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The Centers for Medicare & Medicaid Services (CMS) has complex billing rules and experienced medical coding companies are well aware that errors in processing claims for these government-sponsored health programs can prove extremely costly, making providers vulnerable to audits and penalties.

According to a recent report from the HHS Office of Inspector General (OIG), hospitals nationwide did not comply with Medicare requirements on billing for right heart catheterization (RHC) performed during the same patient encounter as heart biopsies during the years 2011 and 2012. In fact, the OIG estimated that the errors in billing these services cost Medicare $7.6 million in overpayment over this period.

OIG’s Findings on Coding Errors for RHC with Biopsy

The National Correct Coding Initiative (NCCI) was developed by CMS to promote correct coding by providers and to prevent Medicare payments for improperly coded services. The NCCI edits include procedure-to-procedure edits that define HCPCS/CPT codes that generally should not be reported together for the same beneficiary on the same date of service. One goal of these edits is to prevent payments for codes that report overlapping services except in circumstances where the services are separate and distinct, such as provided at a different session or encounter. If each of the procedures is performed separately, modifier-59 may be appended to evade the edit.

Both heart biopsy and RHC are routinely performed together after heart transplantation to monitor heart function and the surgery’s success. Normally, NCCI edits would prevent the payment for a RHC when billed on the same claim as a heart biopsy. However, the HSS pointed out that the billing error occurred because the hospitals appended modifier-59 to the HCPCS code to indicate that the procedures were separate and distinct. When the RHC is performed to obtain a heart biopsy, the two procedures are not considered “separate and distinct” and modifier-59 cannot be used.

Specifically, the OIG found that:

  • U.S. hospitals complied with the Medicare requirements for billing outpatient RHCs and heart biopsies provided during the same patient encounter for 8 of the 100 sampled line items.
  • The hospitals did not comply with the Medicare requirements for 92 of the 100 sampled line items.
  • Modifier-59 was incorrectly appended to the HCPCS code, indicating that the RHCs were separate and distinct procedures from the heart biopsies even though the medical record documentation did not support the use of the modifier.

CMS has agreed with the recommendations made by the HSS which are as follows:

  • To educate hospitals on how to appropriately bill for RHCs performed during the same patient encounter as heart biopsies.
  • Identify claims in the years subsequent to our audit period that did not meet Medicare payment requirements and recover any associated overpayments.
  • Notify providers of potential overpayments so that those providers can investigate and return any identified overpayments, in accordance with the 60-day rule.

RHC – Key Points to Note

RHC involves the introduction of acatheter(s) into the right atrium, right ventricle and pulmonary artery, and pulmonary capillary wedge positions, where pressure measurements are taken and imaging may be performed. RHC is a diagnostic procedure and is indicated to evaluate the following:

  • Valvular heart disease
  • Congestive heart failure
  • Congenital heart disease
  • Cor pulmonale
  • Pulmonary hypertension
  • Intracardiac shunts
  • Endocarditis and Myocarditis
  • Cardiogenic shock
  • Myocardial infarction
  • Transplanted heart or valve

The endomyocardial biopsy is done to diagnose cardiomyopathy or myocarditis: It can also help diagnose rejection after a heart transplant. Hemodynamic measurements, cardiac output determination, shunt determinations, blood sampling and hydrogen arrival time are commonly included as part of the procedure. Placement of catheter(s), repositioning and replacement with other catheters as well as cannulation of the coronary sinus are included in this procedure.

The first step in billing correctly for diagnostic cardiac catheterization – whether RT or LT – is knowing the relevant CPT codes.

Cardiac Catheterization CPT Codes

Right (RT) and Left (LT) Heart Catheterization (Cath)

93451 RT heart cath including measurement(s) of oxygen saturation and cardiac output, when performed
93530 RT heart cath, for congenital cardiac anomalies
93452 LT heart cath including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed
+93462 LT heartcath by transseptal puncture through intact septum or by transapical puncture (to be listed separately in addition to code for primary procedure)

Combined RT and LT Heart Catheterization

93453 Combined RT & LT heart cath including intraprocedural injection for LT ventriculography, imaging S & I, when performed
93531 Combined right heart cath and retrograde left heart catheterization, for congenital cardiac anomalies
93532 Combined right heart cath and transseptal left heart catheterization through intact septum, with or without retrograde left heart catheterization, for congenital cardiac anomalies
93533 Combined right heart cath and transseptal left heart catheterization through existing septal opening, with or without retrograde left heart catheterization, for congenital cardiac anomalies)

Catheter Placement

93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging S&I
93455Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography
93456 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization
93457 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization
93458 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
93459 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculogr+B13aphy, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography
93460 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
93461 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

Injection Diagnostic Cardiac Catheterization

Each site may be injected multiple times; each code should be reported only once.
+93563 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective coronary angiography during congenital heart catheterization (to be listed separately in addition to code for primary procedure)
+93564 Injection procedure during cardiac catheterization including imaging supervision and interpretation, and report; for selective opacification of aortocoronary venous or arterial bypass graft(s) (eg, aortocoronary saphenous vein, free radial artery, or free mammary artery graft) to one or more coronary arteries and in situ arterial conduits (e.g., internal mammary), whether native or used for bypass to one or more coronary arteries during congenital heart catheterization, when performed (to be listed separately in addition to code for primary procedure)
+93565 Injection procedure during cardiac catheterization including imaging supervision and interpretation, and report; for selective left ventricular or left arterial angiography (to be listed separately in addition to code for primary procedure)
+93566 Injection procedure during cardiac catheterization including imaging supervision and interpretation, and report; for selective right ventricular or right atrial angiography (to be listed separately in addition to code for primary procedure)
+93567 Injection procedure during cardiac catheterization including imaging supervision and interpretation, and report; for supravalvular aortography (to be listed separately in addition to code for primary procedure)
+93568 Injection procedure during cardiac catheterization including imaging supervision and interpretation, and report; for pulmonary angiography (to be listed separately in addition to code for primary procedure)

Miscellaneous

+93463 Pharmacologic agent administration (e.g., inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, when performed (to be listed separately in addition to code for primary procedure)
+93464 Physiologic exercise study (e.g., bicycle or arm ergometry) including assessing hemodynamic measurements before and after (to be listed separately in addition to code for primary procedure)

It is the responsibility of providers to submit accurate and appropriate claims for services. The documentation should establish medical necessity and define the proper site for delivery of any services. Accurate documentation will allow medical coding service providers to assign appropriate codes, charges, and modifiers for the services rendered to meet payer rules.