Cardiology Coding Alert
CPT 2002 Changes Include New Brachytherapy, AngioJet Codes
The full effect of these changes on billing and reimbursement will not be known until CMS publishes its fee schedule in the Federal Register, to include relative values of all new and existing CPT codes.
New Brachytherapy Code
Restenosis, the recurrence of coronary artery blockage at the treatment site, often complicates the treatment of coronary artery disease with angioplasty or stents. Restenosis at the site of a prior stent placement occurs in 15 to 25 percent of patients who undergo coronary stent implantation during a percutaneous transluminal coronary angioplasty (PTCA).
Intracoronary brachytherapy, also known as coronary artery radiation treatment, is being used more and more to treat restenosis following an earlier intervention. The radiation is delivered via a special catheter that is passed into the coronary artery to the area of restenosis, explains Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in Seattle.
While anticoagulants can prevent thrombosis (blood clotting) at the treatment site, they cannot prevent the tissue buildup associated with restenosis at the treatment site. Researchers have postulated for several years that small doses of radiation applied to the section of the coronary artery being treated might prevent the tissue growth associated with restenosis. The FDA approved two coronary artery radiation systems in November 2000, the Beta-Cath System (Novoste Corp.) and the Checkmate System (Cordis Corp.). The systems differ in that Beta-Cath uses beta radiation and emits electrons, whereas Checkmate uses gamma radiation and emits photons.
The treatment prevents restenosis by killing the cells that have reoccluded the stent and by inhibiting further tissue growth, Yakovlevitch says. The techniques require special equipment and trained individuals and have similar FDA-approved labeling that limits coverage of brachytherapy to treatment of in-stent restenosis in native coronary arteries.
Cardiologists who use brachytherapy have several reimbursement issues to consider. Until recently, the FDA had not approved the devices that are used to perform the service. Although the FDA has approved the treatments, carriers still may not cover the service for coronary interventions. And, the CPT manual did not include a brachytherapy code until now, so cardiologists who performed the service had to use an unlisted procedure code (93799, unlisted cardiovascular service or procedure), which involves manual review and all of its associated problems.
CPT 2002 introduces 92974 as the code to report coronary brachytherapy services. As welcome as its introduction may be, this new code alone will not solve all the billing issues associated with brachytherapy procedures. Many carriers, particularly those who have not paid for brachytherapy in the past, may still deny the claims until CMS issues specific coverage instructions.
Furthermore, the relative value of the new code will remain unknown until the 2002 CMS Physicians Fee Schedule is formally released. The codes or procedures that 92974 may be listed in addition to are also unknown.
Carriers who cover intracoronary brachytherapy do so only for restenosis of vessels. There is interest in the use of intracoronary brachytherapy as an adjunct to initial angioplasty to prevent stenosis from occurring in the first place, either with or without associated stent placement.
In published local medical review policies on intracoronary brachytherapy, intracoronary vascular brachytherapy is considered medically necessary only as an adjunct to PTCA, atherectomy or excimer laser therapy in patients with an in-stent restenosis of a native coronary vessel. These and any other brachytherapy treatments are considered investigational:
New AngioJet Code
In March 1999, the FDA approved use of the AngioJet Rheolytic System (Possis) to remove blood clots in symptomatic native coronary arteries and coronary bypass grafts. (Other versions of AngioJet have been approved to remove clots in peripheral vessels and atrioventricular dialysis grafts.) AngioJet did not have its own CPT code, leading to much confusion about how coronary thrombectomies performed using AngioJet should be reported.
AngioJet thrombectomies are considered percutaneous, allowing the physician to perform the thrombectomy without opening up the patient. The new code also applies to other catheter-based thrombectomies that are performed less often.
Reimbursement for AngioJet in all cases remains uncertain: Many carriers do not pay separately for the treatment, considering it part of any other intervention performed during the same session. Of the carriers willing to cover and pay for the procedure, most required that unlisted procedure code 93799 be used.
Other carriers instructed providers to accept codes that only superficially resembled AngioJet. Codes such as 92995 (atherectomy) or 92975 (thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography), for example, proved less than accurate. Unlike AngioJet, which removes blood clots, atherectomies are performed to remove plaque from the walls of a coronary vessel, says Diane Elvidge, CPC, a coding and reimbursement specialist with Princeton Reimbursement Group in Minneapolis. Thrombectomy code 92975 is incorrect because it implies infusion by a thrombolytic agent, which AngioJet does not use.
As with new brachytherapy code 92974, attention turns to both the CPT 2002 manual (to determine which codes 92973 can be added on to) and the CMS Physician Fee Schedule (which will set the relative value for this service), Elvidge says.
Carriers who cover AngioJet treatment determine their own rates. Georgia Medicare, for example, instructs providers to bill coronary AngioJet thrombectomies at the same rate as they would bill 92982 (percutaneous transluminal coronary balloon angioplasty; single vessel). Nor is it yet clear how a percutaneous thrombectomy using AngioJet should be billed when it is not performed in conjunction with another procedure. As an add-on code, 92973 should not be billed if it is performed without an accompanying procedure.
