Significant Changes to Peripheral Vascular & Cardiac Catheterization

By Michelle Reese, CPC

2011 brought considerable changes to Cardiology, specifically in the coding of cardiac catheterizations and peripheral vascular studies/interventions of the lower extremities, (now called endovascular revascularization services), AND in their reimbursement. The changes we see in these two common areas of Cardiology result from the bundling of component services said to be performed together over 95% of the time. New PV rules are now similar to those followed for coronary interventions.  Bill only for the most intensive service provided in the vessel.

Almost all cardiac catheterization codes have been deleted and were replaced with new bundled service codes.  The new code descriptions have combined heart catheterization, injections, and imaging supervision and interpretation into single codes depending on the procedure being performed.  For example, the frequently performed left heart catheterization commonly reported in 2010 with codes: 93510, 93543, 93545, 93555, and 93556 will now be reported with a single code 93458 – Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed.  New single codes have also been created for left and right heart cath combinations, coronary only studies, cath with injections for bypass grafts/internal mammary/venous grafts, etc.

Significant changes have also been made with the codes for lower extremity peripheral vascular interventions. Bundling of all lower extremity interventions. In the past, multiple codes may have been used to report when angioplasty along with atherectomy and/or stent was performed.  The new codes simplify reporting of multiple revascularization procedures.  For example, in 2010, an angioplasty, stent, and atherectomy of the common femoral artery could potentially be reported with three codes: 37205, 35474, and 35493.  At times there has been uncertainty as to the circumstances when each of these codes may be reported together.  The basic rule of thumb has been based on the intent of the procedure, and was dependent on accurate physician documentation of that intent. (Suboptimal results, anyone?)  In 2011 intent becomes a moot point as these three procedures, when performed at the same encounter, are reported with the single code 37227, eliminating any uncertainty.  Code 37227 reads: Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed. 3 new vascular territories: Iliac, femoral/popliteal, and tibial peroneal. The new codes include catheter placements and radiological supervision & interpretation, and are no longer separately reimbursable.  Post intervention image codes are no longer separately billable. Diagnostic S&I (70000s) codes MAY be billed when performed at the time of the intervention IF no prior angiogram has been performed, or if patient’s condition has changed remarkably since the last angiogram. Append modifier -59.  Diagnostic angiography performed at a separate session from an interventional procedure is separately reported.

In addition to these changes, Category I CPT codes for atherectomy of vessels in other anatomic sites have been deleted and replaced by Category III CPT codes, 0234T – 0238T. The open atherectomy codes 35480-35485 and percutaneous atherectomy codes 35490-35495 were deleted for 2011.

So what revenue changes can we expect due to these new comprehensive codes? HCFA may sometimes change the relative value or work RVU of a procedure to reflect changes in the resources needed to perform the procedure, and this is exactly what has occurred with many of our codes for 2011. New codes reflect huge losses in work RVUs.  Impact to PV physicians could be great if compensation is based on RVUs.

Because of the complex bundling and variety of methodologies used this year to develop RVUs for the new comprehensive codes, the actual payment changes for these services are difficult to calculate.  However, these bundling changes have impacted the endovascular revascularization services more significantly than diagnostic cardiac catheterization services.

Work RVUs for comprehensive endovascular revascularization services will be on average 27% lower than the summed work RVUs of the component services, but the combination of the lower RVU and bundling of catheter placement codes and supervision/interpretation codes has actually reduced the overall reimbursement of these procedures by about 56%.  The American Medical Association/Specialty Society RVS Update Committee (RUC) made this recommendation and CMS was in agreement with this revaluation. 

For the comprehensive cardiac catheterization codes, the AMA RUC and CMS did not see eye-to-eye.  The AMA RUC recommended a methodology that would have the work RVUs be on average only 1% lower than the sum of the work RVUs for the component services included in the bundle.  CMS disagreed, stating that if they accept this recommendation they would essentially be agreeing with the presumption that there is negligible work efficiencies gained in the bundling of these cardiac catheterization services.  CMS does not believe this to be true and requested that the AMA RUC reexamine these codes as soon as possible and put forward an alternative approach to valuing these services.  In the meantime, CMS will use an interim methodology resulting in a 10% less than the sum of the current work RVUs for the component codes.

CMS tells us to expect continued bundling of component services over the next several years as the AMA RUC further considers the efficiencies in work and/or PE that may occur when component services are furnished together. 

