Cardiology Coding Alert

Tip:  Find out how your payers want you to report bilateral cath placements

Stop having to appeal denials for renal angiographies your cardiologist performs on the same day as a cardiac catheterization. Follow this expert advice and get your claim paid the first time every time.

First, Start With 2 Renal Study Codes

If you're reporting selective renal angiography on the same day as the cath, you would report two codes:

• 36245--Selective catheter placement, arterial system; each first-order abdominal, pelvic, or lower extremity artery branch, within a vascular family

• 75724--Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation.

Here's why: The first code is specific to the selective catheter placement for the renal study. The second code shows the bilateral radiologic imaging of these arteries.

Focus on Bilateral 36245

Payers, however, vary on the way they prefer you to report bilateral selective catheter placements. The most common examples are:

• 36245-LT (Left side) and 36245-RT (Right side),

• 36245-LT and 36245-RT-59 (Distinct procedural service),

• 36245-50 (Bilateral procedure), or

• 36245-50-59.

Each of these accurately reports that you are billing for bilateral selective renal artery catheterization, but your payer may only automatically adjudicate the claim with one particular approach.

"Some insurance companies, such as National Heritage Insurance Company and BCBS [Blue Cross Blue Shield], require one line, one unit with modifier 50 attached. Others require two lines with modifier 50 on the second, but I feel it makes sense for us to code them with modifiers RT/LT," says Carolyn MacDonald, CPC, coding manager of the New England Health Care Foundation in Boston. "Using this method, we don't get rejections--but that may not work for other states."

Make the call: You need to identify the proper way to bill for these services to ensure proper and efficient reimbursement. Your first line of action is to call your various carriers and ask how they prefer you code these procedure. You might also review your claim history to identify the preferred billing method of your payers. "Each carrier can have their own way of wanting to see these services reported, so this can vary at times," says Angela N. Andersen, CPC, coding and documentation quality assurance at the Department of Defense, Division of the Navy, NMCP in Portsmouth, Va.

Be Wary of Modifiers With 75724

You'll also have to be careful about modifiers when reporting 75724. Because 75724 is a bilateral code, you won't be able to report it with any of the bilateral modifiers (such as 50, LT or RT), MacDonald says. Clinically, the code represents the cardiologist engaging both renal arteries (right and left) and visualizing them.

You'll most likely report modifier 59 with this code quite frequently. You should also be prepared to include modifier 26 (Professional component) to show that you're reporting the physician work only and not the technical component (which includes equipment, supplies, technical staff, utilities, rent, and so on).

Second, Fill Out Your Left Heart Cath Codes

In addition to the renal angiography codes (36245 and 75724), you'll also report:

 • 93510-26--Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral  
artery; percutaneous

• 93543--Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography

• 93545--...for selective coronary angiography (injection of radiopaque material may be by hand)

• 93555-26--Imaging supervision, interpretation and report for injection procedure(s) during cardiac
catheterization; ventricular and/or atrial angiograph

• 93556-26--...pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass).

These remaining five codes are what payers consider the "basic" full left heart catheterization code package.
Red flag: Make sure, however, the cath you are reporting meets the standard. Many heart catheterizations are more extensive (such as bypass graft angiography) or less extensive (such as no left ventriculogram 93543 and 93555-26).

Keep in mind: The National Correct Coding Initiative bundles 36245 and 75724 into the heart cath code 93510. You'll have to append modifier 59 onto 75724.

And modifiers 59, LT or RT will work to unbundle the edit for the cath placement code 36245. Otherwise, the edit would suggest that a selective catheterization below the diaphragm (36245) and selective renal angiography (75724) are bundled--which isn't the case.

Third, Double-Check Your Diagnoses

Another step to beat back those denials is to make sure you report a diagnosis code that accurately reflects the indication for the study (if the study is negative) or the findings of the study (if the study is positive).

You should report findings of peripheral vascular disease with the appropriate diagnosis code (such as 440.1, Atherosclerosis of renal artery). Many practices inadvertently report the diagnosis of coronary artery disease (414.01), which is appropriate only for the heart catheterization-specific codes.

Best bet: "Be sure to use two different diagnoses for the cath and renal procedure," says Lori Gearhiser, business office director at Louisville Cardiology in Louisville, Ky.

If All Else Fails, Start a Discussion

If these approaches fail, you may need to open a dialogue with your payer. "We call our customer representative of that particular insurance company to discuss it," MacDonald says.

Despite the fact that many coverage policies state that the indications for peripheral studies at the time of a heart cath are limited, you should keep in mind that atherosclerosis is a systemic condition that affects the entire vascular system. Therefore, patients who require coronary angiography will have a higher rate of peripheral disease than the rest of the population.

"Medicare will probably reduce the reimbursement on one of the procedures, but you should get paid something," Gearhiser says. The heart cath (93510) pays less than a selective bilateral renal (36245-50), so you'll face a 50 percent reduction on 93510 due to the multiple-procedure payment reduction rules. However, if you report the bilateral selective renal cath placements on separate line items, then carriers would pay your heart cath (93510) slightly more, and both of the 36245s (such as 36245-LT and 36245-RT) would be reduced by 50 percent. 

"Besides continuing to submit appeals, you may also consider having the cardiologist get involved via a phone hearing with the claims examiner or request a phone conference with the medical director of the insurance company," says Anne Sady, business manager at Orlando Heart Center in Orlando, Fla.