Instill Ideal Reporting Practices for IR and Cardiology
Recognize strengths and weaknesses in procedure documentation to ensure your coding is built upon a solid foundation.
By David Dunn, MD, FACS, CIRCC, CPC-H, CCVTC, CCC, CCS, RCC
The physician procedure report is the foundation for coding, charge capture, and the reimbursement process. If that foundation is weak, your ability to code will be, too. Weak coding leads to shaky claims reporting and dangerously unstable reimbursement. Before your walls come tumbling down, consider the following recommendations to strengthen physician reporting of interventional radiology (IR) and cardiology services, and build a solid foundation for accurate coding and reimbursement.
Be Mindful of Templates
Many providers use templates to ensure the consistency and comprehensiveness of the reporting process. Templates are valuable as a reminder list, but may leave important information out and/or crowd the record with irrelevant details. Templates might also require editing (i.e., the deletion of items that have not been performed); overlooking such manual overrides may result in conflicting (and often confusing) reporting, which results in non-compliant documentation and improper coding and reimbursement.
The following is a general outline and explanation (not a template) of items that should be addressed in a typical report.
Recommendations for procedural reports in IR:
- State the history, medical necessity, prior interventions, and reasons for repeat diagnostic study after prior catheter-based angiography/computed tomographic angiography (CTA)/magnetic resonance angiography (MRA).
- State the vascular access site(s) and what is being performed (diagnostic angiography and/or intervention) via each access site, as well as timing of each procedure.
- State the vessel(s) catheterized, describing the catheter tip location and any variant anatomy.
- State the vessel(s) injected, the areas imaged (for medical necessity), interpretation of findings, specific percentage of stenosis, exact anatomical location of the lesions, and description of any normal vessels in between the stenosis, as well as if the stenosis is a lesion that bridges two vessels.
- State the intervention(s) and adjunctive procedure(s) performed. Also state any complications or additional treatments provided.
- State the specific device(s) and special supplies used during the procedure.
Recommendations for procedural reports in
- State the history (acute myocardial infarction (MI), unstable angina, chronic total occlusion (CTO), planned intervention), prior surgeries or interventions, medical necessity for diagnostic and interventional procedures, and reasons for repeat diagnostic study after prior catheter-based angiography.
- State the vascular access site(s), and what is performed via each access.
- State the peripheral vessel(s) catheterized, describing the catheter tip location and any variant anatomy or surgically-created grafts.
- State the heart chamber(s) entered with pressures obtained, as well as any injection and images.
- State the coronary vessel(s) injected, the areas imaged (for medical necessity) with interpretation of findings, and specific documentation of exact locations of the lesions treated (native vs. graft) and the degree of stenosis of the lesions treated.
- State other diagnostic(s) performed (intravascular ultrasound, fractional flow reserve, optical coherence tomography, near-infrared (NIR), InfraReDx), as well as intervention(s) performed (angioplasty, atherectomy, bare metal stent placement, drug-eluting stent placement, and aspiration or mechanical thrombectomy).
- State the specific device(s) and specialty supplies used during the procedure.
Documented patient history is critical in defining medical necessity. For example, if a patient has hypertension and the plan is for a renal angiogram, and during the course of the procedure a celiac artery is inadvertently selected and imaged, you should not code for a visceral angiogram. The visceral angiogram was not intended, and medical necessity for it does not exist.
Watch Out for Repeat Studies
A problem involving medical necessity is that repeat diagnostic studies are not allowed; the physician must document the prior diagnostic studies, dates of service, and findings to avoid compliance issues.
It’s common for a diagnostic study to be performed one day and the intervention to be performed another day, or to stage multiple interventions over the course of several days. Imaging will still be performed in these scenarios, but is not reported because it isn’t considered diagnostic.
After a diagnostic CTA, MRA, or contrast angiogram is performed and a plan to intervene has been made, a repeat diagnostic study cannot be coded unless there is clear documentation outlining the reasons why (i.e., new medical necessity).
For example: A diagnostic coronary angiogram is performed, and the patient returns with new onset of angina a week later. The assumption would be that something has changed in the interim, and this change represents new medical necessity.
On the other hand, if a diagnostic MRA shows an 80 percent right renal artery stenosis, and the patient is counseled for a right renal artery stent placement, a repeat diagnostic angiogram would not be submitted during the stent placement. Any imaging is considered confirmatory or guiding.
Another example would be “re-look” angiography during planned, staged coronary stent placements. If there was no clinical change in a patient’s status, you would not code for a re-look angiogram of a recent stent placement during the staged procedure; re-look, repeat, confirmatory, guiding, sizing, positioning, road mapping, and completion angiography are not separately reported. Only first-time diagnostic studies should be reported, unless there is new medical necessity documented (e.g., a clinical change in the patient).
