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Cardiology Coding Alert

Avoid Confusing Atherectomy Codes With Other Similar Procedures

Published on Sat Sep 01, 2001

Of the three coronary interventions performed by cardiologists, atherectomy is the least-often performed, the most poorly understood and, as a result, one of the more difficult procedures to code correctly.
 
"Coding and documentation errors can arise when atherectomy procedure codes are used incorrectly to describe other services that have some similarity to atherectomies but are not the same procedure," says Nikki M. Vendegna, CPC, a cardiology coding and reimbursement specialist in Overland Park, Kan.
 
Atherectomies are also subject to the same guidelines that apply to percutaneous transluminal coronary interventions (PTCAs) and stents, with which they are frequently combined, she adds.
 
When filing claims for PTCAs, coders need to read the operative report carefully to ensure they know the vessel and branch that received the service, because this information has a direct impact on how the procedure(s) should be coded. The cardiologist's documentation must clearly indicate the vessel that received the intervention, as well as the type and number of atherectomies, PTCAs and/or stents performed.
 
Note: See box on page 67 for a definition of the procedure.

Code Accurately for Atherectomies: Single and Multiple
 
CPT Codes 2001 includes the following coronary atherectomy codes:
 
  • CPT 92995 -- percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; single vessel; and
     
  • CPT 92996 -- ... each additional vessel.
    •  
    Code 92995 should be reported for an atherectomy (with or without PTCA) of a single vessel. If atherectomies are performed on more than one coronary artery, 92996 should be used to report the additional procedure.
     
    If the cardiologist performs two atherectomies in the same vessel or within one of its branches, only 92995 should be billed. For example, if the cardiologist performs atherectomies on the distal and proximal portion of the left anterior descending artery, report 92995 only.
     
    Similarly, because branch vessels are considered part of the major artery that they are associated with, a second atherectomy performed in a branch of a major artery that received an atherectomy should not be billed separately as well. For instance, if the cardiologist performs an atherectomy in the left anterior descending artery and another in diagonal side branch, bill 92995 only.
     
    Most Medicare carriers recognize only three coronary arteries. These are identified by appending the following modifiers to the appropriate atherectomy code:
     
  • LD -- left anterior descending, or LAD;
     
  • LC -- left circumflex, or LCX; and
     
  • RC -- right coronary, or RCA.
    •  
    Most carriers cover only one intervention per coronary artery, including its associated branches. If more than one procedure is done on an artery, list only the most complex procedure.
     
    Coronary interventions are organized in a hierarchy that reflects the relative values of the three procedures, with stents at the top, atherectomies in the middle and PTCAs at the bottom:
     
  • 92980 -- transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel; 24.90 transitioned facility RVUs;
     
  • 92995 -- 20.28 RVUs; and
     
  • 92982 -- percutaneous transluminal coronary balloon angioplasty; single vessel; 18.44 RVUs.
    •  
    When more than one intervention is performed within the same vessel, report only the highest-paid procedure. If one procedure is performed within one vessel and a second procedure is performed within another, the highest-valued single-vessel code should be reported with the second-highest-valued additional vessel code, as appropriate.
     
    For example, if the cardiologist performs a stent in the LAD and an atherectomy in the RCA, code the procedures  as 92980-LD and 92996-RC, respectively. Similarly, if an atherectomy is performed in the LCX and a PTCA is performed in the LAD, report the session as 92995-LC and 92984-LD ( ... each additional vessel [list separately in addition to code for primary procedure]), respectively. However, if an atherectomy and PTCA are performed within the same vessel, bill only the atherectomy. If a stent is performed within a main vessel and an atherectomy is done within one of that vessel's branches, bill only the stent.
     
    Note: Two single-vessel intervention codes should never be reported during the same session.
     
    If an atherectomy is performed in either the LAD or LCX, and a second intervention is performed within the left main artery, bill for the atherectomy only, because the left main, which feeds both the LAD or LCX, is considered part of whichever coronary artery received the first intervention. However, some payers, including some Medicare carriers, recognize the left main as a separate artery and may even assign a special modifier to indicate its use.
     
    The American College of Cardiology recommends that the left main be considered a major artery when only a single intervention is performed. If more than one intervention is performed (for example, an atherectomy in the LAD and a PTCA in the left main), bill only for the atherectomy, as the left main PTCA would be considered in the same vessel family as the atherectomy in the LAD.
     
