Don’t Miss a Beat When Coding Coronary Arterial Procedures

By David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC
From a coder’s perspective, the heart is made up of chambers, valves, and coronary and pulmonary arteries and veins. Let’s focus on outpatient hospital and physician CPT^® coding for diagnostic and interventional coronary arterial procedures.

Branch Out Coronary Artery Coding Know-how

Anatomically there are two coronary arteries, the right coronary (RC) and the left main coronary arteries. The left main quickly bifurcates into the left circumflex (LC) and the left anterior descending (LAD) coronary arteries. A common anatomic variant is trifurcation of the left main, with a ramus intermedius artery situated between the LAD and the LC. Branches of the LAD include several diagonal and septal perforator arteries. Branches of the LC include several marginal and, occasionally (five percent of patients), the posterior descending arteries (PDA) and branches of the RC include the acute marginal and the PDA (95 percent of patients). Branch vessel knowledge is imperative when coding coronary arterial intervention as CPT^® coding considers all interventions performed within the main vessel (as defined by the coronary arterial vascular distribution modifiers LC, LD, and RC) and all of its branches to be a single vessel intervention.
Diagnostic coronary angiography (93508) describes a procedure involving selective injection and imaging of coronary arteries. CPT^® codes 93539, 93540, 93541, 93544, and 93545 represent injection procedures for arterial conduits, saphenous vein bypass grafts (SVBPG), pulmonary arteries, the aortic root, and native coronary arteries. Each of these injection procedure codes are billed only once per patient encounter, regardless of how many individual vessels in each group are injected. This rule applies to all cardiac and coronary injection and imaging codes, 93539-93556.
Code 93539 Injection procedure during cardiac catheterization; for selective opacification of arterial conduits (eg, internal mammary), whether native or used for bypass is unusual as it is billed for selective arterial graft injection or when an artery (such as the internal mammary artery) is injected prior to coronary artery bypass graft surgery (CABG) to evaluate the vessel as a potential bypass graft. This imaging includes imaging of the proximal subclavian artery. Usually, code 93544 Injection procedure during cardiac catheterization; for aortography is performed as a necessity for aortic valvular disease or aortic aneurysm evaluation; however, it may be injected to evaluate the origins of SVBPG’s when they are difficult to cannulate  due to occlusions. When the aortic injection shows a patent graft, and then it is selected and injected (93540), the aortic root injection is not billed as it is considered a guiding shot to localize the graft’s origin. If there is an additional separate medical necessity such as aortic valve regurgitation, then code 93544 can be billed for this indication. Codes 93539, 93540, and 93545 require selective catheter placement while the aorta (93544) is a non-selective vessel. The pulmonary arteries can be injected non-selectively from the right ventricle (RV) or main pulmonary artery (MPA), or selectively in a branch vessel.

Report Imaging S&I Separately

The injection imaging’s supervision and interpretation (S&I) is reported separately.  Arterial imaging code 93556 Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass) is billed once regardless of how many arteries are injected per patient encounter. This rule also applies to heart chamber injection and imaging codes 93542, 93543, and 93555. When diagnostic angiography is performed at the same setting as a coronary arterial intervention, append modifier 59 Distinct procedural service to codes 93555 and 93556 to alert Medicare the imaging procedures were part of a diagnostic exam (which led to the intervention procedure) and not just the intervention’s  guiding or follow-up image.

Know Intervention’s Hierarchy Rules

Coronary arterial interventions include thrombolysis, thrombectomy, brachytherapy, angioplasty, atherectomy, and stent placement. The coronary interventional CPT^® coding rules are well defined, are consistent across payers, and unchanged for the past 15 years. There is an established hierarchy for catheter based coronary arterial interventions:

• Stent placement supersedes atherectomy
• which supersedes angioplasty.

For Medicare hospital billing, drug-eluting stent (DES) placement supersedes stent placement. This rule applies to each separate coronary arterial distribution as defined earlier. For all angioplasty, atherectomy, and stent placement procedures performed in a single coronary vascular distribution (LAD, LC, or RC), you are allowed a single interventional procedure code. For example, if stents are placed in two diagonals, a septal perforator and the LAD itself, only one stent placement code is allowed. Since intervention in the left main is considered part of any distal vessel intervention, only one stent is billed for all five stents placed even if a left main stent was also placed.
When performing multiple interventions (defined as interventions in the LC, LAD, and/or RC), coding guidelines mandate billing the highest level of intervention as an initial vessel intervention. Any other vessel interventions are again coded to the highest level of intervention but as an additional vessel intervention. You should never see two initial vessel coronary arterial interventional codes used during a single patient encounter.

