Cardiology Coding Alert

Experts explain how to recoup your practice's ultrasound pay

When cardiologists perform intravascular ultrasounds (IVUS) to diagnose lesions or to help guide therapeutic interventions in the coronary or peripheral vessels, make sure you've got a grip on the primary diagnostic or interventional procedure--this must be crystal-clear to report the IVUS study.
 
First, Investigate These IVUS Basics

What it is: Cardiologists use IVUS in coronary and peripheral arteries to diagnose problems such as the amount of plaque burden and the amount of calcium in the vessel wall. IVUS can be a quantitative aid to determine the degree of coronary stenosis.

Physicians may use intravascular ultrasound during cardiac catheterization, interventions (such as percutaneous transluminal coronary angioplasty [PTCA], atherectomy or stent placement), or to assess treatment results. During an IVUS, the physician places a special ultrasound catheter in the vessel to visualize its structure. Although an IVUS has obvious diagnostic applications, some carriers may be reluctant to pay for this study, restricting coronary ultrasounds for therapeutic procedures only or rejecting peripheral ultrasounds altogether.

Problem: Some insurance carriers will try to deny IVUS codes, especially when the cardiologist performs a diagnostic procedure only, says Sandy Fuller, compliance officer at Cardiovascular Associates of East Texas. "You'll see this discussed a lot in the cardiology discussion group," Fuller says. (To join the free e-mail discussion group, go to www.coding911.com.)

Good news: If you demonstrate appropriate medical necessity for the visualization service with a primary procedure, however, you may have an easier time convincing payers to reimburse. 

Example: A physician may note that an angiography study does not clearly reveal whether plaque is significantly narrowing a vessel and may document that the IVUS yields a more accurate assessment of the degree of narrowing, says Jerome Williams Jr., MD, FACC, a cardiologist with Mid Carolina Cardiology in Charlotte, N.C.

In addition, IVUS can give more information about plaque pathology, such as the presence of significant calcium, a thrombus or dissection within the artery, Williams says.

Your physician can use these details to guide the appropriate interventional therapy, so you should look for this information in the procedure note.

Follow these three expert tips for improving your IVUS reporting:

1. Pair IVUS With Primary Procedures

First, both the coronary and peripheral IVUS codes are add-on codes, so don't try reporting them without the accompanying primary service, or you'll face denials, says Jennifer Bankhead, RHIT, CPC-H, CIC, specialized coding analyst for St. Joseph's Mercy Hospital in Hot Springs, Ark.

In other words: "Because you'll be using add-on codes, you have to match them up to the correct primary codes," says Yvette Hofmeister, CPC, coding analyst for OSU Internal Medicine in Columbus, Ohio.

When cardiologists perform IVUS with coronary interventions, including stenting and PTCAs, report +92978 (Intravascular ultrasound [coronary vessel or graft] during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel [list separately in addition to code for primary procedure]) for the initial vessel ultrasound and 92979 for each additional vessel.

Similarly, add peripheral vessel IVUS codes +37250 (IVUS [non-coronary vessel]; initial vessel [list separately in addition to code for primary procedure]) and +37251 (... each additional vessel), as appropriate, to peripheral interventions. If you're not sure which peripheral vessel the cardiologist performed the IVUS in, ask the physician because this must be in the notes for insurers to pay, Bankhead says.

Example: A cardiologist places a stent in the left anterior descending artery, performs a PTCA in the left circumflex artery, and performs IVUS in both the left anterior descending and left circumflex coronary arteries. You would report 92980-LD (Transcatheter placement of an intracoronary stent[s] ...; left anterior descending coronary artery) for the stent, +92984-LC (Percutaneous transluminal coronary balloon angioplasty; each additional vessel [list separately in addition to code for primary procedure]; left circumflex, coronary artery) for the PTCA, 92978-LD for the IVUS in the left anterior descending, and 92979-LC for the IVUS in the left circumflex artery. 

Keep in mind: Watch your anatomical modifiers. "We always append HCPCS Level II coronary modifiers LD, LC or RC for coronary IVUS, as well as LT (Left side), RT (Right side) or 59 (Distinct procedural service) for peripheral IVUS to describe where the physician performed the procedure," says Heather R. Stecker, CPC, director of compliance and charge entry at Cardiology Consultants of Philadelphia PC.

You can use the base IVUS code (92978) only once per operative session. Similarly, you can use the "each additional vessel" code (92979) only once for each of the other recognized coronary arteries, the American College of Cardiology (ACC) says.

Example: If the cardiologist places three stents in one coronary artery and uses IVUS to assess each stent placement, you can report 92978 only once, even though he inserted the ultrasound catheter three times.

2. Report Peripheral Interpretation Separately

Unlike the coronary codes, peripheral IVUS codes 37250 and 37251 do not include imaging supervision, interpretation (S&I) and report. 

So if the cardiologist interprets peripheral IVUS images, bill 75945 (Intravascular ultrasound [non-coronary vessel], radiological supervision and interpretation; initial vessel) for the initial vessel interpretation with 37250, and add +75946 (... each additional non-coronary vessel [list separately in addition to code for primary procedure]) to 37251 for additional vessel interpretation.

3. Convince Payers That IVUS Is Necessary

Carriers will likely pay for ultrasounds performed with a coronary intervention, but they may be reluctant to reimburse for ultrasounds in non-coronary vessels. So what's a coder to do?

As long as you submit the documentation and include the anatomic modifiers on the claim for IVUS with coronary artery interventions, you will get reimbursed by Medicare and others, experts agree.

Good idea: "I would copy the CPT book description that states, 'during diagnostic evaluation and/or therapeutic intervention.' This seems pretty clear-cut," Fuller says.