Header Tag Line

Cardiology Compliance Question of the Week

Cardiology Compliance Question of the Week
Archive

To return to the current Cardiology Compliance Question of the Week, click here

August 30, 2010

Question:

Is modifier Q0 required on a claim with diagnosis code V12.53 (personal history of sudden cardiac arrest)?

Answer:

No, this modifier is not required for payment, and there are also several others that do not require modifier Q0. As listed in Transmittal R663OTN (March 15, 2010), neither do the following:

427.1 - Ventricular tachycardia
427.41 - Ventricular fibrillation
427.42 - Ventricular flutter
427.5 - Cardiac arrest
427.9 - Cardiac dysrhythmia, unspecified
996.04 - Mechanical complication of cardiac device, implant, and graft, due to automatic implantable cardiac defibrillator
V53.32 - Fitting and adjustment of other device, automatic implantable cardiac defibrillator

-------------------------------------------------------------------------------

August 23, 2010

Question:

Recently one of our physicians performed a bilateral lower extremity study and a selective left subclavian artery angiography. Since we are reporting the 75716 for the bilateral lower extremity exam, what can we report for the left subclavian angio?

Answer:

Modifier 75710-59 would be assigned for the imaging portion and code 36215 for the catheter placement.

-------------------------------------------------------------------------------

August 16, 2010

Question:

Can we charge for 92960 in the following cath lab situation? The patient is having diagnostic angiography when she goes into an arrhythmia for which she receives external cardioversion.  This is obviously not an "elective" cardioversion. Can I still charge 92960?  Or is this type of cardioversion considered inherent to one of the diagnostic angiography codes and there is no other CPT code that can be charged for it? 

Answer:

A review of the national correct coding initiative (NCCI) edits shows the following. Code 92960 is listed as a component of the heart catheterization codes 93508, 93510, 93526 and so on. Therefore, based on CMS instructions regarding the use of modifier 59, if the cardioversion is performed during the catheterization procedure, it should not be billed separately. However, if the patient presents to the lab and requires cardioversion before the initiation of the cardiac catheterization cardioversion, it can be billed with modifier 59 because it was performed in a separate operative session.

-------------------------------------------------------------------------------

August 9, 2010

Question:

If a patient has a left heart catheterization (CPT 93510) and a short time later comes in for a stent placement, I understand that a limited heart cath cannot be charged. However, if the patient who had the left heart catheterization (CPT 93510) had a stent placement two weeks later  and then, perhaps, a month later had another stent placement, is it appropriate to charge a limited heart cath CPT 93508?  If it is correct, would we need to use a modifer 59 with the limited heart cath?

Answer:

The issue with charging additional heart catheterizations relates to medical necessity. If the physician stages the patient for specific reasons and the patient presents for the intervention (stent) but there are no new signs and symptoms, it would not be appropriate to code for additional heart cath procedures (93510 or 93508). However, if the patient is returning because of new signs and symptoms, a new diagnostic heat catheterization should be coded.

-------------------------------------------------------------------------------

August 2, 2010

Question:

Last week you provided possible CPT codes for reporting an aneurysm repair of a coronary artery or a SVG. Can you provide choices for diagnosis codes?

Answer:

First, be sure to check your payer’s local coverage determination (LCD) to see what codes are considered medically necessary. In general, the following ICD-9 diagnosis code options support these types of aneurysms: 414.1 Aneurysm and dissection of heart 414.10 Aneurysm of heart (wall) 414.11 Aneurysm of coronary vessels 414.12 Dissection of coronary artery 414.19 Other aneurysm of heart 421.9 Acute endocarditis, unspecified 424.90 Endocarditis, valve unspecified, unspecified cause 996.0 Mechanical complication of cardiac device, implant, and graft 996.00 Unspecified device, implant, and graft 996.01 Due to cardiac pacemaker (electrode) 996.02 Due to heart valve prosthesis 996.03 Due to coronary bypass graft 996.04 Due to automatic implantable cardiac defibrillator 996.09 Other

-------------------------------------------------------------------------------

July 26, 2010

Question:

What code would be used to report aneurysm repair of coronary artery or a SVG?

Answer:

The CPT manual does not have a specific code for aneurysm repair of coronary artery or a SVG. Therefore, the unlisted code of 37799 would be used. The CPT code choices below relate to heart catheterizations as well as to when a stent placement was part of the treatment for the aneurysm.   

Diagnostic heart catheterization, injection, and imaging CPT code choices:

Aneurysm treatment code choices: 

-------------------------------------------------------------------------------

July 19, 2010

Question:

Last week you had a question about assigning either code 93279 or 93280 for a patient who had a dual-chamber pacemaker implanted. Only one lead was turned on, and the patient was having her pacemaker programmed. In our office, we do not agree with your answer to assign 93280 and believe it should be coded 93279. Can you please verify your answer and respond?

Answer:

The answer is incorrect, and we apologize for any confusion. We have corrected the answer to read as follows:
The American College of Cardiology’s publication Cardiovascular Coding 2009: Practical Reporting of Cardiovascular Services and Procedures (page 3.35) says the following: "...the number of leads will be based on the number of active leads and the number of chambers paced."  Therefore, if it's a dual system but only one lead is active and only one chamber is being paced, you would assign code 93279 for a single chamber.

-------------------------------------------------------------------------------


July 12, 2010

Question:

A patient has a dual-chamber pacemaker implanted. Only one lead is turned on, and the patient is having her pacemaker programmed. Would you use CPT code 93279 or 93280?

Answer:

The American College of Cardiology's publication Cardiovascular Coding 2009: Practical Reporting of Cardiovascular Services and Procedures (page 3.35( says the following: "...the number of leads will be based on the number of active leads and the number of chambers paced." Therefore, if it's a dual system but only one lead is active and only one chamber is being paced, you would assign code 93279 for a single chamber.

-------------------------------------------------------------------------------

July 5, 2010

Question:

My question is regarding the coding of peripheral angioplasty and atherectomy.

