One of the most complex areas of coding for cardiac catheterization procedures is determining when to code a diagnostic heart angiogram (imaging) separate from a percutaneous coronary intervention (PCI). The guidelines for reporting separate diagnostic imaging are found under the heading Therapeutic Cardiovascular Services and Procedures on the Coronary Vessels (92920-92979) in the CPT book and give clear instruction that diagnostic imaging should not be used in conjunction with PCI procedures to report:

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.

This has led many coders to believe that it is never appropriate to code imaging separate from the PCI. However, the guidelines go on to state that diagnostic angiography may be reported if:

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:

a. The patient’s condition with respect to the clinical indication has changed since the prior study, or
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.
And what does the National Correct Coding Initiative (NCCI) manual have to say about it? The NCCI manual states:
Percutaneous coronary artery interventions (e.g., stent, atherectomy, angioplasty) include coronary artery catheterization, radiopaque dye injections, and fluoroscopic guidance. CPT codes for these procedures (e.g., 93454-93461, 76000) shall not be reported separately. If medically reasonable and necessary diagnostic coronary angiography precedes the percutaneous coronary artery intervention, a coronary artery or cardiac catheterization and associated radiopaque dye injections may be reported separately. However, fluoroscopy is not separately reportable with diagnostic coronary angiography or cardiac catheterization.

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

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).

2 Comments

  1. Andrew Matheson

    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?

    Reply

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