Apply Bundling and Add-on Codes Rules

Certain coronary arterial interventions, such as rotational atherectomy, frequently lead to severe bradycardia. Temporary pacemaker use during coronary intervention is bundled in the procedure and is not separately billable. Some procedures, particularly SVBPG interventions, utilize a distal embolic protection device to capture embolic material. A few payers allow unlisted code 93799 to describe this while others bundle this into the primary interventional procedure. Catheter directed coronary arterial thrombolysis (drug infusion of a thrombolytic agent to dissolve blood clot, code 92975, is rarely billed as a stand-alone code. If catheter directed thrombolysis is successfully performed and an underlying stenosis is identified, followed by balloon or stent intervention, the thrombolysis becomes bundled in the intervention and is not separately billable. Catheter directed thrombolysis can only be billed if it is performed as the only intervention in a vascular distribution.
Percutaneous coronary arterial thrombectomy (the removal of clot or thrombus, code 92973 Percutaneous transluminal coronary thrombectomy (List separately in addition to code for primary procedure), is an add-on code used with any subsequent intervention performed with a balloon, atherectomy device, or stent placement. Bill these additional interventional procedural codes per separate coronary arterial vascular distribution.
Coronary brachytherapy is the placement of a localized radiation therapy source- usually a catheter, across a recurrent stenosis- and coded with 92974 Transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy (List separately in addition to code for primary procedure). Because of the advent of DES placement due to the decline in recurrent stenoses within these stents, coronary brachytherapy is performed less frequently. When a diagnostic coronary angiogram indicates a hazy or indeterminate lesion, further evaluation with an intravascular ultrasound (IVUS) (codes 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)) or intravascular Doppler also known as wave wire or FFR, (codes 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)) procedure may be necessary. Because the vascular distribution rules apply to IVUS and intravascular Doppler, only one code is used to describe IVUS performed in the LAD, the first diagonal and the left main coronary arteries. All four IVUS and intravascular Doppler codes are add-on procedure codes.
Coronary angioplasty involves using a balloon to dilate a stenosis (initial and additional vessel codes 92982 and 92984) and may be the only intervention performed in a vessel. If a higher level intervention is also performed, the angioplasty is bundled and not billed. If a cutting balloon containing little “razor blades” on the outside to cut the recurrent stenoses’ intimal hyperplasia is used, balloon angioplasty (POBA) codes 92982 and 92984 are used.
Coronary atherectomy involves removal of atheromatous material from a coronary artery (codes 92995 Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; single vessel and 92996 Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; each additional vessel (List separately in addition to code for primary procedure) and may utilize photoablation technique (laser), rotational, side-cutting, or other extraction devices to remove plaque material. Stent placements within the coronary arteries use initial and additional vessel codes 92980 and 92981 for physician billing and for non-drug eluting stents placement for hospital billing. Hospitals may use initial and additional vessel HCPCS Level II codes G0290 Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel and G0291 Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel when billing Medicare for drug eluting stents placement.

Expect Reviews With Modifier Usage

Code interventions performed within a graft with a modifier representing the vessel the graft is anastomosed to. If an intervention is also performed in the same vascular distribution but through the native vessel origin, both interventions may be billed only if the separate interventions were not approachable via one vessel origin. One intervention would be the initial vessel intervention, the next would be an additional vessel intervention, but both with the same vessel modifier (LC, LD, or RC). The additional intervention requires modifier 59 and you should expect a report review. Intervention within a ramus intermedius should receive the modifier LC or LD describes the vessel more closely. Usually when a ramus variant is present, the LC or LD is a smaller vessel. If intervention is performed in a ramus and the LD, call the ramus the LC. If an intervention is performed in a ramus and the LC, call the ramus the LD. If intervention is performed in all three vessels, code the ramus appended with 59-LC (or LD) and again, expect a review of the report. Left main intervention alone is coded as either LC or LD; however, remember that with distal LC or LD intervention, the left main is included in the distal LC or LD intervention.

Watch Out When Billing Infusion Agents

Watch out when billing procedures for intravenous coronary thrombolysis, (code 92977), and catheter directed infusion of non-thrombolytic agent, (code 37202 and 75896). Code 92977 describes a high dose bolus of thrombolytic agent’s intravenous injection to dissolve coronary arterial thrombus. This is usually performed in the emergency room by a nurse for a patient with acute myocardial infarction. The use of bolus IV infusions has waned when the critical “door to balloon” time was shortened during patient’s care. Don’t use code 92977 when an anti-thrombotic agent is infused intravenously during coronary intervention. This drug infusion is meant to prevent clot formation in the immediate post-stent placement time frame. It is only billed by the hospital and only with a HCPCS Level II J code for the infused drug. Code 37202 is intended for the long term catheter directed drug infusion, not for the drug’s bolus injection during an intervention (such as nitroglycerin or Verapamil for localized arterial spasm treatment). This is inherent to the intervention. Code 37202 is rarely ever billed during cardiac procedures.
These guidelines are well established and universally accepted in the CPT^® coding literature in regards to coronary diagnostic and interventional outpatient procedural coding. Due to peripheral procedures’ expansion into the cardiac catheterization lab, hospitals and cardiologists should be careful to use coronary interventional codes for coronary arterial interventions and peripheral interventional codes for peripheral interventional procedures performed in the catheterization lab.

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