February 2013

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Coding Percutaneous Coronary Intervention Procedures

By Theresa Rihanek, MHA, RHIA, CCS

The Current Procedural Terminology (CPT) 2013 updates included a major revision of the Coronary Therapeutic Services and Procedures section. The previous percutaneous coronary intervention (PCI) codes 92980-92984 have been deleted and replaced with 13 new codes and guidelines. These new codes (92920-92944) include the work of accessing and selectively catheterizing the vessel, crossing the lesion, as well as radiological supervision and interpretation directly related to the intervention, including contrast injections, angiography, road-mapping, fluoroscopic guidance, vessel measurement, and post intervention angiography when performed.

CPT has developed a hierarchy for revascularization procedures that is built on the complexity of service, from highest to lowest (see table 1). A total of eight codes can be assigned for native coronary artery procedures (92920-92934). Codes 92937-92944 describe procedures performed on coronary artery bypass grafts.

The most extensive intervention in each major coronary artery is reported with the base codes. Additional interventions during the same session in coronary artery branches are to be reported using the add-on codes. Higher level interventions include angioplasty and the lower level interventions. This same hierarchy is observed when assigning add-on codes.

Table 1 – Hierarchy of revascularization procedures

Hierarchy Tier

Base Code
(1st Vessel)

Description

Add-on Codes
(in hierarchical order)

Tier I
(most complex)

92933

Atherectomy with stent and angioplasty, single artery or branch

92944, 92934, 92925, 92929, 92921

92941

Acute total/subtotal occlusion during MI, any PCI, single vessel

92944, 92934, 92925, 92929, 92921

92943

Chronic total occlusion, any PCI, single vessel

92944, 92934, 92925, 92929, 92921

Tier II

92924

Atherectomy with angioplasty, single artery or branch

92944, 92925, 92921

Tier III

92928

Stent with angioplasty, single artery or branch

92944, 92925, 92929, 92921

92937

Through graft, any combination of stent, atherectomy or angioplasty, single vessel

92938 or 92944, 92934, 92925, 92929, 92921

Tier IV

92920

Angioplasty, single artery or branch

92921

CPT recognizes five major coronary arteries for percutaneous interventional revascularization procedures. These five arteries include: the left main, left anterior descending (LAD), left circumflex, right, and ramus intermedius arteries.  Only one base code will be assigned for each major coronary artery procedure. The base code reports all services that occurred in the major vessel whether it occurred proximally, mid, or distally. For example, if an angioplasty is done at the mid and distal LAD, only 92920 would be assigned.

CPT also allows the assignment of additional codes for interventions performed in up to two additional branches of the LAD, circumflex and the right coronary. The left main and ramus intermedius do not have recognized branches for reporting. Note that if an intervention is done in a third branch of the same artery, it is not reported separately. Table 2 shows a listing of recognized major coronary arteries and corresponding branches.

Table 2 - CPT Recognized Major Coronary Arteries

Major Coronary Arteries  (Base Code)

Recognized Branches

Left Main (LCA or LMCA)

NONE

Left Circumflex

Two obtuse marginal branches

Left Anterior Descending (LAD)

Two diagonal branches

Right Coronary (RC)

Posterior descending; Posterolateral

Ramus

NONE

CMS has created two new HCPCS Level II modifiers to represent the left main (-LM) and ramus (-RI). Existing modifiers for left circumflex (-LC), left anterior descending (-LD), and right coronary (-RC) remain the same.

 

References

American Medical Association. CPT 2013, Professional Edition. Chicago, IL. American Medical Association, 2012.

American Medical Association. Changes 2013: An Insider’s View. Chicago, IL: American Medical Association, 2012.

Centers for Medicare and Medicaid Services. (2012). National Correct Coding Initiative Associated Modifier Changes (Additions) (Publication No. R1136OTN). Available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1136OTN.pdf

Theresa Rihanek is a director of HIM excellence at AHIMA.

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Test Your Skills

When you have finished the article, use the new percutaneous coronary intervention codes discussed to assign the right code or codes in the following scenarios. (Answers follow)

Scenario 1
Percutaneous transluminal coronary balloon angioplasty (PTCA) involving the left main and left circumflex coronary arteries

Scenario 2
PTCA of the right coronary artery and placement of a stent at the site of the blockage

Scenario 3
Percutaneous transluminal angioplasty, atherectomy, and stent of the left anterior descending artery and angioplasty of one diagonal artery branch


Answers

Scenario 1:  92920, 92920

Rationale: CPT recognizes both the left main and left circumflex arteries as major coronary arteries. One base code is assigned for the procedure(s) performed in each major coronary artery. In this case the same procedure, PTCA, was performed in both arteries so the same base procedure code (92920) is assigned twice. Please refer to payer policy for modifier usage. Certain payers may require the use of CPT modifier -59, such as 92920, 92920-59, and other payers may require the use of applicable HCPCS level II modifiers such as 92920-LM and 92920-LC.

Scenario 2:  92928

Rationale: Using the hierarchy, the most complex procedure performed was the placement of the intracoronary stent. Procedure code 92928 includes PTCA and intracoronary stenting. Note that the –RC modifier may be required with code 92928 per payer guidelines.

Scenario 3: 92933, 92921

Rationale: The procedure in the left anterior descending (LAD) artery, a major coronary artery, included atherectomy, stent placement, and PTCA. This complex procedure is captured with CPT code 92933. Add-on code 92921 is assigned for the angioplasty in the diagonal artery, which is a recognized branch of the LAD. Note that the –LD modifier may be required with procedure code 92933 per payer guidelines.