Cardiology Coding Alert

Cardiologists should consider using modifier -59 (distinct procedural service) to avoid denials when they report cardiac catheterizations during the same session as a non-coronary procedure, such as a renal angiogram. Some carriers inappropriately will bundle renal angiogram procedure codes into the heart cath procedures, or vice versa, even though procedures at these two different sites arent bundled.

Using modifier -59 indicates the procedures were separate and helps avoid inappropriate bundling. The modifier should be attached to the procedure with the fewest relative value units.

In addition, when cardiac and non-coronary procedures are combined, a second diagnosis is required to show medical necessity for both procedures.

For example, a the patient has coronary artery disease (CAD). That diagnosis provides medical necessity for the heart cath but doesnt cover looking at the patients renals or carotids or legs, says Sandy Fuller, a coder with Cardiology Consultants, a nine-cardiologist practice in Abilene, TX. The patient may have a problem in these non-cardiac sites, but the cardiologist has no reason to go there and look for anything based merely on CAD. So providing a second diagnosis is crucial to getting paid for the non-coronary procedure.

For problems with the carotid artery, acceptable diagnosis codes include 433.10 (occlusion and stenosis of precerebral arteries [carotid artery]), 433.9 (unspecified precerebral artery); 436 (acute, but ill-defined cerebro-vascular disease, including stroke), or 435.9 (unspecified transient cerebral ischemia). For peripheral problems, cardiologists can use ICD-9 code 443.9 (peripheral vascular disease, unspecified), while renal procedures could take the following two hypertension codes: 401.1 (essential hypertension, benign); or 401.9 (unspecified), as well as 440.1 (atherosclerosis, of renal artery).

If a renal angiogram is performed, the procedure should be coded 36245-59 (selective catheter placement, arterial system; each first order abdominal, pelvic or lower extremity artery branch, within a vascular family). Fuller further recommends putting the term renal in the comments section because 36245 also is used for peripheral angiograms. If an iliac (peripheral) procedure is performed, iliac should be entered in the comments section.

For the carotids, Fuller uses 36216-59 (selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family) and enters carotid in the comments section.

Angioplasties are performed in the renal and peripheral arteries. Because angioplasty codes are area specific, there is no need to put a comment. For example, an iliac angioplasty would be coded 35473 (transluminal balloon angioplasty, percutaneous; iliac), while renal would take a 35471 (transluminal balloon angioplasty, renal or visceral artery). Both 35471 and 35473 may be billed bilaterally using a -50 modifier (bilateral procedure), and because the codes are so specific, neither requires a -59 modifier when billed with a heart cath.

Heart Cath S&I Codes Need -59

Non-coronary angioplasties and angiograms have corresponding imaging codes that should be billed if those services are provided by the cardiologist. The imaging code for carotid angiograms is 75660 (angiography, external carotid, unilateral, selective, radiological supervision and interpretation). If the procedure is bilateral, code 75662 (bilateral) should be used. For peripheral angiograms, the correct radiological codes are 75710 (angiography, extremity, unilateral, radiological supervision and interpretation) and 75716 (bilateral). Renal angiograms would include 75722 (angiography, renal, unilateral, selective [including flush aortogram], radiological supervision and interpretation); and 75724 (bilateral).

For angioplasties, there is a radiological code for the first vessel and another for any additional vessels. For renal angioplasties, the first vessel is coded 75966 (transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation), and each additional other vessel receives 75968 (each additional visceral artery, radiological supervision and interpretation [list separately in addition to code for primary procedure]). The angioplasty performed on the first peripheral vessel receives code 75962 (transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation). Any subsequent angioplasties on other vessels should be listed 75964 (each additional peripheral artery [list in addition to code for primary procedure]).

Note: 75964 and 75968 are add-on codes that can be used only in conjunction with 75962 and 75966, respectively.

If a patient had a renal angioplasty as well as a cardiac catheterization, the coronary supervision and interpretation (S&I) procedures 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]) may be bundled within 75966, the imaging code for the renal angiogram. Again, modifier -59 would need to be attached both to the 93555 and the 93556 (because the two codes have fewer RVUs than the 75966: 93555 = 7.92 RVUs; 93556 = 12.05 RVUs; 75966 = 19.03 RVUs) to designate that the S&I for the heart caths and the renal angiogram are separate.

Use Units Box When Coding for Stents

Any non-coronary stents should be coded 37205 (transcatheter placement of an intravascular stent[s] [non-coronary vessel], percutaneous; initial vessel) for the first vessel and 37206 (each additional vessel [list sep-arately in addition to code for primary procedure]). The corresponding radiology supervision code is 75960 both for initial and subsequent vessels. If more than one vessel receives a stent, 75960 would list the number of stents supervised in the units box on the HCFA 1500 claim form.

A cardiologist who placed bilaterial iliac stents as well as one renal stent should code the procedures as follows:

Procedure/ Units/ Comments
37205/ 1/ Renal
37206/ 2/ Iliac
75960/ 3/

Note: Cardiologists also should check with their carriers to make sure they have met additional documentation requirements for such procedures, such as listing the specific vessel stented. In some states it is extremely important to identify where non-coronary stents were placed, because some peripheral stents, including the iliac stent mentioned above, are not FDA-approved, though some Medicare carriers pay for the procedures because they are gaining widespread acceptance and meet national standards of care.
If the cardiologist ends up performing five or more procedures, Medicare will want to see the operative report. When there are that many procedures, sending the report to private payers usually is a good idea as well.