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Coding Cues: Reimbursement for cardiac electrophysiology consult

Article

Our large cardiology group encompasses numerous subspecialties, invasive and noninvasive cardiology and cardiac electrophysiology among them. When one of our general cardiologists refers a patient to our cardiac EP, who sees the patient on the same day, our claims are often rejected. Both the generalist's visit and the EP consult are typically paid on appeal, but we'd like to avoid having to file an appeal. What's happening, and what do you suggest?

Key Points

Our large cardiology group encompasses numerous subspecialties, invasive and noninvasive cardiology and cardiac electrophysiology among them. When one of our general cardiologists refers a patient to our cardiac EP, who sees the patient on the same day, our claims are often rejected. Both the generalist's visit and the EP consult are typically paid on appeal, but we'd like to avoid having to file an appeal. What's happening, and what do you suggest?

One possibility is that the claims-from the same EIN and for the same day-are seen as bundled E&M services. Another is that the insurer doesn't recognize electrophysiology as a distinct subspecialty.

Arrange a meeting with the provider relations staff of the third-party payers who reject such claims and discuss ways to get paid on the first try. Provide Medicare's rule on payment of consultations for different specialties within the same practice, and offer to add a modifier or other mechanism that will alert the insurer to the need to pay for both services. If individual meetings don't lead to resolution, seek help from your state insurance commissioner.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.

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Jennifer N. Lee, MD, FAAFP
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health