Cardiology Coding Alert

Struggling with high/low aortography? You aren’t alone.

Whether you’re looking for documentation clues to let you know the provider performed a left heart catheterization or you can’t quite get a handle on when angiography is medically necessary, the solutions below should help point you in the right direction.

1. LHC Is in Procedure List, Not Procedure Description

The procedure list at the top of a cardiac catheterization report may help in narrowing your code choices, but you should always make your final code selection from the procedure description.

Problem: One coder wrote in that a procedure listing referred to a left heart catheterization (LHC), but the documentation specifically stated the catheter did not enter the left ventricle. 

Solution: You should not report a left heart catheterization code for this case because the catheter did not enter the left ventricle. CPT® guidelines for the cardiac catheterizations help point you in the right direction: “Left heart catheterization involves catheter placement in a left-sided (systemic) cardiac chamber(s) (left ventricle or left atrium) and includes left ventricular injection(s) when performed.” In the case described, the procedure listing said LHC, but the procedure description does not meet the CPT® requirement for LHC. 

Bonus tip: Not crossing the aortic valve is another sign that the cardiologist did not perform an LHC. The aortic valve sits between the aorta and the left ventricle, so if the cardiologist doesn’t move the catheter across the aortic valve, he can’t place the catheter in the chambers on the heart’s left side. “Based on the information given, the provider didn’t cross the aortic valve,” says Christina Neighbors, MA, CPC, CCC, ACS-CA, a cardiology coding expert in Tacoma, Wash. 

Other clues you may see in documentation that the cardiologist performed an LHC include LVEDP (left ventricular end diastolic pressures), LV pressures, or an LV-gram. Note that 93452, 93453, and 93458-93461, which all include LHC, specify that they include but do not require an LV-gram: “including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed.” 

2. Angiography Injection Occurs Above Aortic Bifurcation

When the cardiologist performs an angiographic injection in the aorta following cardiac catheterization, choosing the proper code can be confusing. 

Problem: A coder asked which code to use for imaging with catheter placement just superior to the aortic bifurcation with bilateral lower extremity runoff.

Solution: Given the placement of the catheter just above where the aorta splits into the iliacs, the most likely code for the scenario above is 75716 (Angiography, extremity, bilateral, radiological supervision and interpretation), says Neighbors. But she warns you’d need additional details to be sure you can code the service.

To support reporting the additional angiography, the documentation should describe why the cardiologist determined it was medically necessary as well as what he found.

Neighbors offers this example of documentation for why the cardiologist performs 75716: “Due to history of PVD and the patient’s continuous cramping pains while walking, usually in calf muscles but sometimes in thighs or buttocks, a bilateral angiogram is indicated and provided.” 

Please note: “Pre-procedural indications must be documented stating history of PVD, and medical necessity must be available within the patient stay to provide this additional service,” Neighbors explains. Check your payers’ LCDs for supporting diagnoses.

Keep in mind: In some cases, the cardiologist will place the catheter at the level of the renals and provide one fluid injection. This is so he can view the abdominal aorta through the femoral arteries bilaterally (at least to the common femoral). You’ll report 75630 (Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation) for this service. 

Or if the cardiologist had performed an abdominal aortogram from high in the aorta and then repositioned the catheter to perform the lower-extremity angiography you would report the abdominal aortography using 75625 (Aortography, abdominal, by serialography, radiological supervision and interpretation) in addition to the lower-extremity angiography code. Use 75716 for a bilateral extremity service or 75710 (Angiography, extremity, unilateral, radiological supervision and interpretation) for unilateral. Because the cardiologist places the catheter high in the aorta and then at a lower position, you may see this service referred to as a high/low.

3. No Documented Reason for Angiography Near Access Site 

As described above, following cardiac catheterization, the cardiologist may perform extremity angiography, and having documentation of the reason for it is crucial to proper coding. One additional reason you need documentation is that sometimes the cardiologist performs imaging simply to assess the vessel near the access site.

Problem: Many coders have asked how to report femoral or iliac angiography at the end of a cardiac cath.

Solution: CPT® guidelines state, “Contrast injection to image the access site(s) for the specific purpose of placing a closure device is inherent to the catheterization procedure and not separately reportable.”

If you don’t see mention of a closure device, it’s still possible this was the purpose of the imaging. In some cases the cardiologist may image the vessel and then decide to use a hemostasis patch instead, notes Neighbors.

Bottom line: “Without knowing the medical necessity and findings for the imaging, it’s tough to say what can be coded,” Neighbors says. Work with providers to ensure documentation includes the information you need to support proper coding. If the cardiologist performed the imaging to assess the access site, he should state that. Even more important, if the cardiologist performed the imaging for diagnostic reasons, he should spell out the medical necessity for the angiography and detail his findings in the report.