Coding for Holters, stress tests, and ECGs needs close attention
At the heart of cardiac codes
In general, when coding a cardiac study, use a global code only when appropriate. The other codes in the series are not add-ons but individual services.
CPT's cardiography section (93000-93278) includes codes for three tests: Holter monitoring, stress tests, and ECGs. The series for each begins with a global code, and that refers to hookup, scanning analysis, and interpretation/report. Following the global code are codes that break out the components separately.
Physicians sometimes think they should append modifier 26 (professional component) to the global code to show that they provided only some of the services, but doing so will result in a claim denial, says Kathy Pride of QuadraMed, based in San Rafael, CA.
"Cardiology codes are unusual in that regard, and you can't separate out the professional component of the code by appending a 26 modifier," Pride says. Instead, if you perform only some of the services described in the global code, bill just those components.
"Holter monitoring is the most confusing of the cardiology code series," Pride says. CPT shows three series (93224-93227, 93230-93233, and 93235-93237), and each describes slightly different Holter techniques.
"To know which one to use, you have to know which technology you have," Pride says. The difference among the codes is in how the heart rhythms are recorded, stored, and analyzed:
93224 ECG monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation.
93230 ECG monitoring for 24 hours by continuous original ECG waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; includes recording, microprocessor-based analysis with report, physician review and interpretation.
93235 ECG monitoring for 24 hours by continuous computerized monitoring and noncontinuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient-activated; includes monitoring and real-time data analysis with report, physician review and interpretation.
"You need to distinguish between the types of monitors for reimbursement reasons also," says Bruce Rappoport, an internist with RCH Healthcare Advisors in Fort Lauderdale. The 93230 series is the highest-paying series, some $10 more than the 93224 series. The 93235 series is the lowest-paying.
Designate the first code in the series for Holter monitor testing if you perform all of the described serviceshooking up and removing the monitor, analyzing the scan, and reviewing and interpreting the results. If you perform only some of those services, bill only for the individual services provided.
All three of the Holter monitor code series break out the individual components separately. Let's say your office monitored the patient using the equipment described in 93224, but you didn't do the scanning analysis.
"Commonly an outside company will perform that technical component," Pride says. In that scenario, you would code 93225 for the recording, hookup, and removal of the Holter monitor, and 93227 for physician review and interpretation. The scanning company would bill on its own for the analysis.
"The simplest way to look at it is: He who provides the service, bills and collects," Rappoport says.
Exercise stress test codes are set up the same way as the Holter monitor codes, with a global followed by breakouts of the components:
93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous ECG monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report.
93016 . . . physician supervision only, without interpretation and report.
93017 . . . tracing only, without interpretation and report.
93018 . . . interpretation and report only.
"Most offices will never use 93015 because they typically don't have the equipment," Rappoport notes.
If you send the patient to the hospital for the stress test, you may go to monitor it. Use 93016 in this scenario. If you don't supervise the stress test but interpret the results, use 93018. If you do both, code both 93016 and 93018.
Choosing a CPT code for an ECG is simpler than the other cardiac tests. Use the global code 93000 (routine ECG with at least 12 leads; with interpretation and report) when the patient has the ECG in the office and you interpret the results. If you send the patient elsewhere for the ECG but performed the interpretation and report, use 93010 (. . . interpretation and report only). You're unlikely to use the other code in this series, 93005 (. . . tracing only, without interpretation and report).
Be sure your diagnosis code supports the medical necessity for the cardiac test you code. "If you want to know why your ECG was denied, look first to your ICD-9-CM code," says Rappoport. You may have inadvertently coded using a noncovered diagnosis.
Carrier interpretations of covered diagnoses vary from state to state. For example, Cahaba GBA, the Medicare carrier in Iowa and South Dakota, considers 345.00-345.91 (epilepsy) a covered diagnosis for Holter monitor testing, but First Coast Service Options, the Florida carrier, does not. In Florida, 423.1 (adhesive pericarditis), 423.2 (constrictive pericarditis), 424.0 (mitral valve disorders), and 425.0-425.9 (cardiomyopathy) are covered diagnoses, but they're not in Iowa and South Dakota.
If a diagnosis code isn't covered for a diagnosis, look at the patient record to see the signs and symptoms that prompted the order. Was the patient having chest pain or shortness of breath? Is he going on a medication that can affect the heart? Is he scheduled for surgery?
What about coding the diagnosis if the test shows no problems with the heart? Code those instead.
The same holds true if the test proves normal. "A lot of people are confused and think that if you have a normal test, you have to code it as a screening," says Pride. "That's incorrect. If the diagnostic test didn't provide a definitive diagnosis or was normal, the testing facility or the interpreting physician should code the sign(s) or symptom(s) that prompted the treating physician to order the study," according to Section 15021.1 of the Medicare Carriers Manual.
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Coding Consult: At the heart of cardiac codes. Medical Economics Oct. 10, 2003;80:26.