Radiology Coding Alert

Correct documentation solves your high/low aortography challenges.

When reporting radiological supervision for cardiac catheterization and angiography, you should be very specific for each step that your physician performs during the procedure. Look for clues in documentation to support that your physician performed a left heart catheterization (LHC), i.e. LVEDP (left ventricular end diastolic pressures), left ventricle (LV) pressures, or an LV-gram. 

1. Make Note of All Steps in Angiography

To do a left heart ventriculography, your physician will need to do a LHC. You should specifically look in the procedure note for details of your physician’s access to the LV. You confirm that your physician accessed the LV when your physician places a catheter (not wire) across the aorta into the LV. If your physician doesn’t document a catheter crossing the aorta, then you look for LV pressures. A catheter must cross the aorta to identify LV pressures, so this implies that your physician gained access to the LV. 

For LHC, you report code 93452 (Left heart catheterization including intraprocedural injection[s] for left ventriculography, imaging supervision and interpretation, when performed). When your physician does catheterization in both the right and left sides of the heart, you report code 93453 (Combined right and left heart catheterization including intraprocedural injection[s] for left ventriculography, imaging supervision and interpretation, when performed).

Remember: Code 93452 and 93453 are inclusive of the following services that your physician may offer during the left heart ventriculography:

• Any injections that your physician may provide during the procedure, 
• Supervision of the imaging, if any, and 
• Interpretation of the radiological reports.

Your physician may be performing a coronary angiography in addition to a LHC. In this case, you look at codes 93458 (Catheter placement in coronary artery[s] for coronary angiography, including intraprocedural injection[s] for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection[s] for left ventriculography, when performed) and 93460 (Catheter placement in coronary artery[s] for coronary angiography, including intraprocedural injection[s] for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection[s] for left ventriculography, when performed) depending upon the left or both left and right heart catheterization. 

Similarly, when your physician performs an additional bypass graft angiography, you select from the following two codes: 

• 93459, Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography 
• 93461, Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography.

2. Angiography Injection Occurs Above Aortic Bifurcation

When the radiologist performs an angiographic injection in the aorta following cardiac catheterization, choosing the proper code can be confusing. You will have to look for a code which you can report for imaging with catheter placement just superior to the aortic bifurcation with bilateral lower extremity runoff.

Given the placement of the catheter just above where the aorta splits into the iliacs, the most likely code for the scenario above is 75716 (Angiography, extremity, bilateral, radiological supervision and interpretation). But don’t forget that you also need additional details to ensure you can code the service.

To support reporting the additional angiography, the documentation should describe why the radiologist determined it was medically necessary as well as what he found.

You can typically report 75716 when your physician is treating a patient who has a history of PVD and the patient’s complaints include continuous cramping pains while walking, usually in calf muscles but sometimes in thighs or buttocks. In this case, a bilateral angiogram is indicated and provided.

Please note: Pre-procedural indications must be documented stating history of PVD, and medical necessity must be available within the patient stay to provide this additional service. Check your payers’ LCDs for supporting diagnoses.

Keep in mind: In some cases, the radiologist will place the catheter at the level of the renals and provide one fluid injection. This is so he can view the abdominal aorta through the femoral arteries bilaterally (at least to the common femoral). You’ll report 75630 (Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation) for this service. 

Or if the radiologist had performed an abdominal aortogram from high in the aorta and then repositioned the catheter to perform the lower-extremity angiography you would report the abdominal aortography using 75625 (Aortography, abdominal, by serialography, radiological supervision and interpretation) in addition to the lower-extremity angiography code. Use 75716 for a bilateral extremity service or 75710 (Angiography, extremity, unilateral, radiological supervision and interpretation) for unilateral. Because the radiologist places the catheter high in the aorta and then at a lower position, you may see this service referred to as a high/low.

3. No Documented Reason for Angiography near Access Site 

As described above, following cardiac catheterization, the radiologist may perform extremity angiography, and having documentation of the reason for it is crucial to proper coding. One additional reason you need documentation is that sometimes the radiologist performs imaging simply to assess the vessel near the access site.

You may often face a challenging situation when you have to report femoral or iliac angiography at the end of a cardiac catheterization.

Note: CPT® guidelines state, “Contrast injection to image the access site(s) for the specific purpose of placing a closure device is inherent to the catheterization procedure and not separately reportable.”

If you don’t see mention of a closure device, it’s still possible this was the purpose of the imaging. In some cases the physician may image the vessel and then decide to use a hemostasis patch instead. 

Bottom line: Without knowing the medical necessity and findings for the imaging, it’s tough to say what you can code. Work with providers to ensure documentation includes the information you need to support proper coding. If your physician performed the imaging to assess the access site, he should state that. Even more important, if your physician performed the imaging for diagnostic reasons, he should spell out the medical necessity for the angiography and detail his findings in the report.