Hello, and welcome to another session in our Cardiovascular Coding Essential Education Series. My name is Jolene Bruder, and I'm a manager for Revenue Cycle Solutions and Coding at MedAxian. In this session, I'd like to cover coronary angiography and interventional CPT coding, better known as Heart Cath and PCI. Before we get started, I would like to go over our disclaimer. This is standard for us. It basically states that this does not constitute any legal advice and that you should always check with your local carriers or your practice's legal counsel for any billing or reimbursement advice. Next, our CPT disclaimer lets you know that all of these codes did come from the CPT American Medical Association. So our objectives for this session is I'm going to cover brief heart anatomy. We're going to talk about CPT coding and guidelines for billing cardiac cath and PCI, and then we're also gonna touch on the documentation requirements that actually support the medical necessity of these. So let's start with some anatomy of the heart. So let's start off by looking at the right and left side of the heart. So as you know, blood flow comes through the vena cava, enters into the right atrium of the heart, which flows then through the tricuspid valve to get down to the right ventricle. Then that ventricle contracts, pushes the blood through the pulmonary valve, and then that goes out to the pulmonary arteries and goes to the lungs where the blood is now reoxygenated. Then it comes back through the pulmonary vein into the left atrium, and then pushed out or pushed down through the mitral valve, and then that left ventricle will contract and pushes the blood through the aortic valve, through the aorta, and back out to the body. So this picture, or these pictures, actually depict where our coronary arteries are. Now, this didn't cover all of them. The Ramos is not on this picture, on this one here to the left, but we have the left main coronary artery, and then that splits out into your circumflex and your left anterior descendant. Over here is the right coronary artery. And then, like I said, the circumflexes here, LAD, or left anterior descendants there. This is kind of a more split out version and actually labels the different branches off of the main arteries. So we have the posterior descending artery, which comes off the RC, which is a right coronary. We also have like the obtuse marginal one, obtuse marginal two, that comes off the circumflex. Now, keep in mind, the circumflex actually runs behind the heart, but in order to show that, that's why it's drawn this way so you can see. And then, of course, for the LAD, we have the diagonals. Those are branches off of them as well. This also shows a Ramos. Now, not everyone has a Ramos, so that is just dependent on whether or not a person's born with that. So let's talk about overview of diagnostic cardiac cath coding. So let's go over some definitions and terms. This slide contains the definition and the terms of cardiac cath. So a cardiac cath actually refers to any diagnostic angiographic procedures that evaluate the heart structures and the muscles. The chambers, which are the atria and the ventricles, and that is on both the right and left side of the heart, those are evaluated as well as pressures. Pressures are required to be documented. For a right heart cath, a Swan-Ganz catheter is used. Coronary angiography is not really considered a cath procedure, so pressures are not required. So if they're only doing coronary angiography, you won't have anything about pressures. For a true left heart cath, we'll get into, there must be pressures documented, but we'll discuss that in detail in a few slides. So again, the types of cardiac caths, we have a right heart cath, a left heart cath, or a combination of both. The disease types are acquired heart disease and then congenital heart disease. Now, keep in mind, congenital is not just for children, but it is for all of those that are born with some type of congenital problem. We are not going to discuss congenital heart caths today. That would be a totally different session. We are going to focus on adult and their acquired diseases. So there are some procedures that are included in a diagnostic heart cath, and these are not separately billable. Those procedures would be any introduction and positioning of catheters, any recordings of those pressure blood samples, any venous infusion, closure devices, drug injections, anything like that are not separately reportable. They would be included. So when it comes to diagnostic catheterization billing, you are allowed to bill for these with intervention, providing you have met these requirements. So there either can be no prior base catheter that was recent. Now, Medicare does not define what recent is. A lot of practices will look at three to six months. So anything older than six months is probably okay. But again, that's something you need to check with your carers. Now, if there is a prior catheter-based angiography that's available, then there's other ways that you could still charge for another diagnostic, and that would be if the patient's condition has changed since that previous cath, or if it's documented in the note that that previous cath had inadequate visualization of the anatomy and or pathology. And then of course, if there's a clinical change for the patient that requires a new evaluation, which is outside of the target area of intervention. So let's say that the patient was having an intervention done on their left anterior descending artery. During that procedure, if they develop a new problem, so let's say they now have chest pain going on, and the physician discovers that there's a problem with the right coronary artery, and they go in and decide to look at that right coronary artery, that's outside of that target area of intervention. So keep that in mind. So these are some critical documentation points that aren't necessarily billable, but they are required to be in that catheter report. And I know with the advent of structural reporting, sometimes these reports are lacking. So it's important that you discuss this with your physicians too, and let them know we need this information. So we need to know the access point. Did they come through an artery or did they go through a vein? To get to the right heart and do a right heart cath, they have to go through the vein. For the left heart, they should be going through the artery. So that needs to be clearly documented. Any movements of that catheter, where did the catheter go and how did it get there? Any injections, so when they inject on the left side, on the left coronary arteries, we need those injections. When they inject on the right coronary artery, we need that. We also need that interpretation of any imaging that's done. And then what is the