Cardiology Coding Alert

The physician's procedure report must specifically describe the results of the radiological study to support billing for radiology S/I codes, coding consultants say. These codes imply that the physician is interpreting the findings, so if you're billing for S/I, this information should be in the notes, says Cynthia Swanson, RN, CPC, a cardiology coding consultant with Seim, Johnson, Sestak and Quist in Omaha, Neb.

For example, if a cardiologist reports that he or she selected and imaged the left and right renal arteries, the report must indicate that the renals were normal or that the physician detected an abnormality such as renal stenosis (440.1), says Sheldrian Wayne, CPC, a cardiology coding specialist with Coding Strategies Inc. of Atlanta.

The same results requirement applies to run-off studies. If the physician states that he or she performed a run-off study, report 36200 (Introduction of catheter, aorta) for the catheterization and 75625 (Aortography, abdominal, by serialography, radiological supervision and interpretation) for the study. The documentation must include comments regarding any vasculature viewed in the run-off and any disease process, Wayne says.

This is especially important when moving a cardiac catheter down to view the vascular system, she adds. You generally have a diagnosis to support the cardiac catheterization, such as cardiovascular stenosis (429.2), but you also need a diagnosis to support viewing lower arterial areas, such as atherosclerosis of the extremities (440.20).

Reporting findings helps support medical decision-making for subsequent treatment, Swanson says.