Cardiology Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: A cardiologist in our practice reported that he performed a balloon pericardiotomy. He stated that he used a valvuloplasty balloon to dilate the pericardium in a patient with recurrent pericardial effusion. Should I use the unlisted-procedure code or is there a better way to code this procedure? California Subscriber Answer: According to CPT 2002, you should select the code that accurately identifies the service or procedure performed. "Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code," CPT states. Consequently, you should report this procedure using 33999 (Unlisted procedure, cardiac surgery). You should attach the operative report and a letter detailing in lay terms what the procedure entailed to the claim to illustrate clearly what the procedure involved. The letter should include an adequate description of the nature, extent and need for the procedure, as well as the time, effort and equipment necessary to provide the service, according to CPT. Additionally, you may include the complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care.