The NCCI Policy Manual for Medicare Services (Chapter 5, Section D, Item 17) says the following: "When percutaneous angioplasty of a vascular lesion is followed at the same session by a percutaneous or open atherectomy, generally due to insufficient improvement in vascular flow with angioplasty alone, only the more comprehensive atherectomy that was performed (generally the open procedure) [should be reported (see sequential procedure policy, Chapter I, Section M)."

As required by CCI, we only have been coding the comprehensive atherectomy. However, some of us recently listened to a webinar where the speaker said that the parameters listed in CCI only apply when angioplasty is performed first followed by atherectomy. In fact, she stated that the reverse is true. That is, if atherectomy is performed first then followed by angioplasty, the angioplasty can be coded also.

It that correct? Should we be coding for both when the angioplasty follows the atherectomy? 

Answer:

Our understanding of the sequential procedure policy is that if an atherectomy is followed by adjunctive angioplasty to complete the atherectomy, only the atherectomy is coded.  However,if the atherectomy was unsuccessful and the physician indicates that the angioplasty was successful only the angioplasty should be coded.  We recommend consultation with the performing physician to determine if the atherectomy was the definitive treatment and was followed by adjunctive angioplasty or if the atherectomy was suboptimal requiring angioplasty.   

The rule governing this can be found in the NCCI Policy Manual, version  15.3 (effective October 1, 2009), Chapter 1, section M, as reproduced below.

“Some surgical procedures may be performed by different surgical approaches. If an initial surgical approach to a procedure fails and a second surgical approach is utilized at the same patient encounter, only the HCPCS/CPT code corresponding to the second surgical approach may be reported. If there are different HCPCS/CPT codes for the two different surgical approaches, the two procedures are considered ‘sequential’, and only the HCPCS/CPT code corresponding to the second surgical approach may be reported. For example, a physician may begin a cholecystectomy procedure utilizing a laparoscopic approach and have to convert the procedure to an open abdominal approach. Only the CPT code for the open cholecystectomy may be reported. The CPT code for the failed laparoscopic cholecystectomy is not separately reportable.”

-------------------------------------------------------------------------------

June 28, 2010

Question:

I just read the June 7 electrophysiology question.  My understanding is that any procedure performed after an abalation (RV recording and pacing) to see if the procedure worked should not be coded.  Can you explain?

Answer:

You are correct that if the follow-up EPS is performed to determine if the ablation was successful there are no additional codes to report. However, if full and complete studies are performed to determine if there are any other areas that may require a separate ablation, it is appropriate to report the full and complete diagnostic studies.

-------------------------------------------------------------------------------

June 21, 2010

Question:

There are times when a patient has a left heart cath performed in another facility, and then is referred to our hospital for a PTCA and /or stent. The patient is brought to the cath lab, and conscious sedation is administered. After reviewing the left heart cath films, our cardiologist does a fractional flow reserve (FFR) measurement (93571) and then decides the occlusion in the artery is not large enough to perform an interventional procedure. Since the FFR is an add-on code, it cannot be charged alone.

Is it appropriate to charge the FFR and the intended procedure (PTCA or stent) if modifier 74 is appended to capture all of the resources used in the cath lab?

Answer:

We assume that coronary angiography was not performed in addition to the FFR. If the coronary angiography was repeated due to uncertainty of the original cath, then codes 93508, 93545 and 93556 would be appropriate and 93571 could be added to the primary procedure.

If not, there is really nothing you can bill based on current guidelines. We would not code the angioplasty with modifier 74 because it was never attempted.

The other option would be to assign a visit code (e.g., 99204). If you do not have these codes established, discuss this with your chargemaster department manager. Other departments such as pain management and radiation oncology probably have the code set up and could help you with the guidelines associated with the use of these codes.

-------------------------------------------------------------------------------

June 14, 2010

Question:

Is there a code for placement of distal embolic protection device prior to an angio procedure that does not specifically have it listed in the procedure description?

Answer:

It depends upon the procedure that will use the embolic protection device. For example, some payers may accept 37799 for peripheral procedure although no code exists. There also is no code for coronary, but some payers may accept 93799.

-------------------------------------------------------------------------------

June 7, 2010

Question:

One of our physicians dictated that the following were performed along with atrial fibrillation ablation: HIS recording, RV recording and pacing (post-ablation), LA recording and pacing, and induction of arrhythmia. What codes are appropriate to assign?

Also, there is no mention of recording and pacing in the RA, and the medical director of our EP lab informed me that they don't always perform RA pacing and recording during an a fib ablation. They do perform everything else as described.

Answer:

Based solely on the information provided we would recommend the following codes:

93600 - HIS Recording
93603 and 93612 - RV recording and pacing
93602 and 93610 - LA recording and pacing
93651 - Ablation

-------------------------------------------------------------------------------

May 31, 2010

Question:

Can we code 92980 x 2 if two lesions are stented in the same vessel?

Answer:

No, code 92980 was valued to include multiple stents if placed in the same vessel. If a separate lesion in another recognized vessel is stented, code 92981 should be reported.

-------------------------------------------------------------------------------

May 24, 2010

Question:

Can 92960 (elective external cardioversion) be used for emergency defibrillation?

Answer:

According to CPT Assistant, the answer is no. Stand-alone emergency defibrillation does not have a separate code, and if it is done as part of cardiopulmonary resuscitation or other procedures, it is included in those codes.

-------------------------------------------------------------------------------

May 17, 2010

Question:

We performed a stress cardiac MRI study (75563). Is that the only code we use?

Answer:

The appropriate code (codes) from the 93015-93018 series can be assigned along with the above MRI code.

-------------------------------------------------------------------------------

May 10, 2010

Question:

My doctor wants us to code 93508 when he places a coronary stent. I don't think this is correct. Can you tell me if it is?

Answer:

You may assign 93508 with 92980 if, and only if, the physician performed a separate diagnostic angiogram at the same session. (If so, add modifier 59 to 93508.) If only a stent placement is performed (i.e., the patient had a prior angiogram), do not code 93508. Code 92980 includes any catheter placements and angiography inherent in the stent placement.

-------------------------------------------------------------------------------

May 3, 2010

Question:

What type of physician can order codes 78811-78813 and the place of service for the imaging? Is it appropriate for a cardiologist to use these codes if they have a PET scanner in their office?

