Cardiology Coding Alert

When coronary and selective (peripheral) catheter placements are performed during the same operative session, often both services may be separately billed. But billing them together correctly can be confusing because peripheral and coronary intervention guidelines differ significantly. As a result, cardiologists sometimes bill inappropriately for peripheral services already included in the cardiac catheterization (such as aortography of the aortic root), and carriers may deny selective catheter placements that were appropriately billed (for example, if renal angiography is performed).

To minimize such errors and denials, cardiologists and their coders need to:

1. Determine if the peripheral catheter placement was selective, and, if so, find the appropriate code;

2. Select the appropriate imaging code(s);

3. Be aware of applicable national Correct Coding Initiative (CCI) edits; and

4. Provide clear and detailed documentation that indicates where the catheter entered the body, where it was finally placed, and why it was necessary.

Only Selective Catheter Placements Are Paid

Determining the correct code for a vascular procedure has been likened to calculating a taxi fare: It all depends on where you start and where you end. There are no fixed nonselective or selective arteries. Depending on where the catheter was introduced, any artery can be a selective destination.

When a catheter is introduced directly into the destination artery, or if there is a clear pathway that requires no manipulation, the catheter placement is nonselective (for example, if a catheter is placed in the ipsilateral common iliac artery via the common femoral artery to perform an angiogram). When such a procedure does not follow a cardiac catheterization, it should be coded 36140 (introduction of needle or intracatheter; extremity artery).

Note: Ipsilateral placements are introduced on the same side of the body as they are placed. Contralateral placements which usually require more manipulation and consequently are much more likely to be selective placements are introduced on the side of the body opposite the destination vessel.

If the same iliac angiogram is performed following a left heart cath (93510, left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous), however, 36140 should not be billed if the heart cath was introduced via the same femoral artery. The CCI considers the nonselective iliac catheter placement a component of the heart cath because it has traveled along the same route, and bundles 36140 (and 36120, for the brachial artery) with 93510. Only selective vessels are separately payable. If the vessel placement is nonselective, youre unlikely to be paid for it, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

During a selective placement, the catheter must be manipulated from a blood vessel into one of its branches. For example, if the cardiologist inserts the catheter via the femoral artery, threads it through the iliac artery and aorta and finally places it in a renal artery, a first-order selective catheter placement has been performed (36245, selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family).

If renal angiography is performed following a heart cath, 36245 should be billed in addition to 93510 because selective catheter placements are separately payable, reflecting the additional work required to position the catheter inside the renal artery. If the catheter is positioned in a sub-branch of an arterial system, the procedure is coded as a selective second- or third-order placement.

Note: According to CPT, Selective vascular catheterizations should be coded to include introduction [i.e., nonselective] and all lesser order selective catheterizations used in the approach (e.g., the description for a selective right-middle cerebral artery catheterization includes the introduction and placement catheterization of the right common and internal carotid arteries).

For example, if first-, second- and third-order catheterizations are performed in the same vascular family, only the third-order cath should be billed. Any additional second- and third-order vessel catheterizations, should be coded 36248 (...additional second order, third order, and beyond, abdominal, pelvic or lower extremity artery branch, within a vascular family [list in addition to code for initial second or third order vessel as appropriate]) or 36218 (selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family [list in addition to code for initial second or third order vessel as appropriate]).

Although nonselective catheter placements following a left heart cath cannot be billed separately, the supervision and interpretation (S&I) of any angiography performed in these vessels, or any other vessel, may be separately billed. For example, if angiography of the iliac artery is performed, 75710 (angiography, extremity, unilateral, radiological supervision and interpretation) should be billed in addition to 93510 and the appropriate coronary injection and coronary S&I codes.

Note: For the cardiologist to get paid for radiologic S&I, he or she alone must file a separate radiology report (i.e., a radiologist shouldnt also submit a report). Medicare will pay only once for the S&I

Use Coronary Aortography Codes

Coding for catheter placement and imaging in the aorta is additionally complicated because aortic catheter placement and imaging can be both peripheral and coronary. When aortography is performed on its own or in conjunction with other peripheral procedures, 36200 (introduction of catheter, aorta) should be billed. When aortography is performed as part of a left heart cath, however, the entire operative session should be coded as follows:

93510;

93543 injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography;

93544 for aortography;

93545 for selective coronary angiography [injection of radiopaque material may be by hand];

93555 imaging supervision, interpretation and report for injection procedure[s] during cardiac catheterization; ventricular and/or atrial angiography; and

93556 pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits [whether native or used in bypass]

Note: Some left heart caths do not require all the injection and S&I codes listed here; others may require additional injection codes (93959-93542).

