To Code or Not to Code? That is the Question.

Diagnostic Angiography with Therapeutic Interventions

Stacie L. Buck, RHIA, CCS-P, RCC, RCCIR, CIRCC: President & Senior Consultant, RadRx

One of the most common inquiries I receive about interventional radiology procedures is how to determine when to code for angiograms performed during the same session as a therapeutic intervention. Now more than ever it is important to correctly apply the coding rules as MACs, RACs and others step up their scrutiny of procedures billed with modifier -59 and other NCCI modifiers.

The CPT manual has specific rules concerning the reporting of diagnostic angiography/venography performed in conjunction with therapeutic interventions. These instructions can be found in the introductory sections for Vascular Procedures for “Aorta and Arteries” and “Veins and Lymphatics”. Here is a summary of the CPT guidelines:

Diagnostic angiography or venography performed during the same session as a therapeutic intervention may be reported separately when one or more of the following criteria are met:

· No prior catheter-based angiographic 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 Ac

It is very common for diagnostic and therapeutic interventions to be performed during the same session, mainly because it is relatively easy to proceed with a therapeutic intervention at the same time the diagnosis is made during a percutaneous vascular procedure. If the decision to intervene is based on the results of the diagnostic angiogram, then code for both the diagnostic and therapeutic portions of the procedure performed at that session as long as the imaging is not otherwise included in the code description for the therapeutic intervention.

There is no specified time frame that must elapse before a new diagnostic angiogram can be coded in conjunction with a therapeutic intervention. Whether or not the diagnostic angiogram is separately reported will depend on the patient’s condition. It is important for the radiologist to document medical necessity as noted in the instructions contained in the CPT manual when a repeat diagnostic angiogram is necessary.

It is important to note that the NCCI manual supports CPT coding instructions, however it adds one additional caveat concerning a prior diagnostic angiogram.

· Diagnostic angiography (arteriogram/venogram) performed on the same date of service by the same provider 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. (Chapter 9, NCCI Manual)

While CPT specifically mentions a “prior catheter based study”, the NCCI manual considers a computed tomographic angiography (CTA) as a prior diagnostic study, therefore for Medicare and other payers that follow NCCI guidance, a prior CTA should be considered a prior diagnostic angiogram and the same rules should be applied as with a prior catheter based study – medical necessity for the catheter based diagnostic angiogram should be documented.

Here are questions to ask to know when to code:

· Was a prior catheter based angiography study (CTA for Medicare) performed?

· Is the prior study available? If so:

o Was the decision to perform the therapeutic intervention based on the angiograms performed?

o Has the patient’s condition changed with respect to the clinical indication since the prior study?

o Was there inadequate visualization of anatomy and/or pathology?

o Was there a clinical change during the procedure that requires new evaluation outside the target area of intervention?

· Was a full and complete diagnostic angiogram performed immediately before the therapeutic intervention?

Stacie L. Buck, RHIA, CCS-P, RCC, RCCIR, CIRCC is President & Senior Consultant at RadRx in Stuart, FL. Stacie is a nationally sought out speaker who provides consulting services to providers of diagnostic and interventional radiology services. Stacie has 28 years experience in healthcare, 20 of which she has spent working in radiology.

She is the author of the book Cracking the IR Code: Your Comprehensive Guide to Mastering Interventional Radiology Coding and creator of Mastering Interventional Radiology & Cardiology Online Education Program.

For additional information on interventional radiology coding education as well as testimonials please visit: https://radrx.com/education/online-education/

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