Coding Spotlight: Cardiovascular System

Every month, Global Healthcare Resource's General Manager of Coding Quality, Viba Raghavendran (CPC) and Deputy General Manager of Coding Operations Sivashankari Thangavelu (CPC,BCHHC,RCC & CCS) share helpful rule reminders and coding  information for specific medical conditions. In honor of Heart Awareness month, our experts dive into coding areas prone to mistake surrounding heart related conditions and procedures. 

Coding Tips:

Common mistakes regarding coding CT & CTA HEART:

The most frequent mistakes when coding CT Cardiac & CTA cardiac procedures are misidentifications of the actual procedure. Below are the key identifications for each CPT code.

Understanding common confusions:

• The code set for Cardiac CT and CCTA (CPT® 75572-CPT® 75574) include quantitative and functional assessment (for example, calcium scoring) if performed.
• Coronary imaging is not included in the code definition for CPT® 71275. 1. The AMA definition for CPT® 71275 reads: “CTA Chest (non-coronary), with contrast material(s), including non-contrast images, if performed, and image post-processing.” To evaluate the great vessels, Chest CTA (CPT® 71275) can be performed instead of CCTA or in addition to CCTA.
• 75571- Code 75571 is for cardiac scoring only, and it is generally not reimbursed by Medicare nor if it is a screening exam. CPT® 75571 describes a non-contrast CT of the heart with calcium scoring and should be reported only when calcium scoring is performed as a stand-alone procedure. CPT® 75571 should not be reported in conjunction with any of the contrast CT/CTA codes (CPT® 75572- CPT® 75574).
• Coronary calcium scoring as a standalone test is considered investigational in asymptomatic patients with any degree of CAD risk.

Medicare policies consider that there is insufficient evidence-based data to support performance of Coronary:

• Calcium Scoring-75572: Code 75572 is CT of the heart, generally done prior to surgery. Cardiac CT (CPT® 75572) can be performed to evaluate anatomy of the pulmonary veins prior to an ablation procedure performed for atrial fibrillation.
• Indication for CT Cardiac: 1) Repeated post-procedure between 3-6 months after ablation because of a 1%-2% incidence of asymptomatic pulmonary vein stenosis.
• If pulmonary vein stenosis is present on imaging following ablation and symptoms of pulmonary vein stenosis (usually shortness of breath) are present, can be imaged at 1, 3, 6, and 12 months.
• 75573: Code 75573 is the same as 75572, except that it is done in the context of congenital heart disease.
• 75574: Code 75574 is a CTA of the heart including angiographic evaluation of the arteries and grafts.

Transcatheter Aortic Valve Replacement (TAVR):

Once the decision has been made for aortic valve replacement, the following may be used to determine if a patient is a candidate for TAVR:

• CTA of chest (CPT® 71275), abdomen and pelvis (combination code CPT® 74174) are considered appropriate.
• Cardiac CT (CPT® 75572) may be considered to measure the aortic annulus.
• Coronary CTA (CCTA CPT® 75574) may be considered to both measure the aortic annulus and assess the coronary arteries in lieu of heart catheterization.

Understanding myocardial nuclear study with cardiovascular stress test coding:

As per CPT Manual, Myocardial perfusion and cardiac blood pool imaging studies may be performed at rest and/or during stress.

When performed during exercise and/or pharmacologic stress, the appropriate stress testing code from the 93015-93018 series should be reported in addition to 78451-78454, 78472-78492.

CPT Updates for 2020 for “Myocardial PET study”

Revisions:

Myocardial PET codes underwent description revisions to include ventricular wall motion and ejection fraction, when performed.

• 78459- Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study.
• 78491- Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic).
• 78492- Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic).

Additions:

New codes were introduced to identify component services with PET myocardial perfusion and metabolic imaging, to include ventricular wall motion and ejection fraction when performed. In addition, the codes detail whether CT transmission images for anatomical review were concurrently acquired.

• Category III code 0428T is deleted & entered to Category I code as 78434.
• 78429 Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan.
• 78430 Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan.
• 78431 Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan.
• 78432 Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability).
• 78433 Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan.
• 78434 Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure).
  