These codes should always be used when aortography is performed during the same session as a left heart cath. Coding 93556 for coronary angiography S&I only and using 36200 for incidental aortography related to the heart cath would be unbundling because the catheter used for the coronary angiography has gained access through the aorta.

Note: If significant pathology is encountered in the abdominal aorta that requires further investigation, the aortography would not be incidental and would be separately payable using cath code 36200 and imaging code 75625 (aortography, abdominal, by serialography, radiological supervision and interpretation).

Understanding Payment Issues

Cardiologists report that many carriers are denying selective catheter placements (such as renals) when they are performed at the same time as a left heart cath. Often this occurs because the carrier sees only one diagnosis (for example, coronary artery disease or angina) for both procedures. Renal caths require a specific diagnosis (hypertension, for example), but some carrier software systems only read one diagnosis. When that occurs, the denial should be appealed and full documentation should be submitted to indicate that the patients hypertension made the renal catheterization medically necessary.

Additionally, many coders believe some carriers erroneously determine that the catheter placement for the renals has already been reimbursed through the payment for the left heart cath, even though the physician is also advancing the catheter into the lower extremity.

Peripheral and coronary catheterizations confuse carriers too, says Diane Elvidge, CPC, a coding specialist with Princeton Reimbursement Group in Minneapolis. The carriers look at the renal cath, and they see that one [the heart cath] has already been placed and that the renals are nearby, and assume that, like a nonselective placement, these too are included.

Extra risk and effort are required to place the catheter in the renals, Elvidge says. She notes that even though certain components of the renal catheterization may duplicate the cardiac catheterization already performed, these are two entirely different procedures in completely different regions, on arteries in a vascular family unrelated to the heart or its vessels.

Although 36245 includes vascular access which has already been gained by the cardiac catheterization no reduction in services should be billed and modifier -52 (reduced services) should not be attached, Callaway says.

The renal angiography will be reduced in any event, Callaway says, noting that when peripheral angiography is reported together with cardiac angiography, Medicare carriers likely will apply the multiple surgical procedures rule, in which the highest-valued surgical procedure code is reimbursed at 100 percent and each additional surgical code (i.e., the renal angiogram) is reimbursed at 50 percent.

Note: Imaging codes are not affected by this rule.

Fees are cut for multiple procedures specifically to reduce the kind of duplication that occurs when a heart cath and renal angiography are performed. Therefore there is no reason to reduce them further by attaching modifier -52, Callaway adds.

Some carriers may require that modifier -59 (distinct procedural service) be appended to the appropriate placement code. It also may be helpful to attach either the -LT (left side) or -RT (right side) modifier to the catheterization, as appropriate.

HCFA does not dictate guidelines or edits for coronary and vascular catheterizations performed at the same session. Therefore, the individual carriers payment history should be examined or the carrier should be contacted to determine any specific bundling guidelines or whether modifier -59 should be used.

If the selective catheter placement is denied and there is no CCI edit for the procedures billed, the claim should be appealed. The success of the appeal likely will hinge on the quality of the accompanying documentation.

Operative Note Should Show Where, Explain Why

A well-documented operative note is a powerful weapon when a denial is appealed. When peripheral and coronary catheterizations are performed during the same session, the operative note should:

Clearly document where each catheter was introduced and placed;
Provide medical necessity for the service; and
Include a treatment plan based on the angiography findings.

Clear documentation is the key, Elvidge says, and its all up to the doctors. If they want to be reimbursed appropriately for both procedures, then they need to treat both as separate and equally important procedures in their documentation.

To set the peripheral placement apart from the heart cath so coders and carriers alike can easily distinguish the two procedures, Elvidge recommends:

Listing both the coronary and noncoronary procedures at the top of the operative report;

Including an Indications section that clearly states why the noncoronary service is being performed (a presumptive diagnosis could be used);

Including a section that describes both noncoronary and coronary findings; and

Describing the noncoronary procedure in a separate paragraph in the procedure notes (restate the indications for the noncoronary procedure in the procedure notes).

In addition to providing an Indications section, cardiologists also need to document the medical necessity of the noncoronary procedure by associating it with an appropriate ICD-9 code.

Finally, documentation should include a clear treatment plan after the findings are listed. Increasingly, carriers are denying claims that do not include treatment plans, which could describe possible consultation with a cardiovascular surgeon, or the performance of a PTA or stent placement.

Carriers want to see a treatment plan because they want to make sure physicians are performing angiograms only when they are necessary, says Gay Boughton-Barnes, RN, CPC, MPC, senior medical compliance officer with University of Oklahoma Medical Center in Tulsa. She adds that without a treatment plan carriers may determine there was no medical necessity for the service.