intention of the cath? Was this just a road mapping? So again, we already knew what the problems were, and we're just going in, doing some shots to make sure we're in the right area to intervene, or is it truly a diagnostic study? We also should have documentation of the patient's any congenital history or any prior surgeries, interventions, or variant anatomy. So these next couple of slides, I like to go over common acronyms. Now, these are gonna be familiar to those of you that are used to billing these, but those of you that are new, I thought there was a lot of acronyms when I was in the military, but medicine has a lot more on them. So here we have left heart cath is referred to as LHC, right heart cath, RHC. CORS, that stands for coronary arteries only. EF is ejection fraction. EDP is end diastolic pressure. LV is left ventricular gram. And then LVEDP is left ventricular gram end diastolic pressure. So here we're gonna talk about our diagnostic cath codes. So we have 9-3-4-5-4 and 9-3-4-5-5. Now this is truly only looking at the coronaries. We're only looking at the coronary arteries. We don't care about the right heart chamber or the left heart chamber. So for these, they would just be doing injections of the coronaries themselves. And they're basically split out with the 9-3-4-5-4 is when the patient only has native arteries. And then 9-3-4-5-5 down here, this shows graphs. So this is a patient that's had a coronary artery bypass and these are the different graphs that they could have. So this one actually depicts the lemma, which is the left internal thoracic artery, which is sewn in its native bed basically to the left anterior descending. And then here would be, this is also, they took, this picture denotes that it's a femoral artery. These can be veins as well. They don't have to all be arteries. This one is a grafted femoral artery to the right coronary. This picture itself just kind of shows what's going on. So that catheter is threaded up through the aorta. And again, this is for coronary angiography. And they bring that catheter into these vessels, dye is injected, and then they can visualize what's going on and see any stenosis. Now again, see how this vessel here is dotted out? That's because it's a left circumflex and it's behind the heart. That's why they have it dotted. And then this of course is our left anterior descending. And as you can see, this picture kind of denotes some narrowing of the artery and some stenosis in there. So that's what that is basically for. Now, if we're doing a true left heart cath, it does require that that catheter crosses the aortic valve. If they document a left ventricular atrophy, or they could state that they crossed the aortic valve, then we know we have a true left heart cath. So this would be not only those coronaries are imaged, but they're actually into the left side of the heart itself. These codes are split out again by 93458 and 93459. Difference being the 93458 is talking about your native arteries. And then again, on the 93459, we're looking at if the patient has any types of grafts. Now, sometimes, and it has to be well-documented, sometimes the physicians will do, they'll look at the LEMA and or the REMA, which again, LEMA is left internal mammary artery, REMA is right internal mammary artery. They can look at those for potential of bypass, and then you can build that 93459. But it needs to be clearly documented that they were looking at those for potential bypass use for a patient. So sometimes we can't intervene on the patient and their disease is too far advanced. So then they'll go ahead and do imaging on those LEMAs and REMAs to see if they would be good conduits to use for coronary artery bypass, which would then be performed by a CT surgeon. So let's take a little closer look again at that heart cath. So again, it does require placement in the left heart chambers. So it has to be in the atrium and it has to be in the ventricle. Now, sometimes how do we know that it's true left heart cath? Well, best case scenario would be that the provider document, I crossed the aortic valve, but that doesn't always happen. So there's other things you can look for that would tell you that, well, the only way that they could have done this is if they crossed that aortic valve. So for instance, a left ventricular gram. Now that is not required to do that LV gram, but if they do perform it, then you know they had to cross that aortic valve, but they don't always do that injection, especially if there's patients that have diabetes or they have kidney failure or anything like that, because the more dye you inject, the more stress that puts on the kidneys themselves. So they may or may not do that LV gram. So it's no longer a, back in the day, gosh, when I first started these, LV grams, they had to be done in order to be considered a left heart cath, but that was many, many, well over a decade ago. So that's no longer the case. So that's why the description will state if performed. Now, keep in mind, they don't have to do that LV gram, but they may talk about ejection fraction. If they have documented ejection fraction, they had to cross the aortic valve in order to get that information. Same thing if there's an LV pressure noted. So it might be documented as LV-EDP, which again is that end diastolic pressure, or it might just be documented as EDP. They may not call it the LV-EDP. So just look for these types of acronyms here in your report and then you know you have a true left heart cath. All right, so for the right heart, we're actually interested in what is going on on the right side of the heart. So we're looking at the right atrium, the tricuspid valves, pulmonary valves, the right ventricle. So these are the things we're looking for there. Our codes for these, so we have primary codes and we also have some add-on codes. So our primary code for just a plain old right heart cath is 93451. And that's going to measure oxygen saturation, any cardiac output, things like that, when they perform that. They can also do what's called a selective right ventricular or right atrial angiography. And that add-on code is 93566. I've also included on this slide the codes that are considered primary for that 93566. So it's not just the right heart cath, there's other things it adds on to. For 93463, that is an add-on code for pharmacological agent that assesses hemodynamic measures. So this would be, if you think about like a stress test and they can use that drug to stress the heart, they can also do this during a heart cath. This can be right heart, left heart, both, either way. But the caveat to this is there has to be measurements before the injection, after the injection, and during the injection. So it's not enough to just say, I injected during the heart cath. That doesn't cover it. We have to have those measurements before, during, and after. So for 93464, now this would be, again, the same type of measurements, only this time they have to do some type of exercise. So now the patient's either getting on a treadmill or an exercise bike during a heart cath. I don't see that done a lot, but it is an option. And again, we have to have that before, during, and after measurements. So for non-selective pulmonary angiography, this actually changed this year. The add-on code is still the same, but they revised it to basically state that this is non-selective pulmonary artery angiography. It is also used with several different codes, not just heart caths. So if you notice like the 33361, 333366, those are all of your TAVR codes. 