Cardiology Coding Alert

The key to successfully coding and gaining reimbursement for diagnostic right and left heart catheterizations is mastering the four separately billable components of these procedures, which are the decision to perform the catheterization, catheter placement in the right and/or left sides of the heart, dye injection, and radiologic supervision and interpretation (S&I).

Coders should be aware that many components of cardiac catheterization procedures are not separately billable, including the following:

History and physical (H&P) on the day of a scheduled catheterization

Local anesthesia and sedation

Repositioning of the catheter

Recording of pressures

Obtaining blood samples

Dilution curves

Cardiac output measurements

Fluoroscopy for catheter placement

Final report

Although these components are included in the catheterization procedure, the documentation should include this information to provide a complete record of all the services the physician provided during the procedure.

 

Coding experts give the following tips for stepping up your cardiac cath coding expertise:

1. Bill for Decision to Perform the Catheterization

Accurately billing for a decision to perform a heart catheterization depends on whether the cardiologist makes the decision on the same day that he or she does the procedure.

If the physician makes the decision and performs the procedure on the same day, report the appropriate E/M service code according to where the service is provided. Typically, when the physician makes the decision for the catheterization and performs the procedure on the same day, the patient's condition is urgent, and the patient is in the emergency department (ED) or in the hospital, says Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.

If the cardiologist admits the patient to inpatient status from the ED, the appropriate code could be a hospital admission (99221-99223), Pride says. If the patient is already an inpatient under the cardiologist's care, you would report a subsequent visit code (99231-99233).

Patients could also be admitted to observation status (99218-99220) rather than inpatient status. Observation status indicates that a supervising physician, who decides whether admission is appropriate, is monitoring a patient's condition, whereas inpatient status indicates that the patient has been admitted to the hospital. The distinction between observation and inpatient is critical in light of the HHS Office of Inspector General and Medicare's new focus on appropriate place-of-service coding, coding consultants say.

Reserve Modifier -25 for Urgent Catheterizations

Append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E/M code to indicate to the insurer that the E/M service was necessary to make the decision to perform the catheterization.

In nonemergency situations, such as the day of a previously scheduled catheterization, you should not report an E/M service. Hospitals typically require that the admitting physician dictate a history and physical (H&P) for all admissions, but this is not a separately billable service.

Some Medicare carriers require you to append specific modifiers to the E/M code if the physician performs the E/M on the same day as the catheterization, says Carrie Robison, CPC, CHCC, with New Bern Internal Medicine in New Bern, N.C. So, check with your carriers to verify appropriate modifiers for heart catheterization decisions.

2. Aortic Valve Makes All the Difference in Left Heart Catheterizations

The more familiar you are with the coding distinctions between left and right heart catheter placement, the more likely you'll receive appropriate reimbursement for the procedures and avert denials.

Technically, once the physician places the catheter across the aortic valve, the catheterization becomes a left heart catheterization procedure. To confirm a left heart catheterization, coders should know whether the cardiologist performed only a left and not a combined right and retrograde left heart catheterization, Robison says.

To do this, look for specifics on the aortic valve crossing in the operative note to support billing 93510 (Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous) when the physician performs the left heart catheter placement.

Remember to append modifier -26 (Professional component) to catheter placement codes if the physician performs the procedure in the hospital. If you're ever unsure about which codes have professional and technical components, refer to the Medicare Physician Fee Schedule. Codes that have professional components (modifier -26) and technical components (modifier -TC) will have separate fees listed for the code with "-26" and "-TC" modifiers in addition to the code with no modifier. The code with no modifier is the "global service" code.

Left Ventricle Pressure Required for 93510

Also scan the note for hemodynamic measurements taken in the left ventricle (LV) to verify that the procedure  is in fact a left heart catheterization, says Happiness Miller, RN, an auditor with the cardiac catheterization lab in Central Baptist Hospital in Lexington, Ky.

"If the note does not include ventricular pressure measurements or a true attempt to measure pressure, then we cannot validate that the procedure was a left heart catheterization," Miller emphasizes. Code 93510 includes measurements of hemodynamic pressures, which should be documented in the cath note, Robison adds. For instance, the note may indicate that a patient's left-ventricular pressure was 167/22 (which refers to the systolic and diastolic pressure inside the ventricle). If these tell-tail signs are present, it is safe to report 93510.

Without documentation of left-ventricular hemodynamic pressure and no indication that the catheter crossed the aortic valve, the procedure is likely catheter placement in a coronary artery and/or a bypass graft for angiography. In this case, report 93508 (Catheter placement in coronary artery[s], arterial coronary conduit[s], and/or venous coronary bypass graft[s] for coronary angiography without concomitant left heart catheterization) for coronary catheterizations.

