Coding/Billing Corner – Patient Case: Stenting in NSTEMI With ACLS, Cardiogenic Shock, PCI

A 65-year-old male patient presents to the emergency room with non-ST-elevation myocardial infarction (NSTEMI). Cardiology service is consulted for further management. The patient has a history of uncontrolled type II diabetes mellitus and uncontrolled hypertension. During his physical examination, he becomes pulseless. Patient is found to be in pulseless ventricular tachycardia. Advanced cardiovascular life support is initiated and patient regains spontaneous circulation after defibrillation. He then becomes hypotensive, requiring inotropes for cardiogenic shock.

The patient is taken emergently to the cardiac catheterization laboratory. Intra-aortic balloon pump (IABP) is placed urgently and he undergoes percutaneous coronary intervention (PCI) with a drug-eluting stent placed to the proximal left anterior descending coronary artery. The patient is transferred to the cardiac intensive care unit post-PCI. Complete transthoracic echocardiogram reveals reduced left ventricular systolic function, EF 30 – 35 percent. He is placed on dual antiplatelet therapy and guideline-directed medical therapy for his heart failure.

The patient improves clinically over the next 48 hours, IABP is removed at bedside and patient is transferred out of the cardiac intensive care unit. His hypertension and diabetes medications are modified. He is discharged home after five-day hospitalization and referred to outpatient cardiac rehabilitation.

The following CPT® codes can be used for coding and billing during the hospitalization:

  1. 99223: High complexity initial hospital admission (level 3 admission H&P)
    99291: Critical care, evaluation and management of the critically ill or critically injured patient; first 30 – 74 mins and 99292: Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes.
  2. 92950: Cardiopulmonary resuscitation (e.g., in cardiac arrest).
  3. 33967: Insertion of intra-aortic balloon assist device, percutaneous.
  4. 92941: Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel.
  5. 93306: Complete transthoracic echocardiogram – echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography.
  6. 33968: Removal of Intra-aortic balloon assist device, percutaneous.
  7. 99233: Subsequent hospital care, per day, for the evaluation and management of a patient.
  8. 99238: Hospital discharge day management; 30 minutes or less.

Points to consider:

  1. In order to code for a 99223 high complexity initial hospital admission, we need to document all of the following:
    1. Comprehensive chest pain history with four or more descriptors (location, character, severity, duration, associated signs and symptoms, and timing)
    2. Social history, family history, and review of systems.
    3. Comprehensive physical examination that includes at least eight systems (general, eyes, ENT, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, skin, psychiatric, and lymphatic)
    4. High complexity decision making (unstable patient, resuscitation measures, emergent percutaneous intervention, intra-aortic balloon pump placement, antiplatelet therapy, anticoagulant therapy, etc.)
  2. In order to code for a 99291 critical care for the first 30 – 74 minutes, we need to document:
    1. Patient is critically ill, the term "unstable patient" is not considered to be adequate documentation. Critical care time does not apply to non-critically ill patients who are admitted to a critical care unit. Critical care time does not apply to physician management of non-critical conditions in critically ill patients (for example, perioperative evaluation for a critically ill patient).
    2. Face to face critical care time (time in and time out). For academic providers, house-staff time in the absence of attending presence cannot be factored in.
    3. CPT criteria for critical care must be met:
      1. Clinical condition criterion: One or more organ failure with high probability for sudden, clinically significant or life threatening deterioration in patient's condition that requires highest level of physician preparedness to intervene urgently.
      2. Treatment criterion: Critical care services; life support or organ support systems that require frequent, personal assessment and manipulation by the physician.

Email Debra Mariani, coding and physician reimbursement staff at the ACC, and the ACC Coding Task Force, at, for more information or questions on coding or billing.

This article was authored by Aneesh Pakala, MD; Jayanta Mukherjee, MD, FACC; and Dmitriy N. Feldman, MD, FACC, a member of ACC's Coding Task Force Committee. All three are members of the early career coding and billing editorial team.