Cardiovascular Coding: Solve the PCI Puzzle Using CPT® and NCCI Guidelines

Cardiovascular Coding: Solve the PCI Puzzle Using CPT® and NCCI Guidelines

Know what details you need to piece together for proper coding of percutaneous coronary intervention.

Percutaneous coronary intervention (PCI) coding brings to mind Winston Churchill’s line about “a riddle wrapped in a mystery inside an enigma.” Making assumptions about what certain descriptor terms mean and which services are bundled into PCI is sure to lead to errors.

You can remove at least one layer of PCI coding confusion by reviewing these FAQs with answers from CPT® guidelines and the National Correct Coding Initiative Policy Manual for Medicare Services (NCCI manual). For even more clarity, review the official CPT® and Medicare resources, and check your payers’ policies, too.

What Does PCI Stand For?

Before you can code PCI, you need a basic understanding of the P, C, and I:

  • Percutaneous refers to a service taking place through the skin. In the case of PCI, the physician makes a small incision in the skin and inserts a thin guidewire and catheter into a blood vessel. The physician uses imaging to assist with threading the catheter through the vascular system to the target area.
  • Coronary is the term for vessels that surround and supply the heart.
  • Intervention means the procedure was for treatment of a condition.

The basics aren’t enough when it comes to PCI coding, though, so let’s dig deeper.

What Are the Types of PCI?

The 2020 NCCI manual, Chapter XI, Section I.14, lists stent placement (putting a small tube in the artery to keep it open), atherectomy (removing plaque from a blood vessel), and balloon angioplasty (inflating a tiny balloon at the blockage site to widen the area) as types of PCI.

The related CPT® codes are 92920-+92944. The CPT® guidelines that accompany these codes offer more insight into the types of services the codes cover: “angioplasty (eg, balloon, cutting balloon, wired balloons, cryoplasty), atherectomy (eg, directional, rotational, laser), and stenting (eg, balloon expandable, self-expanding, bare metal, drug eluting, covered).”

The physician may perform more than one type of PCI at a session, and there are CPT® codes for different combinations performed on a single vessel. For instance, atherectomy, stent, and angioplasty are all included in the descriptor for 92933 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch.

Why Do Physicians Perform PCI?

In short, physicians perform PCI to restore blood flow through blockages in the arteries that supply the heart.

CPT® guidelines define PCI more technically as a type of percutaneous revascularization aimed at treating occlusive disease of the coronary vessels. Revascularization is a term for restoring adequate blood supply to a body part. And, according to CPT® Assistant (December 2014), “Coronary occlusive disease refers to narrowing and/or blockage of the coronary arteries.”

Many of the ICD-10-CM codes related to coronary disease are in category I25 Chronic ischemic heart disease. The symptoms and diagnoses in Table 1 also may be related to coronary occlusive disease, CPT® Assistant states. (The CPT® Assistant article did not include the ICD-10-CM codes shown, which are offered as possible examples.)

What Coronary Arteries Do Medicare and CPT® Recognize for 92920-+92944?

PCI is specific to coronary arteries and their branches, but not all resources use the same terms when describing these vessels. Fortunately, both the NCCI manual and CPT® guidelines list the same five major coronary arteries and recognize the same branches for reporting purposes.

Medicare created HCPCS Level II modifiers for the major coronary arteries, shown in Table 2, to identify the vessel involved in a procedure. For an example of how to use the modifiers, see the section on using coronary artery modifiers.

What Are the Major Factors to Consider When Choosing a Code From 92920-+92944?

Your PCI coding typically will depend on the type of vessels (native circulation, bypass graft), number of vessels (single, additional), and services (angioplasty, atherectomy, stenting). The CPT® code set also includes 92941 for PCI of total or subtotal occlusion during acute myocardial infarction and 92943/+92944 for PCI of chronic total occlusion.

Table 3 summarizes the main points that distinguish codes 92920-+92944.

How Do You Code for Multiple PCI Services at a Single Session?

You should report one code to represent all PCI procedures performed in all segments (proximal, mid, distal) of a single major coronary artery or a single branch, according to both CPT® and the NCCI manual. For instance, you’ve seen that 92933 represents angioplasty, stenting, and atherectomy in a single vessel.

But watch for services that involve both the patient’s native circulation and a bypass graft. CPT® guidelines state that you may report PCI through a bypass graft separately when the physician treats one segment of a major coronary artery through the native circulation and then accesses another segment of the same artery through a coronary artery bypass graft for treatment. The NCCI manual includes similar wording.

