Cardiology Coding Alert

Coding Case Study:

Coding for Coronary Stent vs. PTCA

Case Description and Procedure

A 73-year-old female undergoes stent placement.

Before reviewing the catheter lab notes (below) for this case, its important to understand the general transcatheter procedure.

After a sheath is inserted through the femoral artery, a guide catheter is placed through the sheath. The cardiologist positions the guide catheter into the coronary artery and injects contrast material to obtain a baseline arteriogram to determine the exact location of the lesion.

The lesion is dilated first with an angioplasty balloon only to open a channel through some of the blockage. Then, a stent is placed over an inflating balloon, which is inserted onto the carrying catheter. Once in the correct position, the carrying balloon is inflated to deploy the stent. Usually, a second balloon is inflated inside the stent to make sure the stent is fully expanded. Once the procedure is completed, antithrombotics may be injected into the vessel to prevent a thrombosis at the site of the stent. The entire procedure is performed under fluoroscopic guidance and pictures may be taken throughout the procedure to assure correct placement of the stent.

The first paragraph of the cath report describes the general preparation of the patient and the initial insertion of the guide catheter into the left femoral artery, along with some appropriate historical information. Following is the procedure as documented in the catheter lab report:

1. A 7 French LAD guiding catheter was inserted into the left main artery where initial injection was done in different projection.

2. A stabilizer plus wire was inserted across the lesion without difficulty and positioned distally. Over this, a 3.0 perfusion balloon was inserted and inflation was carried out up to 5 atmosphere.

3. Balloon was deflated, pulled back, and 3.5 x 13 mm multi-link stent was deployed in the mid LAD. There was a small area of the plague that was not covered by this stent because the stent moved up proximally.

4. In view of the stent movement, another 3.5 x18 mm stent was deployed overlapping with the first stent.

5. Intra-coronary nitroglycerin was given, final picture was recorded, guiding catheter wire was removed, femoral sheath was sutured outside the skin, and patient was transferred in satisfactory condition.

6. Prior to the angioplasty, patient has high-grade 992 lesion in mid LAD. After angioplasty and stenting, there was no vessel narrowing. This result was considered satisfactory.

Coding Principles

In this case, 92980 (transcatheter placement of an intracoronary stent; single vessel) should be billed rather than 92982 (percutaneous transluminal coronary balloonPTCA angioplasty, single vessel).

The rationale is that the PTCA is bundled into the placement of the stent. At $1,000, the stent procedure has a higher reimbursement value for Medicare than a $750 PTCA.

Code 92980 represents service for the first, or initial, vessel treated. It also includes multiple treatments or stents in that vessel. If additional vessels are treated with stent(s), bill 92981 (transcatheter placement of intracoronary stent, each additional vessel) once for each vessel. Because 92981 is an add-on code, you would not append modifier -51 (multiple procedures).

But for Medicare, you should append the modifier that identified in which major vessel the stent was placed. Also, you should check with your local Medicare carrier as to which of the major coronary arteries are recognized.

The CPT Assistant, August 1996, identifies them as follows:
Left main coronary artery
Right coronary artery
Left anterior descending coronary artery
Left circumflex coronary artery

Medicare requires the following modifiers to designate which vessels are being treated.
-LD (left anterior descending artery)
-LC (left circumflex coronary artery)
-RC (right coronary artery)

In this case, the stent was deployed in the left anterior descending artery; therefore, the claim should be coded as 92980-LD. (Even though a second stent had to be inserted, it cant be charged. The code per vessel includes treatment in any branch of the major vessel.)

Sources: Susan Stradley, CPC, CCS-P, senior consultant for Medical Group of Elliott, Davis and Co., LLP, headquartered in Greenville, SC. Along with the 1999 CPT and ICD-9-CM manuals, references included Medicodes Coding Illustrated for Cardiovascular and Respiratory, Coders Desk Reference, as well as Aspen Publishers CPT Made Easy and American College of Cardiologys Practical Reporting of Cardiovascular Services and Procedures.