Cardiology Coding Alert

Take a careful look at whether you may code the catheterization separately.

A 2011 coronary stent session can require combining new codes with older options. Apply your skills to this sample case, and see how your choices compare to the analysis below.

Get started: For this case, assume the cardiologist performed the procedure in a facility setting.

Select Your Codes for the Sample Case

Procedures performed: Selective coronary angiography, right and left coronary arteries; contrast ventriculography with left heart catheterization; stenting of RCA

Indications: Increasing angina, shortness of breath, abnormal stress test indicating myocardial disease.

Approach: The procedure was performed from the right groin using Visipaque. Contrast was tolerated well, a total of 190 cc. The procedure was performed from the right groin using a 6-French catheter and sheath.

Closure device: 6-French Angio-Seal.

Description of Procedure: ... After satisfactory local anesthesia and sedation was achieved, the right femoral artery was accessed ... and a 6-French arterial sheath was placed and flushed. Left heart catheterization, left ventriculography and selective coronary angiography were then performed. Standard angle and views were used for the right and left coronaries....

Summary of Hemodynamics: The heart rate was 69 beats per minute. Pace rhythm with intermittent sinus rhythm. The blood pressure was 135/60. Left ventricular pressure was 135/14.

• Left Main: Left main coronary artery is normal
• Left Anterior Descending Artery: Left anterior descending artery is moderate size vessel with minor luminal irregularities. First diagonal branch has 40% to 50% narrowing.
• Left Circumflex: The left circumflex artery is a small vessel, markedly tortuous consistent with hypertensive heart disease. There is 70% stenosis in second obtuse marginal branch.
• Right Coronary Artery: Rt Coronary artery is a medium size vessel. It is markedly tortuous. There is 99% stenosis in the mid portion.
• Left Ventriculography: Lt ventriculography was performed in 30-degree RAO projection. Overall ejection fraction is estimated 60%.

Coronary Artery Intervention: After diagnostic procedure was performed, 6-French extra backup RCA catheters were introduced in ostium rt coronary artery disease with marked tortuosity. The lesion was crossed with Whisper wire. Predilatations were performed with 2.5 x 15 mm balloon.

Subsequently a 2.5 x 14 mm Integrity stent was deployed at 15 atmospheres, subsequently postdilated with a 2.75 x 12 mm Sprinter balloon at 20 atmospheres, leaving 0% residual stenosis. During the procedure, intracoronary nitroglycerin was injected to multiple severe coronary spasms. ...

Conclusion:

1. Two-vessel disease

2. Normal lt ventricular ejection fraction.

3. Successful stenting of the culprit vessel.

Start With the Simpler Stent Question

The Coronary Artery Intervention section of the report describes stent placement in a single vessel (the right coronary artery or RCA). To represent this portion of the report, you should assign 92980-RC (Transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel; Right coronary artery).

Decide Whether Cath Is Diagnostic

The Description of Procedure and Summary of Hemodynamics, supported by information in the Findings, demonstrate the performance of a left heart catheterization (LHC), left ventriculography (LV gram), and selective coronary angiography.

LHC clue: "By definition, if an LV gram was performed, the physician crossed the AO [aortic] valve into the left ventricle, so you know that a left heart cath was done," says Heather R. Stecker, CPC, compliance director and reimbursement manager for Cardiology Consultants of Philadelphia.

Don't code yet: You need to see indications of why the procedure was performed to determine whether the catheterization was diagnostic (potentially reportable) or roadmapping (not reportable), says Sandy Fuller, CPC, MCS-P, a Texas-based certified coder.

If the indication or history shows the cath was diagnostic, you may report the cath service in addition to the stent placement, says Stecker. "If the patient came in symptomatic or with no prior cath, and the decision was made to turn the diagnostic cath into an ad-hoc intervention, then you can bill both the cath and the stent."

On the other hand, if the patient had a prior cath and comes for a scheduled stent placement with no new symptoms requiring a diagnostic cath, then you should code only the stent placement, Stecker says.

Our sample case refers to the LHC as "diagnostic" in the Coronary Artery Intervention section and the Indications describe the symptoms that led to the diagnostic cath performed at the session: increasing angina, shortness of breath, abnormal stress test indicating myocardial disease. The results of the diagnostic cath, such as finding 99 percent stenosis in the RCA, led to the same session intervention.

Conclusion: You may report the LHC in addition to the stent placement for this case.

Watch How LHC Coding Changed for 2011

For the diagnostic cath, you should report 93458-26 (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; Professional component), Stecker says.

Under CPT® 2011, "all of the injections for LV Gram and coronaries and associated S&Is are included in 93458, so you don't bill those separately anymore," says Stecker. You add modifier 26 because the service took place in a facility, and you're reporting only the physician's services.

Your 2010 coding would have included a longer list of codes, Fuller says. In addition to 92980-RC for the stent, you would have reported five codes for the cath services:

• 93510-26-59, Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous; Distinct procedural service
• 93545-59, Injection procedure during cardiac catheterization; for selective coronary angiography (Injection of radiopaque material may be by hand)
• 93543, Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography
• 93556-26-59, Imaging supervision 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)
• 93555-26-59, Imaging supervision and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography.