Cardiology Coding Alert

Our November issue featured a case study in which the cardiologist performed a left cardiac catheterization and a percutaneous coronary angioplasty (PTCA) and stent of the right coronary artery (RCA) (Case Study: Documentation is Key to Pay Up for Cardiology Procedures). Six hours later, however, the patient was rushed back into the cath lab for emergency angiography followed by rescue angioplasty and stenting of the RCA.

Because this was the patients second operative session on the same day and many of the same procedures were repeated, modifiers play a critical role in coding the session correctly. The correct coding for the angiography and/or catheterization is further complicated by the repeat nature of the session.

In such instances the clarity of the operative report is especially important. As in the report discussed last month, however, this months operative note lists procedures as performed that are not described in the note itself.

Unlike the first reports omission of the original PTCA and stent which the coder could infer from the rescue nature of the following procedure the discrepancy in this report arises because there is no evidence that one of the procedures listed was performed. To determine this, the skilled coder would have to read the cardiologists procedure notes thoroughly.

Operative Report

Date of Service: 8/17/2000, 4 p.m.

Procedures:
1. Emergency coronary angiography
2. Rescue angioplasty and stenting of distal right coronary artery occlusion
3. Right heart catheterization
4. Intracoronary nitroglycerine thrombolytic

Indications for the procedure:
Patient is status-post PTCA and stenting of right coronary artery a few hours previous. The patient complained of chest pain, and ST changes were noted on the electrocardiogram in the holding room. The patient was rushed back to the lab due to suggested collapse and closure of the stent site.

Procedure notes:
Patient was brought back to the cath lab. ... A #7 French JR-4 catheter was advanced and diagnostic right coronary angiography was taken, which showed complete occlusion distal to the stent into the right coronary artery due to spiral dissection, probably caused by edge dissection to the distal edge of the stent. Thereafter, I changed the diagnostic catheter to a #7 French guide catheter, and 100 mg of intracoronary nitro-glycerine was administered. I was able to access the area of occlusion with a Choice PT wire. Over the wire I advanced a 9-mm balloon, and a couple of 0 percent dilatations were performed. Then the balloon was deflated and angiograms were taken that showed restoration of antegrade flow. The dissection was more visible now. ... I advanced a 3.5 x 25 ACS Tri-star stent and placed it across the area of dissection distal to the first stent. The stent was deployed here by inflating the balloon at a maximum of 10 atmospheres of pressure. The balloon was deflated and pulled back slightly. Dilatation was performed, overlapping the two stents at 10 atmospheres pressure for 30 seconds. The balloon was deflated and removed, and final angiograms were taken with and without the wire, which showed good patency, brisk antegrade flow and no residual thrombus, dissection or stenosis. The patient did well and will be admitted to the telemetry unit for continued observation.

Coding the Session

This operative session would be coded as follows, says Terry Fletcher, BS, CPC, CCS-P, an independent cardiology coding and reimbursement specialist in Dana Point, Calif.:

92980-78 transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel-return to the operating room for a related procedure during the postoperative period;

93508-26-59 catheter placement in coronary artery(s), arterial coronary conduit(s), and/or venous coronary bypass graft(s) for coronary angiography without concomitant left heart catheterization-professional component-distinct procedural service;

93545-59 left heart catheterization for selective coronary angiography (injection of radiopaque material may be by hand)-distinct procedural service, and;

93556-26-59 imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aorotography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass)-professional component-distinct procedural service.

Understand the Codes

The coronary angiography should be linked to a diagnosis of chest pain (786.5x), and the stent should be associated with ICD-9 code 996.72 (other complications of internal [biological][synthetic] prosthetic device, implant and graft, due to other cardiac device, implant, and graft).

The PTCA on the right coronary artery is bundled to the stent, Fletcher says. She adds that when two interventions are performed on the same coronary artery (or on any of its branches) only the highest-valued procedure should be charged. The stent should be appended with modifier -78 to indicate complications encountered following a procedure. Some carriers may also require that modifier -76 (repeat procedure) be appended to 92980 to avoid a duplicate claim denial.

Note: Code 92980, like all procedures with 0 global days, includes an inherent 24-hour global period. Because of this, a second stent performed on the same day as the first is considered to have been performed during the first stents postoperative period.

Because stents also include supervision and interpretation (S&I), 93556 should have modifier -59 attached to indicate that it was performed in conjunction with the coronary angiography.

In this instance, however, modifier -59 also serves to distinguish the coronary angiography S&I from the S&I performed during the earlier left heart cath. Modifier -59 has also been attached to the injection code (93545) and to the angiography (93508) to indicate these procedures were performed at different sessions from the similar services billed earlier in the day. In this case, right coronary angiography was performed for diagnostic purposes after the patient complained of chest pain and the electrocardiogram showed irregularities thereby making it billable.

Modifier -59 is not being used here to bypass a bundling edit, Fletcher says. Rather, it demonstrates the procedures were performed at a different operative session and should not be included either in other angiography procedures or the stent performed in the second session.

Note All Procedures Performed

Perhaps the most significant coding issue in this case study concerns the right heart catheterization listed at the top of the operative note. The procedure notes make no mention of a right heart cath and state only that diagnostic right coronary angiography was performed.

Marko Yakovlevitch, MD, FACP, FACC, a Seattle cardiologist, notes that there is no indication that a right heart catheterization was performed. The cardiologist didnt use a PA or Swan-Ganz catheter, which are the catheters normally used when a right heart cath is performed. In addition, there is no description here of anything occurring in the right heart. Only the right coronary artery is mentioned.

Yakovlevitch advises that a right coronary angiogram is not considered a right heart catheterization. Just as a left heart cath must cross the aortic valve, a right heart cath is performed if the catheter is placed in the right ventricle which didnt occur here.

The top of the operative report also lists an intracoronary nitroglycerine thrombolytic among the procedures performed. This listing is almost certainly erroneous, Yakovlevitch says, because nitroglycerin which can be administered to relax coronary vessels is not a thrombolytic.

The nitroglycerine injection should not be billed separately, according to ACC guidelines, which recommend, CPT code 37202 [transcatheter therapy, infusion other than for thrombolysis, any type] not be used in conjunction with diagnostic catheterization codes. Infusion of substances (e.g., nitroglycerine) is considered to be an intrinsic part of the catheterization procedure. The national Correct Coding Initiative also bundles 37202 with 93508 (coronary angiography) and 92980.