Cardiology Coding Alert

In each of these scenarios, the patient sees a specialist without a request for evaluation/consultation from another healthcare professional. In each case, you should bill the cardiologist's services from the new patient code series (for example, 99201-99205) rather than the consult codes. Because these are considered transfers of care, the coding rule holds true even if the patient's prior cardiologist or current primary-care physician recommends that the patient come to your practitioner for future care.

Many cardiology practices report that Medicare carriers hold fast to their belief that "Physicians in the same practice who are in the same specialty must bill and be paid as though they were a single physician" (according to Section 15501[H] of the MCM) and have therefore faced denials for intra-office consultations (those in which one physician asks a group member of the same specialty to provide a consultation for his patient). 

If your physician practices in a multi-specialty clinic, you can code the requested service as a consultation. The above-referenced MCM section states, "Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group." Therefore, if a primary-care physician requests a consultation from a group member in a different specialty such as a cardiologist, the cardiologist should bill his service as a consultation rather than an established patient office visit (99211-99215) or a new patient visit (99201-99205).

Keep in mind: According to CPT, a new patient is one who has not received any face-to-face evaluation and management services from the physician or another physician in the same group practice and in the same specialty for at least three years. "Regardless of the fact that he may have been seen by the requesting physician a dozen times, the patient should be coded as a new patient when a subspecialist in the group, who has never seen him before, evaluates his condition," says Colleen McKee, CPC, senior coding consultant and team leader with Knoxville Cardiovascular Group in Knoxville, Tenn.

For cardiology groups with electrophysiologists (EP) in-house, coding consultations present a unique challenge. Many coders ponder the following question: "If a cardiologist requests a consultation from an EP physician in the same practice, can the EP physician bill his service as a consultation rather than an established patient visit?"

Although considerable differences separate EPs from other sub-specialties of cardiology, Medicare has not established a separate designation for EPs. On the credentialing paperwork (such as the CMS-855), electrophysiologists must designate themselves as "cardiologists." This lack of specificity on registration forms works against EP physicians because, based on the above guidelines, these physicians are in the same group, in the same specialty, and may not be able to secure reimbursement for services that they report as consultative if a cardiologist within the same practice requests the consult.

Many practices, however, have reported success collecting consultative reimbursement for their EP physicians when group-member cardiologists request consultations. Because many professionals characterize electrophysiology as a distinct sub-specialty of cardiology, relatively few diagnostic or therapeutic scenarios overlap.

Several Medicare carrier policies recognize EPs' distinctiveness. Empire Medicare Services (a Part B payer in New York and New Jersey) and HealthNow (a Part B payer in upstate New York) both state, "Electrophysiologic testing is a highly specialized set of invasive cardiac diagnostic procedures individually designed for the accurate evaluation of complex clinical dysrhythmic events because of unacceptable risk factors and/or recurrent life-threatening episode(s)."

If you choose to bill EP services as consultations requested within your group practice, you should be prepared with documentation. HGS Administrators, a Pennsylvania carrier, states, "Consultation services performed by a provider who does not possess an expertise and knowledge base over and above that of the referring provider with regard to the specific nature of the consultation request will be denied as not reasonable and necessary." Make sure you can illustrate why the patient specifically requires a consultation from your EP before you submit your consult claim.

To be safe, however, you may want to document several separate notes that demonstrate the cardiologist and EP's dialogue confirming the consult request, says Brian Outland, CPC, CCS, coding and reimbursement specialist with the Heart Rhythm Society (formerly NASPE). "The cardiologist needs to include in his note back to the physician requesting the consult that the patient needs to see an electrophysiologist," Outland says.

"The EP needs to contact the original physician requesting the consult before seeing the patient (this may be by telephone) and confirm that he or she would like them to consult on the care of this patient. This should be documented, and a separate note from the cardiologist's note should be sent to the requesting physician by the EP," Outland says.

Note: In this scenario, the official request for the consultation comes from the original requesting physician (someone outside of the group practice) rather than an in-house cardiologist. "You may have to appeal one of the claims and send in the notes to Medicare," Outland says. "However, there are no CMS rules or guidelines against billing these two consults on the same day."