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Cardiology Coding Alert

Use Noted 3 for Interventions In Other Coronaries

Published on Mon Mar 22, 2004

Let carrier LCDs steer you in the right direction

When your cardiologist performs interventions in certain coronary conduits, such as saphenous vein bypass grafts, mammary conduits or arterial conduits, report the procedures as taking place in one of the three recognized coronary arteries. You should also append the appropriate HCPCS anatomic modifier (-LC, -LD and -RC) to the procedure code to avoid denials.
 
The problem: HCPCS provides unique modifiers to report procedures in the three main arteries (left circumflex, left anterior descending, and right coronary) but not for interventions in "other" coronary conduits, such as saphenous vein grafts.

The solution: CMS, carriers and specialty societies have issued guidance on these common procedural scenarios, coding experts say.

Best strategy: Before you report "other" coronary conduit procedures, make sure the note is complete. Specifically, the physician's documentation should include a description of the coronary anatomy and any major anatomic variants, says Cynthia Swanson, RN, CPC, a cardiology coding specialist with Seim, Johnson, Sestak and Quist LLP in Omaha, Neb.

To bill these procedures correctly, Swanson advises that coders check the procedure note for the following:

  • The highest-level procedure the physician performed in each major coronary artery and/or its branches should be clearly identifiable. 
  • The cardiologist must identify the anatomic variant for interventions in other coronary arteries and the rationale for considering that vessel as a major vessel equivalent. For instance, a physician may treat a stenosis in a large diagonal branch of a diminutive left anterior descending artery.
  • Documentation must clearly identify the number of ostia the cardiologist cannulated at the approach to each lesion.  
     
    You should ensure that your practitioners are informed of the carrier local coverage determinations (LCDs) and provide ongoing education and feedback when medical record documentation is lacking, Swanson says.

    Carriers Emphasize Parent Vessels 

    Take a look at the following lesser coronary categories and the sampling of Medicare carrier guidelines to help you report interventions in these "other" coronaries:

    Downstream branches: Noridian Medicare, the provider for a number of Western states, including Arizona, Colorado and Nevada, says that "branch vessels are considered a part of and included with intervention in the named parent vessel." 

    Therefore, when the report says "PTCA to the first septal perforator," you should identify which of the three recognized coronary arteries the first septal perforator branches from. In this case, the first septal perforator is a branch of the left anterior descending artery. For this procedure, you would report 92982-LD (Percutaneous transluminal coronary balloon angioplasty; single vessel; left anterior descending coronary artery), if this was the only intervention the physician performed during the procedure.

    Tip: If your physician does not identify which coronary artery the vessel branches from, you may need to research the branch on-line or in an anatomic reference guide. "Become familiar with coronary anatomy and educate the physicians so that they know exactly what is needed in their dictation to properly code these branches," says Sarah Tupper, CMC, coding specialist with Central New York Cardiology in Utica, N.Y.

    The left main: Cigna Healthcare, carrier for Tennessee, North Carolina and Idaho, states that "the left main coronary artery is considered a part of the major left system vessel receiving antegrade flow."  Therefore, you should identify which of the left coronary arteries (left anterior descending or left circumflex) is the dominant vessel. 

    For instance, if the cardiologist inserts an intracoronary stent in the left main coronary artery and mentions that the left circumflex is the dominant downstream vessel, you would report 92980-LC, if this was the only intervention.

    News flash: Watch for a new modifier (-LM) for the left main coronary artery that you will append to the intervention code for left main coronary artery procedures. The American College of Cardiology (ACC) has approached CMS with a request to have a modifier specific to the left main coronary artery added to the coding structure, Anne Bicha, associate director of regulatory and legal affairs for the ACC, tells Cardiology Coding Alert. 

    "The new modifier will have a positive impact on reimbursement," Tupper says. "Our physicians do not do a lot of interventions in the left main alone; however, a new modifier will give the opportunity to code additional stents and/or angioplasty when doing the left main and another major vessel."

    Scrutinize Ramus Variants

    Only about 35 percent of patients have a ramus coronary artery, which arises at the bifurcation of the left main into the left anterior descending (LAD) and the left circumflex (LCX), so you won't see interventions here as frequently as in other coronaries. Even so, you should know how to report ramus interventions when you encounter them. Having the right details on ramus interventions is critical, Tupper says.

    Indeed, Cahaba GBA, Medicare carrier for Alabama, Georgia and Mississippi, specifies that "Anatomic variants (large ramus or marginal branches, unbalanced circulatory patterns, etc.) should be referenced as precisely as possible to a corresponding named vessel." The ACC's Guide to CPT 2003 also advocates using the corresponding vessel as a guide, stating that "when one lesion is treated in the ramus intermedius in addition to a second lesion in the LAD or the LCX, code the ramus intermedius as a separate major vessel."

    Here's how: Therefore, if the note establishes the ramus as being closer to or supplying the same myocardial tissue as the left anterior descending or left circumflex, you should report interventions in the ramus as being performed in that coronary artery, coding experts say. 

    For example, if the cardiologist performs an atherectomy in the ramus and the note establishes the ramus as being close to the LAD, you would report 92995-LD, if this was the only intervention (or at the highest-valued intervention) performed.

    Don't Get Lost in Bypass Vessels

    Your physician may perform an intervention in a coronary artery bypass graft, such as the left internal mammary artery to the distal left anterior descending or the reverse saphenous vein to the right coronary, so you'll need to know which vessel to report.

    WPSIC, Wisconsin's carrier, states, "Bypass conduits are considered, for nomenclature and coding purposes, integral to the vessel of distal anastomosis." This means that you should report the coronary artery or branch that is supplied by the bypass graft.

    For example, if the physician performs an angioplasty in a saphenous vein graft to the right coronary artery, you would report this as an intervention to the right coronary artery, coding experts say.

    Coding scenario: If a cardiologist performs an atherectomy in the left internal mammary artery to the distal left anterior descending, you would use 92995-LD, if this was the only intervention.

    "As always, look to your LMRPs for advice when reporting interventions in bypass grafts," Tupper says. "Most Medicare carriers do state that the bypass grafts are integral to the vessel of distal anastomosis: in other words, the vessel the bypass graft is attached to."

    Note: Although the guidelines presented above were excerpted from individual carrier coverage policies, we found that most carriers use similar, if not identical, verbiage. To be safe, however, check your carriers/payers' coding guidelines for coronary interventions.

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