33418 is mitral valve, so on and so forth. So just keep that in mind. Still an add-on code, but this one is now specifically non-selective. Selective means that catheter actually went into the muscle. Non-selective means the catheter could have just been in the regular aorta and they did an injection and then you can see that. Or it could be, you know, the pulmonary arteries can be seen from different injections that they do within the heart. But they also added, and again, this was all new for this year, they've also added 93569, 93573, 93574, and 93575. So basically this is selective pulmonary angiography. So we have 93569, that is a unilateral code. So that means they only went in either the right or left side, not both. So it's one or the other. If they do both, so if they do bilateral left and right pulmonary arteries, then you would code the 93573. Again, these are add-on codes. So we have to have that primary code billed first. If they look at pulmonary venous of each distinct pulmonary vein, you can also list this separately with code 93574. And then 93575 is actually selective pulmonary angiography of a major aorta pulmonary collateral arteries that are known as MAPCAs. And those are arteries that are rising off of the aorta and its systemic branches. This would mainly be focused around congenital disease. All right, so what happens if we do both right and left heart cath? Well, again, we have a series of codes. So 93460 is a right and left heart cath that includes injections for that LV1 performed. So what does that mean? That means not only did they do the right side of the heart, they also did the left and they crossed that aortic valve. For 93461, not only did they do the right and left and cross the aortic valve, but they also looked at those bypass grafts. So either the internal mammary grafts or any venous grafts. For 93456, so the right heart cath was performed, plus then they looked at the coronary arteries. But on this particular code, they did not cross the aortic valve. So it's not a true left heart cath. For 93457, again, it's the same thing as 56, only now, not only did they look at the native coronary arteries, but they also looked at any bypass grafts. So these are some add-on services that we do with caths and intervention both. So we have 93571, which is better known as FFR, that fractional flow wire is what they will call that. 93571 would be initial vessel, 93572 is for each additional, but you can only build that up to two additional times. So if they do IFR of the LAD, the RC, and the LC, then you can build the 93571 for the first one, and then the RC and the LC, the first one would be the LAD, and then you can build the 93572 two more times for two more arteries. If they happen to do IFR, which is a little bit different than the FFR, it doesn't use that pharmacological stress that's not performed, we have to reduce our code with a 52 modifier. So keep that in mind. Also keep in mind, sometimes you'll have one provider that will do the full heart cath, and then they'll call in an interventionalist, and the interventionalist will do those FFRs or those IFRs. If that happens, because these are add-on codes, you would have to report them with an unlisted code, because you wouldn't have the primary. You can't turn around and bill for all that angiography again. So keep that in mind, because that happens more often than any of us really prefer, but it does happen. We also have IVUS. IVUS stands for intravascular ultrasound, and these are depicted with add-on codes 92978, 92979. Same principle, 92978 is for the initial vessel. They can also perform OCT, which is that optical coherence tomography. You might see that. If you see the word OCT, you'll know it was an IVUS. And then they also have each additional vessel, which can be reported up to two times. So again, you could do a total of three vessels by IVUS imaging. If they do more than that, then that's, unfortunately, they don't get to charge for those. We also have an add-on code for a left heart cath that is performed through a transseptal puncture, and that can either be through a septum that's intact, or they have to do a transapical puncture, either way. Now, these are often reported with EP ablations, so that's your electrophysiology ablations, but they can also be done with your left heart cath, so just keep that in mind. It is an add-on code, so you would have to have a primary code to begin with. We also have an add-on code for aortography. Now, what are they talking about here? Because people get confused on this. They're actually looking at the root of the aorta itself. They're not talking about this part of the aorta, the ascending, the transverse arch, or descending. That is not enough. There's a separate code for that. For a true aortography, for that add-on code 93657, we have to be looking at the supravalvular ascending aorta, and it should also be performed at the time of a heart cath. And again, you're going to look for words that say root angiography, anything like that. You have to have medical necessity in order to code this. And what I mean by that, all especially for our newer coders, Medicare will put out what they call national coverage determinations or local coverage determinations. So just for instance, I live in Illinois, national government services dictates what the state of Illinois can do, what's considered medical necessity for heart caths in my state. So they will give a list of what diagnosis meet that. So that is what, if you don't have that medical necessity, then you shouldn't bill for it because you haven't met that. So sometimes we'll also have abdominal aortography performed at the time of a heart cath. The biggest thing about abdominal aortography, we need to know how many injections and where did they occur and what was imaged and interpreted from each shot. And I'm going to break this out a little bit more. So we're talking about here, on this one, we have the abdomen with runoff and that would be coded as 75630. So what does that mean? Well, it means that the catheter is placed here in the infrarenal area that