Answer:

A cardiologist may use these codes if they are providing these services. They should NOT use these codes for PET imaging of the heart because there are other specific codes for that. Also, remember that for Medicare, these codes have specific policy limitations.

-------------------------------------------------------------------------------

April 26, 2010

Question:

Can we assign code 93539 x 2 if both the left and right internal mammary arteries are selected and imaged during a cardiac cath?

Answer:

No, the code description for 93539 is reported for imaging of any and all arterial conduits and would only be assigned once.

-------------------------------------------------------------------------------

April 19, 2010

Question:

I have a question about transesophageal echocardiography (TEE). What is the difference between CPT code 93318 and 93312? I realize the 93318 also has an assessment of cardiac pumping, but I wondered if there was specific terminology used when reporting the 93318 versus 93312. We are having some discrepencies in the charging versus the coding of these two procedures.

Answer:

Code 93312 is a diagnostic study, while 93318 is monitoring performed during surgery.

In the 2001 CPT Changes, the American Medical Association (AMA) noted that 93318 is a stand-alone code describing placement of a TEE probe. It also describes the use of TEE technology for continuous monitoring purposes during surgical operations and other types of interventions that produce acute and dynamic changes in cardiovascular function (e.g., abdominal/thoracic aneursym repair, open cardiac procedures).

The AMA stated that it added this code to accurately describe TEE monitoring to assess cardiovascular function and assist with therapeutic decisions performed intraoperatively.

Note that 93312 and 93315 also describe probe placement, image acquisition, and interpretation and report for diagnostic assessment of the cardiovascular system.

-------------------------------------------------------------------------------

April 12, 2010

Question:

Is there a code for rest only, thallium heart perfusion? Sometimes we cannot perform the stress portion of a stress test and do the rest study first.

Answer:

Yes, the myocardial perfusion scan codes are for single studies (rest only, or stress only) or multiple studies (rest and stress, or rest and redistribution). The code you choose is based on whether one or multiple studies are done, and whether or not SPECT is done.

A single study, SPECT, would be 78451; and a single study, planar, would be 78453.
In 2010, these codes now include wall motion and ejection fraction, so you only assign one code, not three as we have always done in the past.

-------------------------------------------------------------------------------

April 5, 2010

Question:

Which codes should be used for the removal of a complete bi-ventricular pacemaker system and a bi-ventricular cardioverter-defibrillator system?

Answer:

For BiV pacemaker system removal: Assign code 33233 for removal of existing generator and 33235 for removal of dual leads. There is no specific code for the removal of the LV lead.

For the BiV AICD system removal: For subcutaneous removal of an existing implantable pacing cardioverter-defibrillator pulse generator system (pulse generator and electrodes), report 33241 in addition to 33243 or 33244, depending on how the electrodes were removed. Refer to the American Medical Association's 2000 edition of CPT Changes: An Insiders View for this information.

-------------------------------------------------------------------------------

March 29, 2010

Question:

Which code do you recommend to use for the removal of only the left ventricular pacing lead?

Answer:

There is no specific code for the removal of the LV lead. The American Medical Association (AMA) recommends using code 33244 (CPT Assistant, July 2005, page 5).

-------------------------------------------------------------------------------

March 22, 2010

Question:

When performing a cardiac CTA (75574), including calcium score, can 75571 be billed in addition to 75574?

Answer:

No, code 75574 includes calcium scoring when performed. The guidelines at the beginning of the heart section in CPT say to report only one CT heart study per encounter.

-------------------------------------------------------------------------------

March 15, 2010

Question:

In the past, when doing a myocardial perfusion, we would code 78480, 78478, 78465 and A9502 times two. Am I to understand that 78452 takes the place of 78480, 78478 and 78465?

Answer:

Yes, in CPT 2010, the American Medical Association deleted codes 78480, 78478 and 78465, replacing them with codes 78451-78454. The new codes are all-inclusive codes and include wall motion and ejection fraction studies. The radiopharmaceutical is still reported with the appropriate HCPCS code.

-------------------------------------------------------------------------------

March 8, 2010

Question:

What would be the code when a physician performs selective angiography of the "anterior" and "posterior" superior pancreaticoduodenal artery? I thought it should be 36248 x 1 and 75774 (since the left hepatic was selected first) but have been told to code 36248 x 1 and 75774 x 2, which seems inappropriate.

Answer:

If both the anterior and posterior superior pancreaticoduodenal arteries were the only vessels selected, they would be coded 36247 and 36248. Code 75774 x 2 would be appropriate if there were specific findings associated with the arteriogram and they were just not performed to road map the vasculature of that region.

-------------------------------------------------------------------------------

March 1, 2010

Question:

I am wondering whether there is a rule of thumb for choosing the appropriate order for catheter selection when performing diagnostic and/or therapeutic angiography on "replaced" arteries. For instance, the report reads "selective angiography was performed on the bilateral renals, hepatic proper, gastroduodenal, the replaced right hepatic on the SMA." How do I know what order this should be? Would I use 36247 as if it was the original artery? I am being told to use 36246.

Answer:

The phrase "replaced right hepatic" means that instead of coming off the common hepatic artery it comes off of the SMA. Code 36246 would be appropriate because catheterization of the SMA would be first order (36245) and a branch off of the SMA (replaced right hepatic would qualify) would be a second order (36246).

-------------------------------------------------------------------------------

February 22, 2010

Question:

Can code 75774 be used for routine completion angiography?

Answer:

No, 75774 (an add-on code) cannot be used for routine completion angiography. There is no specific code for routine completion angiography following an angioplasty or stent procedure. Code 75774 is used only when there is a true need for additional diagnostic imaging after the basic or primary study is completed. Physician documentation should clearly state the medical necessity for this additional selective imaging.

To report follow-up angiography after embolization or thrombolytic therapy, assign 75898 one time per operative field.

