# Billing a 93015 and a 93006



## nancy.anselmo@ccrheart.com (Feb 27, 2014)

Ok, I have billed this combo before and have not had any trouble. But now I am getting rejected and I am not sure why
99214-25 786.05
93306 786.05
93015 414.01 
Now the 99214 denied as bundling w/93015 and the 93306 denied for needing notes. But this is what I don't understand I thought that the 25 modifier was what seperated the visit form the procedures. 99214 denied reason states:Not supported. This code is included in CPT 93015. The submitted documentation does not support a significant, separatley identifiable E&M service to support the use of the -25 modifier.
So I am not sure what they want. Any help would be appreciated Thank you

Reason for Appointment 
1. Echo and Tet - last visit 7/3/13 


Assessments 
1. Shortness of breath - 786.05 (Primary) 
2. Coronary atherosclerosis of native coronary artery - 414.01 
3. Coronary atherosclerosis of artery bypass graft - 414.04 
4. Percutaneous Transluminal Coronary Angioplasty Status - V45.82 

69 yo with CAD and previous CABG and PCI, HTN, HLP. Her anginal equivalent was shortness of breath. She has had moderate yet intermittent symptoms despite medical therapy. Her weight has been stable and she denies edema. Echo today demonstrates normalization of her LV function with mild valvular disease. Treadmill testing was limited with a poor exercise performance. There were equivocal ECG changes with development of prominent shortness of breath resulting in termination of the test. This is a limited and submaximal performance to detect ischemia. Will monitor for symptoms and should she have continued dyspnea, will recommend nuclear stress testing. 

Treatment 
1. Coronary atherosclerosis of native coronary artery  
Start Aspir-Low Tablet Delayed Release, 81 MG, 1 tablet, Orally, Once a day, 30 day(s), 30 

2. Others   
Patient is no longer taking Aspirin. She has started taking Folic Acid, Vitamin D, and Methotrexate. She has increased Atorvastatin to 40 MG daily, and has decreased CO Q10 to 50 MG daily , Per pt medication reconciliation.    


Procedures 
TET- Exercise Stress Test:  
       Protocol Bruce protocol.  
       Report The resting heart rate was 55 bpm with a resting blood pressure of 130/80 mm Hg. Utilizing the standard Bruce protocol the patient was exercised for 3 minutes, 07 seconds, achieving a maximum heart rate of 97, which is 64% of predicted maximal heart rate. The maximum blood pressure was150/70 mm Hg, acheiving 1.7 METs. There was submaximal heart rate and physiologic blood pressure response to exercise. Equivocal 0.5mm ST depressions observed with exercise. Test terminated due to sudden shortness of breath.  
Echo:
1. Overall left ventricular systolic function is normal with, an EF between 60-65%.
2. The diastolic filling pattern indicates impaired relaxation.
3. There is mild concentric left ventricular hypertrophy.
4. Left atrium is severely dilated by volume.
5. There is mild aortic regurgitation.
6. Moderate mitral regurgitation is present. 



Follow Up 
3 Months (Reason: ov/ecg) 

History of Present Illness 
HPI:  
       69 year old female presents with c/o Shortness of breath.  c/o Lightheadedness  believes to be from sinus problems. 
       Denies : Chest pain. Swelling in ankles. Inability to lay flat. Need to sleep with multiple pillows. Palpitations. Passing out. Change in exercise tolerance. Pains in legs when walking. 
       She describes intermittent episodes of shortness of breath with exertion. Although she denies chest pains, her anginal equivalent prior to her last PCI was dyspnea. She has been compliant with medications and notes that she has not taken Nitro. She will have episodes about two times a month that resolve with rest. She denies palpitations, syncope or presyncope. 

Current Medications 
Atorvastatin Calcium 40 MG Tablet 1 tablet Once a day 
Naproxen 500 MG Tablet 1 tablet PRN 
CoQ10 50 MG Capsule 1 capsule Once a day 
Plavix 75 MG Tablet 1 tablet Once a day 
Metoprolol Tartrate 25 MG Tablet 1 tablet Twice a day 
Lisinopril 10 MG Tablet 1 tablet Once a day 
Hydrochlorothiazide 12.5 MG Tablet 1 tablet Once a day 
Metformin HCl 500 MG Tablet 1 tablet Twice a day 
Folic Acid 400 MCG Tablet 1 tablet Three times a day 
Methotrexate 2.5 MG Tablet 1 tablet Once a week 
Vitamin D Tablet 1 tablet Once a week 
Medication List reviewed and reconciled with the patient 



Allergies 
N.K.D.A. 


Past Medical History 
Hypertension 
Diabetes 
Angiogram - LIMA to LAD patent, SVG to RCA distal moderate disease. Native PDA and PO branch diffusely diseased. SVG to obtuse marginal branch had 90% stenosis, EFof 35-40% with LA enlargement and some hypokinesis. (2/22/2013) 
Angioplasty - Xience stent to SVG-OM 2/22/13 


Surgical History 
CABG x3 - LIMA to LAD, SVG to RCA, SVG to obtuse marginal branch. 1999 
Hysterectomy  
Cholecystectomy  


Hospitalization/Major Diagnostic Procedure 
 - Chest Pain transferred from  2/22/2013 


Family History 
Father: deceased 52 yrs several MI's  
Mother: deceased 69 yrs rheumatic fever and arrythmia  
Siblings: early 50's yrs brother- bypass and possible MI  
1daughter(s) - healthy.  


Social History 
no Smoking  Are you a:: former smoker , How long has it been since you last smoked?: > 10 years.  
no Alcohol. 
no Recreational drug use. 
Exercise: yes, walking 3 times a week at the school. 
Caffeine: yes, 1 cup of coffee daily.  

Review of Systems 
CCR:  
       Patient denies Fevers-Chills-Cough-Congestion-Abdominal pain-Diarrhea-Constipation-Blood in stool-Burning with urination-Blood in urine-Rashes-Bleeding-Weight loss.  Patient admits Joint pain/ arthritis-Hot/cold intollerance-Weight gain.     


Vital Signs 
Height 5 ft 0 in, weight 154 lbs, BMI 30.07 index, SaO2 96, blood pressure (BP) 134/80, heart rate (HR) 55. 

Examination 
Cardiovascular Examination:
       General Appearance: comfortable, build: obese, good color, looks well.  Carotid Upstroke: normal, no bruit, upstrokes intact.  Jugular Venous Distention (JVD): difficult to appreciate but grossly normal.  Chest: normal shape and expansion, no tenderness on chest wall.  Lungs:  clear to auscultation bilaterally, no rales, wheezes, or rhonchi.  Cardiovascular regular rate and rhythm, normal S1, S2, no S3, or S4, no murmur, rub, gallop or click. No heave or thrill. PMI 5th ICS, MCL.  Abdomen: obese, soft, nontender, nondistended, normoactive bowel sounds, unable to palpate masses due to body habitus.  Extremities: trace pedal edema, no clubbing or cyanosis.  Neurologic:  alert and oriented x 3.  Mood: appropriate, pleasant..


----------

