Cardiology Coding Alert

You may not always have instances when your cardiologist performs an E/M service separately from a stress test, but you should know what to do when she does -- or forfeit reimbursement your practice rightly deserves.

For example, your cardiologist may need to urgently evaluate a patient following a stress test to determine whether the patient's condition requires more care or discharge. But can you report this?

Bottom line: You can report both services, but you need to make certain the E/M visit is separately identifiable from the stress test, says Tammy Anderson, CPC, supervisor of claims at Managed Care Systems in Bakersfield, Calif.

Follow these steps, and your stress tests and E/M services will sail through.

When you report a stress test, you'll use 93015 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report), if performed in the office, for the global service.

If your cardiologist reports only components of the global service, you'll report 93016 (...physician supervision only, without interpretation and report) or 93018 (... interpretation and report only), if performed in the hospital.

Red flag: Be aware of the locations that are specific to these codes. You'll report 93016 and 93018 when your cardiologist performs the test in the hospital. If the test takes place in the office, you'll report 93015.

When you report an E/M service separately, you've got to be wary of two pitfalls.

Pitfall 1: In many circumstances, the diagnosis code you report for the E/M service may be the same as the diagnosis code you use for the stress test. "This is the only problem we have," says Connie Cofer, CPC, CIC, a coder at NE George Heart Center in Gainesville, Fla.

Payers may question whether the E/M service was truly significant and separately identifiable. Regardless of payer suspicions, you should assign the most accurate codes for all claims. See Step 3 below to find out what you can do to help these claims succeed.

Pitfall 2: If, at the time of the stress test, the cardiologist merely reviews the patient's current status for the sole purpose of verifying that the patient is physically stable to undergo the stress test, you should consider that review as part of the test and not report a separate office visit.

You may be wondering if you should attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to your significant and separately identifiable E/M service code when the cardiologist performs a stress test during the same visit.

Warning: "I've noticed much misuse of modifier 25 to get the office visit paid when the documentation may not clearly indicate the cardiologist needed to perform it," Anderson says. Therefore, you've got to be extra vigilant when reviewing your physician's documentation and knowing what your payer truly requires.

Based on current CMS guidelines, you do not need to attach modifier 25 when your physician provides a separate E/M service on the same date as a stress test. In 2006, CMS released Transmittal 954, which instructs you to use modifier 25 only when your cardiologist provides a significant and separately identifiable E/M service on the same day as a procedure that has a global period. (For the exact language, go to www.cms.hhs.gov/transmittals/downloads/R954CP.pdf   to read the full transmittal.)

The codes associated with stress tests (93015-93018), however, have a global-day indicator of "XXX," which means that the global-period concept does not apply.

But you may find that many payers -- including Medicare carriers -- routinely and inappropriately deny claims without modifier 25 appended to the E/M code. Consequently, you may need to use the modifier, Anderson says.

Note: The guideline that instructs you to append modifier 25 only when coding procedures with a global period is Medicare-specific. So you should check with your carriers to learn if they want you to append modifier 25 to your separate E/M service code on the same day as a stress test.