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Angioplasty CPT Codes: Documentation Pitfalls You Should Avoid
Three cardiology documentation errors when applying angioplasty CPT codes could lead to the kind of problems the OIG discovered. Here are the pitfalls you should try to avoid:
Semi-automated reports: Many physicians prefer to use the catheterization lab information system to generate their documentation for procedures, instead of dictating their reports the old-fashioned way. These semi-automated reports don’t explain the reasons that a doctor chose a particular set of interventions. That can lead to incorrect coding.
Documenting procedures in this fashion can also be problematic because the author of each entry in the medical record is not clearly recorded. These are legal documents, and each entry must be signed and dated by the appropriate author. Automated systems are often driven by cath lab technicians, not the physician.
Anatomical misunderstandings: You’re not alone if you have difficulty figuring out what constitutes a single coronary artery, but that sort of anatomical misunderstanding is especially common in situations when the physician performs interventions in branches, bypass conduits, vein grafts or anatomic variants.
You’ll have a sticky problem when a physician who doesn’t understand angioplasty CPT coding or a coder who doesn’t understand coronary anatomy picks the wrong code.
For the coronaries, you should compile a list of the terms and specific locations within each vessel. Neither CPT nor Medicare lists these.
Not giving reasons: A non-physician can almost never tell why your physician performed a specific set of interventions just by reading the medical record. Therefore, you should encourage your physician to give reasons why he performed a procedure. It simplifies the understanding process for payers.
For physicians, they may receive an additional reimbursement if they use the -22 modifier to indicate an unusual procedure to the normal angioplasty CPT codes. The additional reimbursement may vary from payer to payer.
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