has to be up in this area. They do one shot is what they call it, or one in basically they do an injection of dye and from this one catheter placement, not only do they image the aorta from the renals all the way down to the bifurcation, then they have imaging going into both legs. Now it must go from the iliac at least to the femorals in order to qualify for the 75630. Again, our catheter is not leaving the aorta, it's staying right here and they do one imaging shot is what they call it. And then you have the abdomen and then the runoffs of both the iliofemorals for both legs. Now there is some exception to that. You know, if you have a patient that has an amputated leg and they don't, you know, you can't visualize that far depending on how far up the amputation goes, then you would reduce it. But if it's just a normal anatomical procedure, imaging, then we have to have the aorta in both legs, at least to the femorals. So another way we can do this is by two positions of cath and this was probably the most popular that's done. So in this, in that instance, we either have, you have to have the catheter again in the infrarenal. It's not enough to talk about the distal aorta. They have to talk about what's going on in this area of the abdominal aorta. Keep that in mind, make sure your providers know this. They should, but in case they don't, because if they just talk about, I went into the distal aorta and they give me, you know, iliac imaging, that's not enough to code either the 75630 nor the 75625. So keep that in mind. They have to have, we have to have more than just the distal. But normally, so what can happen with the 75625, they start out in this infernal area, then they will pull down to the bifurcation. And when they pull down to that bifurcation, they'll do another imaging shot and then that will give both legs. Or they can be up here in this infernal area, pull down to the bifurcation and then selectively go, you know, so if they started off from the left side and then they come up to the aorta, remember, we're talking about the patient's left side, not an hour. So if they started in the left, they come up into the aorta, they do that imaging shot of the renals and infernal area of the abdominal aorta. Then they selectively come over here into the right side, whether it be common iliad, femoral, wherever. Wherever they park that catheter and they do another imaging, now you have 75710. If they pull back through the sheath, so they always put a sheath wherever they entered. If they pull back through that sheath and do another imaging of the left leg now, then you would have the 75716. So keep that in mind, people get confused about this. And which we do have a whole peripheral section too, but sometimes these are done in conjunction with heart cath, so keep that in mind. All right, so let's get into intervention. So there's lots of different ways they can intervene into the arteries. We have stents, we have balloons and we have what's called atherectomy. So balloon angioplasty would be the most basic that's done. So basically what they do is they would thread that catheter, see all this plaque and all this gunk. So they bring that catheter through this vessel, they inflate a balloon and that pushes all that plaque back against the walls of the vessel. Then they would deflate the balloon and pull everything up. That's for somebody that doesn't have a ton of plaque or they try to treat it that way first, but it doesn't always work depending on how much plaque buildup they have. So if that doesn't work, then they'll use a stent. Now the stent has this little lattice around it, it kind of reminds me of a fence. So what would happen here is they'll thread that stent through and usually what they'll do is they'll put a balloon inside of that, expand that balloon, which will expand that stent and then that stent will stay in place. Then they'll collapse the balloon and pull it back out. That's why if they do a stent, angioplasty is included because now you have to use that balloon to expand the stent. And then finally we have atherectomy. Now this I like to think of, I think of plumbing and I don't know if any of all of you have those, but it's called around here, it's called rotarooter. And what happens is tree roots will get into your sewer pipes and then your pipes get clogged up. So it's kind of the same principle. So they'll run a snake with a machine and they'll cut away at all your tree roots and gunk that's in the sewer pipe. So basically it's the same principle, only now we're talking about the arteries of the heart. So they'll break up all that plaque. It can be directional or it can be rotational, but that is how that's done. Now this can also be done with balloon and it would include the balloon, but then we also have stent and atherectomy. So keep that in mind. There's a code for atherectomy only. There's a code for stent and atherectomy and we'll get into the codes on the next slide. But angioplasty is always included in any of these and not separately reported unless that is the only thing that's done. So these are our primary codes for percutaneous intervention, better known as PCI. So we have stent and atherectomy. We have atherectomy alone. We have stent alone. We have stent and balloon. Then we also have these additional branches codes and we'll talk about this again. So remember when I talked to you about the left anterior descending and it had the diagonal branches came off of that? Well, they can bill for the main, the parent artery and then they can also bill for additional branches. Keep in mind though, they can only be reported up to two branches per artery. Now, also note Medicare will not pay for that. However, they do allow us to go ahead and report them because some of the commercial carriers will go ahead and pay for that. And you wanna make sure that you are reporting it if it's being done because the hope is eventually the more we report it, that eventually Medicare may change their mind and start paying for it. We also have what's called any method code. Now these are split out by, and again, I used acronyms. So we have 92941 for AMI, which stands for acute myocardial infarction. We have 92943, which stands for chronic total occlusion. We'll break all this down too. We also have 92937, which is done either in or through a bypass graft. And we have 92944, which is CTO additional branch. And we have 92938, which is an additional bypass graft branch. Bypass graft branch. Now keep in mind, so what do they mean by any method? So they can either do it a stent, they can do an atherectomy, they can do an atherectomy in a stent, they can just do balloon, it doesn't matter. That's not what we're concerned about. These codes are based on what is the condition of the patient. It doesn't matter what we use to intervene. What matters