Cardiology Coding Alert

When cardiologists perform multiple interventions, the number of coronary vessels being repaired, not the number or type of interventions, determines how the operative session should be coded. Furthermore, if a different intervention is performed on a separate vessel, the lower-valued intervention should be billed using an add-on, rather than a primary, procedure code.

The three types of coronary interventions (stent placement, percutaneous transluminal coronary angioplasty [PTCA], and atherectomy) are coded as follows:

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

CPT 92981 each additional vessel (list separately in addition to code for primary procedure);

CPT 92982 percutaneous transluminal coronary balloon angioplasty; single vessel;

CPT 92984 each additional vessel (list separately in addition to code for primary procedure);

92985 percutaneous transluminal acoronary atherectomy, by mechanical or other method, with or without balloon angioplasty; single vessel; and

CPT 92996 each additional vessel (list separately in addition to code for primary procedure).

Of the three interventions, stents are the highest-valued procedures, followed by atherectomies and, lastly, PTCAs.

Often, cardiologists must perform more than one intervention in different vessels. For example, a stent may be placed in the left anterior descending (LAD) artery and a PTCA performed in the right coronary (RCA) artery. In such cases, billing for two initial interventions (92980 and 92982) is incorrect, says Terry Fletcher, BS, CPC, CCS-P, an independent cardiology coding and reimbursement specialist in Laguna Niguel, Calif.

Only the initial vessel code for the stent (the highest-valued procedure) should be billed. The PTCA would be coded using 92984 (the PTCA add-on code for a second or third, etc., intervention on a different vessel).

An add-on code like 92984 isnt used only when the first procedure was a PTCA. Regardless of what the first intervention was, if the second intervention on a different vessel was a PTCA, 92984 should be used, Fletcher says. The same principle applies to a second stent or atherectomy performed on a separate vessel.

Modifiers Indicate Branches

To inform the carrier that the interventions are performed on separate vessels, modifiers that indicate which vessel receives the intervention should be attached to the appropriate code. In the example above, for instance, 92980 should be appended with modifier -LD to indicate that the stent was placed in the left anterior descending artery. Code 92984 should be appended with modifier -RC to let the carrier know that the PTCA was performed on the right coronary artery.

If three separate interventions are performed in the three coronary vessels designated by Medicare, only the first is coded with an initial vessel code. For example, if the cardiologist performs a PTCA in the LAD and an atherectomy in the RCA, and places a stent in the left circumflex artery, the session would be coded as follows:

92980-LC
92996-RC
92984-LD

To code these three procedures correctly, the cardiologists operative report must be reviewed, Fletcher says. Sometimes office staff code for the procedures in the order they were performed, which is incorrect. The highest-valued procedure [i.e., the one with the most relative value units (RVUs)] should be coded first, followed by each additional procedure in descending-value order. Otherwise, revenue can be lost.

For example, if the PTCA of the LAD was performed first and as a result was the first procedure listed and add-on codes are used for the stent and atherectomy, the RVUs for the session would total 30.91. But if the session is billed correctly, with the stent as the highest-valued procedure listed first, and add-on codes used for the atherectomy and PTCA, the RVUs would total 35.38 (for a difference of 4.47 RVUs, or about $170).

If the operative session involves two interventions in one vessel and one intervention in another, only one procedure per vessel the highest-valued intervention should be billed. For example, if the cardiologist performs a PTCA in the LAD that fails and follows with a bail-out stent placement in the same vessel, and also performs a PTCA in the RCA, the operative session would be coded as follows:

92980-LD
92984-RC

The PTCA in the LAD may not be billed because it is the lesser-valued intervention in the same vessel as another intervention of greater value (the stent). The PTCA in the RCA is separately payable because it is a different vessel, but the PTCA add-on code (92984), not the initial vessel code (92982), should be billed.

Coding Interventions in Other Branches

Medicare carriers recognize only three coronary vessels. Therefore, if more than one intervention is performed on the same vessel or one of its branches, only the highest-paying procedure may be billed.

For example, if a stent is placed in the LAD and a PTCA is performed in the diagonal side branch, only the stent (92980-LD) may be billed to Medicare because the diagonal side branch of the LAD is considered part of the LAD. Although some private carriers may pay for multiple procedures in the same vessel, Fletcher says the carrier can ask for a refund at any time. In addition, she notes, practices should be coding compliantly, rather than based on obtaining greater reimbursement.

Some Medicare carriers also recognize a fourth artery (the left main coronary artery, which branches off into the LAD and left circumflex coronary artery [LCX]) and, in some cases, even a fifth (the ramus intermedius artery, another branch of the left main separate from the LAD and LCX), notes Martha Gerant, CPC, a practice coder with Cardiology Services, an 11-physician practice in Shawnee Mission, Kan.

According to the American College of Cardiology (ACC), Medicare offers no definitive policy for coding interventions performed in these two arteries. In its CPT guide, the ACC recommends that the left main be considered a major artery only when a lesion is treated in that artery alone. If separate lesions are treated in the left main and either the LAD or LCX, only one intervention should be billed, the ACC says.

Interventions involving lesions in the ramus intermedius should be coded as procedures in one of the three major arteries, the ACC advises, adding that if one lesion is treated in the ramus intermedius and a second intervention is performed either in the LAD or LCX, the ramus intermedius should be coded as a separate major vessel. In such cases, however, the ACC recommends cardiologists submit comprehensive documentation regarding the procedure to maximize the chance of obtaining appropriate reimbursement.

In Kansas, Gerant says, Blue Cross and Blue Shield instructs cardiologists to use modifier -LM for interventions performed on the left main coronary artery and modifier -LR for procedures involving the ramus intermedius.

Note: Modifiers -LM and -LR are carrier specific. They are not HCPCS or CPT modifiers.

As a result, Gerant says, if an intervention is performed in the LCX and another lesion is treated in either the left main coronary artery or the ramus intermedius artery, both procedures may be coded. For example, if the cardiologist places a stent in the left main and performs a PTCA in the LCX, both interventions could be billed as follows:

92980-LM
92984-LC

Note: If your carrier has designated the left main or ramus intermedius as a separate coronary artery but has not generated specific modifiers for these two vessels, you should request in writing the carriers policy for indicating that a separate intervention has been performed.