Changes in Balloon Pump Codes
Added
Deleted
In this procedure, a balloon catheter is placed to provide temporary circulatory assistance. The entire apparatus includes both the balloon catheter and a console that houses the pump for the balloon. When the pump is activated, it inflates and deflates the balloon in time to the patient's heartbeat.
In 2001, 93536 had 8.16 transitioned relative value units and zero global days. The new fee schedule should clarify any changes when it is published.
EP Codes Modified
Deleted
When five-catheter studies of the right atrium, right ventricle, left atrium, left ventricle and bundle of His are performed, 93621 is used to describe four of the catheters, including the left atrial study. The left ventricular study has been reported using 93607. Using 93607 this way often requires attaching modifier -59 (distinct procedural service) to alert the carrier that the component code was not part of the 93621 and was performed on a separate site (the left ventricle).
As of Jan. 1, 2002, the services formerly described by 93607 should be reported using 93622, which includes left ventricular recording and induction or attempted induction of arrhythmia. This should eliminate the need to append modifier -59, an often-abused modifier that has been closely watched by CMS and the Office of Inspector General. The left atrial recordings would be reported using 93621.
Revised
Added
These codes should be used to report intracardiac mapping separately. Intracardiac mapping was included in ablations (93650) because the same catheter is used to perform both services. That is no longer the case, because two different catheters are used for intracardiac 3-D mapping and ablations. As a result, 93609 should be reported separately when this service is performed in conjunction with ablations. The fee for this service should not be reduced, because the relative value for add-on procedures is already cut. If intracardiac 3-D mapping is performed, use new code 93613.
Revised
Language that follows both code descriptors has been removed. CPT 2001 instructs physicians that "[93619] is to be used when 93600 is combined with 93602, 93603, 93610 and 93612." Similarly, the 93620 descriptor tells physicians that "[93620] is to be used when 93618 is combined with 93619." Although these additional instructions have been removed, the change should not affect coding and billing for any EP service.
Revised
The most significant change is the "add-on" status accorded 93621 and 93622. CPT should be able to eliminate a major source of coding and billing confusion in making these add-on codes.
Electrophysiologists who perform left atrial or ventricular pacing and recording in conjunction with a comprehensive EP exam have difficulty obtaining reimbursement for the additional left-side study. As of CPT 2001, 93621 and 93622 are valued at little more than 93620, so electrophysiologists who perform left atrial or ventricular studies are not reimbursed fairly for the additional work involved.
The response to this unfair situation was a series of conflicting and sometimes erroneous coding instructions from authoritative publications and organizations. For instance, electrophysiologists have been instructed to bill 93620 separately from 93621 or 93622, in spite of the fact that 93621/93622 includes all the components of 93620 other than the additional left-side study and even though 93622 and 93621 both include 93620 in the national Correct Coding Initiative (for more on this issue, see Cardiology Coding Alert, Vol. 4, No. 5, May 2001).
CPT has gone some way toward resolving this difficult issue. By making 93621 and 93622 add-on codes, CPT is instructing EP physicians to bill for the right-side EP using 93620 (if induction of arrhythmia was achieved or attempted) and 93621 or 93622 for additional left atrial or ventricular pacing, respectively.
Although this may clarify the coding for some, it is important to note that the core of this problem did not involve the coding as much as the payment. For instance, it is correct to bill 93622 only if a left ventricular study was performed in conjunction with a right-side study; the problem with doing so is the minuscule additional reimbursement for 93622 (and 93621) vis--vis 93620.
Therefore, the real impact of the change will be known only when the relative values for 93621 and 93622 are known. The current figures are:
93620 (19.41 transitioned relative value units).
93621 (21.20 RVUs).
93622 (21.32 RVUs).
If the RVU for the add-on codes is equally small, not much will have changed, notes Nikki Vendegna, CPC, a cardiology coding and reimbursement specialist in Overland Park, Kan. "It all depends on how much they ratchet down reimbursement for 93621 and 93622," Vendegna says, noting that if CMS follows a similar model to that used for interventions on additional vessels, reimbursement may be cut severely.
If both left atrial and left ventricular studies are performed in conjunction with 93620, both 93621 and 93622 should be reported. This service is now correctly reported using 93621 (for the right-side and left atrial study) and 93607 (for the left ventricular study).
Modifier -60 Deleted; Modifier -22 Revised
Modifier -60 (altered surgical field) has been deleted only one year after its introduction. The deletion is tacit acknowledgment that CMS and other carriers did not accept the new modifier, despite general praise for it from physician groups. A few weeks after the modifier was introduced, CMS announced that Medicare carriers would not recognize the modifier and instructed providers to continue using modifier -22 (unusual procedural services) in such cases.
CPT 2001 had amended modifier -22, stating that "this modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight ... or trauma (see modifier -60 as appropriate)."
With modifier -60 deleted, modifier -22 should be used to report complicated procedures, regardless of the reason for the difficulty.
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