Today, Ms. Stacie Buck concludes her 3 part series of CodeMap® Radiology Briefings highlighting RAC risk areas for radiology services. This last article points out 4 main coding risk areas for interventional radiology services, including diagnostic angiography performed during the same session as therapeutic interventions, multiple interventions in the same vessel, radiological supervision and interpretation, and medically unlikely edits. As always, please forward any questions, comments, or suggestion to either Ms. Buck or me via email.
Gregory Root, Esq.
CPT Guidelines assist the coder in determining when it is "medically reasonable and necessary" to report diagnostic angiograms in conjunction with therapeutic interventions:
"Diagnostic angiography/venography performed at the time of an interventional procedure is separately reportable if:
No prior catheter-based angiography study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, OR
A prior study is available, but as documented in the medical record:
o The patient's condition with respect to the clinical indication has changed since the prior study, OR
o There is inadequate visualization of the anatomy and/or pathology, OR
o There is a clinical change during the procedure that requires new evaluation outside the target area of intervention"
It is important to note that CMS takes this a step further:
"Diagnostic angiograms performed on the same date of service as a percutaneous intravascular interventional procedure should be reported with modifier -59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier -59. If it is medically reasonable and necessary to repeat only a portion of the diagnostic angiogram, append modifier -52 to the angiogram CPT code. If the prior diagnostic angiogram (fluoroscopic or computed tomographic) was complete, the provider should not report a second angiogram for the dye injections necessary to perform the percutaneous intravascular interventional procedure."
Note that although CPT refers to a catheter-based study, CMS indicates that a prior diagnostic study includes fluoroscopic and computed tomographic studies.
When diagnostic angiograms are performed, medical necessity must be clearly documented and the radiologist must document an interpretation for each of the vessels imaged.
Multiple Interventions in Same Vessel
Very often it is necessary for the radiologist to perform multiple therapeutic interventions in the same vessel.
Currently there is no NCCI guidance that prevents PTA or atherectomy from being coded in conjunction with stent placement, however the following applies to PTA and stenting performed on the same vessel:
Both PTA and stent may be coded for the same vessel when:
The results of a PTA are suboptimal and a stent must be placed
PTA and stent are each used to treat separate lesions in the same vessel
PTA is used to treat a complication of stent placement
It is important that the radiologist clearly document one or more of the scenarios above to report PTA and stenting of the same vessel. Remember, use of a balloon simply to facilitate stent placement (pre-dilation or post-dilation) is not considered a PTA for coding purposes and should not be coded as such.
The NCCI Manual, Chapter 5 offers guidance concerning a PTA and an atherectomy being performed together:
"When percutaneous angioplasty of a vascular lesion is followed at the same session by a percutaneous or open atherectomy, generally due to insufficient improvement in vascular flow with angioplasty alone, only the most comprehensive atherectomy that was performed (generally the open procedure) is reported (see sequential procedure policy, Chapter I, Section M)."
Radiological Supervision & Interpretation
Many of the radiology codes have the words “radiological supervision and interpretation” in the code description. The use of these codes requires that the physician has provided both the supervision for the procedure as well as an interpretation of the procedure performed. For example, when performing diagnostic angiograms it is not enough to state that a vessel was injected with contrast, the physician must provide an interpretation of the vessel that is imaged. Additionally, there are some RS&I codes that have the term “selective” in the code descriptor. These codes should not be assigned unless the catheter was placed into that vessel for contrast injection and imaging. One example of a code that uses this term is the RS&I code for angiography of the external carotids (75662). This code should only be used when the catheter is placed into the external carotid, contrast is injected, and the physician provides an interpretation. It should not be assigned when the external carotids are visualized from a contrast injection in the common carotid.
Medically Unlikely Edits
The introduction of MUEs a few years back has opened providers to more scrutiny when billing for multiple units of a particular service on the same date of service.
On some occasions, units of service may exceed an MUE for a date of service. CPT modifiers such as -76 (repeat procedure by same physician), -77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), -91 (repeat clinical diagnostic laboratory test), and -59 (distinct procedural service) may be utilized to bypass the edits; however caution should be used when appending any modifier to bypass an MUE.
CMS believes that the use of modifiers to bypass MUEs should be rare and if providers find that this is a frequent occurrence, they should review their coding practices. The NCCI manual instructs providers to ask the following in those instances:
Is the HCPCS/CPT code being used correctly?
Is the unit of service being counted correctly?
Are all reported services medically reasonable and necessary?
Why does the provider’s or supplier’s practice differ from national patterns?
Each case must be considered on an individual basis; however one type of procedure where modifiers are not permitted to bypass an MUE is radiological guidance for needle placement. Although CPT Assistant instructs to assign guidance codes per lesion, the NCCI manual Chapter 9 states the following:
“CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.”
The NCCI manual is explicit in stating that these codes are to be reported only once per encounter, therefore it would not be appropriate to report multiple units by listing them as separate line items on the claim.