C9607 — Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must document medical necessity for the PCI, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Each claim must include ICD-10-CM diagnosis code(s) that best describe the patient's condition and the reason for the service; claims lacking ICD-10-CM codes will be returned.
- Documentation must be in the format of a procedure note and must state the indications, any unusual clinical circumstances, and the details and results of the intervention.
- Angiographic documentation (film or digital) and intravascular sonographic recordings must be maintained in the medical record and made available upon request.
Key Coverage Criteria
- Percutaneous coronary intervention (PCI) using angioplasty, atherectomy, or stenting (CPT 92920-92944) on coronary arteries is covered when medically necessary and documented in the medical record.
- If a single contiguous lesion extends across more than one target vessel but can be revascularized with a single bridging intervention, the procedure is reported (and covered) as a single-vessel PCI (example: single left main stent reported as 92928).
- All PCI performed in all segments (proximal, mid, distal) of a single major coronary artery through the native coronary circulation are covered and reported with one code.
- If a single lesion extends from one target vessel into another but can be revascularized with a single bridging intervention, report it with a single code (CPT 92928).
- CPT codes 92920-92944 describe percutaneous revascularization (PCI) for occlusive disease of coronary vessels, including major coronary arteries, coronary artery branches, and coronary artery bypass grafts.
- PCI codes include angioplasty (balloon, cutting, wired, cryoplasty), atherectomy (directional, rotational, laser), and stenting (balloon-expandable, self-expanding, bare metal, drug-eluting, covered).
9 Active Policies
L34761 — Percutaneous Coronary Interventions
J05
A57479 — Billing and Coding: Percutaneous Coronary Interventions
J05
A56823 — Billing and Coding: Percutaneous Coronary Intervention
J06
L33623 — Percutaneous Coronary Intervention
J06
WPS-L34761
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