Case Study:
Coding for Stress Tests During Long-term Follow-up Care
Published on Thu Jul 01, 1999
Coding Dilemma
The scenario is a common one in cardiology practices: The patient returns for a stress test as part of his or her long-term follow-up care after an interventional procedure such as angioplasty, PTCA, and coronary bypass. But how should the service be billed if the patient has had no symptoms after an incident? Automatically appending a modifier -25 (separate significant services) to the office visit could get you a visit from the Office of the Inspector General, whose auditors began examining overuse of this modifier in the fall of 1998. Whether you can ethically bill Medicare for follow-up office visits depends greatly on the documentation.
Lets take a look at an actual office note and see whether modifier -25 is appropriate.
Office Note #1
Subjective: The patient comes in today for follow-up, a year from his last visit. He has had no symptoms of angina. He has a lot of dietary indiscretion and has gained weight. He exercises very little. He has stopped smoking. Medications are listed in the chart. Mevacor has been changed to Lipitor. Continues on Norvasc 5 mg day, aspirin and Colace.
Physical Examination: Blood pressure is 142/90 at rest. With exercise, he is able to do six minutes and have a heart rate of 125, which is better than his heart rate from a year ago. Exercise tolerance is the same.
Conclusion: I dont think there is any evidence of ongoing ischemia. Clearly, his triglycerides and cholesterol need to be improved and he needs to lose about 30 pounds.
Plan: I told him that we will leave his blood pressure medicines where they are now. I put the burden on him to lose weight as a method of treating his blood pressure, cholesterol, and trigclycerides at this time. Follow-up with Dr. X in this regard. See me in one year.
Documentation Critique
The note does not clearly specify the reason for the follow-up, or the date of the original diagnosis or intervention (i.e., history of present illness). Therefore, it would be difficult to determine a diagnosisan important fact since diagnosis determines medical necessity.
I also question, from this documentation, whether he did anything except a stress test for this follow-up, says Susan Callaway-Stradley CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., in Augusta, GA. For example, the documentation indicates a problem-focused exam. Basically, they took a limited history by asking questions such as Have you had chest pain? The examination shows nothing but the blood pressure reading and weight, she points out. All of which would have been done before they put him on a treadmill anyway.
Coding Tips
Callaway-Stradley offers this question to determine whether an office [...]