Note the Importance of Catheter
Placement to Code Selection
Each vascular access must be reported because catheter selection is based on access site(s) and the vessel(s) selected. Documentation should specify where the catheter tip is placed for each diagnostic angiogram or intervention. It should be clear if the vessel was imaged selectively (i.e., catheter is actually within the imaged vessel) or non-selectively (catheter remains outside of the imaged vessel).
“Selective” codes may be reported only when the physician clearly documents the location of the catheter tip. For example, if bilateral renal imaging is performed from the aorta (non-selective), the codes are 36200 Introduction of catheter, aorta and 75625 Aortography, abdominal, by serialography, radiological supervision and interpretation. If each renal is selectively imaged, the code is 36252 Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral.
These codes can only be determined from the physician documentation in the report. Findings for each area imaged for medical necessity must be documented before submitting the angiographic codes. In many instances, a physician will state, “aortogram and run-off are performed,” but findings are only of the extremities; aortography codes would not be submitted in this scenario.
Where stenoses are found, it’s important to quantify via degree of stenosis, and/or that the stenoses are flow-limiting, to accurately define the medical necessity for possible interventions to come. Ask yourself: Is the stenosis bridging lesions involving contiguous vessels, or are they non-contiguous stenoses in different vessels? The answer will help you determine if one or two interventions may be reported.
Keep Everything in Order
All interventions should be documented in a temporal fashion. For example, if angioplasty alone is performed, but stenting is ultimately required, the physician must document the balloon size and why the result is suboptimal. By establishing the medical necessity for subsequent stenting, you may report both interventions—at least, in certain cases (this changes in 2014). For example, a 3 mm “pre-dilation” of a stenosis is performed of a subclavian to allow easier placement of a 7 mm stent. The undersized balloon pre-dilation would not be reported in this case.
Many of the newer interventional codes bundle catheter selection (femoral stent, 37226 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed) or imaging (carotid stent, 37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection). Be aware of these bundling issues. Complications should be documented, as this may allow you to report further imaging and intervention codes.
Lastly, specific devices used should be documented in the report. They may indirectly affect reimbursement because there are many device-to-procedural code edits.
Be Precise on Vessels Selected
For cardiac reports, medical necessity and prior studies must be reported for the same reasons discussed above.
With coronary catheterization codes, it becomes important to document the vessels selected, as well as if bypasses are in place and imaged. The physician should document each chamber entered, as well as the findings, if the chamber was imaged. Pressures must be recorded to document left or right heart catheterizations.
Coronary artery intervention codes require all performed interventions to be documented (e.g., angioplasty, atherectomy, and stent placement). This information drives correct coding, as do the answers to the following questions (which should be answered within the report):
- Is there a CTO intervened upon?
- Is the intervention performed in the setting of an acute MI?
- Is this a planned intervention based on prior imaging?
- Was a bare metal stent or a drug eluting stent placed (C codes for facility Medicare reporting)?
- Is the percutaneous coronary intervention performed via or within a graft?
- Were additional branches intervened upon? With cardiac interventional codes, up to two branch interventions may be reported when performed in the left descending (LD), left circumflex (LC), and right coronary (RC).
- Was this a bifurcation lesion or a bridging lesion (e.g., if one stent is used to treat a single bridging lesion, only one stent code is reported).
Know the Major Vessels
There are five major coronary arteries for interventional coding purposes:
- Left main (LM)
- Left descending (LD)
- Left circumflex (LC)
- Right coronary (RC)
- Ramus intermedius (RI)
Once again, specific documentation of where interventions are performed is imperative to allow for correct reimbursement. For coronary thrombectomy, whether it was mechanical (only Angiojet currently is considered a mechanical thrombectomy) or aspiration-type catheter (which is not reported during coronary interventions) must be determined. As in IR, degree/severity of stenosis must be documented to establish medical necessity for the interventions.
This information represents the minimum guidelines that should be addressed in the physician report for IR and cardiology services to allow for appropriate and compliant coding. When these key components are missing, and the correct code cannot be determined, an addendum is in order. These same documentation issues (and many more), will become even more crucial when the more robust ICD-10 codes are implemented Oct. 1, 2014.
As we move into the future, the need for concise, comprehensive documentation becomes even more critical to reimbursement and compliance. There has never been a better time than now to address physician reporting.
David Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCVTC, CCS, RCC, is vice president of ZHealth. He oversees physician coding and instructs ZHealth educational programs, and 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, 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 of the AAPC National Advisory Board and a member of the Nashville, Tenn., local chapter of AAPC.