is what was going on with the patient. So if they have an acute MI, that means they're coming in, you know, they're coming in through the ER. You hear things such as door to balloon time, things like that. They're coming through the ER. They're symptomatic. They're emergently activating the cath lab. They're taking them into the cath lab, doing their angiography, and then they treat, okay? These are not planned procedures. If, let's say I come into the ER and I have an acute MI, but I'm very unstable and they want me to stabilize a little bit before they take me to the cath, and let's say they don't get me to the cath for three or four hours later, and I'm no longer symptomatic, so you no longer code this, this 92941, then we would revert to your normal stent codes. As far as chronic total occlusion, this means that the vessel is totally occluded. It's been going on for a while. Now, this would be a planned procedure for the most part. These aren't normally done alone. They can be done at the same time as an acute MI for a different vessel, but it's not normally done. They would wait till you were stable to treat that. But chronic total occlusion is a lot of extra work. That's something that's been built up for a long time. You know, the patient is not in the middle of a heart attack while doing this. This is, usually the rule of thumb is there has to be at least 90 days of this occlusion, so keep that in mind. This would be a planned procedure. The acute MI is emergent. So for the bypass graft, that means that they either had to treat the bypass graft of a patient or they had to go through that bypass graft to get to the native artery. That's what that means. The CTO does have a recognized additional branch. The bypass graft also has an additional branch. So you're probably like, well, Jolene, why doesn't the AMI have one? Well, because you only have, there's only one culprit lesion that causes your acute MI. So you might have lesions in branches off of your main artery, but that doesn't mean they all caused the acute MI, only one of them did. So that's why that is that way. So let's get into this some more, some more depth. So there are actually five major coronary arteries that the heart has. So we either have, we have the left anterior descending, we have the left circumflex, the left main, ramus intermedius, and then the right coronary. Out of those branches, only three of them have, or out of those parent arteries, only three of them have recognized branches for billing purposes. And I'll cover that here in a minute. Again, we have those any method codes. So it doesn't matter if it was a atherectomy, balloon, stent, a combination of all of that. The any method codes are split out by whether or not it's a chronic total occlusion, whether it's an acute MI, or whether those interventions went in or through a bypass graft. You also want to be sure that you bill and that it's documented. The diagnosis has to be specified in order to code these. So we need to know, is it truly a chronic total occlusion? Is it truly an acute MI? If we do not have that specificity, then it's, we have to resort to the normal codes. All right. So again, we have those five major coronary arteries. So the top three here, the LAD, the left circumflex, and the right coronary, they have those recognized branches. The left main and the ramus do not. I'm not saying that they don't have branches. They just don't have recognized branches for billing purposes. So there are two branches that are recognized for each set of parent arteries. So, you know, you think of your, you know, the parent artery would be the LAD and then the diagonals are the children of the LAD. When it comes to the circumflex, we're usually looking at marginals or better known as obtuse marginals. Right coronary actually has some of the most obtuse marginals. Right coronary actually has several, but they have the posterior descending, posterior laterals. You'll see that type of documentation. So let's talk about this concept some more as well. So all intervention that is performed in any segment of a main coronary artery is only reported with one code. So that means if they're in, if I'm going to pick on the LAD because that's probably the most popular. So if they're in the LAD and they put a stent in the proximal portion of that LAD, if they put a stent in the mid portion of the LAD and they also put one in the distal portion, you still only code that once, but you're going to code whatever most work that was done. So again, let's say they started with a balloon, they went to the stent, then you're going to code the stent. Maybe they ballooned the proximal and they ballooned the distal and they only put one stent in the mid. You're going to code the stent. Once they actually come out of that parent and enter into a branch, then you can code for those additional branches. If they perform an additional intervention in a third branch of that same major coronary artery, so the diagonals, you have one, two, and three. If they treat the LAD and they treat one, two, and three diagonal, you can only bill for the LAD and then two of those branches. The third one is not reported. So what's included in our interventions? Well, accessing and selectively catheterizing, that vessel is included, that's not separately billable. All supervision and interpretation, which is our imaging that's directly related, is not separately billable. Image performed to document basically that road mapping or if they do, because normally what they'll do is once they intervene, they'll shoot more dye into that vessel to make sure that it worked. That is not separately billable. That's not diagnostic. That's checking your work. Crossing the lesion is not separately billable, nor any closure. Now, there are codes for our ambulatory surgical places and then the hospital itself can code for any type of closure. The providers cannot, so don't bill for that. Also, temporary pacemakers, they're never ever billable with a left heart cath. They bundle or any type of cath, whether it be intervention, right heart cath, I don't care what type, it is bundled and there is no modifier that will allow you to override that, so keep that in mind. So again, let's look at this chronic total occlusion in a little more in-depth. So it is something that means there's no antigravity flow through the true lumen. It is suggested by angiographic and clinical criteria. So normally what happens, so the body does try to heal itself. So if they have that blockage in that artery and it's cutting off blood to the heart, to that area of the heart, the body will try to create little, they're called collaterals, and they'll try to bridge and go around that blockage to keep feeding blood to the heart. So that's when you'll see things like bridging collaterals are present. If