Cardiology Coding Alert

Tricks of the Cardiology Cath Trade:

How to Optimize Reimbursement and Decrease Denials

Editors note: Five years ago, the CPT editorial panel adopted an entirely new coding system for cardiac catheterizations and angiograms that unbundled previous codes. Today, in order to report the complete procedure, coders must correctly select component codes from three different ranges.

Despite the CPTs unbundling of caths/angiograms, coding for these procedures continues to be confusing, for beginning and experienced coders alike.

A common misconception is that because the codes have been unbundled, every injection and every S&I [imaging, supervision and interpretation] can be billed for. Thats just not true, warns Sueanne Bicknell, RRA, CCS-P, reimbursement and compliance specialist at Cardiovascular Provider Resources-Heart Place in Dallas, TX.

But undercoding is also a problem, she points out. Another mistake is to fail to bill for one or both of the S&I codes, she adds. If the cardiologist is doing injections, 90 percent of the time he or she is also doing supervision and interpretation of these injections, so you should bill for them or you are throwing revenue out the window.

Bicknell uses this step-by-step approach to teach the cardiac catheterization/angiography series to her coding staff:

1. The cardiologist places the cath (93501-93533). In a typical cath procedure, local anesthesia and appropriate sedation is used to insert the cath through a vein or an artery, depending upon whether its a right or left heart catheterization. The catheter may be inserted by cut-downan incision of skin and the artery or veinor percutaneous technique through the femoral, brachial or axillary artery. The type of percutaneous technique does not affect coding, Bicknell explains.

Although the patients recovery time may be reduced when a left heart cath is performed through the brachial artery instead of the femoral one, payers dont care. The code should still be 93510, because the CPT description says the procedure may be performed from the brachial, axillary or femoral artery, she says.

Next, the cardiologist, with fluoroscopic guidance, advances the catheter through the circulatory system into the heart. However, you cant bill for fluoroscopic guidance (76000) with a cath/angiogram because it is considered an inherent portion of the procedure.

Likewise, you also would not bill for the following:
introduction, positioning, and, when necessary, repositioning of the catheter(s);
obtaining blood samples to measure blood gases and/or dye or other dilution curves;
measuring cardiac output;
recording of intracardiac and intravascular pressure; and
final evaluation and report of procedures.

However, you can bill for an EKG (93000-93010) prior to the cath/angiogram if the result from the test is the reason the cardiologist made the decision for doing the cath. Some carriers may require modifier -59 (separate significant services) to be added to the EKG code.

To bill a placement code (93501-93533), first study the documentation to find out what was actually done. (Beware: The name of the procedure on the cath lab report may be incorrect, potentially causing you to code incorrectly. See the case study on page 36 for an example.)

Then, make brief notes such as the type of vessel and where the catheter was inserted. Ask yourself: Was this a right heart, left heart or both? Was the approach retrograde, transseptal or ventricular puncture?

Finally, compare what your notes say with those in your coding manuals in order to select the correct placement code. (See page 35 for placement codes.)

Note: Coding for a right heart requires the same selection from the three component ranges as does a left heart. For example, you would bill the placement code (93501) plus appropriate injection codes. However, you cannot bill a separate right heart in conjunction with a left heart (93510-93511, 93514, 93524) if the cardiologist performed a left heart and then went through the other femoral artery to perform a right heart cath. Instead, use the codes reserved for right and left heart cath (93526-93529).

2. The cardiologist injects contrast material (93539-93545). The angiographyan x-ray image that shows any obstructions or abnormalitiesis the second component that should be reported. The cardiologist may inject the dye more than once in one or more of these sites as represented by the following codes:
93539: injection of dye into arterial bypass
93540: injection of dye into saphenous vein grafts
93541: pulmonary angiography
93542: right ventricular or right arterial
93543: left ventricular or left arterial angiography
93544: aortography
93545: selective coronary angiography

The first key to correct billing of injection codes is to check documentation to find out exactly where the injection was performed. This step is necessary, because these codes are only appropriate when the contrast is used in the
specified vessels or chambers. Therefore, urge physicians to dictate specific locations and check documentation carefully to make sure the site matches that of the codes description.

The second key to billing injection codes is not to undercode or overcode. If the injection is performed on more than one site, you can use two different codes. For example, suppose the cardiologist injected the arterial conduits and the left ventricle, then you may bill both 93539 and 93543. But if two injections were performed in the left ventricle, you can only bill once for 93543.

A good rule of thumb is: Each code in the injection series may be reported only once during each cardiac cath procedure.

Note: Do not use 37202 (transcatheter therapy with diagnostic) with any of the cath codes. The American College of Cardiology (ACC) considers infusion of substances, such as nitroglycerin, an intrinsic part of the cath procedure. You can only get paid for transcatheter procedures when thats all that is being done.

3. The cardiologist supervises, interprets and reports the angiogram (93555-93556). The trick to billing these S&I codes is to understand the difference between them as well as how and when they can be used. Each code refers to the S&I of a different anatomical structure: Code 93555 applies to atrial and ventricular spaces; code 93556 to those of the pulmonary vessel, aorta and heart vessels, including venous bypass grafts and arterial conduits.

You may be able to bill for both, depending on what was performed and documented. For example, if the procedure was a left heart cath (93510) with an injection of the left atrial (93543), you would bill only for 93555. But if the procedure was a left heart cath with an injection of the left atrial and injection for selective coronary angiogram, you can code both 93555 and 93556.

Make sure the correct S&I code is matched with the correct injection code, reminds Bicknell.

She also advises readers that regardless of the number of injections performed during the procedure, you may list the supervision and interpretation of them (93555 and/or 93556) only once. The same guidelines that applied to injections apply to S&I services, Bicknell explains. The physician may decide to perform several injections in one site, but he or she cannot bill an injection code for more than one injection code in the same site. Likewise, an S&I code cannot be billed for every injection codeit can only be billed once, she says.

Putting All the Components Together

After youve determined the correct placement, injection and S&I codes, youre ready to bill. When training, Bicknell gives the following example of a cardiologist who performs a left heart cath with a coronary angiography and left ventricle angiogram.
She advises coding the procedure as follows:

CPT / Diagnosis

93510-26 / 414.01
(left heart cath) (coronary artery disease)
93543 / 414.01
(ventricular injection)
93545 / 414.01
(coronary injection)
93555-26 / 414.01
(imaging supervision of
ventricular injection
93556-26 / 414.01
(imaging supervision of
coronary injection

Editors note: For a sample of possible coding combinations of placement, injection and S&I codes for caths and angiograms, see page 39 of the American College of Cardiology Guide to CPT 1999.