Cardiology Coding Alert

Case Description/Op Report

A 79-year-old man undergoes percutaneous transluminal coronary angioplasty (PTCA) and stenting.

Using the Seldinger technique, the cardiologist inserts a guiding catheter into the right femoral artery. The op report reads:

A guiding catheter was positioned into the left main artery where initial injections were done in different projections. Over this, a long attempt was made to cross the subtotal to total occlusion of the obtuse marginal branch of the circumflex artery without success. At this point, it was decided to proceed with angioplasty and stenting of the circumflex artery. All-star wire was inserted and crossed the lesion without difficulty. Over this 3.0 balloon insertion, inflations were carried out in mid and proximal segment. After this, 3.5 x 8mm length, two multi-length stents were deployed in the mid and proximal circumflex artery. Intracoronary nitroglycerine was given, final pictures recorded, guiding catheter and wire was removed and femoral sheath was sutured. Patient was transferred in satisfactory condition.

Results

Prior to angioplasty, the patient had moderate 75 to 89 percent stenosis of the circumflex artery. After angioplasty and stenting, there was no residual narrowing of the circumflex artery. There was an unsuccessful attempt to cross the wire across the subtotal occlusion of the obtuse marginal (OM) branch. The obtuse marginal branch has slow flow identifier at the end of the procedure because of the deployment of the stenting in the circumflex artery for which the OM branch was coming.

Coding Dilemma

Actually, there are two coding dilemmas here which are beyond the coders control: poor physician documentation and variations in the patients anatomy that prevent completion of the procedure. But you can minimize the chance of a denial or upcoding by a thorough reading of the op report, says Nancy Reading, RN, BS, CPC, president of Reading Reimbursement Consultants, a multispecialty coding and reimbursement consulting firm in Salt Lake City, UT.

Never code from the name of the operation, she stresses, explaining her staunch take on this philosophy: Often physicians will list every little procedure performed because it is medically correct and prudent to do so. However, it is not always technically correct to code each and every procedure as they are listed due to bundling and other reimbursement issues.

She adds that medical language is not reimbursement language. In order to be accurate translators, coders must be able to extract charges from the op report, she says.
And that means reading the note to see what is actually documented as well as having a sound knowledge of cardiovascular anatomy and procedures themselves.

Lets look at each procedure listed as name of operation and compare it to the documentation.

1. Left heart cath and hemodynamic pressure study. If you were coding directly from the name of the [...]