Cardiovascular coding is complicated as the procedures are intricate and difficult to understand. In 2019, cardiovascular coding will see several significant changes. Having expert cardiology medical coding services is critical to code correctly, support accuracy and productivity, and prevent denials.
The changes for cardiovascular CPT codes in 2019 (as summarized in a report from Decision Health) can be better understood by looking at the codes for coronary procedures in 2018.
Diagnostic Procedures and Imaging
The 2018 CPT codes for cardiovascular diagnostic procedures and imaging are:
| 93451 | Right heart catheterization |
| 93452 | Left heart catheterization |
| 93453 | Right and left heart catheterization |
| 93454 | Coronary angiography |
| 93455 | Coronary angiography with bypass grafts |
| 93456 | Coronary angiography with right heart catheterization |
| 93457 | Coronary angiography and bypass grafts, with right heart catheterization |
| 93458 | Coronary angiography with left heart catheterization |
| 93459 | Coronary angiography and bypass grafts, with left heart catheterization |
| 93460 | Coronary angiography with right and left heart catheterization |
| 93461 | Coronary angiography with bypass grafts, right and left heart catheterization |
| +93462 | Left heart access via transseptal or transapical puncture |
| +93463 | Pharmacological agent administration with hemodynamic assessment |
| +93464 | Physiologic exercise study with hemodynamic assessment |
| 93503 | Placement of flow directed catheter (eg, Swan-Ganz) for monitoring |
| 93505 | Endomyocardial biopsy |
| 93530 | Right heart catheterization for congenital cardiac anomalies |
| 93531 | Combined right & retrograde left heart cath for congenital cardiac anomalies |
| 93532 | Combined right &transseptal left heart cath through intact septum for congenital cardiac anomalies |
| 93533 | Combined right &transseptal left heart cath through existing septum opening for congenital cardiac anomalies |
| 93561 | Indicator dilution study with cardiac output (separate procedure) |
| 93562 | Indicator dilution study; subsequent measurement of cardiac output |
| +93563 | Injection/imaging for coronary angiography with cath for congenital anomaly |
| +93564 | Injection/imaging for bypass graft angiography with cath for congenital anomaly |
| +93565 | Injection/imaging for left heart angiography with cath for congenital anomaly |
| +93566 | Injection/imaging for right heart angiography with cath for congenital anomaly |
| +93567 | Injection/imaging procedure for supravalvular aortography |
| +93568 | Injection/imaging procedure for pulmonary angiography |
| +93571 | Intravascular coronary flow reserve measurement, initial vessel |
| +93572 | Intravascular coronary flow reserve measurement, each additional vessel |
| +92978 | Coronary vessel or graft imaging with IVUS or OCT, initial vessel |
| +92979 | Coronary vessel or graft imaging with IVUS or OCT, each additional vessel |
- 2019 update for insertion of catheter: The guidelines for 2019 state that:
- The insertion of a catheter into the right ventricle is included in the insertion, replacement or removal of a leadless pacemaker system.
- Right heart catheterization codes 93451, 93453, 93456, 93457, 93460, 93461 and 93530-93533 should not be reported with the insertion or removal codes unless the right heart catheterization treats a condition that is “distinct from the leadless pacemaker procedure.”
- New CPT code 33274 (Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular,) should be reported when a system is removed and replaced during the same session.
Pacemaker or defibrillator
Leadless pacemakers are tiny self-contained units that are directly implanted into the right ventricle. In 2018, physicians go by CMS instructions to report the following CPT Category III codes when billing for implant, replacement, interrogation and programming of the new leadless pacemakers:
| 0387T | (Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular) |
| 0389T | (Programming device evaluation [in person] with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system) |
| 0390T | (Peri-procedural device evaluation [in person] and programming of device system parameters before or after surgery, procedure or test with analysis, review and report, leadless pacemaker system) |
| 0391T | (Interrogation device evaluation [in person] with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system) |
CMS also instructs appending Modifier Q0 (Investigational clinical service provided in a clinical research study that is an approved clinical research study) is appended to the appropriate procedure code, and ICD-10 code Z00.6 (Encounter for examination for normal comparison and control in clinical research program).
The implants are payable in the following places of service (POS):
| POS | 06 – Indian Health Service Provider Based Facility |
| POS | 21 – Inpatient Hospital |
| POS | 22 – On Campus-Outpatient Hospital |
| POS | 26 – Military Treatment Facility |
- 2019 update for pacemaker or defibrillator: The 2019 CPT manual provides the changes to the codes for leadless pacemakers, which are as follows:
- Category III codes 0387T-0391T have been deleted and replaced with permanent codes 33274 (Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance [eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography] and device evaluation [eg, interrogation or programming], when performed) and 33275 (Transcatheter removal of permanent leadless pacemaker, right ventricular).
Central venous access:
In 2019, there are several revisions to central venous access codes:
- Changes to the peripherally inserted central catheter (PICC) codes:Two new peripherally inserted central venous catheter (PICC) codes will be created that bundle the placement of a PICC and all associated radiological supervision and interpretation.
- The descriptors for current PICC insertion codes will be updated to state the service does not include image guidance: 36568 (Insertion of peripherally inserted central venous catheter [PICC], without subcutaneous port or pump, without imaging guidance; younger than 5 years of age) and 36569 (…; age 5 years or older). According to the CPT manual, one of these codes should be reported when a PICC line is placed with magnetic guidance.
- The procedure guidelines for central venous access will be updated to include the saphenous vein as an example of an entry site for a PICC and clarify the instructions for reporting imaging guidance used for centrally inserted central venous catheters. Providers can report code 77001 for fluoroscopic central venous catheter access or code 76937 for ultrasound guidance for vascular access “when imaging guidance is used for centrally inserted central venous catheters, for gaining access to the venous entry site and/or for manipulating the catheter into final central position.”
- Image guidance will be added to PICC replacement code 36584 (Replacement, complete, of a peripherally inserted central venous catheter [PICC], without subcutaneous port or pump, through same venous access, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the replacement).
- There are two new insertion codes that include image guidance –
36572 (Insertion of peripherally inserted central venous catheter [PICC], without subcutaneous port or pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the insertion; younger than 5 years of age)
36573 (…; age 5 years or older) - Chest X-ray codes (71045-71048) or other imaging services to document the final catheter tip position are bundled into 36584 and 36572-36573. If the provider uses imaging but does not confirm the tip’s location, modifier 52 (Reduced services) should be appended with the code
- The manual instructs using a venipuncture code (36400-36410) to report a midline catheter.
Outsourcing medical billing and coding can help practices stay up to date with these changes. However, proper clinical documentation to justify medical necessity is critical for correct code selection and optimal reimbursement. Providers should faithfully record relevant facts, findings and observations as payers scrutinize documentation to verify medical necessity, coding choices, site of service, and appropriateness and accurate reporting of services provided.
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