Cardiology Coding Alert

Cardiologists should consider using modifier -59 (distinct procedural service) to avoid denials when they report cardiac catheterizations during the same session as a non-coronary procedure, such as a renal angiogram. Some carriers inappropriately will bundle renal angiogram procedure codes into the heart cath procedures, or vice versa, even though procedures at these two different sites arent bundled.

Using modifier -59 indicates the procedures were separate and helps avoid inappropriate bundling. The modifier should be attached to the procedure with the fewest relative value units.

In addition, when cardiac and non-coronary procedures are combined, a second diagnosis is required to show medical necessity for both procedures.

For example, a the patient has coronary artery disease (CAD). That diagnosis provides medical necessity for the heart cath but doesnt cover looking at the patients renals or carotids or legs, says Sandy Fuller, a coder with Cardiology Consultants, a nine-cardiologist practice in Abilene, TX. The patient may have a problem in these non-cardiac sites, but the cardiologist has no reason to go there and look for anything based merely on CAD. So providing a second diagnosis is crucial to getting paid for the non-coronary procedure.

For problems with the carotid artery, acceptable diagnosis codes include 433.10 (occlusion and stenosis of precerebral arteries [carotid artery]), 433.9 (unspecified precerebral artery); 436 (acute, but ill-defined cerebro-vascular disease, including stroke), or 435.9 (unspecified transient cerebral ischemia). For peripheral problems, cardiologists can use ICD-9 code 443.9 (peripheral vascular disease, unspecified), while renal procedures could take the following two hypertension codes: 401.1 (essential hypertension, benign); or 401.9 (unspecified), as well as 440.1 (atherosclerosis, of renal artery).

If a renal angiogram is performed, the procedure should be coded 36245-59 (selective catheter placement, arterial system; each first order abdominal, pelvic or lower extremity artery branch, within a vascular family). Fuller further recommends putting the term renal in the comments section because 36245 also is used for peripheral angiograms. If an iliac (peripheral) procedure is performed, iliac should be entered in the comments section.

For the carotids, Fuller uses 36216-59 (selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family) and enters carotid in the comments section.

Angioplasties are performed in the renal and peripheral arteries. Because angioplasty codes are area specific, there is no need to put a comment. For example, an iliac angioplasty would be coded 35473 (transluminal balloon angioplasty, percutaneous; iliac), while renal would take a 35471 (transluminal balloon angioplasty, renal or visceral artery). Both 35471 and 35473 may be billed bilaterally using a -50 modifier (bilateral procedure), and because the codes are so specific, neither requires a -59 modifier when billed with a heart cath.

Heart Cath S&I Codes Need -59

Non-coronary angioplasties [...]