Changes Plus More Changes for Cardiology in 2013

By David B. Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCVTC

Part 1: Reporting coronary artery interventions is altered significantly.

The new year brings major changes to the Cardiovascular System section in American Medical Association’s (AMA) 2013 CPT®, with several deleted codes and 56 new codes—including 30 CPT® codes, 17 Category III codes, and nine HCPCS Level II C codes. This month, we’ll focus on updates affecting coronary artery interventions: 2013 will require us to essentially alter the way we’ve reported such procedures for many years.

Certified Cardiology Coder (CCC) Credential

Number of Major Arteries Increases

Per CPT®, we now have five major coronary arteries for intervention coding (instead of three, as in years past). They are:

  • Left main (LM)
  • Left anterior descending (LD)
  • Left circumflex (LC)
  • Right coronary (RC)
  • Ramus intermedius (RI)

You may report an intervention in each of these vessels, when performed, and in up to two branches of the LD (diagonals), LC (marginals), and RC (posterior descending, posterolaterals). Every bypass graft represents a major coronary artery for coding purposes.

There are now specific, separate code categories to report:

  • Percutaneous coronary intervention (PCI) in the native circulation
  • Intervention performed in a bypass graft, or of the native circulation via a bypass graft
  • Total/subtotal occlusion during acute myocardial infarctions (MI)
  • Chronic total occlusions (CTO)

Physicians must document concisely to ensure accurate reporting with this new and complex system for coronary intervention reporting.

New Codes in Review

Let’s review the new base (primary procedure) and add-on codes for coronary artery interventions. Note: C codes (cited in parenthesis, with CPT® codes for nondrug-eluting stents) report drug-eluting stents for Medicare in the facility setting.

The base codes for initial intervention(s) are:

  • 92920 – Angioplasty
  • 92924 – Atherectomy
  • 92928 – Stent (C9600)
  • 92933 – Atherectomy and stent (C9602)
  • 92937 – For any combination PCI of, or via, a bypass (C9604)
  • 92941 – For any combination PCI during an acute MI (C9606)
  • 92943 – For any combination PCI for CTO (C9607)

The reporting hierarchy, from highest to lowest, for these base codes is:

92943 = 92941 > 92933 > 92924 > 92928 > 92937 > 92920

Source: Distributed during the AMA CPT® 2013 Annual Symposium, based on revised relative value unit (RVU) valuations.

The add-on codes for additional intervention(s) are:

  • +92921 – Angioplasty
  • +92925 – Atherectomy
  • +92929 – Stent (+C9601)
  • +92934 – Atherectomy and stent (+C9603)
  • +92938 – For any combination PCI via bypass graft (+C9605)
  • +92944 – For any combination PCI for CTO (+C9608)

The reporting hierarchy for these add-on services, from highest to lowest, is:

92944 = 92938 > 92934 > 92925 > 92929 > 92921

Tips for Proper Reporting

1.  Angioplasty, when performed, is included in each base and add-on code.

2.  “Any combo” designation for codes 92937-92944 Percutaneous transluminal revascularization … means that angioplasty, atherectomy, and stent are included when performed for interventions via a bypass graft, during an acute MI, or of a CTO.

3.  When choosing the base code for each artery treated, select the one that includes the most intensive service provided.

4.  All interventions within one major coronary artery or branch are reported with one code. For example, if an angioplasty is performed in a proximal RC stenosis, and a stent is placed in a distal RC stenosis, report only the highest level base code, 92928 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch.

5.  Report a base code for each major native coronary vessel intervention, or of a single branch if the major coronary artery is not treated.

6.  Report an add-on code for interventions in up to two additional branches of the LD, LC, and RC, when performed. For example, if a stent is placed in a stenosis in the native LC and angioplasty is performed in two branches of the LC (e.g., OM1, OM2) report 92928, 92921 Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) x 2. The second unit of 92921 does not require modifier 59 Distinct procedural service because this is an add-on code.

7.  Code for two interventions when a bifurcation lesion is treated.

8.  Code for one intervention for treatment of a bridging lesion where the stenosis extends from one vessel into another vessel treated with a single intervention.

9.  If one area of a major coronary vessel is treated via the native circulation, and a different area is treated via a bypass graft, report both. For example, if a proximal LD stenosis is stented via the native LD, and a distal LD stenosis is stented via a saphenous vein bypass graft, report 92928 and 92937 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel.

10. Use base code 92937 for intervention of, or via, a bypass graft. This would include any combination of angioplasty, atherectomy, and/or stent. Add-on code 92938 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure) reports additional intervention in a branch subtended by the bypass graft.

11. A sequential (jump) graft that has more than one distal anastomosis is considered one graft.

12. Intervention for a total/subtotal occlusion during an acute MI is coded 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 for a single vessel. This would include any combination of angioplasty, atherectomy, and/or stent. Code 92941 also includes manual aspiration thrombectomy, when performed.

13. Mechanical thrombectomy (e.g., AngioJet®), when performed, may be reported additionally with +92973 Percutaneous transluminal coronary thrombectomy mechanical (List separately in addition to code for primary procedure)).

14. CTO means no antegrade flow is present, and no current ST elevation or Q wave acute MI.

15. The base code for a CTO intervention (92943 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel) includes any combination of angioplasty, atherectomy, and/or stent. Add-on code 92944 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure) reports additional CTO interventions.

16. Closure of the arteriotomy is always included, and imaging related to closure device is not reported.

17. Only report diagnostic angiography if not previously performed or if there has been a documented clinical change since the prior angiography. For example, a patient has a recent coronary angiogram and the plan is for medical treatment. The patient returns via the emergency room with new onset angina and a coronary angiogram is performed prior to coronary artery bypass grafting (CABG). Report 93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography. Do not code for angiography for a planned, staged PCI or for routine re-look angiography, and do not report for sizing, confirmatory, guiding, positioning, road-mapping, or completion angiography.

