LHC with PCI

[pravintc]

The physician performed LHC with PCI, for which we code 93458-XU and 92941 or 92928. The payment for LHC (93458) gets denied. I don't understand sometimes it is accepted and sometimes denied.

The physician wants that to be accepted every time. i understand that there is a medical necessity.

can anyone provide medical necessity of LHC while doing PCI/PTCA.

 

[jvilla]

you may NOT always bill 93454-93461 with PCI

Per CPT:

"Diagnostic angiography performed at the time of a coronary interventional procedure may be separately reported if:

1. No prior catheter-based coronary angiography study is available, and a full diagnostic study is performed, and a decision to intervene is based on the diagnostic angiography, or
2. A prior study is available, but as documented in the medical record:
a.) the patient's condition with respect to the clinical indication has changed since the prior study, or
b.) there is inadequate visualization of the anatomy and/or pathology, or
c.) there is a clinical change during the procedure that requires new evaluation outside the target area of intervention

Diagnostic coronary angiography performed at a separate session from an interventional procedure is separately reportable"

^^^ of course, the above needs to be concisely documented in the patient's medical record.

Just because your physician(s) want the claims to be paid does not entitle s/he to reimbursement.

In addition, different payers may have different rules.

I encourage you to utilize your MAC LCD tool (My cardiologists reside in Noridian JE) for guidance.

FYI - Modifier 59, or X[EPSU], is the most widely abused and improperly reported modifier per OIG. I would heed applying this just to "have the claim approved," of course doing so would constitute the "f" word (5 letters not 4).

I help code all Cardiology for Kaiser Permanente in Northern CA, the majority of the time that LHC/RHC/CABG/COR cath placements are being captured with PCIs is when our patients have been admitted through the ED for acute coronary ischemia (of course that doesn't always warrant a 92941 as well..)

**Be wary of generalizations/ blanket statement/ rules**
**Documentation in the record is everything**

I hope this helps.

 

[pravintc]

thanks Jvilla
That was indeed helpful information

 

[gufran.ali]

what is complete diagnostic exam here?

As mentioned in above thread about CPT guidelines------


Per CPT:

"Diagnostic angiography performed at the time of a coronary interventional procedure may be separately reported if:

1. No prior catheter-based coronary angiography study is available, and a full diagnostic study is performed, and a decision to intervene is based on the diagnostic angiography, or
2. A prior study is available, but as documented in the medical record:
a.) the patient's condition with respect to the clinical indication has changed since the prior study, or
b.) there is inadequate visualization of the anatomy and/or pathology, or
c.) there is a clinical change during the procedure that requires new evaluation outside the target area of intervention


In first point, as stated "No prior catheter-based coronary angiography study is available, and a full diagnostic study is performed, and a decision to intervene is based on the diagnostic angiography" what is full diagnostic study here? Is examining only coronary arteries and left ventriculogram is not sufficient to justify the full diagnostic study?