the physician documents calcification at the occlusion site, no current presentation with an ST elevation or a Q wave. So that means, again, we're not in an acute MI if we're treating a chronic total occlusion. These are planned. This is not done emergently. Again, for that acute MI, we have that percutaneous transluminal revascularization of either an acute total or subtotal occlusion. Again, the patient has to be symptomatic. It doesn't matter if they're in a coronary artery or a coronary artery bypass graft. So any method codes, that bypass graft code, you would not code a 92941 with that 92937. You would strictly code the 92941 because that's where your acute MI happened. Now, let's say they did an acute MI in the LAD and the patient also had, and then they went through that bypass graft, you're still gonna code that 92941. Well, let's say they also have a lesion over in the right coronary artery, which is not attributed to that acute MI, and they go through that graft to treat a lesion there, then you could code the 92937 with that RC modifier. You'd have to put that muscle modifier on there, and then more than likely a 59 or an X modifier to unbundle them. But in that case, you could code both. Keep in mind, this also includes any aspiration thrombectomy when performed. You cannot bill for aspiration thrombectomy separately. It's only mechanical thrombectomy. We'll talk about that in a little bit too. So again, this is from CPT assistant 2014 in January, and this talks about what is considered an acute MI or what's during acute MI. So again, we have this ST elevation that's not attributed to a bundled branch block. It's new or undetermined left bundle branch block. New or evolving Q waves. This all has to do with what's going on on that EKG. Persistent horizontal ST depressions. Again, that would be found on that EKG. Any ongoing ventricular tachycardia, ventricular fibrillation. Any pulseless electrical activity or a systole in a clinical scenario that's consistent with an acute MI. Basically, the patient has ongoing symptoms and of an acute MI. That's number one. Number two. Again, we have that emergent coronary angiography and PCI are performed. Once it's diagnosed, they get that patient urgently to that cath lab, then it's considered acute MI. Doesn't matter if it's during off hours or whatever. The patient is emergent. The biggest thing is this is not planned. And then intervention is performed on that target lesion that's 100% thrombolyzed and an acute myocardial infarction. Another thing you can look for is TIMI grade. TIMI has to do with, that's that thrombolysis and myocardial infarction. That's what it stands for. So if a physician documents TIMI grade flow zero, you know that that is 100% blocked off and that we're doing an acute MI. It could also be subtotally occluded. So it doesn't have to be 100%, but it's darn close. All right. So for the purposes of PCI coding, the following scenarios do not fulfill the designated requirement of during acute MI. Non-cardiac chest pain is not an acute MI. Unstable angina is not an acute MI. An NSTEMI or non-ST elevation, there is an exception of that. Let me go back to that one. But if they're no longer symptomatic, so that myocardial infarction is complete and now we're just treating it non-emergently. If the PCI, the thrombotic coronary lesion is performed non-emergently after a recent MI. So again, and you know, sometimes people don't make it to the hospital in time to be considered acute MI. Maybe their symptoms went away, but they obviously had one. So you still can't code that as an acute MI. Now let's talk about this NSTEMI. There is some exception to this rule if they have ongoing symptoms. So a lot of times NSTEMI happens, the patient doesn't even know they had a heart attack. A lot of people think maybe they have indigestion. Because they do mimic each other. But if the patient comes in having problems, even if it's an NSTEMI and there's an emergent activation in the cath lab and the patient is symptomatic and they do have a subtotal or total coronary occlusion of a culprit vessel, then you could code it as an acute MI, but that doesn't happen very often. Again, we have, this is from the CPT assistant, that target vessel for acute MI is inclusive of all balloon angioplasty, atherectomy, stenting, aspiration thrombectomy, all of that stuff is included in that acute MI code. Mechanical thrombectomy is separately reported. Keep in mind for the mechanical thrombectomy itself, as of this broadcast is angiojet only, nothing else. I know there's a catheter out there called a benumbra catheter, but it still has the word aspiration in it, therefore it's an aspiration catheter. And no one has come out to say, oh yes, that's considered, no one in the authority, I should say, has come out to say, yes, that is considered mechanical thrombectomy. So until we see guidance from either the AMA or any of our Medicare carriers, as of now, angiojet is the only one that's approved. So let's talk about the bypass graft codes, 92937, 92938. So this code applies whether that lesion is in the graft or if you have to go through the graft to get to the native artery. If the lesion involves a branching or a Y graft, if both sections of that Y graft are treated, both are coded. Keep in mind though, that sequential graft only represents one graft, even if it has more than one distal anastomosis. So make sure your providers are documenting correctly. And if you have any question and you're not sure, then you need to check with them. Was this a Y graft or was it sequential? If you see the word sequential, it's considered one graft. You can also use two base codes, which would be one bypass and one primary if lesions in both native and in or through bypass are treated. And then this code also applies of any method, doesn't matter. So if it's a stent, a balloon, an atherectomy, or a combination of those, it's still coded as that bypass graft. The only exception to that again is that acute MI. That acute MI trumps the bypass graft code. It's rated higher. So for coronary lithotripsy, this is an add-on code 92972. It is done in conjunction with other interventions. So you would use this code with 92920, 24, 28, 33, 37, 41, 43, and then 92975. Keep in mind that this is done per vessel, not per use in the same vessel. So if they do this lithotripsy with the left anterior descending, for example, and then again with the right coronary artery, you would bill it twice. But if they do multiple in the left anterior descending, you would only code this once. All right, so let's talk about some of our best documentation, the best practices for our clinical documentation. We need details. Coders are, you know, we're very detail-oriented. We want specifics. We want the story. So, you know, talk with your providers and say, I need