Cardiology Coding Alert

Add-on code opportunities do exist if you know where to look.

"Major overhaul" sums up CPT 2011's changes to cardiac catheterization coding fairly well.

In fact, you have 19 deleted cardiac cath codes, 20 added cardiac cath codes, and only eight cardiac cath codes that stay the same, as David B. Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCS, RCC, of ZHealth Publishing, pointed out at The Coding Institute's December 2010 coding and reimbursement update conference.

Cardiology Coding Alert will discuss these changes in the coming months. As a starting point, this article will focus on the rules that apply jointly to new left (LHC) and right heart cath (RHC) codes 93451-93453:

• 93451 -- Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed
• 93452 -- Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed
• 93453 -- Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed.

Keep in mind: Among the deleted cardiac cath codes are 93501 (Right heart catheterization), 93510 (Left heart catheterization ...), and 93526 (Combined right heart catheterization and retrograde left heart catheterization), which you may have used in reporting similar services in 2010. The complete list of deleted codes includes 93501, 93508-93529, and 93539-93556.

Explore the Overarching Section Guidelines

As you'd expect with so many code changes, CPT offers new "Cardiac Catheterization" section guidelines to help you use the new codes properly, as revealed in the presentation by Kenneth P. Brin, MD, PhD, FACC, CPT editorial panel member, and James Blankenship, MD, FACC, FSCAI, relative value update committee member, at the AMA's CPT and RBRVS 2011 Annual Symposium.

Here is a closer look at the guidelines that apply jointly to 93451, 93452, and 93453. For guidelines that apply to the codes individually, see Part 2 in next month's issue.

Families: Keep Congenital Case Codes Separate

CPT divides the cardiac cath codes into two families:

1. Those for congenital heart disease

2. Those for all other conditions.

Codes 93451-93453 fall under the "all other" family. But don't miss that CPT guidelines include them in the codes appropriate for cases involving "anomalous coronary arteries, patent foramen ovale, mitral valve prolapse, and bicuspid aortic valve." Also, as Dunn pointed out, there is no separate code for congenital LHC.

What's Included: Cath Introduction to Closure

CPT section guidelines indicate that a cardiac cath is a diagnostic medical procedure including all of the following:

• Introduction, positioning, and any required repositioning of catheter(s) within the vascular system
• Recording intracardiac and/or intravascular pressure(s)
• Final evaluation and report of the procedure.

If you check the codes in the manual, you'll also see the symbol indicating the codes include conscious sedation when performed by the same physician, Dunn noted.

Codes 93451-93453 also include the "roadmapping" angiography the cardiologist uses to place the catheters, CPT guidelines state. That means, you should not separately code injections or the imaging supervision and report related to the roadmapping. However, you may report contrast injections and the supervision and report for imaging that has a separate procedure code (see section below).

Finally, CPT guidelines declare that you should not separately report placing the closure device at the access site. You also should not report any contrast injection required for placing the closure device.

Add-On Codes: Capture Separate Injection

CPT created several new add-on codes that you may report in addition to multiple cardiac cath codes, including 93451-93453.

First are several imaging/injection procedure codes:

• RV/RA angiography: +93566 -- Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective right ventricular or right atrial angiography (List separately in addition to code for primary procedure)
• Aortography: +93567 -- Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary procedure)
• Pulmonary angiography: +93568 -- Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for pulmonary angiography (List separately in addition to code for primary procedure).

CPT's "Injection Procedures" guidelines indicate that the above codes do not include catheter introduction, but they do include repositioning the catheter and using automatic power injectors. You also have CPT's approval to report any combination of +93566, +93567, and +93568 with your cardiac cath code. For example, if the cardiologist performs and documents both aortography and pulmonary angiography, you may report both +93567 and +93568. You aren't limited to reporting just one code.

Additionally, if the cardiologist performs angiography of noncoronary vessels "as a distinct service," you should turn to the Radiology and Vascular Injection Procedures sections to find the proper codes, CPT guidelines instruct.

More Add-On Codes: Seize Hemodynamic Response Opportunity

If the cardiologist administers a pharmacologic agent or has the patient exercise to evaluate hemodynamic response, you may report the following in addition to the cardiac cath codes:

• Agent: +93463 -- Pharmacologic agent administration (e.g., inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, when performed (List separately in addition to code for primary procedure)
• Exercise: +93464 --" Physiologic exercise study (e.g., bicycle or arm ergometry) including assessing hemodynamic measurements before and after (List separately in addition to code for primary procedure)

You should use each code only once per cath procedure. CPT guidelines indicate the above codes are appropriate when the cardiologist uses the pharmacologic agent or exercise "with the specific purpose of repeating hemodynamic measurements to evaluate hemodynamic response." For example, you may report +93463 for a Flolan study.