Cardiology Coding Alert

Get expert tips on which modifiers to use for vessels beyond the big 3.

When you know the CPT traps to watch for, you can make your coronary stent coding questions a thing of the past.

In last month's issue, "Part 1: Sidestep These Top Stent Coding Pitfalls" discussed the services included in the coronary artery stent codes as well as the rules for coding diagnostic heart catheterizations along with the stent code. Below you'll find more important stent coding tips, including how to handle multiple stents and the arteryidentifying modifiers you need for your claims.

Steer Clear of Multiple Stent Mistake

The code definitions for 92980 (Transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel) and +92981 (... each additional vessel [List separately in addition to code for primary procedure]) provide a very important clue about how to code when the cardiologist places multiple stents in a single vessel. The definitions state, "placement of intracoronary stent[s]."

The "[s]" on the word "stent" indicates that a single unit of the code is appropriate whether the cardiologist places one stent in a single vessel or multiple stents in a single vessel. Your coding, therefore, is based on the number of vessels involved rather than the number of stents. You should report 92980 for the first vessel and +92981 once for each additional vessel stented.

Match Modifiers to Vessels for Claims Success

The codes' emphasis on the number of vessels raises the question of which vessels are involved.

Answer: Codes 92980 and +92981 are specific to intracoronary stents, so you need to know the coronary arteries.

Start with the basics: Medicare identifies only three vessels, each of which has its own modifier, intended for use with the stent codes:

• LD -- Left anterior descending coronary artery
• LC -- Left circumflex coronary artery
• RC -- Right coronary artery.

So if the cardiologist places one or more stents in the right coronary artery only, you would report 92980-RC.

Dig Deeper to Handle Additional Vessels

Medicare's recognition of only three coronary vessels presents a problem for coders because the cardiologist may refer to additional branches and vessels. That leaves you with the question of which of the three modifiers to append to your stent code.

Next time you face this dilemma, consider this expert advice on which branches fall under each modifier. (In the next section, find information on coding additional arteries and grafts.

Modifier LD: This left anterior descending (LAD) artery modifier includes diagonal branches and septal perforations, says Christina Neighbors, MA, CPC, CCC, ACS-CA, charge capture reconciliation specialist and coder with St. Joseph Heart & Vascular Center in Tacoma, Wash.

Modifier LC: The left circumflex (LCX) artery modifier includes the obtuse marginal and posterior lateral branches.

Modifier RC: The right coronary (RCA) artery modifier includes the posterior ventricular and acute marginal branches.

Check Documentation for Anatomy Clues

Sometimes you'll have to look in the documentation for information about the patient's anatomy to decide which modifier to use. For example, suppose that "anatomically the cardiologist identifies the right coronary artery, left main, left anterior descending, left circumflex, and ramus intermedius (when present)," says Anne C. Karl, RHIA, CCS-P, CPC, CCC, coding and compliance specialist with St. Paul Heart Clinic in Minnesota.

When the cardiologist places the stent in the left main, for example, you must decide which of the three modifiers (LD, LC, RC) to append to your stent code. Here are some tips to get you started.

Left main (LC or LD): The left main coronary breaks out into the LCX and LAD. Payers typically ask that you append a modifier based on which artery is the dominant downstream branch. So if the cardiologist documents that the LAD is the dominant downstream branch, you should append modifier LD for a stent in the left main. The left main is usually always considered the LAD, says Neighbors. But sometimes the LCX is dominant, she adds. In that case, append modifier LC to the stent code.

Ramus (LC or LD): The ramus artery is a branch that arises between the LCX and LAD (this happens only in about one-third of the population) or it may branch from the LCX or LAD. Payers typically ask that you choose the modifier for ramus interventions based on which artery it leans closer to or it's attached to, Neighbors says.

PDA (LC or RC): The posterior descending artery (PDA) is a branch that arises between the RCA and LCX or branches from the RCA or LCX, Neighbors says. When the PDA originates between two arteries, payers may ask you to choose the artery it is closer to or the segment of the heart muscle it feeds. If you see the phrase "left dominate," the PDA branches off of the LCX, Neighbors  ays. In that case, append modifier LC. A "right dominate" PDA branches off of the RCA, she says. And you should append RC in that situation.

Bypass (LD, LC, or RC): To determine the appropriate modifier for bypass grafts (also known as saphenous vessels) and bypass conduits (known as LIMA, RIMA and radial vessels), look at which vessels they are attached to and replacing, Neighbors notes. Then append the related modifier.

Smart move: Try to get your payers' policies in writing on how they expect practices to determine which modifier is correct for these additional vessels. Let the cardiologist know the payers' requirements so he knows to document such items as which artery is the dominant downstream branch or which artery the stented vessel is closest to.