-------------------------------------------------------------------------------

February 15, 2010

Question:

My question relates to coronary imaging for ablation mapping. If right and left coronary imaging was done during an ablation procedure for the purpose of mapping for further ablation, can we code for the coronary imaging (93508, 93545, 93556)? I would think if one procedure is done solely to facilitate another then it should not be coded.

Answer:

If the angiogram was performed to merely show a road map of the anatomy or system, it would not be coded separately. Angiography is performed to make a medical decision.

-------------------------------------------------------------------------------

February 8, 2010

Question:

I read the January 18, 2010, question and answer, but I still don't understand if I can charge for 92960 in the following cath lab situation. The patient is having diagnostic angiography when he goes into an arrhythmia for which he receives external cardioversion. This is obviously not an "elective" cardioversion. Can I still charge 92960? Or is this type of cardioversion considered inherent to one of the diagnostic angiography codes, and there is no other CPT code that can be charged for it?

Answer:

Code 92960 is listed as a component of the heart catheterization codes 93510, 93508, 93526 and so on. Based on CMS's instruction regarding the use of modifier 59, if the cardioversion is performed during the catheterization procedure, it should not be billed separately. However, if the patient presents to the lab and requires cardioversion prior to the initiation of the cardiac catheterization, you can bill cardioversion with modifier 59 because it was performed in a separate operative session.

-------------------------------------------------------------------------------

February 1, 2010

Question:

My question is regarding pacemaker insertions (insertion, replacement, conversion). If the radiology department provides the imaging, whether in the department or the OR, is 71090 the correct code to capture the technical component?

Answer:

Yes, fluoroscopy guidance code 71090 should be reported for the procedures you mention. It is also the guidance code used for the implantations of AICD devices.

-------------------------------------------------------------------------------

January 25, 2010

Question:

A patient comes in with a dual-chamber pacemaker, and the pacemaker is changed out for a new device. It turns out that the atrial lead is non-functioning, and it is capped off and a new atrial lead inserted. Would you charge 33233 for the removal, 33213 for the insertion of the new device, and 33216 for the single atrial lead inserted?

Answer:

It is appropriate to charge code 33233 for the removal of the existing device. However, Medicare has issued an edit that prohibits the reporting of codes 33213 and 33216 together. It wants providers to treat this as a new device implant and bill based on work performed. Therefore, report code 33206 for insertion of the new device with a new atrial lead, and report code C1785 for the device.

-------------------------------------------------------------------------------

January 18, 2010

Question:

Can you clarify when to use CPT 92960 and 92961? There seems to be several interpretations of the word "elective" in the description. Does this mean that the cardioversion needs to be scheduled? Are we able to charge ED patients the cardioversion charge if the cardioversion is not "emergent," and the MD "elects" to perform the procedure during an ED visit?

Answer:

The best answer to your question can be found in CPT Assistant, November 200, page 9, under a section entitled Cardioversion: External vs. Internal. The following key points are covered about codes 92960 (cardioversion, elective, electrical conversion of arrhythmia; external) and 92961 (internal). Also be sure to check the parenthetical note under 92961 in the 2010 CPT Manual, which lists the codes that should not be used when reporting internal cardioversion:

- Code 92960 specifically describes elective (nonemergency) external electrical cardioversion, which is most often used to treat atrial fibrillation and atrial flutter if anti-arrhythmic drugs fail to convert the heart back to normal sinus rhythm, or if the patient is hemodynamically unstable.
- Code 92961 describes internal cardioversion, which is most commonly used to convert atrial fibrillation to normal sinus rhythm when external cardioversion is unsuccessful. According to the AMA Assistant article, "Code 92961 is designated as a separate procedure. Internal elective cardioversion is not separately reported when performed as an integral component of another procedure/service as in an electrophysiological study or cardiac catheterization. However, if the internal elective cardioversion is performed independently, unrelated or distinct from other procedure(s)/service(s) provided at that time, then it would be appropriate to separately report the internal cardioversion."

-------------------------------------------------------------------------------

January 11, 2010

Question:

Can add-on code 75774 be used for routine completion angiography?

Answer:

No, do not use 75774 for routine "completion" angiography. Use this code only when there is true need for additional diagnostic imaging after the basic or primary study is completed. Physician documentation should clearly state the medical necessity for this additional selective imaging.

-------------------------------------------------------------------------------

January 4, 2010

Question:

We had a patient who presented with an uncontrollable nosebleed, and the physician performed angiography of the external carotid arteries. What code would be assigned?

Answer:

Assign code 75662 for the above scenario. When the catheter is subsequently advanced into the internal maxillary artery and a full and complete diagnostic angiogram is performed, report 75774 for this additional angiogram.

-------------------------------------------------------------------------------

December 28, 2009

Question:

In the process of doing a left heart cath, we found a subclavian stenosis (while looking for the IM artery) and did angioplasty and stenting. We coded the PTA and stent codes. My question is whether we also charge an extremity angio for this.

Answer:

It would be appropriate to code for the subclavian angiogram if a full and complete study was performed. This means that the physician indicates that he did the procedure, obtained images, and described findings. We would recommend codes 36215-59 and 75710-59 for the left subclavian artery and 36216-59 and 75710-59 for the right subclavian artery when billed with heart catheterization codes.

For the stenting, assign codes 37205 and 75960 and bill the PTA with 35475 and 75962 if the physician indicated there was residual stenosis necessitating the stent following the PTA.

-------------------------------------------------------------------------------

December 21, 2009

Question:

Regarding vascular access devices: Can you charge for the heparin 500 units and sodium 20 ml drugs as well as the IV infusion CPT code 96523 when this is the only procedure done during an encounter? Or are the drugs included in 96523?

Answer:

Assuming you work for a hospital, the drugs could be billed separately with the appropriate HCPCS J code.

-------------------------------------------------------------------------------

December 14, 2009

Question:

When using a thrombectomy catheter during PCI, can 92973 be assigned when a manual extraction catheter such as the Pronto or Quick-Cat is used?

Answer:

Yes, code 92973 can be used regardless of the method of thrombectomy.

-------------------------------------------------------------------------------

December 7, 2009

Question:

I would like to know the guidelines for cardiac CTA in regards to whether an order from the ordering physician is required because contrast is being injected?

