Clarify Mitral and Aortic Valve Coding Confusion
Correct procedural coding relies on deciphering similar terminology and acronyms.
By Debra Mariani, CPC, CGSC
Due largely to the confusingly similar terminology used to describe various valve procedures, they can be a challenge to document and report. Let’s review common terms and coding guidelines to reduce the confusion.
First, Know Your Terms
There are several types of valve procedures that are better known by their acronyms:
- Transcatheter aortic valve implantation (TAVI)
- Transcatheter aortic valve replacement (TAVR)
- Transcatheter mitral valve implantation/replacement (TMVI)
- Transcatheter mitral valve repair (TMVR)
- Transcatheter pulmonary valve implantation (TPVI)
It’s important to understand the differences in these procedures to correctly apply their corresponding CPT® codes.
New Category III Codes Describe TMVI
CPT® 2018 introduces two new Category III codes to report TMVI. This procedure is generally performed for mitral regurgitation, mitral stenosis, and complication of a previously placed mitral valve prosthesis:
0483T Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed
0484T transthoracic exposure (eg, thoracotomy, transapical)
The procedures include vascular access, catheterization, balloon valvuloplasty, valve deployment and (as needed) repositioning, temporary pacemaker insertion for rapid pacing, and access site closure.
Heart Catheterization with TMVI
Per CPT® guidelines, do not bill diagnostic right and left heart catheterization codes (93451, 93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530, 93531, 93532, 93533) with TMVI codes when using:
- Contrast injections, angiography, road-mapping, and/or fluoroscopic guidance for the TMVI
- Left ventricular angiography to assess or confirm valve positioning and function
- Right and left catheterization for hemodynamic measurements before, during, and after TMVI for guidance of TMVI
Example: If the physician must access the patient’s hemodynamics (left heart catheterization) while performing the TMVI, do not code both a TMVI and a left heart catheterization because the catheterization is bundled into the TMVI procedure.
Right and left heart catheterization codes (93451, 93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530, 93531, 93532, 93533) may be reported during the same session as TMVI only if:
- No prior study is available and a full diagnostic study is performed.
- A prior study is available, but as documented in the medical record:
- There is inadequate visualization of the anatomy and/or pathology; or
The patient’s condition with respect to the clinical indication has changed since the prior study or there is a clinical change during the procedure that requires new evaluation.
Example: The physician may perform a diagnostic catheterization on the same day during the same session as a TMVI if the patient develops a significantly clinical change during the procedure, which requires a new evaluation. In this case, report a TMVI (0483T) and the diagnostic catheterization code with modifier 59 Distinct procedural service appended.
Diagnostic coronary angiography (93454 – 93564) performed during the same session as TMVI may be reported for right and left catheterization for the same reasons, stated above.
Example: The provider performs a coronary angiogram prior to TMVI because the patient had a prior coronary angiogram of inadequate diagnostic quality. In this case, report TMVI and a coronary angiogram with modifier 59 appended to indicate a separate and distinct procedure.
Angiography, radiological supervision and interpretation, intraprocedural road mapping to guide the TMVI, left ventriculography, and completion angiography are included in 0483T and 0484T. When right and left catheterization and/or angiography are performed during the same session/same day, append modifier 59 to indicate that a separate and distinct procedural service was performed with TMVI. For the full guidelines, see your 2018 CPT® code book.
The TAVR/TAVI codes (CPT® 33361-33366) have been in place since 2013, and their use is fairly straightforward; however, you may have questions about how to code for transcatheter aortic valve in valve procedures. The answer is, use the TAVR/TAVI procedure codes with modifier 22 Increase procedural service appended, with adequate documentation of the procedure.
Example: A patient has a failed bioprosthetic valve. The surgeon determines the patient is not a candidate for another open heart procedure, and would benefit from a valve in valve TAVR procedure. The interventional cardiologist performs the TAVR. Report TAVR (33361–33366, as appropriate) and append modifier 22 to indicate an increased procedural service.
Mitral Valve Procedures
TMVR describes repair only, and is reported using 33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis and, when appropriate, +33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure). These codes describe TMVR, not implantation (i.e., 0483T is for TMVI, not repair; 0484T is for transthoracic exposure).
Transesophageal echocardiography (TEE) usually is performed with transcatheter valve procedures. This service is performed by a echocardiographer, who reports the service separately.
Report TMVR via the coronary sinus using 0345T Transcatheter mitral valve repair percutaneous approach via the coronary sinus.
Report TPVI using 33477 Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed.
Example: A patient may have a history of a tetralogy of Fallot repair, and has developed shortness of breath and extreme weakness upon exertion. The patient is believed to have a failing pulmonary conduit. After imaging confirmation of pulmonary regurgitation, the patient undergoes TPVI. Report using 33477.
Debra Mariani, CPC, CGSC, is a coding and physician reimbursement associate with the American College of Cardiology. She has participated in her local chapters for the past 17 years, and has served in several officer roles. Mariani is a member of the Frederick, Md., local chapter.