  

Circulatory system_ ICD 10 CM coding tips and guidelines:

Hypertension with Heart Disease

There is a specific category within ICD-10-CM for hypertensive heart disease (I11). This category is only to be used when there is a causal relationship stated (i.e., due to hypertension) or implied (hypertensive) Hypertensive heart and Chronic Kidney Disease: 1) I13 - Hypertensive heart and chronic kidney disease 2) I50 – or I51.4 – I51.9 Heart failure 3) N18 – CKD 4) code from acute renal failure (If applicable) Hypertensive Cerebrovascular Disease: 1) I60-I69 and appropriate hypertensive code.

Atherosclerotic Coronary Artery Disease and Angina: Atherosclerotic Coronary Artery Disease and Angina ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are:

• I25.11- Atherosclerotic heart disease of native coronary artery with angina pectoris
• I25.7- Atherosclerosis of coronary artery bypass graft(s) & coronary artery of transplanted heart with angina pectoris

Hypertension: When documenting hypertension, include the following:

• Type: e.g. essential, secondary, etc.
• Causal relationship. Renal, pulmonary, etc.

 Atherosclerotic Heart Disease with Angina Pectoris

When documenting atherosclerotic heart disease with angina pectoris, include the following:

• Cause: Assumed to be atherosclerosis; notate if there is another cause.
• Stability: e.g. Stable angina pectoris, unstable angina pectoris.
• Vessel: Note which artery (if known) is involved and whether the artery is native or autologous.
• Graft involvement: If appropriate, whether a bypass graft was involved in the angina pectoris diagnosis; also note the original location of the graft and whether it is autologous or biologic.

Example: I25.110 Atherosclerotic heart disease of a native coronary artery with unstable angina pectoris I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris.

Cardiomyopathy

When documenting cardiomyopathy, include the following, where appropriate:

• Type: e.g. Dilated/congestive, obstructive or nonobstructive hypertrophic, etc.
• Location: e.g. Endocarditis, right ventricle, etc.
• Cause: e.g. Congenital, alcohol, etc.

Example: I42.0 Dilated cardiomyopathy I42.1 Obstructive hypertrophic cardiomyopathy I42.3 Endomyocardial (eosinophilic) disease.

Heart Valve Disease

ICD-10 assumes heart valve diseases are rheumatic; if this is not the case, notate otherwise. When documenting heart valve disease, include the following:

• Cause: e.g. Rheumatic or non-rheumatic.
• Type: e.g. Prolapse, insufficiency, regurgitation, incompetence, stenosis, etc.
• Location: e.g. Mitral valve, aortic valve, etc.

Example: I06.2 Rheumatic aortic stenosis with insufficiency I34.1 Nonrheumatic mitral (valve) prolapse.

Arrythmias/Dysrhythmia

When documenting arrhythmias, include the following:

• Location: e.g. Atrial, ventricular, supraventricular, etc.
• Rhythm Name: e.g. Flutter, fibrillation, type 1 atrial flutter, long QT syndrome, sick sinus syndrome, etc.
• Acuity: e.g. Acute, chronic, etc.
• Cause: e.g., Hyperkalemia, hypertension, alcohol consumption, digoxin, amiodarone, verapamil HCl

Example: I48.20 Chronic atrial fibrillation I49.01 Ventricular fibrillation.

Acute Myocardial Infarction

• If a Non-ST elevation myocardial infarction (NSTEMI) evolves to a ST elevation myocardial infarction (STEMI), assign only the STEMI code.
• If a STEMI converts to a NSTEMI due to thrombolytic therapy, it is still coded as a STEMI.
• A myocardial infarction remains acute for 4 weeks and is coded with a code from category I21, STEMI and NSTEMI myocardial infarction.
• If a patient has a new AMI within the 4-week timeframe of the initial AMI, then a code from I22, Subsequent STEMI and NSTEMI myocardial infarction, is assigned.
• A code from category I22 must be used in conjunction with a code from I21 and the sequencing depends on the circumstances of the encounter.
• For encounters after the 4-week time frame and the patient is still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned.
• For old or healed myocardial infarctions not requiring further care, code I25.2, Old myocardial infarction, may be assigned.

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