Advanced Search

Cardiology Coding Alert

4 Steps to Tilt-Table Coding Perfection

Published on Fri Jul 16, 2004

If you're billing pharmacological intervention with 93660 in a hospital, think again

If your cardiology practice can't keep tilt-table test coding guidelines straight, you're not alone. Our experts show you how to nail down 93660's requirements in four simple steps.

Cardiologists who treat patients with recurrent syncope (780.2, Syncope and collapse) often perform tilt-table tests (93660, Evaluation of cardiovascular function with tilt-table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention). But if you're not following the tilt-table testing requirements to the letter, you may find yourself facing denials for these pricey procedures.

Tilt-table testing helps the cardiologist diagnose and categorize forms of reflex-mediated syncope (also known as neurally mediated, vasodepressor, neurocardiogenic or vasovagal syncope). This test should only be performed after other potentially harmful causes have been ruled out by history, physical examination, or other appropriate tests. A lack of preliminary evaluation may cause your claim to be denied.

1. CPT 93660 Includes Pharmacologic Intervention in Hospital Setting

No optimal duration for tilt-table testing exists, but without pharmacologic intervention, most studies cite tilt test durations of 30 to 45 minutes at 60 to 80 degrees as the most widely accepted range for older adolescents and adult patients.

If the results remain undiagnostic after that period of time, technicians, as a second-stage approach, will administer isoproterenol infusion or sublingual nitroglycerine. You should not bill for the cost or administration of these pharmacologic interventions in a hospital setting, because like the ECG and blood pressure monitoring, 93660 includes all aspects of the test.

If, however, you administer the testing in the cardiologist's outpatient office, you can report the pharmacologic interventions separately.

2. Cardiologist Must Be Present

Although coding experts often debate whether the cardiologist must be present during the tilt test procedure because of the low risk to the patient, most carriers require the cardiologist to be physically in attendance or close by should a problem arise. "This could be for liability reasons or hospital policy," says a Missoula, Mont., subscriber and coder for a multi-cardiology specialty office. "The patient's heart rate and blood pressure could bottom out."

Some insurers may deny your claim if you don't document the physician's personal supervision, while some payers only require direct supervision. You should therefore always confirm your payers'policies in writing before you report any tilt-table testing codes.

3. Document History, Physical Exam, and Test Report

You should always submit documentation supporting medical necessity with each tilt-table test claim. The Empire Medicare policy (a Part B carrier in New York) dictates that medical record documentation must include the following information:

  • A history detailing the frequency and length of the syncopal episodes, triggering events, comorbid illness, medication use, alcohol use, assessment of oral intake, and results of prior diagnostic testing

  • A physical exam including a cardiovascular evaluation, neurological evaluation, measurement of orthostatic blood pressure, and assessment of carotid sinus sensitivity unless contraindicated

  • A formal report through the test itself, indicating the duration and progress, along with abnormal hemodynamic responses or clinical observations as well as the results.

    4. Know Which Modifiers May Apply

    You can split code 93660 into two components. If the cardiologist does not own the tilt-table equipment, you should append modifier -26 (Professional component) to 93660. The facility that owns the equipment will report the technical component. But if cardiologist or her practice owns the tilt table, you should report the global code (93660 without a modifier), which includes professional and technical components.

    You cannot bill a separately payable E/M code on the same day that you report the tilt test unless the physician's documentation supports this separately identifiable service. In this case, you can 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 (99201-99215 for outpatient office visits).

    Example 1: If you see a patient in the hospital and perform tilt-table testing, you can code 99235 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...) with modifier -25 and 93660 with no modifier, because if you talk to the patient in the hospital setting and diagnose him there, you should be able to charge for the admit/discharge as well as the testing, says B.J. Stepps, office manager at Heart Rhythm Associates in Greenville, N.C.

    Example 2: If a patient presents to your practice for her first visit and the cardiologist performs a tilt-table test later that day, you can report both the E/M code and 93660. "A patient referred to the office in the morning can warrant an E/M code with modifier -25 if the tilt-table test takes place in the afternoon at the hospital," the Montana subscriber says.

    • Other Articles in this issue of

    Cardiology Coding Alert

    View All