    Local medical review policies (LMRPs) on atherectomies or other coronary interventions may state that any coronary angiography or arteriography performed with an atherectomy is covered and payable separately. But this usually refers to diagnostic services only and not to coronary angiography performed solely to guide the procedure. In other words, if the coronary angiogram (93508) or left heart cath (93510) indicated the need for an intervention, or if the cardiologist suspected another problem and ordered a coronary angiogram for that reason, 93508 (or 93510, as appropriate) would be payable separately. If a previous heart cath diagnosed the problem, and a coronary angiography was performed just to guide the procedure, it should not be billed separately.

    92995 and 93556 Are Now Bundled
     
    Until 2000, the National Correct Coding Initiative (CCI) did not bundle 92995 and 93556 (imaging supervision, interpretation and report for injection procedure[s] during cardiac catheterization; pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits [whether native or used in bypass]), even though the other supervision and interpretation (S&I) codes 93555 (... ventrical and or atrial angiography) and 92995 were bundled. This anomaly has been corrected.
     
    If a diagnostic left heart cath (93510) is performed and determines the need for an atherectomy (or a PTCA that subsequently requires atherectomy), 93555 and/or 93556 may be billed. Modifier -59 (distinct procedural service) should be attached to both codes to indicate that these S&I codes are linked to the heart cath and not the atherectomy.
     
    Note: If these services are performed in the hospital, modifier -26 (professional component) should be appended to 93510, 93555 and/or 93556.
     
    When this occurs, the cardiologist's notes should describe the medical necessity for performing both procedures on the same day during the same session. A cardiac cath that finds an obstruction requiring an atherectomy, for example, is medically justified and billed separately.

    Similar Procedure, New Devices
     
    In recent years, new devices have come into use in many cardiology practices, including Angio-jet and the cutting balloon, which perform functions (in some cases, only superficially) similar to atherectomy. Although some carriers require that atherectomy codes be used, if the payer's instructions are not available in writing, using 92995/92996 to report these procedures is not recom-mended. In the case of Angio-jet, which uses water jets to remove thrombi from coronary vessels, an unlisted- procedure code should be used.

    If the cutting balloon is used, 92982-22 (unusual proce-dural services) should be reported. The documentation should note in a separate paragraph that this was not a routine angioplasty, the cutting balloon was used and, as a result, the procedure required more work and time, Vendegna says.

    Documentation and Diagnoses
     
    For any claims with modifier -22, the documentation should note how and why the procedure was more exten-sive than an "average" atherectomy. Start and stop times may also help. The cardiologist should increase the fee for the procedure, as the carrier is unlikely to raise the fee on its own, even with a modifier -22 attached to the atherectomy.
     
    For example, if three or more atherectomies (or a mixture of atherectomies and other interventions) are performed in the same vessel family, modifier -22 should be appended to the highest-valued intervention performed, indicating the procedure involved much more time and effort than a typical, single atherectomy.
     
    If the cardiologist performs atherectomies in the proximal and distal LCX and an obtuse marginal branch, the session should be reported as 92995-RC-22.
     
    There are no ICD-9 codes that specify the anatomy of coronary vessels or the extent of plaque formation. Therefore, coronary atherosclerosis codes, among others, should be linked to 92995 to indicate the medical necessity for the procedures. Such codes include 414.01 (coronary atherosclerosis of native coronary artery), 414.02 (of autologous vein bypass graft) and 414.03 (of nonautologous biological bypass graft). Other ICD-9 codes that may be used, when appropriate, include but are not limited to:
     
  • 410.xx -- acute myocardial infarction;
     
  • 411.1 -- intermediate coronary syndrome;
     
  • 411.8x -- other acute and subacute forms of ischemic heart disease;
     
  • 413.0 -- angina decubitus;
     
  • 413.9 -- other and unspecified angina pectoris;
     
  • 414.11 -- aneurysm of coronary vessels; and
     
  • 414.8 -- other specified forms of chronic ischemic heart disease.
     
    Note: ICD-9 requirements vary from carrier to carrier.
     
     
    In addition to using an approved ICD-9 code, the cardiologist should include a sentence explaining why atherectomy was necessary. For example, when an atherectomy is performed because PTCA was unable to clear a coronary vessel blockage, the cardiologist should note why the atherectomy was performed. Such a sentence or paragraph might state, for example, that "the patient has single-vessel atherosclerotic coronary artery disease with a stenosis that is discrete and subtotal," or "the patient has diffuse coronary disease with a long, heavily calcified stenosis."

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