Cardiology Coding Alert

Tip:  If you're thinking of using an add-on code, you cannot report that code alone

When your electrophysiologist (EP) performs a procedure that doesn't have a perfect code to represent it, you may find yourself caught in a quagmire of possible coding options that you know aren't right. Follow this example and see how to tackle even the most unusual operative reports with ease.

Review This EP Note Example

Procedures

Administration of intravenous stimulants for detection of ventricular ectopy.

History

This 41-year-old patient has a history of symptomatic, late diastolic PVCs. They were thought to have an outflow tract origin. She underwent admission for potential electrophysiologic evaluation and possible mapping and ablation.

12-Lead Electrocardiogram

The 12-lead electrocardiogram at rest indicated sinus rhythm. Minor J point elevation was present in lead V1. Noted accentuation of T wave voltage in lead V2.

Description of Procedure

After providing written and informed consent, the patient was taken to the electrophysiologic laboratory in a postabsorptive nonsedated state. After the initial nursing assessment, the patient was placed in the supine position on a padded procedure table. I established noninvasive blood pressure and arterial oxygen saturation monitoring. I established continuous electrocardiographic monitoring.

I started supplemental nasal oxygen. Then I applied anterior and posterior defibrillation pads to the chest. I obtained baseline electrocardiographic recordings. The patient had no ectopy at rest. Then I started her on intravenous isoproterenol. The initial dose was 1 mcg per minute. I subsequently increased in incremental doses to a total of 4 mcg per minute. I performed serial electrocardiograms following the administration of intravenous isoproterenol.

There was accentuation of T-wave voltage in V2 and minor ST segment elevation in V2. There was accentua-tion of J point elevation in V1. I observed neither arrhythmias nor ectopy. I thus discontinued the isoproterenol. After 20 minutes, the patient received 250 mg of intravenous aminophylline. Once again, I obtained serial electrocardiograms. There was no major change in electrocardiogram. The patient remained asymptomatic. I induced no ventricular ectopy.

Discussion

Despite the fact that the patient demonstrated spontaneous ventricular ectopy on an outpatient basis and has been off of her beta blocker medications, the patient has no evidence of spontaneous or inducible ventricular ectopy today. Her mapping and ablation procedure was canceled. She will continue on medical therapy.

Now Simplify What You Read

If you found this example to be challenging, you're probably on the right track. "This is an unusual case," says Anne Karl, RHIA, CCS-P, CPC, coding and compliance specialist at St. Paul Heart Clinic in Mendota Heights, Minn.

First, you should break down what happened. The EP tried to induce ventricular ectopy using infusions of isoproterenol and aminophylline. He monitored her on EKGs throughout the procedure, but the patient proved asymptomatic.

Note: "Ectopy is abnormal extra heart beats originating from the ventricles," says Jerome Williams Jr., MD, FACC, a cardiologist with Mid Carolina Cardiology in Charlotte, N.C.

Strike Through These 4 Options

You may think this procedure is similar to various procedures, but if this note does not accurately fit the code, you should not report it.

Cross out #1: You can't report an electrophysiological study (93600-93662) because the EP did not place an internal catheter, Karl says.

Cross out #2: "You can't use +93623 (Programmed stimulation and pacing after intravenous drug infusion [list separately in addition to code for primary procedure]) because this is an add-on code to the standard electrophysiology study package," Karl says.

This coincides with what CIGNA, a Medicare provider of North Carolina, instructs in its local medical review policy (LMRP). CIGNA says you should only bill 93623 when the EP provides the service with the electrophysiology study.

Cross out #3: Although the patient received an IV infusion of isoproterenol and aminophylline, you probably shouldn't rely on the IV infusion code 90765 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour). Code 90765 doesn't cover the EKG work the EP provided, Karl says.

But you may want to keep the substance codes in mind--J7658, Isoproterenol HCl, inhalation solution administered through DME, concentrated form, per milligram; and J0280, Injection, aminophylline, up to 250 mg.

Cross out #4: This procedure sounds a lot like a drug- induced stress test, Karl says, but you shouldn't report a code such as 93015 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report) because this procedure did not induce "stress." "Stress" usually means that the patient's heart rate increases to a certain speed, and then the physician assesses the patient for stress-induced changes.

Second, the typical stress test agent is Adenosine, not Isuprel. Isuprel is typically limited to infusions and arrhythmia inductions performed as a component of an invasive EP study.

Finally, staff with direct physician supervision typically performs stress tests in the office--not in an EP lab with defibrillation pads positioned on the patient.

Come to Your Coding Conclusion

You may try to report 93015 with modifier 22 (Unusual procedural services). You should submit both a paper claim and the op report.

Some may think, however, that because this procedure took place in an EP lab, involved defibrillation pads, and included personal physician supervision, this procedure was more intense than a typical stress test.

Best bet: "I am leaning toward the unlisted-procedure  code," Karl says. If you report 93799 (Unlisted cardiovascular service or procedure), you may use 93015 as a benchmark for your reimbursement.

Remember, when you submit claims for an unlisted procedure, be sure to include:

• a detailed description of the procedure
• copies of articles in medical journals (to support reasonableness)
• documentation of medical necessity
• the patient's indications
• the patient's follow-up and prognosis
• an explanation of time, effort and equipment.

Want more? Check out the Cardiology Coding Alert April 2006 article "Submit Top-Quality Unlisted- Procedure Claims" for more information on how to get those unlisted-procedure claims paid every time.