Answer:

The use of contrast is the responsibility of the radiologist as is the thickness of the cut.

-------------------------------------------------------------------------------

November 30, 2009

Question:

During cardiac cath procedures, the cath lab techs actually perform the injection portion of the procedure. Under these circumstances, is the physician allowed to bill for the injection portion of the cardiac cath procedure? I am thinking that the physician may bill for this portion of the cardiac cath procedure since the injection is performed under direct supervision of the physician.

Answer:

It would be appropriate to bill for the injection of the contrast because, as you say, the physician directly supervised the type and amount of contrast given and the staff assisting.

-------------------------------------------------------------------------------

November 16, 2009

Question:

In the cardiology compliance question for November 9 regarding percutaneous pulmonary thrombectomy, you stated that the pulmonary arteries are really veins when they leave the heart and that code 37187 (mechanical thrombectomy of a vein) should be used. This is incorrect.

Arteries always take blood away from the heart, and veins always return blood to the heart. Even though the vessels are taking deoxygenated blood away from the heart to the lungs, they are still arteries. The pulmonary veins likewise return oxygenated blood to the heart, which is different from any other artery in the body.

The catheter placement of 36014 is correct since these vessels are pulmonary arteries.

In your answer, the catheter placement is in an artery for a venous thrombectomy. This is not possible.

Answer:

You are correct. As you say, the pulmonary arteries are a unique vessel in that they deliver de-oxygenated blood to the heart, nevertheless they are arteries. Therefore, the thrombectomy should be coded with code 37184 (initial vessel) and 37185 (each additional vessel) with 36014 x 2 for catheter placements, which is consistent with current coding guidelines.

The answer in the November 9 question has been corrected in the archive.

-------------------------------------------------------------------------------

November 9, 2009

Question:

One of our doctors performed a percutaneous pulmonary thrombectomy. The femoral vein was accessed, and he entered the pulmonary artery via the right heart. He then performed the thrombectomy with an angiojet catheter in the right and left pulmonary artery. How would I code this?

Answer:

Since the pulmonary arteries are really veins when they leave the right side of the heart, code 37187 would be billed twice along with code 36014 for the catheter placements.

-------------------------------------------------------------------------------

November 2, 2009

Question:

A patient has a CT coronary angiography and the finding is "abnormal calcium score," what would you say is the most appropriate (not necessarily "payable") ICD-9 code to reflect abnormal calcium score?

Answer:

Depending on how you are coming up with a calcium score, you could try using either code 275.49, disorder of calcium metabolism, or 275.40, unspecified disorder of calcium metabolism.

-------------------------------------------------------------------------------

October 26, 2009

Question:

Please review the answer to last week's question, which is "What are the correct procedure codes for the following? The patient has a dual-lead pacemaker. The atrial lead is malfunctioning. The physician extracts the malfunctioning atrial lead and inserts a new atrial lead. Nothing is done with existing ventricular lead."

The actual question says nothing about the generator being replaced, it is only asking about a lead replacement. Wouldn't the codes be 33216 and 33234?

Answer:

As you point out, the answer to last week's cardiology question was incorrect. There is no mention of a device just the lead. We apologize for any inconvenience, and the correct coding would be as follows:

- 33216 for the new lead
- 33235 for the extraction of the old lead
- 71090 for the fluoroscopic guidance.

-------------------------------------------------------------------------------

October 19, 2009

Question:

What are the correct procedure codes for the following? The patient has a dual-lead pacemaker. The atrial lead is malfunctioning. The physician extracts the malfunctioning atrial lead and inserts a new atrial lead. Nothing is done with existing ventricular lead.

Answer:

The followig codes should be assigned:

- 33216 for the new lead;
- 33235 for the extraction of the old lead; and
- 71090 for the fluoroscopic guidance.

-------------------------------------------------------------------------------

October 12, 2009

Question:

Could you provide me with the correct coding, along with any needed modifiers, for a left heart cath with selective bilateral renal angiography and/or selective bilateral iliac angiography? I know that G0275 and G0278 are the codes for non-selective, but many of our physicians are performing selective angiograms.

Answer:

The codes for a bilateral selective renal angiography would be 75724-59 and 36245-59-50. Modifier 59 is required because of the edits connected to the heart cath codes. Bilateral selective iliac angiography is assigned codes 75710-59, 36245-59 (assumes catheter placed in contralateral common iliac artery) and G0278. G0278 is required for the ipsilateral study of the iliac arteries.

The reference for the aforementioned coding is Chapter 11, Section I, Number 12 of the NCCI Coding Manual, which states the following:

12. While withdrawing the catheter during a cardiac catheterization procedure, providers often inject a small amount of dye to examine the renal arteries and/or iliac arteries. These services, when medically reasonable and necessary, may be reported with HCPCS codes G0275 or G0278. A provider should not report CPT codes 75722 or 75724 (renal angiography) unless the renal artery(s) is (are) catheterized and a complete renal angiogram including the venous phase is performed and interpreted. A provider should not report CPT codes 75625 (abdominal aortography) or 75630 (abdominal aortography with bilateral iliofemoral lower extremity angiography) unless a complete study including venous phase is performed and interpreted. In order to report angiography CPT codes 75625, 75630, 75722, 75724, or others with a cardiac catheterization procedure, the angiography procedure must be as complete a procedure as it would be without concomitant cardiac catheterization.

-------------------------------------------------------------------------------

October 5, 2009

Question:

If the physician performs both right and left atrial pacing and recording during the same procedure without doing a full comp study (93620), how can these be coded?

Answer:

Report codes 93602 and 93610 once per session.

-------------------------------------------------------------------------------

September 28, 2009

Question:

We are starting to use the CT heart codes 0144T-0150T. Can you tell me if the insurers are reimbursing for these codes? How do we split the codes for billing purposes?

Answer:

Many insurers are paying some of these codes. Code 0144T (cardiac scoring) is usually not paid by insurance as it is a screening test. Some insurers do not pay for code 0147T as they believe it is an attempt to get screening cardiac scoring paid by adding the angiogram, but others do pay depending on diagnosis. You will need to check with your specific payers for their policies. The Centers for Medicare & Medicaid Services (CMS) do not price these codes but, instead, let each state contractor set price and policy. You will need to check your Medicare payer's most current local coverage determination (LCD).

