Cardiology Coding Alert

Consultations don't have to be an uphill battle, especially if you're trying to collect on a consultation your practice's cardiologist and electrophysiologist (EP) perform on the same patient on the same date.

Isolate these Medicare and cardio-specific problem areas, and you'll discover what obstacles you need to conquer -- before you send your same-day consult claims.

Many 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 30.6.5 of the Internet Only Manual [IOM]), 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).

Exceptions happen: If your physician practices in a multi-specialty clinic, however, you can code the requested service as a consultation. The above-referenced IOM 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."

What this means: Suppose a primary-care physician requests a consultation from a group member in a different specialty -- such as a cardiologist. How should the cardiologist report this visit? Solution: The cardiologist should bill his service as a consultation (99241-99245, rather than as an established patient office visit (99211-99215) or a new patient visit (99201-99205).

Tribulations arise, however, when the subspecialist isn't listed as such with Medicare, especially EPs. Medicare does not recognize EPs as a subspecialty and instead usually credentials them as cardiologists.

Problem: This lack of specificity on registration forms works against cardiology groups with in-house EP physicians. 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. Some payers, such as Health-Now (a Part B payer in upstate New York) recognize EPs' distinctiveness, but others don't.

One resourceful office manager took matters into her own hands. "We bill both services and appeal the one denied with records and a medical necessity letter," says Sylver A. Vasquez, business office manager with Cardiology Associates of Corpus Christi in Texas. "We are successful in getting the denial overturned, stressing the fact that EP is a specialized field in arrhythmia disorders. [The insurers] want medical records and a copy of the EP physician's EP board certification."

Vasquez reports a 50-percent success rate using her method, but she moves forward with her appeal for the remaining half of these denied claims. "We continue to appeal and have found success because of our persistence," she says. "I only had to go to the QIC [qualified independent contractor] level twice, and that's only because I forgot to appeal with one of the items essential to the process."

Best advice: The most important tools that Vasquez has in her appeals arsenal include:

• consult request from the referring cardiologist to the EP

• consult report from the EP to the requesting cardiologist

• copy of board certification for the EP subspecialty

• letter of necessity from the cardiologist advising that the patient's rhythm problem requires the EP physician's expertise.

Don't forget: As always, your consultations must meet the Medicare requirements of request for consult, rendering of the exam, and report back to the requesting physician, says Heather Corcoran, coding manager with CGH Billing in Louisville, Ky.

Solution: Practices in this situation continue to hope for changes that would allow them to collect using easier methods. "CMS needs to create a subspecialty classification for electrophysiology so that the need for continued appeal of a justifiable claim will stop," Vasquez says.