Cardiology Coding Alert

Peripheral Vascular Case Study:

Get a Grip on Left Heart Caths With PTAs

Let our experts show you the PV ropes

If coding heart catheterizations - particularly procedures that include peripheral vascular (PV) interventions - sends you into cardiac arrest, a few minutes brushing up on the basics could be just what you need to improve your cath coding acumen.

Take a look at the following left heart cath procedure with percutaneous transluminal angioplasty (PTA) and review our experts' coding recommendations:

1. Procedure Overview: See What Was Done

Here's a quick service synopsis:

A 60-year-old male patient with peripheral vascular disease (443.9) had a left heart catheterization with left ventriculography. The physician performed selective left and right coronary angiography, selective left and right carotid and renal angiography, an abdominal aortogram, and right iliac angiography.

The physician also performed a PTA to eliminate a blockage in the right anterior tibial artery.

2. Operative Note: Trace the Cath Placement, PTA

The pertinent details from the operative note follow:

The physician inserted a 5-French sheath into the left femoral artery and used diagnostic JL4 and JR4 diagnostic catheters to obtain selective left and right coronary cinean-giograms in multiple projections. He also used the JR4 catheter to obtain selective cineangiograms of the left and right carotid arteries and the renal arteries. He used a pigtail catheter to cross the aortic valve and obtained measurements, followed by a left ventriculogram. He calculated a pullback gradient across the aortic valve. He then brought the pigtail catheter into the abdominal aorta and performed an abdominal aortogram. Due to sub-optimal visualization of the distal leg arterial system, he advanced the catheter past the aortic bifurcation using the pigtail catheter and performed a selective cineangiogram of the right iliac artery.

The physician identified a lesion in the right anterior tibial artery. He advanced a multipurpose guiding catheter over the wire down to the distal right superficial femoral artery (SFA). He performed cineangiograms, which confirmed the target. He advanced a balloon dilation catheter over a 0.14 guidewire through a guiding catheter down to popliteal artery.

3. Coding Advice: Follow These 6 Steps

Now, you're ready to tackle the coding. Our experts offer these six steps for breaking down the procedure.

1. Fill in the holes. You probably noticed that this operative note has some missing information. So if you were coding this, you'd need to get all the details down before you start, experts say.

In this situation, you should begin by asking the cardiologist to clear up any confusion about whether he performed both a left heart cath with left ventriculography and left and right coronary angiography, says Judy Allen, CPC, compliance privacy officer for Birmingham Radiology Group in Birmingham, Ala.

Also, find out if the carotid arteries the physician identifies are common, internal or external carotids, Allen says. Finally, clarify the location of the lesion the cardiologist angioplastied. The note suggests the lesion is in the right anterior tibial artery, but the note describes an angioplasty in the popliteal artery, she says.

Once the physician fills in the gaps, you may need to attach an amendment to the dictated report to support all the billable services, Allen adds.

2. Complete the heart caths. You can start by reporting the left heart catheterization. Use 93510-26 (Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous; professional component) for the left heart cath procedure, coding experts say.

For the dye injection in the left ventricle, report 93543 (Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography), and use 93545 (... for selective coronary angiography [injection of radiopaque material may be by hand]) for injection in the coronary arteries, Allen says.

Remember that you should not append modifiers to 93539-93545, because these injections, usually performed by hand during cardiac catheterizations, do not have both a technical and professional component, says Carrie Robison, CPC, CHCC, with New Bern Internal Medicine in New Bern, N.C. Hand injections represent a professional service only, she says.

Report 93555-26 (Imaging supervision, interpretation and report for injection procedure[s] during cardiac catheterization; ventricular and/or atrial angiography; professional component) for the left ventricular injections' supervision and interpretation (S&I).

Use 93556-26 (... pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits [whether native or used in bypass]) for the S&I of the coronary arteries, says Kim Doyle, CPC, business manager for North Phoenix Heart Center.

"Also, report 75630-26-59 (Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation, professional component, distinct procedural service) to private payers." Add to this point, "You would append modifier-59 because 75630 is bundled into the left heart cath code (93510); however, keep in mind that appending modifier -59 in this case may or may not be necessary for non-Medicare payers."

"For Medicare patients, you instead would report G0278 (Iliac artery angiography performed at the same time of cardiac catheterization, includes catheter placement, injection of dye, radiologic supervision and interpretation and production of images [list separately in addition to primary procedure]) for the procedure. Note that you would not report G0275 (Renal artery angiography...) because the documentation did not mention a non-selective renal study, the study included information on the leg arterial system, and reporting G0275 with 75724 (selective renal angiography) is a CCI edit violation."

Keep in mind that the notes should include information on the interpretation of the coronaries, says Anne C. Karl, RHIA, CCS-P, CPC, coding and compliance specialist with the St. Paul Heart Clinic in Mendota Heights, Minn. Providers should indicate that they performed interpretations before you bill the S&I codes, she adds.

3. Tackle the carotid studies. For the carotid studies, you'll need to know if the cardiologist imaged the common, external or internal carotids, Allen says. "For example, if the physician imaged the common carotids, you would report 36216-RT (Selective catheter placement ... initial second order thoracic or brachiocephalic branch, right side) for the right common carotid and 36215-LT (Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family, left side) for the left common carotid.

"You should 75680-26 (Angiography, carotid, cervical, bilateral, radiological supervision and interpre -tation; professional component) for the carotid imaging", Allen says.

4. Get the renals done. Next, code the renal studies with 36245-LT (Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family; left side). Use 36245-RT for the right renal angiogram. Add the statement, "Some carriers may require you to append modifier-50 (Bilateral procedure ) to code 36245 (one line item) instead of listing the code twice with anatomical modifiers (-LT and -RT) for bilateral renal studies." And then report 75724-59-26 (Angiography, renal, bilateral, selective [including flush aortogram], radiological supervision and interpretation. Again, you use modifier -59 to indicate that the procedure is distinct from the heart catheterization, Allen says.

5. Record the right leg study. The documentation describes interpretations for the right leg only, so you should report 75710-59-26 (Angiography, extremity, unilateral, radiological supervision and interpretation) and +75774-59-26 (Angiography, selective, each additional vessel studied ... radiological supervision and interpretation [list separately in addition to code for primary procedure]), Karl says.

6. Clear up the lesion confusion. To code the right leg intervention (PTA), you will need to clarify the lesion location, experts say. The physician's angiogram interpre -tation indicates that he looked at the anterior tibial artery, but the note only describes the angioplasty balloon going as far down as the popliteal artery, Karl says.

So, if the physician performed the PTA in the anterior tibial artery, you should report 35470 (Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel) and 75962-26 (Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation), Doyle says. If the physician confirms that he did the PTA in the popliteal artery, you would report 35474 (Transluminal balloon angioplasty, percutaneous; femoral-popliteal) and 75962-26 for the popliteal radiological S&I, she adds.

 You should also report 36247 for catheter placement in the distal leg vessels.