Cardiology Coding Alert

Full-study echos with Dopplers pay $291

If your practice is offering AV optimization - a new approach to pacemaker reprogramming - you'll need to learn which device codes to report and whether the procedure includes a full or limited echo study, coding experts say.
 
AV optimization (also known as "echo optimization") results in device settings that generate the most beneficial pause between the atrial contraction and the ventricular contraction (the "AV delay"), says Jim Collins, CHCC, CPC, cardiology coding consultant with Compliant MD Inc.
 
Collins explains that optimizing this pause is beneficial because it "allows the ventricles to fill with blood as much as possible before they contract and push blood out of the heart." The benefits are "multi-faceted" but most notably include "increased cardiac output (the amount of blood circulated by the heart) and increased myocardial perfusion (the amount of blood supplied to the heart muscle through the coronary arteries), he says.

Device Determines Reprogramming Code

To bill for the optimization, you'll need to know the device type (pacemaker or defibrillator) and also any carrier/payer policies specific to biventricular device programming, Collins says.
 
For most states, you would report CPT Codes 93732 (Electronic analysis of dual-chamber pacemaker system [includes 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]; with reprogramming) for pacemakers. For defibrillators, report 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).
 
But at least one Medicare carrier (TrailBlazer) specifies that you should report reprogramming of biventricular devices with unlisted-procedure code CPT 93799 (Unlisted cardiovascular service or procedure), Collins says.

Check for Full or Limited Echo 
 
Typically, AV optimization includes either a full or limited echocardiography study with Doppler:
 
Full study: 93307 (Echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; complete) and +93320 (Doppler echocardiography, pulsed wave and/or continuous wave with spectral display).
 
Limited study: 93308 (Echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; follow-up or limited study) and +93321 (Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; follow-up or limited study).
 
Coders cite general success in billing both study types. "We have been billing both studies and have not had problems getting them paid," says Sarah Cruz, CPC, coding specialist with Metro Heart Group of St. Louis Inc. "We bill 93308, 93321 and 93744 and have had no problems with reimbursement or denials," says Shelley Davis of Rocky Mountain Heart Associates in Denver.

Medicare Sets 'Full' and 'Limited' Distinctions

Even so, you should make sure you can accurately differentiate between a full study and a limited study in the procedure note. For 2004, Medicare lists an 83 percent payment variance between the two studies: A full echo and Doppler will pay $291, whereas a limited echo and Doppler will pay $159.
 
Because CPT does not clearly specify the difference between the two studies, Collins recommends looking to CMS and Medicare carriers for the distinctions.
 
For instance, the Medicare carrier for Wisconsin, WPSIC, differentiates the two as follows: "A complete study includes a full evaluation of all aspects of the heart, including the cardiac chambers, valves, blood flow and great vessels," Collins says. WPSIC characterizes a limited study: "a less than complete examination is performed for the purpose of evaluation of one specific cardiac problem, region of the heart, or the patient's condition requires only a limited examination."
 
Although physicians may lean toward the limited study codes for AV optimization, the decision should be made on a patient-by-patient basis. This is because many heart-failure patients will need full echo studies performed periodically. Rather than perform the AV optimization procedure on one day and have the patient come back a week or two later for a complete echo study, physicians may choose to perform a full echo study at the time of the device reprogramming, Collins says.
 
Note: Cardiology Coding Alert will keep you up-to-date on any new coverage developments specific to AV optimization.