Since Gruentzig's 1979 report of coronary balloon angioplasty, percutaneous
transluminal coronary interventions have substantively altered the management
of patients with symptomatic arteriosclerotic heart disease. Balloon
angioplasty rapidly expanded from single to multiple vessels and from simple
to complex anatomic substrates. Transluminal interventions now encompass
balloon dilation (PTCA), a variety of atherectomy devices, high pressure and
biologic/polymer coated stents as well as transluminal thrombectomy.
Additionally, intracoronary ultrasound is often employed to assess the
efficacy of these interventions. In addition to medical therapy and coronary
bypass surgery, percutaneous coronary intervention has emerged as a primary
option for the management of patients with acute coronary syndromes and
selected patients with chronic angina.  
  
 **Indications:**  
  
Percutaneous coronary intervention (PCI) may be indicated in the management of
:

  * patients with acute coronary syndrome (eg acute myocardial infarction, unstable angina)
  * patients with a history of significant obstructive atherosclerotic disease
  * patients with restenosis of a coronary artery previously treated with intracoronary stent or other revascularization procedure
  * patients with chronic angina
  * patients with silent ischemia

Intracoronary ultrasound may be separately covered when needed to assess the
extent of coronary stenosis if equivocal on angiography, or when needed to
assess the patency and integrity of a coronary artery post-intervention.
Alternatively, intravascular Doppler velocity and/or pressure derived coronary
flow reserve measurement may be performed to assess the degree of stenosis
within a vessel.  
  
**Limitations:**  
  
A diagnostic cardiac catheterization to assess the nature of the lesion(s)
prior to the intervention is a covered service. The diagnostic cardiac
catheterization may be performed at any time prior to the PCI, including the
same day as the PCI.  
  
Performance of a diagnostic cardiac catheterization and interventional
procedure on the same day is increasingly the standard of practice. While
there may be reasons for delaying the interventional procedure (e.g., transfer
from a community hospital to a tertiary center, excessive dye load, further
treatment planning or evaluation of angiography, etc.), it is recommended that
both procedures be performed during the same encounter when medically
appropriate. Separation of these procedures for the purpose of circumventing
the multiple surgery pricing, or for the convenience of physician or hospital
scheduling, is considered an inappropriate practice and may subject the
services to review and denial for medical necessity. The decision to stage
these procedures is deferred to the judgment of the interventional
cardiologist, and individualized only to the clinical needs of the patient.
(e.g., dye load already received, need to correlate findings with other test
results, etc). Reasons for delaying indicated intervention should be
documented in the medical record. Unless there is a new clinical event or
change in symptomatology, examination or other test results, a repeat
diagnostic catheterization service within three months of a previous
diagnostic catheterization, and prior to completion of the staged intervention
is generally not reimbursable and is considered not to be reasonable and
necessary.

  
Angiography during the procedure, used to monitor the course of the
intervention, is considered part of the PCI and is not separately billable to
Medicare. Diagnostic angiography may be separately payable in situations where
no previous catheter-based coronary angiography study is available, or a
previous study is no longer adequate due to changes in the patient's
condition.  
  
The deployment of a device for distal embolic protection during an
interventional procedure is considered part of the more complex procedure and
is not separately billable.  
  
Prophylactic insertion of a temporary transvenous pacemaker, repositioning or
replacement of catheters and administration of medications during the
procedure are included in the procedure and are not separately billable. Right
heart catheterization and insertion of a Swan-Ganz catheter are not generally
medically necessary for a PCI and will be denied, unless medically necessary
when performed incident to a diagnostic catheterization prior to the
intervention. Standby services of a surgeon or anesthesiologist are not
covered services.  
  
Intracoronary _injections_ of drugs during diagnostic or therapeutic
procedures are considered to be part of the procedure and are not separately
reimbursable.  
  
Percutaneous vascular closure devices (PVCD) may be used to facilitate closure
of an arterial puncture site after angiography, cardiac catheterization and
interventional cardiology procedures in addition to or in place of manual
compression, use of a mechanical clamp or a sandbag, or a combination of these
methods. These services are inherent to the invasive procedure and are not
separately payable.