Percutaneous coronary interventions (PCI) continue to be among the most scrutinized cardiovascular procedures from both clinical and billing perspectives. CPT 92928 is one of the most commonly used PCI codes and includes stent placement performed during percutaneous coronary intervention in a single major coronary artery or branch.
This guide outlines correct coding principles, supporting documentation, bundling rules, prior authorization considerations, and common payer-specific issues to help physicians, coders, and practice managers ensure full compliance and accurate reimbursement.
Overview of CPT 92928
CPT 92928
Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed, for a single major coronary artery or branch.
This code represents:
- Placement of one or more stents (bare-metal or drug-eluting)
- Including balloon angioplasty if performed in the same vessel
- For one major coronary artery or branch
Separate stents in the same vessel are not coded separately unless involving a different branch of the same major artery.
Components Included in CPT 92928
The following services are bundled into 92928 and not billed separately:
- Vascular access
- Catheter placement into the coronary artery
- Radiological supervision & interpretation for the intervention
- Balloon angioplasty in the same vessel (pre-dilation or post-dilation)
- Closure devices
- Use of embolic protection if required
- Moderate sedation by the same provider
When to Use Add-On Codes (Modifier Required)
Use the following codes with 92928 only if additional distinct vessels are treated:
Additional Coronary Arteries
- 92929 – Stent placement in each additional branch (add-on code)
Diagnostic Angiography (Only When Allowed)
Report diagnostic coronary angiography only if:
- No recent (≤ 1 year) diagnostic angiogram exists, or
- There is a change in clinical status requiring a repeat study, or
- The decision for PCI was not made before angiography
Use codes:
- 93454 – Coronary angiography (no left heart cath)
- 93458 – Coronary angiography with left heart cath
- Add S&I codes only if medically necessary and not included in the PCI procedural code set.
Correct Use of Modifiers
Modifier –59 or –XS
Used when interventions are performed in distinct coronary branches (different major arteries).
Modifier –RC
Some payers require coronary modifiers to differentiate arteries:
- LC – Left circumflex
- LD – Left anterior descending
- RC – Right coronary
Documentation Requirements
Physician documentation must clearly support:
1. Indication for PCI
- Unstable angina
- Acute myocardial infarction
- NSTEMI/STEMI
- Significant stenosis (>70%) with evidence of ischemia
- Lesion characteristics (calcified, bifurcation, ostial, diffuse)
2. Diagnostic Angiographic Findings
Include:
- Vessel treated
- % stenosis pre-intervention
- TIMI flow grade (before and after)
- Lesion complexity (Type A/B/C)
3. Intervention Details
- Type of stent(s) placed (DES vs BMS)
- Pre-dilation and post-dilation details
- Number of stents in the vessel
- Use of adjunctive devices (atherectomy, intravascular imaging)
4. Complications Managed
For example:
- No-reflow
- Dissection
- Perforation
- Thrombosis
5. Post-Intervention Results
- Final % stenosis
- Final TIMI flow
- Hemodynamic stability
6. Medical Necessity Statement
Include:
- Symptoms
- Failed medical therapy, if applicable
- Reason for PCI over CABG (if relevant)
Prior Authorization Considerations
Although prior authorization is not required for emergency PCI, elective stent placement often requires it from commercial payers.
Considerations:
- Unstable angina or documented ischemia generally supports medical necessity
- Stress imaging or coronary CT angiography is often needed for authorization
- Medicare typically does not require prior approval, but may review documentation in audits
- Some payers require documentation of a dual antiplatelet therapy (DAPT) plan, especially with DES
Failure to obtain medical necessity documentation is a common reason for the denial of claims.
Payer-Specific Notes
Medicare
- Uses NCD 20.7 for PCI
- Strong emphasis on documentation of symptomatic coronary artery disease
- DES coverage depends on lesion characteristics (e.g., in-stent restenosis, large-vessel disease)
Commercial Payers
Common criteria required:
- 70% stenosis AND symptoms despite optimal medical therapy
- 50% stenosis in the left main artery
- Abnormal stress test results
Medicaid
Often follows Medicare’s NCD framework but may require additional prior authorization documentation.
Common Denials for CPT 92928
1. “Medical Necessity Not Met.”
Usually due to:
- Lack of documented ischemia
- Insufficient evidence of stenosis
- No documentation of symptoms
2. Incorrect Vessel Coding
Not specifying the LC, LD, or RC modifier where required.
3. Unbundling
Billing angioplasty separately in the same vessel—this is included in 92928.
4. Missing Diagnostic Justification
If diagnostic angiography is billed, payers must see:
- Why was a diagnostic study needed
- That a prior study was inadequate or outdated
5. Lack of Timely Prior Authorization
Commercial payers will deny unless emergent.
Intravascular Imaging (IVUS / OCT)
These are separately billable only when medically necessary and properly documented.
Codes include:
- 92978/92979 – Intravascular ultrasound (coronary)
- 93571/93572 – Fractional flow reserve (FFR)
Documentation must include:
- Indication for imaging
- Pre- and post-intervention findings
- How imaging influenced medical decision-making
Compliance & Audit Considerations
- PCI procedures are high-risk for CMS audits
- Cloning of PCI notes is monitored closely
- Ensure a clear clinical rationale for each intervention step
- Diagnostic angiography must be separate and distinct from known lesions
- Overuse of stents without proper ischemia testing triggers payer scrutiny
- Time-stamped procedural logs help support accurate reporting
- Accurate vessel hierarchy (major artery → branch) is essential
RVUs & Reimbursement (Approximate National Medicare Average)
(Note: These values vary by region and year; always verify with the current CMS fee schedule.)
- CPT 92928
- ~17–20 RVUs (combined facility/non-facility)
- Final reimbursement depends on the geographic practice cost index (GPCI)
Final Notes
Accurate coding of CPT 92928 requires a complete understanding of coronary anatomy, correct identification of distinct vessels, compliance with bundling rules, and clear documentation linking the PCI decision to the patient’s clinical presentation.
For practices requiring coding or audit support, Global Tech Billing LLC can assist in ensuring adherence to payer guidelines.
FAQs
1. What does CPT 92928 cover?
It covers percutaneous coronary stent placement, including angioplasty, in one major coronary artery or branch.
2. Can angioplasty be billed separately with 92928?
No. Pre- or post-dilation angioplasty in the same vessel is bundled.
3. When are additional vessel codes used?
Use 92929 for stent placement in each additional distinct coronary artery or branch.
4. Are diagnostic angiograms separately billable?
Only if medically necessary and not recently performed or if the clinical status changed.
5. Are IVUS or FFR separately billable?
Yes, when medically necessary and properly documented.
6. Do payers require coronary artery modifiers?
Many commercial plans require LC, LD, or RC modifiers to indicate the treated vessel.
7. What are common denial reasons for 92928?
Medical necessity issues, incorrect vessel modifiers, missing prior authorization, or unbundling errors.
8. Does 92928 require prior authorization?
Emergent PCI does not; elective cases often require authorization from commercial payers.
