Cardiology Coding Alert

Several percutaneous vascular closure devices (PVCDs) are used to close an arterial puncture site following angiography, cardiac catheterization and interventional cardiology procedures. These devices of which the best-known are Perclose, Angio-Seal and VasoSeal may be used as an alternative to more traditional methods (for example, manual compression) to help close a punctured vessel (such as a femoral artery).

The device may be advantageous for patients because hemostasis may occur more quickly, allowing the patient to become ambulatory sooner after the angiographic or cardiac procedure. Additionally, the cardiologist may need to spend less time compressing an artery or monitoring the patient after the procedure.

The devices are not identical: The May 2001 Journal of Invasive Cardiology reports a significant difference in outcomes between Perclose and Angio-Seal. All three devices are identical in at least one respect, however; none of them offers cardiologists a chance at additional reimbursement, regardless of the claims of the company representative who sold the device.

Just because the salesperson said that using Perclose or Angio-Seal is separately payable doesnt make it so, says Sandy Rubio, RN, CPC, a cardiology coding and reimbursement specialist in Omaha, Neb. She notes that neither the device nor the angiography performed to guide the closure is separately payable.

According to Denise Reckers, CPC, a practice coder with Cardiology Consultants, a 13-physician practice in Abilene, Texas, heart caths and interventional procedures such as percutaneous transluminal coronary angioplasties and stents include opening and closing the patient.

Percutaneous vascular closure is just another way of closing the patient. You dont charge extra for stitching up a patient after a procedure. Therefore, you shouldnt charge extra for using Angio-Seal, Reckers explains.

If an angiogram is used only to determine if the PVCD can be placed, it should not be billed separately either, Reckers adds. Imaging injections may be payable, depending on the reason they are performed. If an angiogram is taken just to guide the Perclose or Angio-Seal, however, it too is included in the primary procedure [heart cath, for instance] and shouldnt be billed separately.

Rubio adds that the angiogram is not a medical necessity because it is performed solely to guide the placement of the vascular closing device. When you bill a procedure, there should be a corresponding diagnosis to indicate that it was medically necessary. In this case, there is no peripheral vascular disease or any other diagnosis that justifies performing the angiogram, she explains.

Typically, neither Medicare nor private carriers cover services that are not medically necessary, and PVCDs and the angiography that guides their placement arent excepted.

For example, Cigna Healthcare, which operates private plans in many states and is the local Medicare Part B carrier in Idaho, North Carolina and Tennessee, issued the following bulletin (GR-98-5, Sept./Oct. 1998):

The CPT coding for the diagnostic or interventional vascular procedure includes reimbursement for the catheter introduction and removal and necessary post-procedure care specifically related to the injection/intervention procedure. Accomplishing hemostasis after the performance of these procedures is included in the work related to the procedure.

The amount of work and the complexity of diagnostic and interventional procedures is included in the resource based relative value scale (RBRVS) used to establish Medicares reimbursement for the particular procedure. Additional reimbursement, regardless of the device used to promote hemostasis after the procedure, would not be warranted. No additional payment will be allowed for the device since it is considered an integral part of the . . . procedure.