Cardiology Coding Alert

Two weeks after the closest election in U.S. history, Vice president-elect Dick Cheney had what his physicians described as a very slight heart attack. On Nov. 22, Cheney, who has a history of heart problems dating back to 1978, checked into George Washington University Hospital after complaining of chest pains. According to news reports, the initial electrocardiogram (ECG) and blood test did not reveal signs that a myocardial infarction (MI) had occurred. Initially, physicians said Cheneys chest pain had been traced to a narrowed artery that deprived his heart muscle of blood. This would have been termed unstable angina, acute coronary syndrome or, in more general terms, something short of a heart attack.

A second blood test forced the physicians to amend their description. The test showed that a portion of Cheneys heart muscle had died due to lack of oxygen, which meant that Cheney had suffered what his physicians described as a very slight heart attack. Cheney underwent a left cardiac catheterization, including a coronary angiography that showed a 90 percent narrowing (due to fatty plaque) of the diagonal branch of the left anterior descending artery.

Angioplasty was performed, but did not succeed in unblocking the artery. A stent was implanted to shore up the artery walls and stop the blockage from recurring.

For 30 days after the procedures, Cheney was put on Plavix, or clopidogrel, a blood thinner that reduces the chance of blood clots from covering the foreign material of the stent. After 30 days the risk is reduced because new tissue grows over the stent.

Given the information available, the services provided to Cheney would have been coded as follows if general coding principles were observed:

92980-26-LD transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel left anterior descending artery;

93510-26 left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous professional component;

93543 injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography;

93545 injection procedure during cardiac catheterization; for selective coronary angiography (injection of radiopaque material may be by hand);

93555-26-59 imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography professional component distinct procedural service;

93556-26-59 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) professional component distinct procedural service;

99223-25 initial hospital care, per day, for the evaluation and management of a patient, which requires comprehensive history and examination, and medical decision making of high complexity; and

93010 electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.

Associated diagnosis codes are:

414.01 coronary atherosclerosis of native coronary artery;

410.02 myocardial infarction, of anterolateral wall, subsequent episode of care; and

786.5x chest pain.

The ICD-9 code correctly associated with the ECG is 786.5x, because the MI was diagnosed by the second blood test, not the ECG. Therefore, the sign or symptom that brought Cheney to the hospital (chest pain) should be used to justify the ECG. All procedures performed after the MI was diagnosed should be linked to 410.02, with the exception of the stent, which is linked with 414.01, because the diagnosis of coronary atherosclerosis explains why the intervention was performed to the highest degree of specificity, says Stacey Elliott, CPC, head of contracts, compliance and information systems with COR Medical Associates, an 11-cardiologist practice in Torrance, Calif.

The -LD modifier indicates the stent was implanted in the left anterior descending artery or one of its branches, in this case, the diagonal branch, Elliott says. Modifier -26 should be added to the stent and to the heart catheterization code and its two associated supervision and interpretation (S&I) codes (but not to the linked injection codes) to indicate the cardiologist does not own the equipment and provided professional services only.

Because the stent procedure includes imaging supervision and interpretation, modifier -59 must be added to the two S&I codes associated with the left heart catheterization, to indicate that these are separate from the stent and should not be bundled to it.

The PTCA performed before the stent cannot be coded: American College of Cardiologists and Medicare guidelines state that only one intervention per vessel (the highest valued procedure, in this case, the stent) may be coded.

Because of the nature of the procedures performed, and because none of the procedures were planned and Cheney checked himself into the hospital, a level-three initial hospital care visit could reasonably be charged by the admitting physician, Elliott says.