Alright, the first one, this is the 2 and a half hour one: coding cardiac catheterizations. It seemed like an innocent little question. So I need help in billing cardiac caths. I’m new to cardiology and she gives two patient examples. So what I want to do is teach what cardiac caths are and then go and try to answer the questions.
So let me click on my little answer sheet and hopefully, that would pull up correctly. Yeah, we had to go to making separate sheets to do the answers for your questions because it’s just so much, we can’t fit them on the slides.
Coding Cardiac Catheterization Video
First of all, when I teach this to my students, I make them stop a minute. We hear it all the time but sometimes, as a coder, we need to stop and ask, “What is it really? What are they doing?” And it’s a diagnostic procedure. They’re not trying to fix anything. They’re trying to diagnose a problem. And the way they do that is with imaging. They want to take a picture of the heart and in order to get a good image, they need to get dye going through the vessels so they can visualize that. In order to get the dye in, they got to put a catheter up there. So if you can keep that in mind, that will help you. I did find really, two excellent YouTube videos that are designed more for patients who are about to get the procedure but very, very visual. I will invite you to go ahead and click on them. Even if you go to YouTube and just Google cardiac catheterization procedure… not Google, YouTube. And for our Replay Club members that get that handout packet you know, this will be hyperlinked and you can go check it out. [Ed. Note: see handout for the hyperlink.]
So prior to 2001, when you coded a cardiac cath, you actually needed 3 codes at a minimum. You needed 1 catheterization code to say if it’s the one on the right or the left. You needed one or more injection codes, because wherever you inject the dye would get a code, and then one or more imaging codes, you know, where did you take images? Was it of the chambers of the heart? Was it of coronary vessels? So in 2011, they came out with packaging these cardiac cath codes.
So what you need to actually go in and abstract for when you’re looking at a cardiac cath report is was it for congenital reason or not? Because that’s going to change how you do your coding. That’s the number 1 thing you need to figure out. Then you need to figure out which side of the heart was catheterized. Was it the right, the left, or both? Then the last thing is are there any add-on procedures that were done, that you’re allowed to code as well?
So for my day job, I had to update these codes in 2011. And so I was like… as I said many times in this webinar, I’m a very visual learner and I was reading all the changes and I’m like, “I’m not getting it.” So I had to make my little chart so I’m going to share that with you here. And by the way, CPT has their own chart on page 493 to 496 if you have the professional version. But for me, that wasn’t working. It was on 4 pages, it was unwieldy and it wasn’t how I thought I wanted to start with, the way the reports often start out, “which side are they doing the catetherization?”
So that’s what I look for in the report first. Is it a right heart cath only? A left heart cath only or combo? Okay… or it could be vessels only. Sometimes, they don’t even go into the chambers. They just look at the vessels, the major coronary arteries around the heart.
So for a right heart cath, the default code, if you will, is 93456. And these are all in this chart, non-congenital codes because the non-congenital codes bundle in the injections and the imaging now. They didn’t use to but now they do. So it’s just one code to report that. Now if it was also done of bypass grafts because many times, they’ll do cardiac caths to make sure the grafts are still open and the blood’s flowing through them nicely still, that’s going to be code 93457. And that again, includes injections and imaging.
Then we have the right only and this one does not include any coronary artery so just going into the right heart chambers. That’s your 93451. Then your left heart cath, same pattern. The default with bypass grafts, left ventricle only, they include the injections and imaging. Combo, same thing. Default with bypass, just the ventricle only. They all include injections and imaging. So by putting it in this visual, you’re like, “Oh, these aren’t so hard after all.”
Okay, vessels only, if it’s the native vessel, meaning the vessel you were born with… it’s not a bypass graft vessel, it’s 93454. If it’s a native vessel and a bypass then it’s 93455. And again, both of them include injections and imaging.
Now here’s some add on codes, injection add on codes. The right ventricular or right atrial angiography is not included. A lot of coders think that it is and the codes that I just went over for the right heart cath. It’s not. This is an add on code. You’re allowed to bill that if it was done. If they do an aortic… imaging of the aorta, that’s your 93567. If they do of the pulmonary vessels, pulmonary angiography, it’s 93568. So these codes can be added on to one of the primary catheterization codes.
Then other add on codes are… normally, when they do a cardiac cath, they will start the catheter in that nice, big, juicy leg vein and thread it on up. And that YouTube video shows that very well. But sometimes, they can’t do that. They have to go through a different way. And if it’s a transseptal route to get there, they literally go through the septum of the heart, it’s 93462 as an add on code. So it increases in the RVU, the value of what the physician’s going to bill out. If pharmacologic agent administration was done, you can bill the add on code 93463. And if a physiologic exercise study was done at the same time as a cardia cath then it’s 93464.
