheter is threaded into the vessel, and the wire is extracted. The catheter equipped with a biopsy instrument travels to the area to be sampled. The instrument extracts for biopsy tissue affixed to the vessel wall. Pressure is applied over the puncture site to stop bleeding after the catheter is removed. The procedure may also be performed through a skin incision with direct exposure of the access vessel.

37202- Transcatheter therapy, infusion other than for thrombolysis, any type (e.g., spasmolytic, vasoconstrictive). A catheter equipped with an infusion tip is threaded into the vessel, travels to the point of vasospasms, and drugs are infused to reduce the spasms. Pressure is applied over the puncture site to stop the bleeding after the catheter is removed. Sandy Fuller, a coder with Cardiology Consultants of Abilene, TX, says she used to use this code for infusion of nitroglycerine as part of a heart catheterization. But now Medicare has bundled it with the heart catheter and the American College of Cardiology guidelines have done the same, she says.

37203- Transcatheter retrieval, percutaneous, of intravascular foreign body (e.g., fractured venous or arterial catheter). A catheter equipped with a grasping instrument travels to the site of the foreign body, grasps it and retrieves it. This code is used when the broken tip of a Swan-Ganz catheter has to be removed, Fuller says, adding that it is accompanied by radiology code 75961 (transcatheter retrieval, percutaneous, of intravascular foreign body [e.g., fractured venous or arterial catheter], radiological supervision and interpretation) filed by the attending radiologist.

37205-37206- (37205, transcatheter placement of an intravascular stent[s], [non-coronary vessel], percutaneous; initial vessel; 37206, each additional vessel [list separately in addition to code for primary procedure]).

A catheter travels to the point where the vessel needs additional support, and the compressed stent(s) is passed from the catheter to the vessel, where it expands to support the vessel walls. We do a lot of those, Fuller says. She suggests coders check with the Food and Drug Administration to find out which regions of the body are approved, and which are not.

Medicare wont pay for stents placed in non-FDAapproved body regions, Fuller says.

Codes Describe Treatment, Not Access Point

Sometimes catheters break away and need to be removed during a subsequent procedure. This procedure (37203) can be performed either by entering the blood vessel directly over the location of the foreign body, or, depending on where the foreign body is lodged, by using the standard mechanism of entering the femoral artery and from there, straight into the aorta, which then branches off in many directions, providing relatively easy access.

One factor in determining access location is the condition of the patients blood vessels. An elderly patient, or an individual who has had many vascular procedures, may have vessels too weak to withstand the procedure at the usual entry points.

All this relates to coding in that physicians, when billing for the procedure, may list the specific access point and then attempt to find a specific matching code for that location.

In this situation, a physician might conclude that because entry was done at the brachial instead of the femoral location, modifier -22 (unusual procedural services) can be used to obtain higher reimbursement.

That conclusion is false, says Callaway-Stradley. Transcatheter codes are not categorized on the basis of point of access. Rather, they are listed by treatment, which was performed after access already was achieved.

So even though access can be achieved from more than one location, there is no additional reimbursement for any particular access point.

In short, it would not be appropriate to ask for more reimbursement for a brachial rather than a femoral access.