1. Contrast injections, angiography, roadmapping, and/or fluoroscopic guidance for the coronary intervention,
2. Vessel measurement for the coronary intervention, or
3. Post-coronary angioplasty/stent/atherectomy angiography.
1. No prior catheter-based coronary angiography study is available, and a full diagnostic study is performed, and a decision to intervene is based on the diagnostic angiography, or
2. A prior study is available, but as documented in the medical record:
b. There is inadequate visualization of the anatomy and/or pathology, or
c. There is a clinical change during the procedure that requires new evaluation outside the target area of intervention.
This statement has left many scratching their heads wondering what is medically necessary, so here are a couple of hard and fast rules I live by.
First Trip to the Cath Lab
The first tip is the easiest. If the patient has never had a trip to the cath lab, it’s a diagnostic angiogram. Even though the physician may have a good idea going in that something is wrong, based on patient symptoms and tests, the diagnostic imaging will definitively show him what’s causing the patient’s signs and symptoms.
Quick Door-to-Balloon Time
Hospitals pride themselves on quick door-to-balloon times for patients who have suffered an acute myocardial infarction (AMI). It’s such a big deal that there’s a CPT code specifically for PCI in a patient suffering an AMI (92941). Patients who are rushed to the cath lab for PCI during an AMI are going to have diagnostic imaging first; they are looking for the source of the AMI. If you find yourself assigning code 92941, or the companion HCPCS codes for a drug-eluting stent (C9606), then you should also have a code for the diagnostic imaging with modifier 59 or XU to show that it was truly separate and distinct.
New Symptoms
When the patient has experienced new symptoms since his/her last coronary imaging procedure, the imaging is separately reportable. For example, a patient who had a cardiac catheterization the week prior, presents with increased chest pain and EKG changes that are new since the previous exam. The patient is taken to the cath lab and a blockage in the right coronary artery is stented. In this case, the patient’s condition worsened since the last exam and the physician was looking for the cause.
When Diagnostic Imaging isn’t Diagnostic
I’ve seen the gamut of excuses when it comes to coding diagnostic imaging when it isn’t truly diagnostic. Obviously, if the patient had a diagnostic exam by another physician but the report is not available to the current treating physician, a diagnostic angiogram is warranted and can be coded separate from any PCI procedure. That doesn’t count a report that is available, but the current treating physician doesn’t trust the results from the other physician (yes, that’s a real excuse!).
Often physicians will separate the PCI procedure from diagnostic imaging because of the amount of contrast used during the initial cardiac catheterization. For some patients, it’s simply not safe to keep administering contrast for PCI, so they bring the patient back to the cath lab a day or two later. For the second trip to the cath lab, all imaging is considered guiding shots for the PCI unless there has been a change in the patient’s condition, warranting further study (I refer you to “New Symptoms” above).
Diagnostic Imaging Diagnoses Something
All things considered, I think the best way to decide when to code diagnostic imaging separate from PCI is to remember that the purpose of “diagnostic” imaging is to “diagnose” something. That may seem like a “no duh” statement, but it’s amazing how complicated we make the issue of whether to code diagnostic imaging separate. When the decision to perform PCI is based on the results of imaging, that imaging is diagnostic. When the physician knows going into the procedure what is wrong and what treatment the patient needs, the imaging is guiding shots for PCI.
Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer
Senior Consultant
Kristi is a senior consultant with more than 20 years of industry experience; she is responsible for the development of web-based, instructor-led, and webinar training materials; conducting training in ICD-10-CM/PCS and CPT; and performing DRG and APC audits. Kristi has an extensive background in coding education and consulting and is a national speaker on topics related to ICD-10 and CPT coding as well as code-based reimbursement. She has designed and developed training programs for inpatient and outpatient hospital-based coding, including vascular interventional radiology, interventional cardiology, orthopedics, and obstetrics.
Kristi has served the Colorado Health Information Management Association (CHIMA) as board Director, co-chair of the Data Quality Committee, and co-chair for the ICD-10 Task Force. She is also a past president of the Northern Colorado Health Information Management Association (NCHIMA). Kristi devotes extra time to mentoring current and future coders through her Coder Coach blog and is the proud recipient of the 2011 AHIMA Triumph Award for Mentoring. She has also received awards from CHIMA for Distinguished Member (2018) and Outstanding Volunteer (2013) and from AHIMA for Roundtable Achievement in Coding Excellence (RACE).
Hi,
We have one MD that does a cath and frequently sends the patient home and then brings them back in 2-3 days for PCI…most of the other docs do PCI at time of cath??? Is this ok to do and does it change the reimbursement?
Hi Pam – Thank you so much for your inquiry. Here is the response from our team:
There are various factors that are considered when deciding whether to perform PCI on the same day as a diagnostic study. This can range from physician preference to concern for administering too much contrast in a single encounter, which can be hard on the kidneys. When a patient has a diagnostic study and is then brought back a couple days later for PCI, in most cases, it will not impact the codes reported or the reimbursement.
CPT guidelines prior to code 92920 state that diagnostic angiography performed at the time of PCI may be coded separately with modifier 59 (or XU) if:
-The patient has not had a prior catheter based study, or -A prior study is available but a) the patient’s condition has changed since the prior study, b) there was inadequate visualization of the patient’s anatomy, or c) there is a clinical change during the procedure requiring new evaluation outside the area targeted for intervention
For physicians performing the diagnostic study and PCI in the same encounter, the PCI code is assigned along with the diagnostic study. Modifier 59 (or XU) is appended to the diagnostic code to bypass the NCCI edit since both services were mutually exclusive.
For physicians performing the diagnostic study on one date of service, the diagnostic study code without a modifier is assigned. When the patient returns for PCI, all imaging performed to complete the PCI is bundled into the PCI code and no diagnostic study is reported. Again, please refer to CPT coding guidelines for exceptions to this rule.
Excellent article and pure commonsense. It is easy to assume we can bill the angiography in every case but medical necessity has to be evident and clearly documented. Why subject a patient to unnecessary contrast exposure if you have all the information you need?
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