Cardiology Coding Alert

Case Study:

Billing for Multiple Stents in the Same Vessel

Coding for cardiology procedures that include multiple stents in the same vessel can be complicated. Bundling issues abound, not only because the procedures typically make up only part of a longer surgical session that may include diagnostic as well as other interventional services, but also because for billing purposes, CPT codes 1999 considers the placement of stents in a single vessel as a single procedure, regardless of the number actually placed.

Complicating the issue further is that both Medicare and the American College of Cardiology (ACC) group all cardiac blood vessels into one of the three (in the case of the ACC, four) large cardiac blood vessels. So even if the stents were placed in different vessels anatomically, if they are in the same group they would be considered the same vessel, which makes reimbursement for the extra vessel(s) difficult.

Case Description

Take, for example, the case of a 40-year-old patient with known coronary disease who already has had a stent placed in the circumflex coronary artery (CLX). More recently, the patient suffered a non-Q wave infarction and was admitted to the hospital. Diagnostic studies were suggested, and the patient requested same-setting revascularization.

The patients preoperative diagnosis was unstable angina pectoris with non-Q wave myocardial infarction, posterolateral, while the post-op diagnosis was coronary heart disease.

A number of procedures were performed on the patient. The case was submitted to the insurer with the following CPT codes:

Diagnostic procedures:

93510: left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery;
93543: injection procedure during cardiac catheteri-
zation; for selective left ventricular or left atrial
93545: injection procedure during cardiac catheteri-
zation; for selective coronary angiography [injection of radiopaque material may be by hand].
93555-59: imaging supervision, interpretation and report for injection procedure[s] during cardiac catheteri-
zation; ventricular and/or atrial angiography; distinct procedural service.
93556-59: 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]; distinct procedural service.

Interventional procedures:

CPT 92980 transcatheter placement of an intracoronary
stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel.

Note: CPT code 92982 (percutaneous transluminal coronary balloon angioplasty [PTCA]) is bundled into 92980.

There were complications during the procedure that necessitated the placement of additional stents. According to the operative report, stenting across an obtuse marginal resulted in transient total occlusion of this vessel with ST segment elevation and complaints of chest pain.

ReoPro intracoronary nitroglycerin and intravenous nitroglycerin were able to abate the patients symptoms complex.

According to Medicare bundling guidelines, intracoronary nitroglycerin cannot be billed because it is considered part of the heart catheter procedure.

Significantly, the report also notes this was a very difficult procedure requiring multiple catheters and multiple wirings of the vessels. As well, complications forced the cardiologist to add two additional stents. In total, three stents were placeda 4.0-x-15-mm Crown stent in the proximal circumflex and two 3.0-x-18-mm Nir stents in the distal vessel.

Coding Supervision and Interpretation

If the session had been billed with only the procedure codes listed above entered on the HCFA 1500 claim form, the two supervision and interpretation (S&I) codes, 93555 and 93556, would likely have been denied because they are bundled into the two (interventional) stent procedures92980 and 92981.

But the session was billed correctly and the S&I procedures were performed as part of the (diagnostic) catheter, and to indicate that, modifier -59 (distinct procedural service) was attached to both S&I codes.

In this case the -59 modifier is appended to indicate the stent or angioplasty was done as part of the diagnostic catheter procedures, says Terry Fletcher, BS, CPC, CCS-P, a cardiology coding specialist and president of Physician Reimbursement Solutions, a coding and reimbursement consulting company in Laguna Beach, CA.

Coding Multiple Stents Isnt Easy

Coding for multiple stents in the same vessel is more difficult, but not impossible, says Fletcher, depending on the amount of time the extra stent placement(s) adds to the procedure. She notes that although CPT 1999 defines 92980 for single or multiple stents in the same vessel, CPT is generally not referred to for bundling guidelines. And both organizations that follow such guidelinesthe ACC and Medicareare more lenient in this regard.

Although written guidelines are yet available, Fletcher says that both the ACC and Medicare coding officials have stated that it is appropriate to bill for extra time spent placing two or more additional stents in the same vessel through the use of modifier -22 (unusual procedural services). According to Fletcher, Medicare says it will reimburse the additional time on an individual, paper claim basis on review if the physician spent double the time it would have taken to place one stent in the vessel. If the procedure took only 50 percent more time, perhaps because only one additional stent was placed, no extra reimbursement will be forthcoming and the
-22 modifier (unusual procedural services) should not be used, Fletcher adds.

Sandy Fuller, a practice coder with Cardiology Consultants, a nine-physician cardiology practice in Abilene, TX, says that when you add a modifier -22 to indicate something unusual, you need to include a short letter that explains the situation, adding that the letter should be in laymans termsthats very important because usually the person looking at this letter will not be familiar with the language.

When the cardiologists in her practice place two stents in the same vessel, I dont even worry about it, thats the way it pays, Fuller says. But for three or more vessels, Fuller says, I will attach a -22 modifier to the stent procedure, and include the letter and the op report and code after finding out from the physician involved how much more difficult the job was.

Fuller says the idea of extra reimbursement in blocks of time doesnt take into account the real-life experiences of the cardiologist. When performing a procedure, the physician is not watching the clock, hes watching the patient. She notes that when cardiologists perform stent procedures, angioplasties must be performed first, and an athrectomy may also be done. So determining how long a stent takes is not a realistic thing. Youre doing one, sometimes two procedures just to get there, depending on how long the blockage is and how difficult the blockage is to clear. It might be possible, Fuller says, to determine the length of the entire session, including the preparatory procedures mentioned above, but nobody knows how long a stent alone actually takes, Fuller explains.

Still, she says, the letter she writes to the carrier often will say this procedure (which includes the angioplasty, etc.) normally takes 40 minutes, but this time it took an hour and a half.

Increased reimbursement is not automatic, Fuller says, adding that when modifier -22 is used, an operative report is required. Medicare requests a letter as well, she says, and if you dont send it, they arent likely to consider giving you extra reimbursement.

Note: Medicare has not yet defined how to code interventions performed in the left main coronary artery (LMCA) or in the ramus intermedius branch, which arises from the left main artery apart from the LAD or LCX, according to the American College of Cardiology Guide to CPT 1999.