to know the details so I can code this correctly. If you just tell me that you placed a stent in a patient and you didn't tell me and it was an acute AMI, well, then I just build a stent. So, again, same with those chronic total occlusions. They need to specify. Now, let me back up on that too a little bit. Total occlusion is not the same as chronic. Chronic means it's been there a while. So, if it's an acute total occlusion, more than likely you're having that acute AMI. So, but if, you know, if they bring them in a different time, they're not symptomatic and they say this vessel is totally occluded, but they do not use the word chronic, then you cannot code it as a chronic total occlusion. You want to make sure your diagnoses are matching if billing that acute AMI. You don't want to code an acute AMI for the right coronary if they're treating an acute AMI of the left anterior descending. So, make sure that the diagnosis match what you're doing. We should have good details on when that acute AMI occurred. We're looking for symptoms. We're looking for the word acute. Clinical details are very essential in a cath report. We need all the clinical data we can possibly have, so it's important that your providers document that. All right, so let's look at some of our coding guidelines. So, again, we have our major coronary arteries and our additional branches. We're going to bill the highest primary code per major coronary artery. So, let's talk about those branches and that parent. So, let's say they actually put a stent in the diagonal and then they ballooned the parent LAD. If that happens, you still want to bill your stent as the primary code, and then your balloon would be billed as your additional code, so keep that in mind. If the major work is done in a branch, you treat it as if it was done to the parent. For those branches, you can bill up to two branches, again, for the LAD, the circumflex, and the right coronary. You can bill any method codes for acute MI, CTO, and bypass in place of primary and additional code. So, if they do an acute MI, let's say they have an acute MI in the LAD and then they also have, they put an additional stent in that diagonal, you're going to code that 92941 for that acute MI, and then you would code the additional stent code for the diagonal, which would be off the top of my head, 92929. So, keep that in mind. So, you're going to use one primary code for each coronary artery treated, and then any additional are limited to the artery where the primary code has been used. So, if they do the left main and they talk about treating a branch off the left main, you only code the left main. That's the same with the ramus intermediates, because they do not have recognized branches for billing. So, what do we do if we have lesions in two vessels? So, if a lesion extends from one target vessel, major coronary artery, coronary artery bypass, or coronary artery branch into another target vessel that can be revascularized with one intervention, which bridges the two vessels, you only report one. So, again, let's say we have stenosis here in the left main, and then we also have stenosis that comes into the LAD. Let's say it's a contiguous lesion, right, and then they put in one stent, and that stent is long enough and covers the left main and the LAD. You're going to code it as one intervention, and you would code it with the LAD, because that's the furthest away. That's the furthest, but if they had a lesion here, and then we have native, and then we have another lesion here, and they stent the left main, and then they also stent the LAD, then you can code both. This also applies with bifurcating lesions. So, like here, we have the LAD, and then it's branching off into one that's diagonal. When that happens, you can't, you know, if that lesion is bridging or it's in that Y shape, well, stents don't go around corners, so you would have to do, or atherectomy, whatever, whatever you're doing. Same with balloons. Since you're treating both, you would code one as the parent, and then the other one as the additional. All right, so let's talk again about this mechanical thrombectomy. Again, it is only angioject that is considered the approved FDA method of performing mechanical thrombectomy. All other devices, Export, DiverCE, Fetch, Pronto, all of those things do not mechanically actually, they don't mechanically break up that clot. They actually use some type of aspiration in a back-and-forth manner that is not mechanical thrombectomy, regardless of what any of these owners of these, you know, whatever the vendors tell you, Medicare has not come out, nor has the AMA, and said, okay, yes, you can go ahead and build this stuff for mechanical thrombectomy, so keep that in mind. All right, and this is just kind of expanding upon that more, and I think we've talked about that enough. All right, so what's some other billable services that we do? Well, they can also place balloon pumps. They can insert a balloon pump percutaneously with code 33967, and you can also bill for a removal of a balloon pump. Now, this would have to be a separate setting, that removal. You're not going to remove and insert and remove at the same setting. If they perform that, you would only code for the insertion. We also have ventricular assist devices. You've seen Impella, the Tandem Heart, 33990 is those Impellas. 991 is the Tandem. We have code 33992, which is removal, and then we have 33993, which is repositioning. Again, removal and repositioning would need to be done at separate sessions in order to code for them. So, let's talk, too, a little bit about modifier 22, because sometimes people have difficult anatomy. It was a very difficult case, and there is a modifier that can be placed that can possibly give you an additional 20 percent in reimbursement. Now, here's the thing with these. Some carriers, they don't care. They're not going to pay them, so you need to find out what your carrier stance is on it and whether or not it's worth the time and effort to report the modifier 22. Whenever we add a modifier 22 to a claim, the carrier is going to request documentation to support that modifier 22. If the best scenario for that is your providers need to plead their case in a separate paragraph within that procedure note explaining why they feel this was a more difficult case. So, again, was the patient morbidly obese? Did they have aberrant anatomy? What was going on that you feel you need this extra money? Did it take you extra time? So, like a lot of times I tell my providers, if a heart cath and an intervention normally would take you a half hour and you spent three hours, then you need to document that. What'll happen is you'll send that off. The carrier will request the note. A reviewer will look at that note in order to make that decision, but all of this