Cardiology Coding Alert

Hint:  Only apply modifier 25 when your cardiologist performs minor procedures

When a patient presents for an in-office diagnostic test and your cardiologist provides an evaluation, you'll need to know two important aspects to code the test and office visit correctly:

1. whether your cardiologist already scheduled the test
2. the nature of your cardiologist's pre- and post-test work.

To make sure your providers receive their fair share for in-office testing services, our experts say you should implement these three rules of thumb:

1. Bill the E/M with the test if the patient receives an unscheduled test in the office on the same day as the visit.

If the cardiologist decides to perform a diagnostic test, such as an echocardiogram or a nuclear study, on the same day as the office visit, you should report both the appropriate diagnostic test code and the office visit code. You should also append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. Appending modifier 25 will tell payers that the E/M service is separate from the usual patient evaluation that is necessary before, during and after the diagnostic test.
 
Same-day test example: An established patient comes in complaining of palpitations (785.1) and light-headedness (780.4). The provider performs a complete cardiac workup and orders a same-day, in-office echocardiogram.

To report the visit, bill the echo as 93307 (Echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; complete). You may need to add additional codes, depending on the equipment and the images the physician obtained. These additional codes could include +93320 (Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; complete [list separately in addition to codes for echocardiographic imaging]) or +93325 (Doppler echocardiography color flow velocity mapping [list separately in addition to codes for echocardiography]).

Report the office visit with an E/M code, such as 99214 (the level would depend on the physician's documentation), and append modifier 25, says April Leaver, CPC, patient account manager at Morristown Cardiology Associates PA in New Jersey.

"You should add modifier 25 to the E/M code because the patient came in for a specific illness reason and the cardiologist ordered the echo as a result of the exam," says Karen Dearduff, CPC, coding specialist at the Saint Joseph Physician Network in Mishawaka, Ind.

Heads up: "In the past, I didn't use modifier 25 when I reported ancillary codes from the medicine section in addition to an E/M code, but more and more companies are denying your claims if you don't," says Kimberly Engel, CPC, coding coordinator at Advanced Healthcare SC in Germanton, Wis.

2. When the office visit is solely to convey test findings, you should not bill an E/M code for the visit.

If, for example, a patient has an echocardiography on Monday and your cardiologist has him come in on Wednesday to discuss the test results, do not submit any charge. Communicating test findings is included in the payment for performing the test.
 
However, if the test is positive and the patient comes in for more extensive evaluation in light of the test findings, such as a more focused exam and further diagnostic testing, you can bill for the office visit. But the cardiologist must have clearly documented the separate service that he provided in addition to discussing the findings. No modifier is necessary, but the documentation must support the level of service reported. To bill an E/M in this situation, the physician would have to make perfectly clear what he discussed, the exam, medical findings that ensued, and decision-making.

Keep in mind: Many physicians document the chief complaint as "test results returned" and address little, if anything, in addition to the test findings in their office visit notes. If the note simply states "F/U Echo" and offers no other signs or symptoms, you would not be able to bill an E/M because it would not meet medical-necessity guidelines, coding experts say.

Use caution when billing E/M on the same day as testing because your modifier use will be scrutinized, says Carrie Caldewey, CPC, coding supervisor at Northern California Medical Associates in Santa Rosa, Calif. Practices should develop policies concerning this so physicians will have guidelines to help them decide how to report E/M services on the day of a test.

In a nutshell: Your modifier depends on the separate procedure the cardiologist performs. "Only minor surgeries or procedures that have a global indicator of 000, 010 or 090 on the Physician Fee Schedule absolutely require modifier 25," Caldewey says. You can indicate that the complete E/M was necessary prior to the minor surgery or procedure with a separate diagnosis or by the physician's report.

3. On the day of a scheduled diagnostic test, you should bill an office visit only if the physician's service exceeds the typical services he provides to a patient receiving the diagnostic test.

You'll notice a certain amount of pre- and post-test work associated with each diagnostic test, such as assessing the patient's condition, prepping for the test and reviewing results, but this work is not separately billable.

When the physician provides a substantial service in excess of the typical pre- and post-test service, you can bill the office visit with modifier 25 attached. Keep in mind that abusing this billing provision will most likely attract regulatory attention.

For instance: If a patient scheduled for an echocardiogram complains of a new symptom or has high blood pressure during the pre- or post-test phase, the physician may need to give an injection to lower the blood pressure or check for fluid retention. He may also perform a complete exam before or after the echocardiogram, Caldewey says. In this case, "you would be justified in charging the E/M even though the test was preplanned," she adds.