Cardiology Coding Alert

A CCI error could delay some moderate sedation payment until after April 1.

Starting in January of this year, you've had to deal with roughly 100,000 new Correct Coding Initiative (CCI) edit additions, including those for moderate sedation, angioplasty, and pain management. Watch out: A handful of those edits may cause some unexpected problems. Brush up on your CCI knowledge today to safeguard your cardiology reimbursement.

Discover When to Separately Report Moderate Sedation 

One of the biggest changes for CPT^® 2017 requires you to report moderate sedation separately to get paid for the service. In previous years, CPT® and payers bundled the moderate sedation pay into certain specified procedures. In 2017, if a cardiologist performs moderate sedation along with a cardiology procedure, he should report 99151-+99153 (Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status ...), along with the appropriate cardiology procedure code.

For example, say your cardiologist performs a procedure represented by 92920 (Percutaneous transluminal coronary angioplasty; single major coronary artery or branch) for a 70-year-old patient. If the cardiologist also provides moderate sedation (99152) for the patient, he can report both the angioplasty and the moderate sedation services on the same claim. CCI does not include an edit bundling the two codes together.

However, CCI version 23.0, effective Jan. 1, 2017, prevents you from reporting moderate sedation services that another provider performs - 99155-+99157 (Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports ...) - in conjunction with your cardiologist's procedure. This makes sense because, on your cardiologist's claim, you should not be reporting moderate sedation that another healthcare professional provides.

Important news: The CCI edits tables effective Jan. 1, 2017, included errors for some 99151-+99153 edits. The edits have a modifier indicator of "0," so you can't override the edits. Some of the cardiology codes impacted include those for repositioning/relocation of aortic counterpulsation ventricular assist devices (0459T-0461T), the new dialysis circuit codes (36901-36909), and the new angioplasty codes (37246-37249).

The upcoming April 1, 2017, updates will correct these errors. If you submit claims prior to the April 1 corrections, your claims will be denied, but you will be able to appeal the denials on or after April 1, 2017. The CCI contractor recommends holding your 99151-+99153 claims until after the correction. You can find the news posted at www.acr.org/~/media/ACR/Documents/PDF/Economics/2017-Moderate-Sedation-Code-Edit-Deletions.pdf.

Understand When to Override New Angioplasty Edits

Another pattern you will see with the 2017 CCI edits involves the new transluminal balloon angioplasty codes 37246-+37247 (Transluminal balloon angioplasty [except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit], open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery ...) getting bundled into many cardiovascular procedure codes like 37220 (Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty) and coronary angioplasty code 92920. The modifier indicator for these edit pairs generally is "1," meaning you can use a modifier to override the edits when documentation supports doing so.

Example: Take a look to see when you can override the 92920 and 37246 pair edit described in this scenario from Jim Pawloski, BS, MSA, CIRCC, R.T. (R)(CV), interventional radiology technologist/coder at William Beaumont Hospital in Royal Oak, Mich., and coder at Adreima in Phoenix, Ariz.: 

The cardiologist performs coronary angioplasty for a patient with a diagnosis of I25.110 (Atherosclerotic heart disease of native coronary artery with unstable angina pectoris), and the cardiologist clears the stenosis. You report this coronary angioplasty using 92920. Don't forget to append the appropriate anatomic modifier to identify the artery, if this is something your payer requires.

The patient also has hypertension (I10, Essential [primary] hypertension), and during the same encounter as the 92920 service, based on the patient's specific case, the cardiologist looks to see if renal artery stenosis is the cause of the hypertension. He selects the left renal artery and finds an 80 percent stenosis. You report this diagnostic service using 36251 (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; unilateral).

At the same session, the cardiologist performs an angioplasty to remove the renal vessel stenosis. You code the renal angioplasty using 37246.

There is not a CCI edit that requires you to use a "distinct services" modifier on 36251 in this specific case, but you may find your payer prefers that you do so when the patient has both the diagnostic and interventional procedures during the same session, says Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions, Coding Quality & Education Department. Remember that to be able to code the diagnostic service in addition to the intervention, the 36251 study must be a true complete renal diagnostic study and not part of a planned intervention.

Because CCI does have an edit for the pair 92920 and 37246, you should append a "distinct services" modifier like XS (Separate structure) or 59 (Distinct procedural service) to 37246, dependent upon your payer's preferences, Pawloski says.

Keep in mind: Neighbors states that it's rare to see a coronary interventional procedure (such as 92920) with 37246. Double-check your documentation to be sure you have support before overriding the edits and reporting those services for the same encounter.

Decipher Pain Management Code Changes

Yet another pattern you will notice in CCI version 23.0 is that new-for-2017 spine injection codes like 62320 (Injection[s], of diagnostic or therapeutic substance[s] [e.g., anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance) also got bundled into numerous procedure codes, including many cardiology-related codes. 

As a cardiology coder, these spine injection codes may not be high on your priority list. But the edits do offer a reminder that you can sometimes find helpful explanations for edits in the CCI manual. According to the CCI manual, in Chapter 1, Section G, "The physician performing a surgical or medical procedure should not report an epidural/subarachnoid injection (62320-62327) or nerve block (64400-64530) for anesthesia for that procedure."

You can find the CCI manual on CMS's website under the Downloads section: www.cms.gov/medicare/coding/nationalcorrectcodinited/index.html.