So hopefully, this chart will help you and for the Replay Club members, you’ll get access to that as well.
So that was for non-congenital. If you’re talking about congenital condition that a cardiac cath is being done for then you’re going to use this code range here, 93530 to 93533. I was going to show you my document camera but it’s acting up. Now this, the congenital ones, do not include the injections so you can bill for them separately. That’s what got me really confused when I looked at these changes was they were saying that, “Oh, now injections and imaging is bundled in.” But then I saw these injection codes. I’m like, “Wait a minute.” But when you really read them carefully, you’ll see they all say congenital, either in the code description or in the parenthetical note. So that’s the difference and that’s why that’s the number 1 thing you need to ascertain. Is it a congenital problem or not?
Now this is starting to get into the person’s question. If diagnostic angiography is performed during the same time as therapeutic… so we’ve got diagnostic – trying to figure out what’s wrong, therapeutic – trying to fix something… you can append 59 to the supervision and interpretation codes. And you’re allowed to bill them in addition to. Now for supervision and interpretation, we did that last webinar so… and I believe… yes, Boyd just put up the video clip for that so it’s on the website so you can check that out if you were in attendance last month and that will kind of go into that stuff.
S&I codes are not used to report post intervention injections in the coronary vessels to determine level of effectiveness. Those are bundled in. You do a procedure and then you do something to double check to make sure everything’s okay before you close up, so to speak. That’s bundled in. And you can get more information on that in the CPT Changes 2011 Insider’s View book. If you belong to any encoders online and you pay extra for the CPT Assistant-type access, you might have access to this as well.
Also, cardiovascular stents and other therapeutic interventions, I was asking Alicia, “Didn’t I cover that?” So I went and actually Google-d my own site and sure enough, we have two videos where I have covered that. So I put the hyperlinks in here for you know, when you get the transcript. But if you just go to www. and type in stents in our search box, you’ll find these two video clips to look up the stents. And basically, it’s things that are done to the vessels to treat them. So the cardiac cath is to figure out something that’s wrong. A stent will bridge open the vessel if it’s got a weakened wall. And then we’ve got plaque removal codes, that kind of thing.
So the reason I mentioned all that is because the questioner said it was a cardia cath question but there is also questions about these procedures, highly, highly abbreviated. So she said, “The doctor did a 93459 with a stent, an IVUS on the LAD and descending aortagram. On the second patient, did the same thing, with a stent IVUS, FFR, and an LAD.” So first of all, we need to define what all this alphabet soup is. The first thing is defined is the code and basically, 93459 is the left heart cath. If we go take a peek at that again right here, this is the one with bypass grafts. Okay so now, that one code is telling the story, the catheterization’s on the left side. It’s with bypass codes and we don’t bill injections or imaging separately because it’s bundled. So that takes care of the first thing and of course, you gave me the codes. That wasn’t hard for me to figure out.
Then she said stent and IVUS. LAD is actually referring to the vessel. So there’s a left anterior descending coronary artery and you need to figure that out because there are some procedures that are done on non-coronary vessels and then those that are done on coronary. So you need to make that distinction. So the LAD is a coronary artery then and IVUS was done. That’s intravascular ultrasound which basically is allowing you to look at a vessel from the inside out. It’s kind of cool. And there is a great site, angioplasty.org, if you want to go read about that. It’s very, very good reading.
And so the code for that is 92978. This is the coronary one. Now there’s one in the 30,000 series but that’s for non-coronary IVUS. Okay so that would be the code that. So far, we have the 93459 and the 92978.
Now for the stent, again, there are stents in non-coronary vessels and then there are stents in coronary vessels. So this one is 92980, transcatheter placement of intercoronary stent or stents. Okay and then for the descending aortagram.. because we’re dealing you know, with the heart and the descending aortagram, typically… and I don’t have an op report to go by… but typically, that might be done just to evaluate the site of where they put the catheter to make sure everything was okay. So I don’t think there’s a separate code for that so I didn’t put a code for that.
And then FFR, that was in the second abbreviated situation here and that stands for Fractional Flow Reserve. And that code is 93571 for the initial vessel. And if you do more than one in that same session then there’s an add on code, 572.
Okay so that’s kind of how you break it down. I hope that helps understand the cardiac caths better.
Alicia: I might add too, only because someone asked me the other day you know, what does congenital mean? And it’s real simple, it just means you were born with it.