Cardiology Coding Alert

You can streamline your unlisted-procedure code claims and ensure your physician gets reimbursed without specific codes by following these four pointers.

Anytime you file a claim using an unlisted-procedure code (for example, 93799, Unlisted cardiovascular service or procedure), you should include a separate report that explains, in simple, straightforward language, exactly what the physician did.

Example: Your cardiologist cardioverts a patient by using a patient's internal defibrillator. The cardioversion uses timed impulses to convert an arrhythmia back to normal sinus rhythm. You try to find a CPT code to represent this procedure, but you can't locate one.

You'll likely have to look at the unlisted-procedure code 93799, says Sandy Fuller, CPC, compliance officer at Cardiovascular Associates of East Texas in Tyler.

Describe a cardioversion through an implanted device in layman's terms -- your reviewer may not be familiar with cardiology. For instance, your procedure description could read: "An external cardioversion is the application of timed electrical stimuli through the patient's chest with external electrodes."

Keep in mind: Insurers consider claims for unlisted-procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide. Unfortunately, claims reviewers frequently do not have a high level of medical knowledge, and physicians don't always dictate the most informative notes.

Good idea: You may even want to include diagrams or photographs to better help the insurer understand the procedure. "We highlight or make notes on the actual op report indicating where in the body of the op report the unlisted procedure is being described," says Melanie Uitto, CPC, CMC, coder at the CORE Institute in Sun City West, Ariz.

An insurer will decide to pay an unlisted-procedure claim by comparing your procedure description to a similar, listed procedure with an established reimbursement value. Rather than leave it up to the insurer to determine which code is the "next closest," you should explicitly make reference to the nearest equivalent listed procedure. After all, the treating physician is best equipped to make this determination. You should also note the specific ways that the unlisted procedure differs from the next-closest listed procedure.

Example: Using the same scenario above, in which your cardiologist cardioverts a patient using the patient's internal defibrillator, you should show that "internal" cardioversion is a similar procedure but one in which the cardiologist passes electrodes to the inside of the patient's heart through a transvenous approach. Using a patient's internal defibrillator is somewhat of a hybrid procedure, meaning that you aren't likely to find a regular CPT code to represent it.

This will help relate the procedure performed to an existing procedure as support for reimbursement. And explain how your procedure differs to show why you didn't choose the existing code, says Heather Corcoran, manager at CGH Billing Services in Louisville, Ky. Basing your fee on a similar procedure is helpful in claims processing but not mandatory.

For the scenario above, you should request reimbursement at a level somewhere between that of 92960 (Cardioversion, elective, electrical, conversion of arrhythmia; external), 92961 (... internal [separate procedure]) and 93744 (Electronic analysis of pacing cardioverter-defibrillator [includes interrogation, evaluation of pulse generator status, evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response]; dual chamber, with reprogramming).

In other words, this procedure is a hybrid between these three codes: internal conversion (because the cardiologist is delivering impulses directly to the myocardium), external cardioversion (because the cardiologist is performing the procedure noninvasively), and defibrillator interrogation (because the cardiologist is using a previously implanted cardiac rhythm management device to perform the procedure).

If the cardiologist uses equipment and techniques for which there is no dedicated CPT code, you may be able to enlist the manufacturer's aid to receive appropriate reimbursement. Manufacturers often maintain free information and help lines to advise physician practices on how to approach insurers regarding new technologies.

Use caution when applying manufacturers' suggestions, because you are responsible for the accuracy of your claims. You should never misrepresent a claim to gain payment.

Stick to unlisted-procedure codes when no other codes describe the procedure the physician performed. Always provide ample documentation to justify the claim's necessity.

You should also contact your specialty societies, such as the American College of Cardiology. They may have supporting descriptions to explain the procedure that you can attach to your claim.

If your cardiologist is repeating the same type of unlisted procedure, prepare an information file so you don't have to reinvent the wheel every time you submit a claim. Each time a carrier denies a similar claim, you will already have an appeals packet ready to send the payer to defend your claim.