Cardiology Coding Alert

"Coders need to read through the operative report before billing for a catheter that in fact may not have been performed. Otherwise, they may bill for a procedure that was not done, which can lead to charges of fraud.

In the following operative report, the cardiologist describes bilateral selective renal angiography, which was in fact performed. The procedure note, however, does not confirm that a catheter was placed into the renal arteries, and a coder who doesnt read through the notes carefully might infer otherwise.

Operative Report

Angioplasty/stent placement/arteriograms

Superior mesenteric artery angioplasty and stent placement and bilateral selective renal arteriography

This is a 79-year-old gentleman with abdominal angina and a tight lesion in the superior mesenteric artery.

Procedure: The procedure was performed via the right femoral artery. The right groin was prepped and draped in the usual manner. Xylocaine 2 percent was administered, and a French introducer was placed in the right femoral artery. The patient was systemically heparinized with 4,000 units of heparin and we positioned a ... guiding catheter at the origin of the superior mesenteric artery. Baseline angiograms were performed. An extra support wire [was placed] down the superior mesenteric artery and was pre-dilated using a 5.0 x 20 mm balloon. We then placed a 7 x 10 mm Hurculon stent and dilated the stent up to nine atmospheres. Follow-up angiograms were performed. The balloon dilatation catheter guidewire and guiding catheter were removed. We positioned a ... right diagnostic catheter at the origin of the right and left renal arteries, and performed selective renal arteriography. The diagnostic catheter was removed. The introducer sheath was removed and we deployed an angio-seal device at the right femoral puncture site.

Findings: The baseline angiogram demonstrates an 80-90 percent stenosis at the ostium of the superior mesenteric artery. Following balloon angioplasty and stent placement, this is reduced to 0 percent and there is excellent flow in the superior mesenteric artery. The left renal artery demonstrates a fairly long segment of up to 80 percent stenosis. The right renal artery has a 25 percent stenosis.

Conclusions:

1. Successful percutaneous transluminal angioplasty
and stent placement superior mesenteric artery.

2. Left renal artery stenosis.

3. Right renal artery stenosis.

4. Hypertension.

5. Abdominal angina.

Coding the Procedures

Based on the information provided in this operative report, the following codes should be billed, says Rebecca Sanzone, CPC, assistant billing manager with Mid-Atlantic Cardiology, a 45-member cardiology practice in Baltimore, Md., noting that vascular procedures arent limited like cardiac catheterizations.

The procedures are listed in the order they were performed, not highest-to-lowest based on relative value units (RVU).

36246selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family

75726angiography, visceral, selective or supraselective, (with or without flush aortogram), radiological supervision and interpretation

35471transluminal balloon angioplasty,
percutaneous; renal or visceral artery

75966transluminal balloon angioplasty, renal or
other visceral artery, radiological supervision and
interpretation

37205transcatheter placement of an intravascular
stent(s),(non-coronary vessel), percutaneous, initial vessel

75960transcatheter introduction of intravascular
stent(s),(non-coronary vessel), percutaneous and/or open, radiological supervision and interpretation, each vessel

75724angiography, renal, bilateral, selective
(including flush aortogram), radiological supervision and interpretation

The primary diagnosis code for all the procedures is 557.1 (chronic vascular insufficiency of intestine; mesenteric: angina; artery syndrome [superior], vascular insufficiency). Code 440.8 (atherosclerosis, of other specified artery, mesenteric) should be listed as the secondary diagnosis.

Note: Aortography and arteriography are types of angiography.

You can bill almost everything you do, unlike the cath, every shoot you do, every selection, can be billed, Sanzone says. She likens coding vascular surgery to being on a taxicab. Its where you start and where you end. The first order selection is the femoral artery, thats where they inserted the catheter. Then they moved it up to the SMAs, the superior mesenteric arteries. Take a left turn, and youre in the second order.

At that point, the first baseline shoot (75726) was performed in the SMA, followed by PTA, or angioplasty (35471); the interpretation code for the PTA is 75966. The cardiologist then placed a stent in the SMA and moved to the renals, shooting both (75724).

The reason you can bill the 75724 is that the op notes conclusion specifically states that the patients renals had 75 percent and 25 percent stenosis. If the cardiologist hadnt said the renals were occluded and given the percentages, the 75724 could not have been billed, Sanzone says.

First-Order Catheter Cant Be Billed

Based on the procedure notes, a second catheter was not placed inside the renal arteries, says Susan Callaway-Stradley, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. And because a catheter was not introduced to the renals, a selective first-order catheterization was not performed, she explains.

Selective means you left the aorta and went into branches off the aorta, Callaway-Stradley says. Until you move the cath out of the aorta and into a vessel, you havent done a selective procedure.

There is no one-to-one link between which blood vessel received the angiogram and the pictures it provides. For example, an angiogram in the abdominal aorta also takes pictures of the renals.

In some cases, practices concede that the description of what was performed could be better but insist that the cardiologist did in fact go into the vessel that is being claimed. Callaway-Stradley maintains, however, that specific dictation as to where the injections were placed is necessary to claim for selective procedures. Otherwise, insurance companies say, you leave yourself wide open to be downcoded.

Documentation Key to Billing S&I Although some cardiologists dont bill for supervision and interpretation (S&I) for a variety of reasons" they are missing out on payment to which they are entitled. But the documentation clearly must indicate the absence of a radiologist and the date and time of the procedure to show that the cardiologists interpretation guided the session says Kathleen Mueller RN CPC CCS-P a coding and reimbursement specialist in Lenzburg " Ill. With any angiography" film is produced that is sent to the radiology department where it is read Mueller says and The first claim in is the one that gets paid. Medicare guidelines state however " that the physician whose interpretation guides the further care and treatment of the patient is the one who should be paid. Often" the radiologist reviews the film the following day but the cardiologist cannot wait for the radiologist to read the report. In these circumstances " the cardiologist should get paid because he or she is now directing the patients care. Mueller recommends that the cardiologist and radiologist make an arrangement before any S&I is billed. That way" she says the possibility of two separate bills being submitted is minimized.

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