Cardiology Coding Alert

Matching "left heart catheterization" to 93510 (Left heart catheterization ...) may seem like an easy day's work. But not so fast. The cardiologist must meet and document a crucial left ventricle requirement for you to choose this code. Work your way through this case study to see if 93510 belongs on the claim.

Get started: Assume that the sample case below took place in a facility that will report the technical component, and you are reporting only the professional component.

Remember to append modifier 26 (Professional component) to codes that have a professional and technical component, says Heather R. Stecker, CPC, ACS-CA, compliance director and reimbursement manager for Cardiology Consultants of Philadelphia. That way the payer knows you are asking for reimbursement of physician services only.

Procedure: Left heart catheterization, bilateral selective coronary arteriography, radiological interpretation.

Indication: Equivocal stress echocardiogram for ischemia with development of chest pain on the treadmill, and equivocal lateral wall ischemia being noted.

Procedure in detail: ...A 6 French sheath was then placed in the right femoral artery by Seldinger technique. Next, a JL4 and JR4 diagnostic coronary catheter was used to visualize the native coronary arteries in multiple views. Following the procedure, 30 minutes of hand-held compression was used to achieve hemostasis due to mild development of hematoma during angiography. There were no complications.

Results: The left main was normal length and caliber. Minimal calcification of left coronary system was noted to give rise to a large left anterior descending and circumflex. No diameter narrowing of the left main was noted.

The left anterior descending artery had a 20 percent to 30 percent smooth stenosis right after the first diagonal branch in the midsection. Otherwise, the left anterior descending was smooth in appearance and tapered toward the apex.

The left circumflex ran in the AV groove, and gave rise to two obtuse marginal branches with no significant stenosis. The right coronary artery was small, nondominant, and had no significant disease. Left ventriculography was not done.

Conclusion: Minimal coronary artery disease involving the midsection of the left anterior descending as described, 20 percent to 30 percent smooth plaquing.

Aggressive cholesterol management has been recommended as well as medical therapy.

Choosing the catheter placement code for this scenario offers an excellent lesson in why you should code from the report and not the procedure name.

The documentation states, "Procedure: Left heart catheterization ..."

But the appropriate code for the actual procedure as documented is not a full left heart catheterization, whichyou would report with 93510-26 (Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous).

Correct code: Instead, you should report 93508-26 (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), says Stecker.

"I often see physicians selecting 'Left Heart Cath' when in fact a left heart cath was not performed," Stecker warns. "For a left heart cath to be performed, the physician must cross over the aorta into the left ventricle," she adds.

For more on documentation that signals whether the cardiologist performed a full left heart cath, see "Guard Against 93510 Mishaps Using Documentation Clues" on page 67.

Once the catheter is in position, the cardiologist typically performs an injection procedure to visualize the area. CPT offers several options (93539-93545) to report these procedures.

The cardiologist doesn't necessarily have to document the word "injection" -- but he does need to establish definitively that he performed, interpreted, and reported the service, says Jim Collins, CCC, CPC, ACS-CA, CHCC, president of CardiologyCoder.Com in Saratoga Springs, N.Y.

If the report comments on what the angiography revealed, you typically have what you need to report both the injection and visualization code, Collins says.

For the sample case, which involves coronary angiography, 93545 (Injection procedure during cardiac catheterization; for selective coronary angiography [injection of radiopaque material may be by hand]) is the correct injection code, says Stecker.

Note that you should report 93545 only once per catheterization, according to AMA's CPT Assistant (November 2002).

You also need to code the contrast injection interpretation.

The appropriate code for the sample case study is 93556-26 (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]), says Stecker.

CPT guidelines for "Injection Procedures" confirm this choice, stating that 93556 is the appropriate choice for 93545, as well as 93539-93541 and 93544.