The only way you can split the codes is for professional and technical charges (the facility that owns the machine bills the TC and the physician who interprets bills the professional). However, if you are asking if you can split the interpretation, the American College of Radiology (ACR) recommends that you do not do split interpretations. See the ACR White Paper on Split Interpretations by clicking here.

I see that you did not include 0151T in your list of codes. Remember to add that code as a secondary code when a function study is done with one of the others.

-------------------------------------------------------------------------------

September 21, 2009

Question:

I have a provider that is doing radiofrequency ablation for atrial fibrillation using a transeptal approach, 3D mapping, point-to-point mapping, and intracardiac ultrasound. CPT does not have a specific code for this procedure, and I would like to know what to bill. Can you advise me?

Answer:

There is not one code that describes all of the services provided. Therefore, the services are coded and billed separately as follows:

- Assign 93651 for the ablation for atrial fibrillation, which is considered a SVT ablation.
- Assign 93613 for the 3D mapping, which includes code 93609 (point-to-point mapping).
- Assign 93662 for intracardiac ultrasound (ICE).

-------------------------------------------------------------------------------

September 14, 2009

Question:

Our hospital coders are questioning the NCCI edit that appears when using code 96372 with 51702 and also code 93005 with a 51701. We are not sure why an injection code would bump up against a Foley or why an EKG would bump up against a straight cath. Any insight?

Answer:

The current edit indicates that code 96372 (subcutaneous or intramuscular injection) is included in code 51702 (insertion of Foley catheter). This edit may be in place so the provider does not bill for an injection to ease the patient's anxiety (which is highly unlikely). However, if the injection was for a substance not related to the Foley catheter insertion, it would be appropriate to assign modifier 59 to code 96372.

In version 15.1, we do not see that there is an edit between codes 93005 and 51701. However, Chapter 7 of the NCCI Policy Manual states the following:

1. Insertion of a urinary bladder catheter is a component of the global surgical package. Urinary bladder catheterization (CPT codes 51701, 51702, and 51703) is not separately reportable with a surgical procedure when performed at the time of or just prior to the procedure.
Additionally, many procedures involving the urinary tract include the placement of a urethral/bladder catheter for postoperative drainage. Because this is integral to the procedure, placement of a urinary catheter is not separately reportable.

-------------------------------------------------------------------------------

September 7, 2009

Question:

There does not seem to be a code for a prograde left heart cath when a septal occlusion device is placed (93580). The physician typically performs a full right heart cath (included in the 93580) then measures left atrial and ventricular sats and pressures via the septal opening. If no device is placed, the 93533 code (congenital r and l heart via existing openings) would be appropriate but if a device IS implanted, the left heart cath is essentially lost, since 93510 seems specific to a retrograde cath. Can you clarify?

Answer:

According to CPT, all of the heart cath codes relative to congenital defects are included and not separately coded. Reference the parenthetical notes following code 93580.

-------------------------------------------------------------------------------

August 31, 2009

Question:

My question is a follow-up to the August 17 cardiology question and answer. If a transseptal puncture was performed in order to do the ablation, could CPT codes 93524 or 93527 be assigned?

Answer:

Medicare has issued an edit that prohibits the use of codes 93527 and 93524 with code 93651. This is because it is rare that a full and complete right and left heart catheterization is performed when conducting an ablation. Medicare does allow the assignment of modifier 59 to the heart catheterization codes 93527 and 93524 as long as the documentation supports the performance of a full and complete heart catheterization. Compare the dictation of a full right and left heart cath with the documentation of the physician for a transeptal approach to perform an ablation. In many cases it is quite different and all the elements of a heart catheterization as described in the CPT manual are not met.

-------------------------------------------------------------------------------

August 24, 2009

Question:

In the process of doing a left heart cath, we found a subclavian stenosis (while looking for the internal mammary [IM] artery) on which we did angioplasty and stenting. We assigned the PTA and stent codes, but my question is can we also charge an extremity angio for this?

Answer:

Assuming medical necessity, it would be appropriate to code for the subclavian angiogram if a full and complete study was performed. This means that the physician indicates that he did the procedure, obtained images and described findings.

From a contralateral or femoral approach, for the left subclavian we would recommend codes 36215-59 and 75710-59 if billed with heart cath codes. For the right subclavian, use codes 36216 and 75710.

For the stenting procedure, use codes 37205 and 75960. For the PTA, assign 35475 and 75962 if the physician indicated there was residual stenosis (typically > 30 percent), flow-limiting dissection or residual pressure gradient (typically > than 5 mm of Hg) necessitating the stent following the PTA.

-------------------------------------------------------------------------------

August 17, 2009

Question:

I have a provider that is doing radiofrequency ablation for atrial fibrillation using a transeptal approach, 3D mapping, point-to-point mapping and intracardiac ultrasound. CPT does not have a specific code for this procedure, and I would like to know what to bill. Can you advise me?

Answer:

There is not one code that describes all of the services provided. Therefore, the services should be coded and billed separately as follows:
- Ablation for atrial fib is 93651 (ablation of a fib is considered a SVT ablation)
- 3D mapping is 93613 and includes code 93609 (point to point mapping)
- Intracardiac ultrasound (ICE) is 93662

-------------------------------------------------------------------------------

August 10, 2009

Question:

At our facility a patient had the following procedure performed in the ED:
93283 Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with physician analysis, review and report; dual lead implantable cardioverter-defibrillator system.

The patient was still experiencing atrial fibrillation and was placed in observation. While in observation, another physician performed the procedure identified by this CPT code:
93289 Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead implantable cardioverter-defibrillator system, including analysis of heart rhythm derived data elements.

We are receiving an edit stating that we cannot report both CPT codes 93283 and 93289 together for the same encounter because 93289 is a component of 93283. Would it be appropriate to append a modifier in this case since the programming evaluation was performed in the ED and hours later the interrogation device evaluation was performed on the unit and ordered by another physician?

