Cardiology Coding Alert

When filing claims for percutaneous transluminal coronary angioplasties, commonly referred to as angioplasties or PTCAs, coders need to read the operative report carefully to make sure they know the vessel and branch that received the service because this information directly affects how the procedure(s) should be coded.

PTCAs, like atherectomies and stents two procedures that are associated with PTCAs and often performed at the same time are interventional or therapeutic procedures performed by cardiologists to improve blood flow through coronary vessels. The procedure involves inserting a catheter with a balloon tip to the area of the blocked artery and then inflating the balloon to flatten plaque that is causing the obstruction against the artery wall.

The procedure almost always is preceded by a diagnostic procedure, such as coronary angiography (93508, catheter placement in coronary artery[s], arterial coronary conduit[s], and/or venous coronary bypass graft[s] for coronary angiography without concomitant left heart catheterization), with or without left cardiac catheterization (93510, left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous).

Coding the Procedure

Code 92982 (percutaneous transluminal coronary balloon angioplasty; single vessel) should be used when a single angioplasty is performed in one vessel. CPT 2000 also lists the following three modifiers that should be attached to 92982 to indicate which vessel (artery) received the PTCA:

-LC left circumflex, coronary artery, referred to as LCX;
-LD left anterior descending coronary artery, or LAD;
-RC right coronary artery, or RCA.

Note: These modifiers need not be used if only one angioplasty is performed; however, they must be used when two or more PTCAs in separate vessels are claimed.

Each of the three arteries has branches connected to them. If angioplasty is performed on the branches, it is coded the same as an angioplasty performed on the primary artery, says Terry Fletcher, BS, CPC, CCS-P, an independent cardiology coding and reimbursement specialist in Dana Point, Calif.

If two or more PTCAs are performed in the same coronary artery (or its branches), 92982 may be billed only once, according to guidelines published in the American
College of Cardiologys (ACC) Guide to CPT Coding. For example, if the cardiologist uses angioplasty to treat a blockage in the RCA and the posterior descending artery, both angioplasties are coded as one procedure, and 92982 is billed only once. No additional PTCA codes may be charged.

If a third PTCA is performed on a vessel in the same family, however, modifier -22 (unusual procedural service) could be added to the 92982 and additional payment could be claimed, if the documentation provided by the cardiologist indicates the additional time and complexity of the procedures.

Additional PTCAs in a Separate Coronary Artery

If the cardiologist performs a second PTCA in a separate coronary artery, code 92984 (percutaneous transluminal coronary balloon angioplasty, each additional vessel [list separately in addition to code for primary procedure]) is used in addition to the 92982, Fletcher says. For example, if the cardiologist performs PTCAs in the RCA and the LAD, the operative session would be coded as follows:

92982-LD, 92984-RC.

If a PTCA also is performed in the LCX or one of its branches, a second 92984 would be included, with the
-LC modifier attached. Using the -LC, -RC and -LD modifiers is mandatory because they help the carrier identify the vessel. If they are not attached carriers will deny the claims as duplicates.

CPT 92984, however, cannot be billed if the PTCA is performed in another, unrecognized coronary vessel or nearby artery because most carriers recognize only the LCX, LAD and RCA, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist in North Augusta, S.C. For example, a lesion treated in the left internal mammary artery at the same time as the LAD artery would be considered as a part of the code for services in the LAD, and would not be billed separately.

Angioplasties With Other Procedures

If more than one intervention is performed on the same vessel or one of its branches, only the most complex procedure should be billed, according to ACC guidelines.
Stents (92980, transcatheter placement of an intra-coronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) are more expensive to perform than atherectomies (92995, percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; single vessel) in part because a device is left in the coronary artery. Both stents and atherectomies, in turn, are more complex than angioplasties. So, for example, if the cardiologist begins by performing a PTCA on the LAD but fails, and a bailout stent is necessary, only 92980 should be billed, Fletcher says.

If the patient requires a stent or atherectomy in one coronary vessel and a PTCA in another, the primary procedure would be Coded 92980, and the PTCA is billable as an add-on code (92984). For example, if the patient requires a stent in the LAD, an atherectomy of the LCX and angioplasty in the RCA, the operative session would be coded as follows:

92980-LD, 92996-LC, 92984-RC.

Note: Code 92996 is the add-on code for an atherectomy in an additional coronary vessel.

Using Modifiers

In addition to the interventional procedures listed above, cardiologists often perform diagnostic left heart catheterizations (93510) that result in PTCA(s) being performed on the same day. In such situations, the heart catheterization, injection procedure, and supervision and interpretation (S&I) codes are billed, as well as the PTCA. Modifier -59 (distinct procedural service), however, should be attached to the S&I codes because Medicare (and most private carriers) bundle S&I codes to interventions such as PTCAs. By attaching the -59 modifier, you are informing the carrier that the S&I is exclusive to the heart cath and is not related to the PTCA.

For example, the cardiologist performs a left heart cath on a patient, after which he determines that a PTCA on the patients LAD is required. He then performs the PTCA. The entire session would be coded as follows:

92982-LD, 93510-26, 93543, 93545,
93555-26-59, 93556-26-59.

Note: Modifier -26 (professional component) should be attached to 93510 and 93555/93556 when the catheter placement is performed in the cath lab or hospital setting. It does not need to be attached to the injection codes (in this case, 93543 and 93545).

Carrier rules vary on whether modifier -51 (multiple procedures) should be attached to the 93510 when a PTCA or other intervention has been performed, Fletcher says. She recommends attaching the modifier, noting that either way, most payers reimburse heart caths performed the same day as PTCAs at 50 percent.