Ideally, for coronary imaging procedures, the physician's documentation should specifically state that he or she did not perform a left heart catheterization, Robison says. This might be reflected in the documented operative report, in the title of the report, or on charge sheets.

Watch for Right Heart Monitoring

When the physician performs a right heart catheterization, report 93501 (Right heart catheterization). To confirm a right heart catheterization, look for indications in the note that the physician directed the catheter into the right atrium, right ventricle, and the pulmonary artery and obtained information and/or images from these sites, coding consultants advise. Check the note to make sure that the physician mentions taking hemodynamic measurements in the right heart or blood samples from right heart areas, Miller says.

In operative reports, physicians frequently mention that they are using a Swan-Ganz catheter to perform the right heart catheterization. This should not be mistaken for a true "Swan-Ganz" cath placement. The placement of a Swan-Ganz catheter (or flow-directed catheter) is typically performed at bedside and is intended to permit continuous hemodynamic monitoring.

Physicians frequently use Swan-Ganz catheters for monitoring while the patient is in an intensive or critical care setting, Pride says. For this procedure, apply 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes), she says.

Find the Right Opening for Right-Left Combos

When the physician catheterizes both the right and left sides of the heart, you should not report each procedure separately (93501, 93510) to avoid duplicating services that both codes include, such as patient preparation and sedation. This would be unbundling, Pride says. Rather, use 93526 (Combined right heart catheterization and retrograde left heart catheterization) for combined right and retrograde left heart catheterizations.

If a patient has a right heart cath in one setting and a left heart cath in another (a rare scenario), you would report 93501 and 93510 separately, Pride says.

There are several combined right and left heart catheterization codes. The key to selecting the correct one is identifying in the note the opening the physician used to access a particular site, Miller and Robison emphasize.

For instance, when the physician performs a combined right and left heart cath and notes that the approach is through an intact septum, use 93527. If the physician performs the combined catheterization through a left ventricular puncture, report 93528. Apply 93529 when the physician uses an existing septal opening for the combined catheterization procedure. When the patient has congenital anomalies and the physician catheterizes both sides of the heart, select a code in the 93531-93533 series.

3. Check the Site for Dye Injection

Once the catheters are in place, the physician injects contrast material to assess a variety of factors, including valve function, the internal structure of the heart chambers, and possible narrowing (stenosis) of the vessels.

You should assign injection codes according to the injection site. Also, remember that you can report each injection code only once, even if the physician injects the site multiple times, Pride and Robison say.

If the physician catheterizes and injects dye into a coronary artery such as the left anterior descending without crossing the aortic valve, for instance, you should report 93508 for the coronary catheterization and 93545 (Injection procedure during cardiac catheterization; for selective coronary angiography [injection of radiopaque material may be by hand]) for the dye injection in the coronary artery.

For injection in the right heart chamber, report 93542 ( for selective right ventricular or right atrial angiography) and 93501 for the right heart catheterization.

When the cardiologist injects dye during a left heart catheterization, use 93543 (... for selective left ventricular or left atrial angiography) for the injection and 93510 for the left heart catheterization.

For coronary bypass angiography, report 93539 if the physician injects such vessels as the internal mammary artery (IMA) and 93540 (Injection procedure during cardiac catheterization ...) for injections in a saphenous (or other) vein graft (SVG). The physician's documentation must state that the selective IMAor SVG occurred and should indicate the results of the angiography to bill these codes, Miller says.

4. Count Supervision and Interpretation

Cardiologists typically supervise and interpret the angiograms resulting from the dye injections they make. Sometimes, a radiologist will interpret the angiograms, but this is rare. When the cardiologist does not interpret these, you cannot bill the S&I codes.

Use 93555 (Imaging supervision, interpretation and report for injection procedure[s] during cardiac catheterization; ventricular and/or atrial angiography) when the physician interprets injections in any of the heart chambers, coding consultants say. Specifically, you should apply 93555 with 93542 (... for selective right ventricular or right atrial angiography) and/or 93543 (... for selective left ventricular or left atrial angiography).

Report 93556 (... pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits [whether native or used in bypass]) with all other injection codes as long as the cardiologist documents performing the S&I.

You can report 93555 and 93556 separately, but you can report each code only once per session, Miller states. If a cardiologist images both a patient's SVGs and coronaries, for instance, you should report 93556 only once, she says.

Don't forget to add modifier -26 to these S&I codes if the cardiologist performs the procedure in a hospital or someone else's facility (such as a free-standing cath lab), Pride adds.