April 28, 2017

Code What the Doctor Did – Not What the Doctor Said

EDITOR’S NOTE: The following is a physician’s perspective on the Sandy Brewton article, “LHC vs Coronary Angiography: Take Heart When Coding.”

I was one of those physicians who once thought a left heart catheterization was done with the coronary artery angiography procedure. That’s because, in the strictest, semantic sense of the phrase, it is. The MedlinePlus definition of “left heart catheterization” is “the passage of a thin flexible tube (catheter) into the left side of the heart. It is done to diagnose or treat certain heart problems.”

At first, I thought this was an example of a coding-clinical disconnect. Clinicians use language to communicate with one another regarding a patient’s care. The fact is that coders and billers and lawyers and auditors also read the practitioner’s documentation to fulfill their own specific purposes, and this can cause problems.

But as I thought about it more, I realized that isn’t precisely the issue. Coders do not really have a different definition of “left heart catheterization.” Confusion has arisen because coding guidelines and interpretations have labeled the hemodynamic measurements in the vessels and heart to evaluate left ventricular function erroneously as the procedure “left heart catheterization.” The real question is, should you be coding it?

In ICD-10-PCS coding, you code what was accomplished during a procedure. Interim and secondary necessary steps are often not captured separately. For instance, if a right colectomy is performed, the surgeon likely looks around in the peritoneal cavity prior to resection of the bowel, but you wouldn’t code an “inspection.” Similarly, the incision is often closed, but you would not code a repair of the abdominal muscles and wall, because it is integral to the intended procedure. You only code open resection of right colon.

If the procedure of a left heart catheterization, in the strict, semantic sense, is done to introduce the catheter in order to inject dye and fluoroscopically record the flow, you only code the fluoroscopy of the heart and/or coronary arteries. If pressure measurements are taken and recorded, then you must go to Measurement and Monitoring, Section 4. In current practice, this step is often supplanted by the non-invasive (and less risky) process of echocardiography. Ultimately, since the catheter is removed at the end of the procedure, there should not be any code capturing it, because temporary devices are not included in PCS character representation.

But aren’t we lucky that coders are permitted to interpret documentation and capture what was actually accomplished, not necessarily merely what the CPT clinical terminology documented by the provider is? You will never read a surgeon’s operative note informing you that he or she extirpated a thrombus, but you don’t need to. My recommendation is to look for what was actually accomplished. Ignore the phrase “left heart catheterization.” For example:

Measurements were taken and recorded:

  • 4A0 Measurement and Monitoring, Physiological Systems, Measurement
    • o Coronary artery? Cardiac Sampling and Pressure, L/(B) heart?
    • o Approach – percutaneous (This is where “left heart catheterization” really resides – when a catheter is introduced percutaneously.)

Angiography performed:

  • B21 Imaging, Heart, Fluoroscopy
    • o Coronary artery/arteries? Coronary artery bypass graft/s? L/(B) heart?
    • o Contrast type?

Angioplasty? Stents?

  • 027 Dilation of heart and great vessels
    • o Coronary artery/arteries? How many vessels?
    • o Drug-eluting (or not) intraluminal device? How many devices?
    • o Bifurcation or not?

The bottom line: Code what was done, not what was said!
Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As Physician Advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July, 2016. Dr. Remer is a member of the ICD10monitor editorial board and co-hosts Talk Ten Tuesdays.

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