Medicare Compliance & Reimbursement

Avoid 3 deadly sins of coronary intervention documentation.

If your arterial stent documentation isn't up to snuff, you should brace yourself for audits.

Watch out: Coders billed 20 of 72 arterial stent placements in the outpatient setting incorrectly, according to an October 2005 HHS Office of Inspector General (OIG) report (A-06-04-00091).

Overall problems: The OIG found that many stent records lacked information on medical necessity for thrombectomy with angioplasty and stent placement. Also, the OIG found that providers failed to use the proper code for thrombectomy in some cases. In others, the provider tried to bill separately for thrombolysis and stent placement, when the thrombolysis should have been bundled.

"Often physicians feel that they should bill for all aspects of the procedure they perform" without taking into account National Correct Coding Initiative bundles and code definitions, explains Belinda Keeling, CPC, audit and education department coder at Acadiana Computer Systems in Lafayette, LA.

You should realize that "thrombectomy code +92973 (Percutaneous transluminal coronary thrombectomy [list separately in addition to code for primary procedure]) is an add-on code," notes Yvette Hofmeister, CPC, coding analyst for OSU Internal Medicine in Dublin, OH.

You must use 92973 with the following codes, according to CPT:

• 92980--Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel

• 92982--Percutaneous transluminal coronary balloon angioplasty; single vessel.

"The cardiologist has to be clear as to why this add-on procedure is needed in addition to the stent, because he would perform this in the same vessel," Hofmeister says. In other words, your physician's documentation has to be up to snuff to avoid the mistakes OIG mentioned.

Evade These Documentation Pitfalls

Three cardiology documentation errors could lead to the kind of problems the OIG discovered. Here are the pitfalls you should learn to avoid: 

Pitfall #1: Semi-automated reports. Many physicians prefer to use the catheterization lab information system to generate their documentation for procedures, instead of dictating their reports the old-fashioned way, experts say. These semi-automated reports don't explain the reasons that a doctor chose a particular set of interventions. That can lead to incorrect coding. 

"Documenting procedures in this fashion can also be problematic because the author of each entry in the medical record is not clearly recorded," says Jim Collins, CPC, ACS-CA, CHCC, president of The Cardiology Coalition in Matthews, NC. "These are legal documents, and each entry must be signed and dated by the appropriate author. Automated systems are often driven by cath lab technicians, not the physician."

Pitfall #2: Anatomical misunderstandings. You're not alone if you have difficulty figuring out what constitutes a single coronary artery, but that sort of anatomical misunderstanding is especially common in situations when the physician performs interventions in branches, bypass conduits, vein grafts and/or anatomic variants like the ramus intermedius.

You'll have a sticky problem when a physician who doesn't understand CPT coding or a coder who doesn't understand coronary anatomy picks the wrong code.

Good advice: For the coronaries, you should compile a list of the terms and specific locations within each vessel (such as LD can be left main, LAD proximal, diagonal 1 and so on), Hofmeister says. "Neither CPT nor Medicare lists these for us, and that is unfortunate" because coronary stents can be anatomically confusing. "Initially, I did not realize you can have only one initial vessel, though one might be a stent and the other a balloon angioplasty," Hofmeister says.

Pitfall #3: No "because." Could a nonphysician tell why your physician performed a specific set of interventions just by reading the medical record? If not, you should encourage him to use phrases like "It was determined that Mr. Smith required thrombectomy and stent placement because...," experts say.

Learn The Value Of Shadow Audits

Challenge findings: If your carrier or payment safeguard contractor decides to audit your claims for arterial stents or thrombectomies, conduct your own "shadow audit" and defend your claims, Collins says.

The coalition is in the midst of challenging the findings of two different audits in which the auditor failed to give credit for information in the medical record, Collins says. In one case, an auditor admitted that she'd been misinterpreting a common clinical statement in the medical record for several years.