Cardiology Coding Alert

Question: The emergency department sent an AMI patient (NSTEMI) through to the cath lab within minutes of arrival. The cardiologist used right femoral access. He performed selective angiography of the left coronary system and determined intervention was required for severe LAD lesions causing the NSTEMI. There was a 99 percent stenosis after the fourth diagonal. He positioned a balloon in the distal portion of the mid LAD stenosis, inflating and deflating. Angiography showed improvement in the stenosis and allowed sizing for the stent. He repeated balloon inflations and angiography. After several attempts to place the stent, the cardiologist decided to abandon the stenting procedure because of the patient’s advanced age and the state of her vessels. How should I code this case?

Florida Subscriber

Answer: Because the procedure occurred during the acute myocardial infarction, you should report 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel).

Append modifier LD (Left anterior descending coronary artery) to 92941 to indicate the vessel involved.

You also may report the diagnostic angiography separately using 93454 (Catheter placement in coronary artery[s] for coronary angiography, including intraprocedural injection[s] for coronary angiography, imaging supervision and interpretation). Append modifier 59 (Distinct procedural service) to 93454 to override the edit with 92941. For those payers who accept or require it, you may use modifier XU (Unusual non-overlapping service) instead of 59.

Support for override: In a case like this where there is no indication of a prior study, CPT® guidelines allow you to report diagnostic angiography at the time of intervention when the physician performs a full diagnostic study and makes the decision to perform the intervention based on the angiography.

The code includes any combination of stenting, atherectomy, and angioplasty, so it’s the only code you need, regardless of whether the cardiologist was able to place the stent.

ICD-10: To report the myocardial infarction diagnosis, use I21.4 (Non-ST elevation [NSTEMI] myocardial infarction).

For the stenosis, report a secondary code of I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris), assuming there is no specific mention of angina pectoris in the documentation.