Use a bypass graft code for the access to the major artery through the graft. The descriptors for both 92937 and +92938 begin with this wording (emphasis added): Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous) …

PCI services in multiple vessels also provide opportunities to report multiple codes. When the physician performs PCI in an additional major coronary artery or an additional coronary artery bypass graft, report an additional appropriate base code. “PCI performed during the same session in additional recognized branches of the target vessel should be reported using the applicable add-on code(s),” CPT® guidelines state.

Does Medicare Pay Separately for PCI in Additional Branches?

“Medicare does not pay separately for PCI in a branch of a major coronary artery as this payment is included in the payment for the PCI code for the corresponding major coronary artery,” per the NCCI manual.

The Medicare Physician Fee Schedule assigns add-on codes +92921, +92925, +92929, +92934, +92938, and +92944 status “B.” This means payment for each code is bundled into payment for other covered services performed on the same date.

Although the codes won’t bring separate payment from Medicare, organizations may opt to report the branch codes for internal tracking or to provide data to payers on how common branch procedures are. This data may influence payers’ future payment decisions.

If you do report the codes, the NCCI manual echoes CPT® by stating that you may report only one PCI code “for each of up to two branches of a major coronary artery with recognized branches.” You should not report PCI of a third branch of a major coronary artery.

How Do You Code for PCI of 1 Lesion in 2 Vessels?

A single lesion may extend from one vessel (artery, graft, or branch) into another vessel. If the physician uses a single intervention for the lesion, you should report one PCI code. Don’t let the involvement of two vessels cause you to report two codes. Both CPT® and Medicare agree on this point.

The CPT® guidelines provide examples to help demonstrate proper coding. First, the guidelines state that if the physician places a single stent to treat a lesion that extends from the left main coronary artery into the proximal left circumflex coronary artery, you should report only 92928. But the guidelines also clarify that you should report both 92928 and +92929 when the physician stents both the left anterior descending artery and first diagonal artery to treat a bifurcation lesion.

How Do You Use the Coronary Artery Modifiers?

The HCPCS Level II coronary artery modifiers identify the vessel, which can be especially important if there are multiple vessels involved in a single service. Using the modifiers shows the payer that the services were for separate vessels and deserve separate payment. Medicare accepts these modifiers, but you should confirm whether other payers accept them.

The December 2014 CPT® Assistant provides this example: The physician performs angioplasty in the left anterior descending coronary and right coronary arteries. Report 92920 Percutaneous transluminal coronary angioplasty; single major coronary artery or branch for the left anterior descending artery angioplasty. For the right coronary artery angioplasty, report 92920 again and append modifier 59 Distinct procedural service. But, as CPT® Assistant explains, payers may require the use of LD Left anterior descending coronary artery and RC Right coronary artery instead. So, you would report 92920-LD and 92920-RC.

The coronary artery modifiers listed in NCCI manual Chapter I, Section E, enable you to bypass NCCI procedure-to-procedure (PTP) edits. Suppose we change the example above to angioplasty (92920) in the left anterior descending coronary artery and atherectomy with stenting (92933) in the right coronary artery. Medicare currently has a practitioner NCCI PTP edit bundling 92920 into 92933. By reporting 92933-RC and 92920-LD, you’ll bypass the edit for Medicare and receive reimbursement for both services. A payer may require you to append another modifier, such as 59, as well, so pay attention to payer policy and the explanations for any issues your claims encounter.

See also Is There an NCCI Edit for Those Codes? for tips on reading NCCI edit files.

What Services Do PCI Codes Include?

Over the years, cardiovascular coding has moved more toward an all-in-one-code approach, and PCI is a good example. If you read only the code descriptors, you’ll miss that CPT® guidelines state that these codes encompass:

  • Accessing and selectively catheterizing the vessel;
  • Traversing the lesion;
  • Radiological supervision and interpretation related to the PCI;
  • Arteriotomy closure through the access sheath; and
  • Imaging to document PCI completion.

Chapter XI of the NCCI manual also reminds us that the codes include other services that are part of a typical PCI such as ECG tracings to assess chest pain. There are services you may report together with PCI, however, such as +92973 Percutaneous transluminal coronary thrombectomy mechanical (List separately in addition to code for primary procedure) and diagnostic coronary angiography (93454-93461). As you may have guessed, you can find answers about when it’s appropriate to use those codes by reading the CPT® guidelines and the NCCI manual.


Resources:

CMS, National Correct Coding Initiative Policy Manual for Medicare Services

Mayo Clinic, Coronary angioplasty and stents

American Medical Association, CPT® Assistant, December 2014, “Reporting Coronary Therapeutic Services and Procedures (92920-92944)”

Cardiovascular and Thoracic Surgery – CCVTC

Deborah Marsh

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