Cardiology Coding Alert

Cardiovascular stress tests are common procedures, but obtaining correct payment for them can be complicated and depends on several factors:

What kind of test was performed?
How many tests were performed?
Was there a payable diagnosis?
What, if any, supplies were used?
Where was the test performed?
Was the cardiologist in the office suite?
Is the patient covered by Medicare or a commercial carrier?

Poor documentation can result in reduced payment. For example, some cardiologists may note merely that the patient received a stress test, when, in fact, additional billable services such as echocardiography (echo), pharmacologically induced stress or nuclear scans were also performed. But if, for instance, documentation specifies that the stress test accompanies either an echo or a single-photon emission computerized tomography (SPECT) scan, both the stress test and the SPECT or echo may be separately billed. The place of service must also be noted and taken into account when choosing a stress test code (and modifiers, when necessary). And because supervision requirements for these procedures differ, documentation should clearly indicate the level of supervision provided. Medicare carriers, for example, will not cover stress tests unless the physician provides direct supervision (i.e., is in-clinic and accessible while the service is performed).

Treadmills and Bicycles

Cardiovascular stress testing is a noninvasive diagnostic test given to patients with coronary risk factors, a history of coronary artery disease (CAD) or symptoms that may indicate CAD. The tests are used (a) to diagnose coronary disease, (b) to evaluate existing disease to determine if change has occurred, (c) to evaluate the risk of an adverse coronary event, or (d) in some combination of the above, says Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in private practice in Seattle.

Typically, stress testing is preceded by an evaluation of the patient that includes history and physical (H&P) and a resting electrocardiogram (ECG). This evaluation aids in the selection of exercise or pharmacologic stresses and helps determine the need for stress imaging (i.e., echo or radionuclide study).

Stress testing is usually performed with the patient on a treadmill, although a stationary bicycle may be used. Readings are taken when the patient is at rest and during exercise. During exercise, the heart and body respond to the stress of increased physical activity. A diseased heart responds abnormally to stress which can be evaluated by monitoring the patients blood pressure, heart rate and electrocardiogram (ECG). The cardiologist makes a diagnosis based on the results, Yakovlevitch says.

CPT includes four codes for the basic stress test:

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

93016 physician supervision only, without interpretation and report

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