Article - Billing and Coding: Percutaneous Coronary Intervention (A56823)

CMS National Coverage PolicyN/AArticle TextThis article contains and other guidelinesthat complement the Local Coverage Determination (LCD) for Percutaneous Coronary Intervention.National Coverage Provisions:Effective January 1, 2013, all PCI codes 92920-92944include the work of accessing and selectively catheterizing the vessel, traversing the lesion, radiological supervision and interpretation directly related to the intervention(s) performed, closure of the arteriotomy when performed through the access sheath, and imaging performed to document completion of the intervention. These codes include angioplasty (eg, balloon, cutting balloon, wired balloons, cryoplasty), atherectomy (eg, directional, rotational, laser), and stenting (eg, balloon expandable, self-expanding, bare metal, drug eluting, covered.) (AMA CPT 2013, Professional Edition).If a single lesion extends from one target vessel (major coronary artery, coronary artery bypass graft, or coronary artery branch) into another target vessel, but can be revascularized with a single intervention bridging the two vessels, this PCI should be reported with a single code despite treating more than one vessel. For example, if a left main coronary artery and a single stent is placed to treat the entire lesion, this PCI should be reported as a single vessel stent (92928). (AMA CPT 2013, Professional Edition).Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Specific Coding Guidelines:The major coronary arteries are the left main (LM), left anterior descending (LD), left circumflex (LC), right (RC), and ramus intermedius (RI) arteries.Claims for percutaneous coronary intervention must report the appropriate modifier(s).All PCI procedures performed in all segments (proximal, mid, distal) of a single major coronary artery through the native coronary circulation are reported with one code. When one segment of a major coronary is treated through the native circulation and treatment of another segment of the same artery requires access through a coronary artery bypass graft, the intervention through the bypass graft is reported separately. (AMA CPT 2013, Professional Edition).Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included withinthe relatedLCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.Documentation must be in the format of a procedure note. The indications and any unusual clinical circumstances must be stated. Details and results of the intervention must be stated. Angiographic documentation (film or digital) as well as intravascular sonographic recording must be maintained and available on request.The medical record must include documentation of the need for repeat diagnostic angiography when previously performed, in the absence of any new clinical symptoms or signs of disease progression, within the preceding three months.Documentation must be available to Medicare upon request.