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Cardiology Coding Alert

Coronary Blood Flow Payable With Heart Cath, Angiogram

Published on Mon Oct 01, 2001

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Two techniques are used to evaluate blood flow around or through a lesion, and both are reported with 93571 (intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement [coronary vessel or graft] during coronary angiography including pharmacologically induced stress; initial vessel [list separately in addition to code for primary procedure]) and 93572 (... each additional vessel [list separately in addition to code for primary procedure]).  
 
Whichever technique is used, this procedure, which previously could be used only in conjunction with an intervention, may now be reported when performed for evaluation only, i.e., during coronary angiography or cardiac catheterization.
 
Many cardiology coders are unfamiliar with both techniques or may not correlate the cardiologist's description of what was performed with the terminology that describes both codes. Depending on the technique performed, the procedure may be referred to as a fractional flow reserve study" " a "pressure wire" or a "Doppler ultrasonography." All the techniques aim to  evaluate accurately coronary blood flow and all are reported using 93571.
 
Coronary blood-flow evaluation provides important information to the cardiologist performing a heart cath or an intervention. Visual assessment of coronary-artery stenosis as viewed on angiography guides treatment decisions on the need for a revascularization procedure such as angioplasty atherectomy or coronary-artery bypass graft (CABG) surgery; however lesions of intermediate severity may require more evaluation.

In such cases cardiologists may measure coronary flow reserve (CFR) which is the ratio of coronary flow under maximal coronary vasodilation to coronary flow under resting conditions. CFR measurements greater than three are considered normal.
 
The measurement of pressure gradients across coronary stenoses was the earliest method used to assess the adequacy of coronary angioplasty but subsequently Doppler ultrasonography was considered more accurate and as a result is more often used. However the recent introduction of new thinner catheters and guidewires (often referred to as a "pressure wire") means pressure gradients can be accurately measured across stenoses before and after interventional procedures. The resulting data obtained by determining the ratio of the mean pressure distal to a coronary stenosis with that proximal of it are often referred to as a "fractional flow reserve" measurement says Marko Yakovlevitch MD FACP FACC a cardiologist in private practice in Seattle.
 
Some cardiologists maintain that with the new devices fractional flow-reserve measurement is easier to perform than Doppler ultrasonography which involves inserting a wire with a Doppler transducer at the tip of the wire to measure blood velocity. The transducer is mounted on a guidewire that is advanced through the stenosis in question to a position distal to the lesion. A baseline measurement of peak velocity is made. Vasodilation is then induced with an intracoronary bolus of adenosine and peak velocity is again measured. Other applications of intracoronary Doppler ultrasounds include estimating the adequacy of a percutaneous transluminal coronary angioplasty (PTCA) and the need for a stent.
 
Although fractional flow-reserve studies and Doppler ultrasonographies do not precisely measure the same thing both services inform the cardiologist about the clinical nature of the lesion and whether it requires treatment Yakovlevitch says.
 
Note: According to the 2001 CPT manual "Intravas-cular distal coronary blood flow velocity measurements include all Doppler transducer manipulations and repositioning within the specific vessel being examined during coronary angiography or therapeutic intervention (e.g. angioplasty)."

93571 and 93572 Are Now Payable Separately

Until recently 93571 and 93572 could be billed only when performed as a diagnostic tool during a session that also included an intervention. So this diagnostic service would not be paid if the cardiologist did not subsequently repair a lesion after evaluating blood flow says Linda Laghab CPC a practice coder with Foothill Cardiology/California Heart a Los Angeles-based practice with 46 cardiologists. But now  the codes are separately payable when performed with cardiac catheterizations and coronary angiograms she says so the cardiologist may be paid just for evaluating the lesion.
 
Because ultrasound is a similar diagnostic tool some coders confuse 93571-93572 with 92978 (intravascular ultrasound [coronary vessel or graft] during diagnostic evaluation and/or therapeutic intervention including imaging supervision interpretation and report; initial vessel [list separately in addition to code for primary procedure]) and 92979 (... each additional vessel [list separately in addition to code for primary procedure]). But Doppler ultrasonography measures blood flow whereas intravascular ultrasound evaluates the vessel's walls from the inside.
 
Codes 93571 and 93572 are add-on codes meaning they are payable separately when performed in conjunc-tion with an intervention such as 92978 and 92979. The fees for the service should not be reduced as per multiple- procedure guidelines because as these are add-on codes the reduction is already taken into account when the RVUs are calculated. Similar to 92978-92979 which do not require an intervention to be billable 93571-93572 are not included in cardiac catheterization and coronary angiography but they are covered by Medicare according to Adminastar Federal the Part B Medicare carrier in Indiana and the group that develops the national Correct Coding Manual for CMS.
 
A diagnosis of angina (413.x) or another form of ischemic heart disease (414.xx) should also be associated with 93571 and if necessary 93572 to provide medical necessity for obtaining the blood-velocity measurement or fractional flow-reserve study Laghab says.

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