Pulmonary embolism (PE) is the third most common cause of death in the United States, with at least 650,000 cases occurring annually. The highest incidence of recognized PE occurs in hospitalized patients.
For example, an 83-year-old woman with Parkinsons disease, who had been admitted nine days earlier for a fever and elevated creatine kinase (CK), suddenly stated that she could not breathe and collapsed from cardiopulmonary arrest. The successful cardioversion included prolonged closed chest massage, after which she was mechanically ventilated. Her blood pressure was being supported on dopamine.
Pulmonary angiography remains the gold standard for the diagnosis of PE. A positive one provides virtually 100 percent certainty that an obstruction to pulmonary arterial blood flow does exist and a negative one provides greater than 90 percent certainty in the exclusion of pulmonary embolism.
In the cardiac cath laboratory, after the patients groin was prepped, draped and infiltrated in the usual manner, a
7-French sheath was placed into the right femoral vein. A pigtail catheter was advanced to the right main pulmonary artery and a pulmonary angiogram was done using 40cc of contrast. Next, a similar angiogram was done in the left artery. After the angiogram showed extensive pulmonary emboli, the cardiologist consulted with one of the practices partners.
I expressed to him my great concern about using even regional thrombolytic therapy with urokinase in a setting of a flail chest and protracted closed chest massage, especially in an 83-year-old lady. He concurred. We agreed that it would be best to try to mechanically agitate these larger pulmonary arteries in an attempt to open up a good canal so that the spontaneous lysis of thrombus could occur with restoration of some blood flow. Then we would placed a Greenfield filter and heparinize, watching carefully.
The cardiologist used a wire to carefully agitate the left lower lobe and right lower lobe pulmonary artery, hoping to disburse the clot burden and to expose greater surface area to clot erosion with blood flow.
Then he performed a vena cavagram and a Braun filter was deployed below the renal vein entry to prevent further embolization. The findings from the operative report were as follows:
1. Fluoroscopy: The pulmonary markings are
2. Hemodynamics: The pulmonary pressure is 50/30.
3. Pulmonary angiography: The main pulmonary artery appears not to be obstructed and not to possess significant amounts of thrombus. However, there is a thrombus in the right upper lobe artery and one to the right middle lobe artery. The right lower lobe artery is almost totally thrombus filled with very little contrast getting past. There is amputation of some of the vessels to the right upper lobe. The pulmonary arteriogram in the left main pulmonary artery shows extensive pulmonary emboli, very similar to that described above. One filled. These thrombi disperse a bit with the pressure of the contrast material.
4. Vena cavagraphy: The ingress of vena cava blood is seen and is marked.
5. Deployment of filter: The Braun filter is deployed at the appropriate level.
This case has two difficult coding challenges:
1. When a cardiologist performs an interventional radiological procedure, you have to consider codes outside the 90000 range.
For example, even though the operative note states the name of the first procedure to be a right heart catheterization, in this case a right heart procedure was not performed, agree the experts.
A right heart cath measures the functions of the heart; it should not be used as a placement code, the experts explain. Therefore, to use 93501 (right heart catheterization) would not be appropriate. Likewise, you would not use the other codes from the cath/angiogram series: 93556 (pulmonary angiography, aortography, and/or selective coronary angiography, including venous bypass grafts and arterial conduits whether native or used in bypass) and 93541 (injection procedure during cardiac catheterization for selective opacification of arterial conduits for pulmonary angioplasty).
2. The second difficulty is that this case differed radically from that of a normal intervention for PE.
For example, usually one of several thrombolytic agents, such as urokinase or streptokinase, is injected through a catheter to break up the emboli and restore blood flow. This procedure is indicated by 37201 (transcatheter therapy; infusion for thrombolysis other than coronary) and 75896 (transcatheter therapy, infusion, any method e.g. thrombolysis other than coronary, radiological supervision and interpretation).
But because of this womans fragile condition, the cardiologist performed mechanical agitation of the right and left lobes of the pulmonary arteries for which there is no code.
Coding for vascular radiological interventions is never easy. And when the procedure is complicated by the unexpected, as well as inadequate documentation, it gets worse. Here are the recommendations by our experts:
1. For the placement of inferior vena cava (IVC) filter, use 37620(interruption, partial or complete, of inferior vena cava by suture, ligation, plication, clip extravascular, intravascular, umbrella device).
Dont forget to code for the S&I of the IVC filter by appending modifier -26 (professional services) to 75940 (percutaneous placement of IVC filter, radiological supervision and interpretation).
