Consult Latest Rules for EKG Payment
Question: Our facility bills for the technical component of pre-operative electrocardiograms (EKGs), but the insurer denies the charges due to medical necessity, and we've been writing off these costs. We bill with only the diagnosis of the appropriate surgery. Could we avoid this denial by including both the surgery diagnosis and an acceptable diagnosis for the EKG?
Delaware Subscriber
Answer: You should report all pertinent diagnoses, such as V72.81 (Preoperative cardiovascular examination) - including the surgery diagnosis and the diagnosis for the EKG. But whether insurers pay you depends on the latest local coverage decision (LCD), national coverage decision (NCD), or other payer guidelines - so be warned that sometimes electrocardiograms may just not be covered by certain payers.
Bill Clinic Visits for Unknown Conditions
Question: When is it appropriate for a hospital to code clinic visits (99201-99205 and 99211-99215)? More specifically, what distinguishes a clinic from an outpatient visit in which no facility fee is charged? For example, if the physician sees a patient solely for a cast window in an orthopedic clinic, should the hospital charge for both the visit and the cast window or only for the cast window?
Tennessee Subscriber
Answer: If the patient presents specifically for a surgical service, such as cast windowing, you should bill only the surgical procedure code. If, however, the patient presents with an unknown condition, receives an examination from the physician, and the physician then decides to perform a surgical service, you should report both the evaluation and management visit code (for example, 99201-99205 or 99211-99215) and the procedure code. This guideline applies to all hospital-based clinics and outpatient areas.
Choose Your Own OR Rates
Question: In the chargemaster, does the operating room (OR) time charge need to be the same per hour for any surgery? What is the going OR charge per hour to ensure all items are captured, such as equipment and supplies?
Oregon Subscriber
Answer: Many facilities have adopted varying rates for major and minor operating room time or for "levels" of surgical services based on the type of equipment used or staffing ratios, among other criteria. You can charge operating room time in minutes, hours, or partial hours as a single or incremental rate, as long as you can apply the method easily and objectively to all patients receiving such services.
There isn't really a "going rate" for this time. Usually, the individual facility sets the rates based on bed size and patient mix, which means these rates can vary dramatically from region to region.
One Vessel, One Code
Question: What advice can you offer for a Medicare hearing appeal for two angioplasties in the femoral and popliteal arteries? We coded the second 35474 with modifier -59. But I am concerned that Medicare is going to look at 35474 and say that the code represents both the femoral and popliteal arteries, so it should be coded only once.
New York Subscriber
Answer: You should code interventions in the peripheral artery system "per vessel." For coding purposes, the femoral artery and the popliteal artery are distinct vessels. Therefore, when the physician performs interventions in each of these vessels, you should bill for each separately.
In this case, you should report the first procedure with 35474 (Transluminal balloon angioplasty, percutaneous; femoral-popliteal) and 75962 (Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation).
For the second angioplasty, you should report 35474 and append modifier -59 (Distinct procedural service) to indicate that it's distinct from the first. Report +75964 (... each additional peripheral artery, radiological supervision and interpretation) for the radiological supervision and interpretation.
-Reader Questions reviewed by Sarah Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.