Answer:

Yes, it would be appropriate to assign modifier 59 to code 93289 because the procedures were performed at different operative sessions. Be sure that the medical record has complete documentation (the elements of the code descriptions) from each physician.

-------------------------------------------------------------------------------

August 3, 2009

Question:

Are oxygen saturation samples (82810) separately reportable with a right heart catheterization (93501)?

Answer:

A request for an oxygen sample via a venous or arterial line during a cardiac catheterization is not, generally, a routine procedure. It is commonly ordered during a right heart cath where the oxygen saturation sample is taken from a venous line and sent to the lab.

The oxygen saturation sample with a right heart cath can be billed separately. Usually the lab bills the 82810 code.

-------------------------------------------------------------------------------

July 27, 2009

Question:

According to Medicare, as of March 1, fluoroscopy 71090 will not be paid separately when billing for a pacemaker or ICD insert. Can you please verify?

Answer:

Under the hospital outpatient prospective payment system (OPPS), fluoroscopic guidance has been assigned "N" status for several years (items and services packaged into APC rates). As a result, Medicare includes the payment for fluoro within the primary procedure.

MedLearn continues to recommend that fluoroscopic guidance (code 71090) be billed (unless otherwise instructed by your payer) because not all of the patients you take care of are Medicare beneficiaries.

-------------------------------------------------------------------------------

July 20, 2009

Question:

Is an EP study normally done when a physician performs an atrial fib ablation by pulmonary vein isolation technique?

Answer:

It depends on the presentation of the patient. If it is know from other tests that the pathway is near the pulmonary veins, the physician may choose to perform the ablation with mapping.

However, a comprehensive EP study may be performed following an ablation to determine if there are other pathways that were undiagnosed prior to the ablation. The documentation that indicates that a comprehensive EP was performed prior to or post ablation is critical for appropriate coding.

-------------------------------------------------------------------------------

July 13, 2009

Question:

If a right heart cath was performed and a pigtail catheter was inserted into the left ventricle to measure pressures, which CPT code should be selected? No LV angiogram was performed, and coronaries were not injected.

Answer:

If a full and complete heart cath was performed in addition to the measurement of pressures in the LV, report code 93526 (combined right heart catheterization and retrograde left heart catheterization). Please note that the heart catheterization codes do not require that an injection be performed.

-------------------------------------------------------------------------------

July 6, 2009

Question:

I'm confused by the limitations for the use of 93306 and 93307. Code 93306 only covers a complete echo (93307+93320+93325), and code 93307 cannot be billed with any add-on codes. So how do you bill for a 2D echo with limited Doppler and color flow? Or even just a 2D echo with limited Doppler?

Answer:

According to the current Medicare national correct coding initiative (CCI) edits, if a 2D echo is performed with limited Doppler and color flow, the only code allowed is 93307.

-------------------------------------------------------------------------------

June 29, 2009

Question:

My question relates to charging for EP when a physician puts in an ICD w/ single lead on the right side and then has to remove one that was put in on the left side. How can I charge for these two procedures without the bill being kicked back out? Should I put any modifiers on either of these besides the Q0 on the insert ICD procedure?

Answer:

Based on the information provided, we recommend the following codes:
33241 - Subcutaneous removal of single- or dual-chamber pacing cardioverter-defibrillator pulse generator
33249 - Insertion or repositioning of electrode lead(s) for single- or dual-chamber pacing cardioverter-defibrillator and insertion of pulse generator
71090 - Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation
93641 - Electrophysiologic evaluation of single- or dual-chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator
C1722 - Cardioverter-defibrillator, dual chamber (implantable)

Note that we checked the above codes against version 15.1 of the National Correct Coding Initiative (CCI) edits and did not receive any edits. See http://www.cms.hhs.gov/NationalCorrectCodInitEd/ for a list of the current CCI edits for hospitals and for physicians.

-------------------------------------------------------------------------------

June 22, 2009

Question:

I disagree with part of the answer you gave to last week's cardiology question of the week. In example 3, you indicated that code G0278 could be charged as a runoff (which is usually to the ankles to check for claudication), but I believe it would be 75716-59 with a heart cath. Please comment.

Answer:

The description of code G0278 reads as follows (note the underlined portions): lliaic and/or femoral artery angiography, non-selective, bilateral or ipsilateral to catheter insertion, performed at the same time as cardiac catheterization and/or coronary angiography, includes positioning or placement of the catheter in the distal aorta or ipsilateral femoral or iliac artery, injection of dye, production of permanent images, and radiologic supervision and interpretation (list separately in addition to primary procedure).

Therefore, for a Medicare patient, a bilateral study with the catheter in the distal aortic performed in conjunction with a cardiac cath is accurately coded with G0278. If this was for a non-Medicare patient, we would agree that code 75716-59 is correct.

-------------------------------------------------------------------------------

June 15, 2009

Question:

A left heart catheterization and aortogram with both lower extremity runoff are performed together. How would the coding be done so that Medicare does not deny the aortogram with runoff?

Answer:

Before we can answer your question fully, we would need the following information: 1) How were the aortogram and runoff completed: one catheter position or two? 2) What was the intent of the abdominal aortogram (e.g., for the evaluation of renal arteries or the aorta)? 3) What was the medical necessity for the procedures?

Below are examples of when certain codes and modifier 59 may apply:

Example 1: Following the left ventricular the pigtail catheter was repositioned at the area of the renal arteries. A non-selective (drive-by) renal angiogram was obtained.
G0275 Renal angiography, nonselective, one or both kidneys, perfomed at the same time as cardiac catheterization and / or coronary angiography
Example 2: Following the left ventricular, and due to the difficulty in advancing the catheter through the aorta, an abdominal aortogram was obtained.
75625-59 abdominal aortogram
Example 3: The patient presents with coronary artery disease and claudication. Following the left ventricular, the pigtail catheter was positioned at the aortic bifurcation and imaging of the lower extremities were obtained.
G0278 Iliac and/or femoral artery angiography, nonselective, bilateral or ipsilateral to catheter insertion, performed at the same time as cardiac catheterization and/or coronary angiography

Other guidelines: 1) Validate medical necessity and the associated documentation to support the codes and the code descriptions, 2) check your payer's local coverage determination (LCD) for applicable diagnosis codes for the above codes, 3) Use the appropriate selective catheter placement codes with the extremity supervision and interpretation code.