List the placement of vena cava filter first because it carries the highest reimbursement.
2. For the placement code use 36014 (selective catheter placement, left or right pulmonary artery).
Youll need to append several modifiers to this code:
-50 (bilateral procedure). Check with your payers to see how they prefer bilateral procedures to be billed.
Some want the code to be listed along with the modifier; others want the code alone to be listed twice on different lines.
- 51 (multiple procedures)
- 22 (unusual procedural services) (See the section on modifier -22 on page 38.)
Note: The coder might have been able to code for the access to the right and left lower lobes by listing 36015 (selective catheter placement, segmental or subsegmental pulmonary artery) twice. Although this choice would mean a slightly higher reimbursement, the documentation was not clear enough as to whether the catheter branched off into the next level. Likewise, if the documentation had stated that additional angiographies of the left and right lower lobe were performed during the artery probing, you could have also listed add-on code 75774 twice (angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation).
3. For the vena cavagram, use 36010 (introduction of catheter, superior or inferior) and S&I code 75825 (venography, caval, inferior with serialography, radiological supervision and interpretation), appended by modifier -26 (professional component).
4. For pulmonary angiography, use 75743
(angiography, pulmonary, bilateral, selective, radiological supervision and interpretation).
Modifier -22 Alert
Append modifier -22 to tell payers that this procedure was truly unusual as compared to the normal expectations of that procedureand mechanical agitation is certainly unusual. But it may not increase reimbursement that much.
Still, its worth a try. For future reference, instruct physicians to carefully document unusual procedures in their operative notes. For example, they can ask themselves the questions below and then explain how this procedure compared to the normal procedure such as greater effort and/or time.
When determining whether or not to append modifier
-22, check the documentation with these questions in mind:
Did the procedure require substantially more time?
Was it more complicated?
Did it involve great difficulty?
Did it involve extensive dissection or similar
If the answer to any one of these is yes, then you can append modifier -22. But you must send in supporting material or the claim will be denied automatically. Just listing an extended amount of time without an explanation of why there was more time involved wont work, says Susan Stradley CPC, CCS-P, senior consultant for Medical Group of Elliott Davis and Co., LLP, Greenville, SC.
Along with the operative report, send a summary letter, advises Stradley. I call it KISS [Keep It Short and Simple], she explains. Its an excellent tool to help insurance claims reviewers understand the exceptional circumstances that caused the -22 modifier to be billed. (See box on this page.)
Use two or three short, simple statements in laymans terms to direct payers to the part of the surgical procedure that is unusual. For example, the KISS letter for this case might explain: Immediately prior to the procedure, this frail elderly patient had undergone prolonged chest massage in order to be resuscitated from cardiopulmonary arrest. Normally, in the case of a pulmonary embolism we use the customary method of breaking up an embolus through administering a drug. However, the patients condition could not tolerate this treatment and the situation was urgent. I used the catheter to very carefully agitate the left lower lobe and right lower lobe pulmonary artery, hoping to disburse the clot burden and to expose greater surface area to clot erosion with blood flow. This mechanical agitation is not included in 36014 (selective catheter placement, left or right pulmonary artery). Therefore, we are adding modifier -22 to and requesting additional reimbursement of 20 percent.
The usual fee for modifier -22 is 20 percent to 30 percent over and above the usual and customary amount the payer reimburses, says Stradley. But a KISS letter in and of itself wont increase reimbursement. In fact, it may produce an automatic review. Documentation must support the reason for the request for additional reimbursement. If it doesnt, the 20 to 30 percent will be denied.
Explain to the cardiologists how insufficient documentation affects reimbursement. Urge them to use CPT terminology rather than medical jargon, whenever possible, and clearly indicate in their documentation of the operative report the unusual service and how it compares to the normal services.
Its also more important than usual to substantiate medical necessity when using modifier -22 by using additional diagnostic codes. For example, in this particular situation, the appropriate ICD-9-CM codes for this case are as follows:
415.19: pulmonary artery embolism
416.0 primary pulmonary hypertension
Sources: Susan Stradley CPC, CCS-P, senior consultant for Medical Group of Elliott Davis and Co., LLP, Greenville, SC; Mary Ann Barry, RN, vascular nurse at Boston University Hospital; Gary Burns, MBA, RRA, principal, Medical Asset Management, Inc., Atlanta, GA; Craig Feied, MD, FACEP, FAAEM, associate clinical professor of emergency medicine, the George Washington University, American College of Cardiology and the American Heart Association.