When the physician performs nonselective renal or iliofemoral angiograms for Medicare beneficiaries during cardiac catheterization, the Centers for Medicare and Medicaid Services (CMS) requires HCPCS codes instead of CPT® codes. So make sure you are familiar with G0275-G0278 when reporting these procedures to your Medicare contractor.

Look at the Rules

CMS maintains that physicians often perform peripheral artery angiography during cardiac catheterization with the catheter in the aorta or in the ipsilateral extremity without selectively catheterizing the imaged artery. In this case, you should not report a catheter placement code for the peripheral procedure because catheterization of the aorta and the ipsilateral extremity are integral parts of the heart catheterization procedure.

For example, if the physician performs cardiac catheterization and then pulls the catheter back to the abdominal aorta and inject contrast, you should not report 36200 (Introduction of catheter, aorta). Instead, any work associated with the abdominal aorta catheter placement is included in the cardiac catheterization code(s).

HCPCS Codes Important for Medicare

At the same time, CMS has issued two HCPCS codes to represent the physician's work associated with the nonselective angiography of the renal or iliofemoral arteries performed during the same encounter as cardiac catheterization:

• G0275 - Renal angiography, non-selective, one or both kidneys, performed at the same time as cardiac catheterization and/or coronary angiography, includes positioning or placement of any catheter in the abdominal aorta at or near the origins (ostia) of the renal arteries, injection of dye, flush aortogram, production of permanent images, and radiologic supervision and interpretation (list separately in addition to primary procedure)
• G0278 - Iliac and/or femoral artery angiography, non-selective, bilateral or ipsilateral to catheter insertion, performed at the same time as cardiac catheterization and/or coronary angiography, includes positioning or placement of the catheter in the distal aorta or ipsilateral femoral or iliac artery, injection of dye, production of permanent images, and radiologic supervision and interpretation (list separately in addition to primary procedure)

"While withdrawing the catheter during a cardiac catheterization procedure, physicians often inject a small amount of dye to examine the renal arteries and/or iliac arteries," according to CMS in the National Correct Coding Policy Manual (Chapter 11, §I.15). "These services when medically reasonable and necessary may be reported with HCPCS codes G0275 or G0278."

Regarding when to report nonselective renal angiography (G0275), the manual (Chapter 11, §I.16) further states:
Renal artery angiography at the time of cardiac catheterization should be reported as HCPCS code G0275 if selective catheterization of the renal artery is not performed.

But you should not report G0275 with CPT® codes 36245 or 75722-75724 because these codes indicate selective renal artery catheterization and imaging, according to the Correct Coding manual. "If it is medically necessary to perform selective renal artery catheterization and renal angiography, HCPCS code G0275 should not be additionally reported," the manual indicates.

When using the HCPCS codes, keep in mind that they do not require modifier 26 (Professional component) because they inherently represent the physician's work associated with supervising and interpreting the service. And Medicare packages G0275-G0278 for hospital outpatient billing.

If you are reporting these services to non-Medicare payors, you can generally use the regular CPT® codes rather than G0275-G0278. There are significant differences in the values assigned to the HCPCS codes and to the CPT® codes. Both G0275 and G0278 carry 0.38 transitioned facility total relative value units (RVUs), according to the Medicare Physician Fee Schedule. At the same time, 75625 has 6.30 RVUs and 75716 has 7.66 RVUs. Of course, you should always follow your payors' published instructions when assigning codes for these services.

Follow These Examples

Here are a few examples of how to properly use G0275-G0278 for Medicare payors, as well as how to report the same services to carriers that do not follow Medicare rules.

Example 1: The physician performs left heart catheterization with coronary angiography and left ventriculography. She also images the renal arteries via nonselective injection in the aorta.

Medicare Answer 1: For a Medicare payor, you should assign the following codes:

• 93510(-26) - left heart catheterization
• 93543 - injection for left ventriculography
• 93545 - injection for coronary angiography
• 93555(-26) - imaging supervision and interpretation for ventriculography
• 93556(-26) - imaging supervision and interpretation for coronary angiography
• G0275 - imaging and interpretation of nonselective renal angiography

Non-Medicare Answer 1: For a payor that does not adhere to Medicare reporting guidelines, you should assign the following:

• 93510(-26) - left heart catheterization
• 93543 - injection for left ventriculography
• 93545 - injection for coronary angiography
• 93555(-26) - imaging supervision and interpretation for ventriculography
• 93556(-26) - imaging supervision and interpretation for coronary angiography
• 75625(-26)-59 - radiological supervision and interpretation of abdominal aortography

Example 2: The physician performs a left heart catheterization with coronary angiography and left ventriculography. He also images the lower extremity arteries via nonselective injection of the aorta.

Medicare Answer 2: For a Medicare payor, you would assign the same codes as in Example 1 for the left heart catheterization, coronary angiography and ventriculography - 93510(-26), 93543, 93545, 93555(-26) and 93556(-26). And you would also assign G0278 to represent the physician's work of supervising and interpreting the nonselective extremity angiography.

Non-Medicare Answer 2: If the payor does not follow Medicare coding rules, you would still assign 93510(-26), 93543, 93545, 93555(-26) and 93556(-26). Instead of G0278, however, you would use 75716(-26)-59 for the extremity angiography.

Example 3: The physician performs a left heart catheterization with coronary angiography and left ventriculography. He also images the renal arteries and the lower extremity arteries via nonselective injection in the aorta.

Medicare Answer 3: When reporting the physician's work to a Medicare contractor, you would again assign 93510(-26), 93543, 93545, 93555(-26) and 93556(-26) for the heart cath, coronary artery angiography and ventriculography. And you would use both G0275 for the nonselective renal angiography and G0278 for the nonselective extremity angiography.

Non-Medicare Answer 3: For non-Medicare payors, you would assign the same codes for the heart catheterization, coronary artery angiography and ventriculography. But you would report 75625(-26)-59 for the nonselective renal angiography and 75716(-26)-59 for the nonselective extremity angiography.

Chris B. Owens, CPC, PCS, is the Director of Online Training at Coding Metrix Inc. (www.codingmetrix.com), an online coding education company that offers specialty-specific e-learning opportunities in such medical specialties as invasive cardiology, medical and radiation oncology, interventional radiology, pain management and pathology, among others. He has been writing about medical coding and reimbursement for more than 10 years and served on the National Advisory Board for the American Academy of Professional Coders from 2005-2007.