Coding Consult

Say a patient complains of chest pain (786.50) and heart palpitations (785.1). You use your local hospital's equipment to perform a cardiovascular stress test, but you supervise the test and provide a written interpretation and report.

In a case like this, you should use two codes: Report 93016 for the physician supervision alone. Use 93018 to code the written interpretation and report, advises Sheldrian LeFlore, a senior consultant with Gates, Moore & Company in Atlanta.

Use this code because it's global-it encompasses all of the procedure's components including the use of the equipment, the supervision, the interpretation, and the report.

"93016-93018 break out the components into the parts of the test that the physician performed when he doesn't do the entire service," Center says.

If you use a pharmacological agent to initiate stress, report the appropriate HCPCS code to specify the agent you use. For dobutamine, use HCPCS code J1250 (injection, dobutamine HCl per 250 mg); for dipyridamole use HCPCS code J1245 (injection, dipyridamole, per 10 mg).

Document medical necessity If you want to ensure that Medicare and commercial insurers pay for the cardiovascular stress tests, you'll need the appropriate ICD-9-CM codes and your payer's documentation requirements for medical justification.

Consider this scenario: Because your patient is obese (278.0x) and has diabetes (250.xx), you want to make sure he doesn't have coronary artery disease. You perform a stress test to screen for the condition. You use code 93015, and your Medicare carrier denies your practice's claim.

"The primary reason for denial of reimbursement for a stress test is the lack of medical necessity," LeFlore says. For instance, most Medicare carriers don't pay for cardiovascular stress tests as a screen for coronary artery disease.

"Doctors must check each of their payer's guidelines to ensure that medical necessity is present in the documentation for performing this service," she says.

Center agrees and adds, "Many offices don't check their contracts, and only later find out they have to write off the stress test because the ICD-9-CM codes they used aren't on the list of approved diagnosis codes."

Generally, a cardiovascular stress test is medically necessary if the patient presents with chest pains or has an abnormal ECG, LeFlore says. In the scenario above, the patient was obese and had diabetes-risk factors for coronary artery disease-but there was no documented medical necessity. Check with your carrier to find out what the medical documentation should contain.

At First Coast Service Options of Florida, for example, the medical documentation must include a history and physical, office or progress notes, and test results. But it also must support the medical necessity beyond payer-approved diagnosis codes. That means the medical record must match the listed diagnosis. For instance, if the diagnosis code is 786.50, your notes should reflect that the patient had chest pains.

If a patient's condition does not meet medical necessity, have the patient sign an Advance Beneficiary Notice. The ABN states that the patient is aware that Medicare does not cover the stress test, and that he will pay the charges.