Q: [Coronary Arteries] I am confused with major coronary arteries questions on practice
exams, board exams.
Can you please give an example of questions with the answer as 92933-RC and 92934-LD?
One of the practice exam questions gave an example of both of these.
I need more clarification on how to answer correctly the questions from major coronary
arteries.
A: Yeah, this is a toughie.
I have to give kudos to Ruth Sheets, who’s on our team, she does all of our practice
exams, and she’s awesome, great rationale writer, so she actually understood this better
than me.
Because you know when you teach something for 10-15 years you get used to teaching it,
and then they changed this on us a couple years ago and I kept struggling with explaining
it right because it’s so different.
But, Ruth picked it up and she actually wrote out most of this answer, so thank you Ruth,
and I’ll be presenting it.
First, some key ideas.
Let me take you down to the bottom real quick to just get a picture of all of these codes,
and this again is in the answer sheet for the Replay Club members.
If you look at my little cheat sheet down here, this is my handwriting and it looks
a little bit messy, so bear with me.
These are done in a hierarchy, you need to look at your documentation and see what vessels
are being worked on.
That’s the first thing that you should do, write it in the margin of the note, just write
down the vessels.
Most vessels have a corresponding modifier like your LD, LC, RC, left descending, left
common, right common, left main, and I forgot what RI means.
{Ed.
Note: RI is ramus intermedius.]
These are the main vessels.
For coding purposes there’s 1, 2, 3, 4, 5 main vessels that are recognized in CPT,
and the hierarchy of how this work, I’ve numbered them.
This is 92243 that’s your first one, 92241 is the second one, in the pecking order.
The 92933 is the third one, 92924 is the fourth one, 92937 is the fifth, and 92928 is the
sixth, and 92920 is the seventh.
They’re not in numerical order.
So what I recommend you to do is take your page, this is page 576 in the CPT Professional
version, and bubble them like this, and then put the corresponding numbers of that hierarchical
order.
Now, where did I get this hierarchical order?
I got it from the guidelines, and then I confirmed with Ruth, I got it right.
Just so you could see the layout of how the codes work, and they’re all kind of all
over the place.
Now, let me go back up to the notes, this answer sheet is worth its weight in gold here.
To do this type of percutaneous coronary intervention, which is abbreviated PCI.
So, percutaneous, they’re poking through the skin, they’re going into the coronary
vessel and they’re doing something.
The three main things that they do is a stent, which is like a little cage that they put
in there to bridge open the vessel.
The second one, they might do an atherectomy which is like scraping of the plaque.
It’s not arterectomy, like they’re removing the artery, like a lot of my newbie students
mistakenly think.
It’s “ather” that means plaque.
And then the third one is angioplasty, that’s normally the balloon thing where they put
the balloon and deflate it and they get it right in the middle of the plaque and then
they inflate it and it squeezes the plaque to the walls and it opens up the pathway a
little bit.
So, those are the three types of interventions that are typically done to these coronary
vessels, so keep that in mind.
These are the main vessels, ramus intermedius, that’s the RI.
So, these are the main vessels that CPT recognizes for coding purposes.
If you’re coding a branch of a coronary major artery, the modifier you use will be
the same as the modifier for the major artery.
So, modifiers are really needed here.
If I go into a branch – I did write the branches on my cheat sheet here too – the
left descending has two diagonal branches, the left common has two marginals, the right
common has a posterior descending and a posterolateral.
And then, the left main and the RI, they don’t have any, so you don’t get to use any codes
- they don’t have any branches.
But, if you did have a diagonal, its modifier would be LD.
If you did have a marginal, its modifier would be LC.
[Ed .note:
If you did have a posterior descending or a posterolateral, which are branches of the
right coronary, its modifier would be RC.]
And there are no modifiers for the others – or they wouldn’t apply, I should say.
Next, you need to realize which coronary artery branches are recognized, we just went over
them.
According to the guidelines, the following branches are recognized: Up to two coronary
artery branches – those are the diagonals.
Up to two branches of the LC – those are the marginals.
Up to two branches of the right coronary – those are posterolaterals and the posterior descending.
The left main and ramus intermedius do not have any.
So, the base codes are 92920, 92924, 92928, and 92933.
They can be coded for a major artery, or a branch.
The add-on codes, 92921, 92925, 92929, and 92934 can only be coded for branches when
some base code was applied to the same major artery or another one of its recognized branches.
And this is coming right from the CPT manual: “PCI performed during the same session in
additional recognized branches of the target vessel should be reported using the applicable
add-on code(s).”
This is one, guys, that you really need to read and re-read the guidelines and really
noodle on it.
Also note that the add-on codes for PCI have parenthetical notes stating which base codes
they can be used with, so I’ll show you that real quick.
You see 92921, in parenthesis it says you can use it with 92920, which we would get
because it’s in the same bubble, it’s indented; but you can also use it with 92924
which is a parent code in the next bubble, 928, 933, 937, 941, 943.
So, pay attention to these parenthetical notes and they’ll clue you in what it’s legal
to use them with.
To get to your question, 92933-RC and 92934-LD, that was an answer on a mock board exam question.
It’s impossible to have just these two codes, so that’s why it’s a wrong answer because
they have mixed modifiers.
It has to have the same modifier if it’s an add-on code.
So, these pair of codes (with no other base code for LD), let’s go find 92934.
92934 is an add-on code, we just read that guideline that it has to have the same main
vessels, so the modifiers would match.
So, this pair of codes with no other base code for the LD would violate the guidelines
because you have to code for the PCI and the main target vessel or branch (of LD) using
a base code before you can possibly code any of the add-on codes for a branch of the LD.
One example of this combination of codes, PTCA (percutaneous transluminal coronary atherectomy
- that’s plaque removal) with intracoronary stent for right coronary artery is coded 92933
with an RC.
Percutaneous transluminal coronary atherectomy, with intracoronary stent for diagonal branch,
D1, of the left interior descending artery, you’re going to code as 92933-LD.
Just an action plan to get more up to speed on this, this particular question I could
probably spend an hour on it.
This could be a content webinar that we could do if you’re interested.
So, read the guidelines on page 574 to 575, it’s a whole page of guidelines, and then
highlight the key notes the way I showed you that I did in my book and bubble and highlight
those codes and make some little cheater notes.
Now, for those who aren’t in the Replay Club, they really would love something similar
this answer sheet, there is a forum post on our site.
If you go to www.cco.us/forum, this is the link here and that Ruth kind of went over
this.
Let me see if I can show you that real quick.
So, if you just type in the search box, if you type in “major coronary arteries,”
it would find this thread for you and you can see Ruth really broke it down very, very
nicely.