Determining and coding for percutaneous transluminal revascularization of acute total/subtotal occlusion

Q.

For CPT^® code 92941 is there a way of determining if the patient has subtotal occlusion or are we strictly left to rely on the physician to document that specific phrase?

A.

The physician should document how much occlusion is present, and for code 92941, that it is the culprit lesion for the myocardial infarct. If he doesn’t say “total occlusion” or 100% occlusion, then I would consider it subtotal. Documentation of the amount of occlusion really only matters for the chronic total occlusion codes (92943/92944), and he or she should be documenting “chronic total occlusion” in those cases.