Revenue Cycle Insider

Question: A patient presents to the emergency department with chest pain pressure and shortness of breath as well as tingling down the left arm. The provider orders an electrocardiogram (EKG), which shows in non-ST elevations. The cardiologist is called in and the decision is made to take the patient emergently to the operating room (OR) for a complete left heart catheterization with possible intervention once the heart catheterization. The left ventricle ejaculation fraction (LVEF) is 40 percent. When all arteries are viewed, findings include that the left anterior descending artery has a 99 percent blockage with significant stenosis. Because the patient is not a candidate for a stent or atherectomy, an angioplasty is chosen. Once the angioplasty is complete, the provider feels that this is sufficient for the treatment of the non-ST elevation myocardial infarction (NSTEMI); the case is completed and the patient is returned to their room. For reference, this patient has not had a previous heart catheterization and therefore a diagnostic heart catheterization was necessary. How do I code this?

North Carolina Subscriber

Answer: Based on the information you include, the appropriate coding for this scenario would be 93458 (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed), appended with modifiers 26 (Professional Component) and 59 (Distinct Procedural Service); and 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel) with modifier LD (Left anterior descending coronary artery).

Modifier 59 is appropriate and can bypass the National Correct Coding Initiative (NCCI) edit, since this was a diagnostic heart catheterization with no previous imaging in the patient’s record. Code 92941 would be appropriate in this scenario since the patient was taken emergently to the OR; if the invention could be delayed for a less severe blockage, then 92920-LD would be billed. The appropriate diagnosis codes for this case would be I21.4 (Non-ST elevation (NSTEMI) myocardial infarction) for the NSTEMI and I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris) for the coronary artery disease.

Cristin Robinson, CPC, CPMA, CCC, CRC, CEMC, AAPC Approved Instructor,
Education Coding Consultant, Bristol, Tennessee