-------------------------------------------------------------------------------

June 8, 2009

Question:

How would we code for an angio seal done with a heart cath?

Answer:

Medicare has issued HCPCS level II code G0269-placement of occlusive device into either a venous or arterial access site, postsurgical or interventional procedure (e.g., angioseal plug vascular plug) for the deployment of an angio seal. However, currently, Medicare does not reimburse for this service.

-------------------------------------------------------------------------------

June 1, 2009

Question:

My question relates to CPT code 93660 (evaluation of cardiovascular function with tilt-table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention). Is it ok to use modifier 51 with this code?

Answer:

In CPT 2008, code 93660 was removed from the list of modifier -51 exempt codes, and it appears in the CPT codebook without the modifier 51 exempt symbol. This code does not meet the new modifier 51 exemption. Because modifier 51 exempt codes are typically reported with more extensive procedures or services, there should be minimal pre- and postservice time (compared to intraservice time) and minimal postoperative visits associated with the valuation of these procedures. The data obtained from the American Medical Association's RVS Update Committee (RUC) indicated that code 93660 has significant pre- and postservice time assigned.

-------------------------------------------------------------------------------

May 25, 2009

Question:

If the doctor performs +93621 (left atrial pacing and recording from coronary sinus or left atrium) without performing the parent code of 93620, how would I code this to capture the services provided?

Answer:

For the recording, report code 93602 (intra-atrial recording), and for the pacing of the left atrium, assign code 93610 (intra-atrial pacing).

-------------------------------------------------------------------------------

May 18, 2009

Question:

Can you provide billing guidance related to intracoronary stent placement?

Answer:

Codes 92980 and 92981 describe placement of an intracoronary stent. These codes are structured similarly to the atherectomy codes in that any other therapeutic modality or percutaneous transluminal coronary atherectomy (PTCA) performed in the same vessel as the stent placement is included in the stent placement code.

For Medicare outpatient hospital services only, report the following HCPCS Level II codes for drug-eluting stent(s). These codes are not for physician billing/reporting:

- G0290-Transcatheter placement of an intracoronary drug-eluting stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel
- +G0291-Transcatheter placement of an intracoronary drug-eluting stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel (list separately in addition to the code for primary procedure)

Angioplasty or atherectomy performed in conjunction with stenting of the same vessel is not separately coded. Only the more complex procedure (i.e., stenting) is coded.

-------------------------------------------------------------------------------

May 11, 2009

Question:

How would you code this: A dual-chamber pacemaker generator is being replaced with the atrial lead being capped and then the ventrical lead is replaced?

Answer:

Medicare wants you to treat this as a new device implant (single ventricular implant). The codes would be 33233 (removal) 33207, 71090 and C1785 or C2619 as appropriate.

Logically, one would think that this should be coded as 33233 (removal), 33216 (single-lead insert) and 33212 (dual-chamber replacement), but the national correct coding initiative (CCI) edits will not allow codes 33216 and 33212 to be billed together.

-------------------------------------------------------------------------------

May 4, 2009

Question:

When a dual-pacemaker device is placed during a procedure with only the right ventricular lead, and then the patient returns at a later date (second visit) to have the right atrial lead inserted, what is the appropriate CPT code?

Answer:

The coding should be relative to the work performed. Therefore:

- For the first day, assign code 33207-Insertion or replacement of permanent pacemaker with transvenous electrode(s);ventricular
- For second day, assign code 33216-Insertion of a transvenous electrode; single chamber (one electrode) permanent pacemaker or single chamber pacing cardioverter-defibrillator

-------------------------------------------------------------------------------

April 27, 2009

Question:

The April 20 cardiology question related to what modifier should be assigned for a carotid endarterectomy performed on one side and then on the other side within the global period of the first procedure. The answer provided was confusing, and I think the first modifier suggested is incorrect. Can you please review and comment on this?

Answer:

We have reviewed the answer provided to the April 20 question and have revised it as follows.

Here is the question to ask: Was the procedure planned at the time of the initial endarterectomy performed during the global period? If the second procedure on the same side was more extensive, then use modifier 58. However, if the second procedure is done on the other side within the global period and is medically necessary, then use 79 since this was not related and not performed in the same vascular family, but on the other side.

-------------------------------------------------------------------------------

April 20, 2009

Question:

If a patient has bilateral carotid stenosis and we do a carotid endarterectomy on one side and then the other side within the global period of the first procedure, would we use modifier 58 on the second procedure (verses 79)?

Answer:

Here is the question to ask: Was the procedure planned at the time of the initial edarterectomy performed during the global period? If the second procedure on the same side was more extensive, then use modifier 58. However, if the second procedure is done on the other side within the global period and is medically necessary, then use 79 since this was not related and not performed in the same vascular family, but on the other side.

-------------------------------------------------------------------------------

April 13, 2009

Question:

For a 12-lead ECG, is there any difference in billing for the physician office vs. the hospital?

Answer:

In the office where the physician owns the equipment, employs the personnel, interprets the ECG, and dictates the report, use code 93000.

When the tracing is acquired in the outpatient setting (where the physician does not own the equipment nor employ the personnel) and the physician provides only the interpretation, assign code 93010 for the professional service.

For hospitalized patients, the physician is generally not involved in obtaining the tracing, and code 93010 would be used for the professional service only. For hospital billing of this service, code 93005 is used. The revenue code that would appear in form locator (FL) 42 of the UB-04 is 730, which describes the ECG/EKG (electrocardiogram).

-------------------------------------------------------------------------------

April 6, 2009

Question:

If the doctor performs +93621 (left atrial pacing and recording from coronary sinus or left atrium) without performing the parent code of 93620, how would I code this to capture the services provided?

Answer:

Report code 93602 (intra-atrial recording) and code 93610 for intra-atrial pacing of the left atrium.