takes time to do. So, anytime you add a 22 modifier to a procedure, it holds up the entire claim. So, let's say we did an acute MI. We put a 22 on that. They also did a left heart cath. They did an IBIS. They did moderate sedation. All of those other codes, that entire claim is held up until that 22 has been resolved, and sometimes that can take up to six months. So, again, keep that in mind, and if your carrier is not one that will reimburse, then you're holding up cash flow coming into your practice in order for this stuff to be adjudicated. My recommendation is always somebody in authority in your billing office should review these prior to just sending them off. All right, moderate sedation. So, let's talk a little bit about moderate sedation. It's also known as conscious sedation. Now, a few years ago, they unbundled moderate sedation and pulled it out of heart caths, interventions, things like that, EP studies. There's lots of different things that moderate sedation is done with. They have basically reduced all procedures by 0.25 percent in order to accommodate for this moderate sedation billing. So, it does add up. So, if your doctor's normal heart caths have now been reduced, because some providers are like, I'm not going to mess with it. I won't deal with the documentation. I don't care. All right, well, then all of your heart caths or all of your interventions are now reduced by 0.25 because you're not willing to dictate this moderate sedation. So, there are some guidelines. Now, this is not to report any pain control medicine. It is not to report minimal sedation or deep sedation or any anesthesia that's monitored by an anesthesiologist. It does require that an independent trained observer who is qualified will monitor that patient during the procedure. They have no other duty other than to monitor that patient. They should also be documenting the patient's status throughout the procedure. So, these codes are, we have 99151, which is for patients that are younger than five years, and we have 99152, which is where we're focused today because we're talking about adults. That is for patients age five years or older. This does include the initial 15 minutes. So, and your CPT book does specify as long as there's at least 10 minutes documented. So, we need to know the start time and then when the physician's face-to-face time ended. So, if it ends up being eight minutes and 32 seconds, that's not enough to code the 99152. For code 99153, notice it has an asterisk. The reason why is that is for each additional 15 minutes of service time of moderate sedation. However, that is billed by the facility, not the provider. So, the hospital can bill for this. If you have your own freestanding cath lab or better known as an OBL, then your practice can code for that 99153 in 15-minute increments, but otherwise it is not billed. So, if your providers are dealing with patients in the hospital, then they would only code the 99152. So, pre-service work is not included in that intra-service time. So, you're not going to count any of that time prior to administering the sedation itself. So, you're not going to count going over the patient's medical and surgical history, any of their patient's previous experience with anesthesia or their family history of any sedation complications, blah, blah, blah. You also are not going, you know, if you're talking to them about any drug allergies or intolerance, you do some type of physical exam, do any pre-sedation diagnostic test. None of that is counted. It counts once the sedation is actually administered. So, that's what I basically just said. It begins with the administration of the agent. It ends when that procedure is complete and the physician walks away. The patient is stable for recovery status. That continuous face-to-face monitoring time has stopped between the provider and the patient. Intra-service time does include any ordering and or administering any additional or subsequent doses. So, if they have to keep giving additional doses, that's all included in that intra-service time, and it does require monitoring that patient's response. So, again, that should be documented. Post-service work is also not included in the intra-service time. So, once that provider's done, walks out of that room, and that face-to-face time has ended with that patient, it's over. Any of that post-service work is not included. So, you know, once they're in recovery and you have, you know, there's people there monitoring the vital signs, the level of consciousness of the patient, assisting in any of that post-sedation recovery, none of that time counts. It's only once the drug is administered and once that procedure ends. Again, this is just kind of going over that documentation requirements. So, you're going to want to include initial sedation, begin and end time, include any of that ordering and or administrating any of that subsequent doses. You have to document that a trained independent observer is there. It's best to name that person in that documentation, and then, of course, you're going to use language that mirrors the CPT terminology, such as total time spent was something to that effect. You have to have that total time, either start and stop, that's probably the best, or total time spent. We cannot use phrases such as approximately 45 minutes, approximately nine minutes, nothing like that. We have to have either start and stop, which is preferred, or total time spent. All right, some final thoughts. We're going to code the cath based on where the provider went, and what they imaged. We're going to code interventions, and the first thing we want to look for is any method procedures first, so we don't want to just go through and go, oh, it's a stent. I'm billing a stent. We want to go through, did the patient have an acute MI? Was that stent placed in a graft, or did they have to go through that graft to get it? Were we treating a chronic total occlusion? We want to make sure that you know exactly what's going on before you just start grabbing code. Again, you're going to code your interventions by location, and what type it was done. Capture all applicable add-on codes, and any other additional procedures that are performed. Bill that moderate sedation if the requirements are met, and as always, if your carrier allows, and it's appropriate, code those 22 modifiers. If you can, send any questions that you have to revenuecyclesolutionsatmedaxiom.com, and either myself or a member of my fabulous team will be more than happy to help you out. Thank you.

Cardiovascular Coding

Coronary Angiography

Interventional CPT Coding

Heart Anatomy

CPT Coding Guidelines

Documentation Requirements

Acute MI

Chronic Total Occlusion

Bypass Graft Procedures

Moderate Sedation

Modifier 22

accurate documentation

modifiers

coding guidelines