Part B Insider (Multispecialty) Coding Alert

Educate your physicians to document catheter placement for angiograms

Watch out: You could be one of the cardiology practices losing out on reimbursement for peripheral procedures performed with heart catheterization, warns Jackie Miller with Coding Strategies in Powder Springs, GA.

The problem: The cardiologists- documentation may not clearly indicate what the physicians did, Miller explains.

For example, Medicare pays much more for a selective renal angiogram (with catheterization of the renal arteries) than for a non-selective renal angiogram (with the catheter positioned in the aorta). 

But many cardiologists don't note whether they catheterized the renal arteries, so you end up reporting a non-selective angiogram, says Miller. Similar problems crop up with lower-extremity angiograms: Did the physician catheterize the contralateral leg? Did the doctor image the legs via a contrast injection in the aorta?

Note: Some cardiologists also perform carotid angiograms along with heart catheterization. Physicians will rarely document whether they imaged the carotids in the aortic arch, in the common carotid or in the internal carotid. You need all of this information to be able to select the correct code, cautions Miller.

Likely culprit: If you-re like most facilities, you use an automated record-keeping system for your catheterization labs. The vendors typically design their record-keeping systems for heart procedures, not peripheral procedures, says Miller. So these systems don't make it easy for doctors to document peripheral procedures completely.

Sometimes, the doctor actually has to hand-write an addendum to supplement the information in the automated record to explain where he/she catheterized, says Miller.

Plus: The physician doesn't always document the indications  or medical necessity for peripheral procedures, Miller says. Example: The physician may go into a lot of detail about the patient's heart problems but not provide much information about why the patient required a renal, lower extremity or carotid angiogram.

The solution: Educate your physicians. Miller suggests showing physicians the possible coding scenarios and the extra reimbursement they can get for a selective, instead of non-selective, catheterization. -That helps them understand why the information is important,- she says. Then teach them what to document to help you code accurately--such as which vessels they catheterized and where the catheter was located when they injected the contrast.

Tip: Whenever St. Paul Heart Clinic has a new physician come on board, a coder spends a day in the cath lab with the physician, notes coding and compliance specialist Anne Karl. That way, the coder can observe what the physician actually does, and they can go over the documentation together afterward. If the physician goes into the renal artery, then the coder can help the physician learn to document that properly--and the coder also can learn more about the anatomy.

Unfortunately you may face an uphill battle to change your facility's automated record-keeping systems, Miller notes. But it wouldn't hurt to ask vendors to upgrade their record-keeping software to allow full documentation of peripheral procedures.