The Coding Sleuth 11
by Tara Conklin
It was a dark and stormy night….. Don’t you just love when a good mystery starts out like that? Sorry had to do it.
I was just getting comfortable at my desk when the phone rang. Another mystery fell right into my lap; actually it was my coffee when I reached for the phone but no difference. On the phone was a well respected doctor with a real predicament on his hands. He was getting denials on his cardiac catheterizations and didn’t understand what he was doing wrong. I told him I would be right down. (I changed my pants first).
Our investigation led us right into the “heart” of town; the Cardiac Business District. This was where it all happened, the constant flow of commerce.., the heart beat of it all.., okay, okay I’ll stop with the puns.
The office was clean and immaculate and the staff was very helpful. A tall man in a white lab coat introduced himself as Dr. Stan Osis. I stood and he took me to the crime scene. Two separate neat stacks of papers lay in one corner of his desk. One was claims with corresponding EOBs stapled to the back and the other was meticulously dictated operative notes. Each stack was in alphabetical order by patient last name so the top op note corresponded to the top claim.. (hmm very close attention to detail). I dove right in.
I ascertained all of his procedures were done at the hospital as he did not have or own a cardiac lab. He also did not provide any supplies or equipment; this was all supplied by the hospital. Looking through the stacks of papers the first thing I noticed was the absence of modifiers and the misuse of some others. I also noticed there were a few codes missing upon review of the operative note. I sat the good doctor down and decided to break the coding down for him.
Diagnostic caths need be broken down into either diagnostic or therapeutic procedures or many times they are both. Depending on what the purpose of the procedure is will depend greatly on what can be coded.
Next they need to be broken down into corresponding components. Most cardiac caths have at least three codes.
1) The Catheter placement
2) Injection procedures
3) Supervision & Interpretation
The first component is the catheter placement itself. These codes start with 93501 and continue to 93533. They are determined based on the final placement of the catheter into specific heart sites. The two most common are Right & Left Heart Caths. These are coded if the catheter crosses the aortic valve and is placed into either the Right or Left Ventricles. If the catheter is placed into both ventricles then a combination Right & Left cardiac cath code is used based on the point of entry. This is called a “concomitant heart cath”. The purpose of this is to obtain the different pressure & measurement recording from the separate chambers of the heart, i.e., arterial, pulmonary, etc. The catheter must cross the Aortic Valve in order to be considered a “concomitant” heart cath.
If the catheter does not cross the aortic valve and is placed directly into the coronary arteries, this is coded with 93508.
Regardless of arteries and heart structures the catheter is placed into, the cardiac catheter code is only reported once for the entire procedure.
Also note the catheter code is done with the used of equipment provided by the hospital, therefore there are both “technical” and “professional” components to the cardiac catheter codes. Dr. Osis informed us he did not own the equipment therefore he would need to append modifier -26 to the catheter codes, as he is only going to get paid for the “doing” portion of the exam.
Once the catheter code is chosen, the next part is to determine the injection procedures performed. These codes report the doctor's work only. The technical component is already being picked up with the catheter code. Therefore these do not need any modifiers whatsoever. I opened the CPT to show Dr. Osis all of these codes in this section are modifier -51 exempt, which means, they don’t bundle and are not subject to the multiple procedure reduced payment rule. (This made him very happy).
I pointed out the injection codes start at 93539 and end at 93545. Each code is used to report injection(s) done in specific portions of the heart. For example, 93539 is used if injections are performed of arterial conduits such as the internal mammarys and are used regardless if these conduits are native or have been placed by way of coronary bypass surgery. It may be necessary to cross through the Subclavian artery in order to perform injection of the LIMA or RIMA (left/right internal mammary artery). When this is done, even though the catheter has left the heart structures itself and has gone up and over into the great vessels that lead to the head and arms; if the purpose of the injection is specifically to visualize the LIMA or RIMA, 93539 is coded in lieu of 36215/36216 and/or 75710 since these are coded for diagnostic purposes of the peripheral arteries, not the heart. If separate injection of the Subclavian or any vessel outside of the heart is performed to diagnose non-cardiac conditions (i.e., peripheral stenosis), the 36215-36217 codes and their corresponding 75000 codes may be coded separately. We’ll get more into these later. If you get confused always ask yourself “What is the purpose of this procedure? What did it accomplish?”
If injection is done of the aorta (regardless of the point of injection) and the purpose of the injection is to visualize and diagnosis the aorta itself, code 93544 is coded instead of 36200 as 93544 is specific to aortography DURING a cardiac catheter procedure. There are a few modifications to this code but we’ll explain these next week.
When aortography is done during a heart cath with the soul intent to interpret the condition of the renal and/or iliac arteries, but doesn’t actually place the catheter into these vessels and perform separate injection, we call these “drive-bys”. I noticed Dr. Osis did these quite a bit but I did not see that he had coded for them on any of his claims. For Medicare claims only, I showed him these “drive-bys’ were billable and were reported with G0275 for renal interpretation and G0278 for iliac interpretation. (Again he was very happy). I told him to be careful though, G0275 included a flush aortogram and therefore if only one injection was done of the aorta during a cardiac cath procedure ONLY G0275 could be coded. In order to code both G0275 and 93544 a separate injection of the Aortic Root would need to be done at the time of the abdominal aortography.
Each of the injection codes 93539-93545 is coded once per total operative session even if multiple injections are performed in one or more vessels. Remember, these codes report a physical injection into their specifically named site(s). If the catheter did not go there, don’t code it.
The last piece of the puzzle is the “supervision and interpretation” or the “I spy” portion of the exam. This is another piece that is using separate equipment, the fluoroscopy machine. The images of the contrast dye are displayed on the fluoro monitor and from these the surgeon can determine the medical state of each of the cardiac vessels. There are only two codes for all the interpretation done for a heart cath. 93556 reports interpretation of injection done in any structure except the Atriums or Ventricles. 93555 is used to report injections of any number of the four chambers of the heart.
These codes are also only reported once regardless if multiple structures within the same code are injected or if multiple injections are done. Lastly they would need to have modifier -26 appended for the physicians’ portion of the exam.
Dr. Osis appeared to have a much clearer understanding of how the cardiac catheter codes worked together to paint a perfect picture of exactly what he was doing. Armed with this information I showed him how the average catheter claim may look. We took an example from his pile, a Medicare patient which he performed a typical “left heart cath with injections of the coronary arteries, left ventricle, and aorta for exam of the renal arteries only. Pressures were taken from across the aortic valve and interpretation was performed. With this exam we had
93510-26
93543
93545
93555-26
93556-26
G0275
Aortography code 93544 was not coded because the only thing we interpreted from this injection was the renals.
Time was calling and so was his wife, so we decided to end our conversation here in order to give him time to digest the information he gained. I told him I would be back next week to clear up his therapeutic interventions during cardiac cath. He thanked me for my time and went to take his call. I got to thinking about “digesting” and decided to head for the diner. I pulled the collar up on my trench coat, grabbed my coding hat and disappeared into the dark misty night.
Until next time Coding Sleuths!
--Tara