Practice Pitfalls:

• Untrained staff that do not understand new codes
• Physicians who do their own billing and don’t understand new codes
• Not updating charge tickets and/or EHR billing templates
• Coding w/outdated codes resulting in loss of revenue
• Uninformed physicians about new bundling rules and loss of RVUs
• Charge entry/coding staff not communicating with payment entry/claim denial staff. (This is typically a BIG problem, even in the best groups. Direct communication is many times not there and so coding errors made are not identified and corrected causing a repeat cycle of denials. Payment entry and/or appeal staff are unfamiliar with PV coding rules and are unsure how to apply appropriate modifiers, etc. to appeal denied claims.)

To Do’s for Practice:

• Train, train, train! Management should afford their staff all available resources to ensure key individuals are properly educated. Use of coding resources, webinars, coding conferences, vascular coding illustrations, list serve, CCI, etc.
• Update all charge tickets and EHR billing templates
• QA. Audit routinely (whether internally or have an outside auditor) to discover coding errors
• Keep MDs informed of potential RVU and revenue impacts

New Revascularization Codes:

• 37220    Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty
• 37221    Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
• 37222    Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (list separately in addition to code for primary procedure)
• 37223    Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (list separately in addition to code for primary procedure)
• 37224    Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty
• 37225    Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed
• 37226    Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
• 37227    Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed
• 37228    Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty
• 37229    Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed
• 37230    Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
• 37231    Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed
• 37232    Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (list separately in addition to code for primary procedure)
• 37233    Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (list separately in addition to code for primary procedure)
• 37234    Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (list separately in addition to code for primary procedure)
• 37235    Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (list separately in addition to code for primary procedure)

New Category III CPT Codes for 2011

• 0234T    Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; renal artery
• 0235T    Transluminal peripheral atherectomy visceral artery ea long description: transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; visceral artery (except renal), each vessel
• 0236T    Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; abdominal aorta
• 0237T    Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; brachiocephalic trunk and branches, each vessel
• 0238T    Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel

New Cardiac Catheterization Codes:

• 93451 Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed
• 93452 Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation
• 93453 Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed
• 93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation
• 93455 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s), (internal mammary, free arterial, venous grafts) including injection(s) for bypass graft angiography
• 93456 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization
• 93457 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization
• 93458 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
• 93459 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography
• 93460 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
• 93461 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography
• 93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure)
• 93463 Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside, Dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after, and repeat pharmacologic agent administration, when performed (List separately in addition to code for primary procedure)
• 93464 Physiologic exercise study (eg, bicycle or arm ergometry) including assessing hemodynamic measurements before and after (List separately in addition to code for primary procedure)
• 93563 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective coronary angiography during congenital heart catheterization (List separately in addition to code for primary procedure)
• 93564 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective opacification of aortocoronary venous or arterial bypass graft(s) (eg, aortocoronary saphenous vein, free radial artery, or free mammary artery graft) to one or more coronary arteries and in situ arterial conduits (eg, internal mammary), whether native or used for bypass to one or more coronary arteries during congenital heart catheterization, when performed (List separately in addition to code for primary procedure)
• 93565 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective left ventricular or left atrial angiography (List separately in addition to code for primary procedure)
• 93566 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective right ventricular or right atrial angiography (List separately in addition to code for primary procedure)
• 93567 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary procedure)
• 93568 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for pulmonary angiography (List separately in addition to code for primary procedure)

Deleted Cardiac Catheterization Codes:

• 93501 Right heart catheterization
• 93510 Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous
• 93511 Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; by cutdown
• 93514 Left heart catheterization by left ventricular puncture
• 93524 Combined transseptal and retrograde left heart catheterization
• 93526 Combined right heart catheterization and retrograde left heart catheterization
• 93527 Combined right heart catheterization and transseptal left heart catheterization through intact septum (with or without retrograde left heart catheterization)
• 93528 Combined right heart catheterization with left ventricular puncture (with or without retrograde left heart catheterization)
• 93529 Combined right heart catheterization and left heart catheterization through existing septal opening (with or without retrograde left heart catheterization)
• 93539 Injection procedure during cardiac catheterization; for selective opacification of arterial conduits (eg, internal mammary), whether native or used for bypass
• 93540 Injection procedure during cardiac catheterization; for selective opacification of aortocoronary venous bypass grafts, 1 or more coronary arteries
• 93541 Injection procedure during cardiac catheterization; for pulmonary angiography
• 93542 Injection procedure during cardiac catheterization; for selective right ventricular or right atrial angiography
• 93543 Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography
• 93544 Injection procedure during cardiac catheterization; for aortography
• 93545 Injection procedure during cardiac catheterization; for selective coronary angiography (injection of radiopaque material may be by hand)
• 93555 Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography
• 93556 Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass)

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