18. When performed, you may also report:

Intravascular Ultrasound (IVUS) +92978 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for primary procedure) and +92979 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (List separately in addition to code for primary procedure);

Intravascular Doppler/Pressure +93571 Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; initial vessel (List separately in addition to code for primary procedure) and +93572 Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; each additional vessel (List separately in addition to code for primary procedure);

Optical Coherence Tomography (OCT) +0291T Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; initial vessel (List separately in addition to primary procedure) and +0292T Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; each additional vessel (List separately in addition to primary procedure); and

Near Infrared Spectroscopy (NIRS) +0205T Intravascular catheter-based coronary vessel or graft spectroscopy (eg, infrared) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation, and report, each vessel (List separately in addition to code for primary procedure) (each vessel).

19. Do not report an additional CPT® code for embolic protection device (EPD), when used.

20. For Medicare facility coding, use HCPCS Level II codes C9600–C9608 when a drug-eluting stent is placed. The other CPT® stent codes denote nondrug-eluting stents.

21. Add modifier 59 to duplicated base codes when multiple major coronary arteries are intervened upon with the same type of intervention.

22. The following codes have been deleted for 2013: 92980, 92981, 92982, 92984, 92995, 92996, G0290, and G0291.

Three Examples to Show the Way

1.  A patient presents with evidence of an acute MI. A diagnostic coronary angiogram is performed and reveals acute thrombus resulting in a total occlusion of the RC. Also noted is a 75 percent stenosis of the LC. An AngioJet® mechanical thrombectomy is performed in the RC, and a DES is placed in the residual 90 percent stenosis. A second DES is placed in the LC stenosis.

Coding: 93454, 92973, C9606-RC (92941-RC for physician), and C9600-LC (92928-LC for physician)

Rationale: Code for initial coronary angiogram (93454) and for DES of the RC in the setting of an acute MI related to the RC (C9606 or 92941). Because this is a mechanical thrombectomy, it is reported with 92973. Also code for DES in the LC stenosis (not the cause of the acute MI) with C9600 or 92928.

2.  A patient has had prior angiography revealing hemodynamically significant stenosis in the LD, diagonal, and RC, and is here for elective PCI. Nondrug-eluting stents are placed into the LD and diagonal. IVUS is performed in the diagonal to confirm adequate stent expansion. An angioplasty is performed in the RC.

Coding: 92928-LC, 92929-LC, 92978-LC, and 92920-RC

Rationale: The patient is here for planned PCIs. Base code 92928 is for the left circumflex stent. The add-on code 92929 is for the additional stent in the diagonal branch. IVUS (92978) is reported for the LC for confirmation of the adequate stent deployment. Lastly, another base code 92920 is for angioplasty in the RC.

3.  A patient has had prior CABG surgery and presents with increasing angina. A left heart cath is performed with normal LV pressures. Angiography reveals a LIMA attached to the LD with an 85 percent stenosis within the LIMA graft. It also reveals a patent saphenous vein bypass graft to the RC, but a distal 70 percent stenosis of the posterolateral branch. A rotational atherectomy is performed and subsequently a non-drug eluting stent is placed in the LIMA. Via the RC vein bypass graft, the posterolateral has a nondrug-eluting stent placed.

Coding: 93458, 92937-LD, 92937-59-RC

Rationale: Code 93458 for initial left heart cath. Atherectomy and nondrug-eluding stent are performed in the LD via the LIMA graft; therefore, report combination code 92937-LD. Lastly, the stenosis in the posterolateral branch is approached via the saphenous vein graft. A nondrug-eluding stent is placed; therefore, report base code 92937 again. Append modifier 59 to the second unit of 92937 because the same base code is needed to describe a stent in the second major coronary artery.

New Robust System with Robust Coding

2013 brings a paradigm shift in coronary arterial intervention coding. The new system is more robust, with increased opportunities for reporting of multiple interventions, and more specific coding for graft interventions, PCI during acute MI, and CTO revascularization. With more detailed procedural reporting by the physicians and due diligence by coders, mastering this new system should be rewarding to the coder, physician, and facility.

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David Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCVTC, is vice president of ZHealth. He oversees physician coding and instructs ZHealth educational programs, as well as contributes to Dr. Z’s Medical Coding Series. A graduate of Texas A&M University, he completed his M.D. at the University of Texas, his surgical residency at Scott & White Hospital, and his vascular surgery fellowship at Baylor College of Medicine. A diplomat of the American Board of Surgery, Dr. Dunn is also certified in Vascular Surgery. He is a fellow of the American College of Surgeons and a member of the Southern Association for Vascular Surgery. He is president-elect of the AAPC National Advisory Board.

 

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2 Responses to “Changes Plus More Changes for Cardiology in 2013”

  1. Marina says:

    We seem to be at odds over the proper ICD-9 code to use for status post stent placement and status post CABG. Can anyone please clarify the proper codes! We use V45.82 for stent placement status, and V45.81 for CABG status, and where we can obtain the information on these codes for education.
    Thank you in advance

  2. Laura S says:

    How do you appropriately code a mechanical thrombectomy done for ONE lesion is located in 2 locations- the distal left main and proximal left anterior descending? Should I report 92973 twice for two vessels, or only once since it is targeting one lesion? And if I only report it once, is it appropriate to append both LM and LD modifiers? Any guidance is appreciated, I can’t find a guideline that applies to this scenerio! Thanks.

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