Cardiology Coding Alert

Already-enrolled physicians must submit change of info application to MAC to update specialty.

CMS has established three new physician specialty codes, including C7 for advanced heart failure and transplant cardiology, according to MLN® Matters MM9957 Change Request (CR) via Transmittals 3762 and 283.

Important dates: The effective date for the new physician specialty codes is Oct. 1, 2017, and the implementation date is Oct. 2, 2017.

To learn more about C7, as well as C8, the new code for medical toxicology, and C9, the new code for hematopoietic cell transplantation and cellular therapy, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3762CP.pdf and www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R283FM.pdf.

Learn C7’s Significance from Pros

To learn how C7 will impact your cardiology coding, look to these thoughts from our experts.

“Congestive heart failure is directly linked to so many other disease processes such as hypertension, renal failure, and cardiomyopathies,” says Carol Hodge, CPC, CCC, CEMC, certified medical coder of St. Joseph’s Cardiology in Savannah, Georgia. “A cardiologist that specializes in heart failure management will be able to oversee medications, lab values, etc. This will in turn decrease complications, slow further disease progression, and reduce hospitalizations.”

Hodge goes on to emphasize her point about C7’s impact.

“For cardiology group practices, this [C7] will allow for a cardiologist who specializes in heart failure to see a patient that may also be seeing a general cardiologist, interventionist, or electrophysiologist within the same group practice because each specialist will have their own taxonomy number,” Hodge says.

Theresa Dix, CCS-P, CPMA, CCC, ICDCT-CM, coder/auditor of East Tennessee Heart Consultants in Knoxville, Tennessee, says that C7 is important because it lets CMS distinguish heart failure and transplant cardiologists from clinical cardiologists when they bill for Medicare services.

“This [C7] will confirm and validate the very important role heart failure physicians have on patient care,” Dix adds.

Dr. Biykem Bozkurt, MD, PhD, FACC, chair of the American College of Cardiology Heart Failure and Transplant Council, and professor of medicine/cardiology at Baylor College of Medicine in Houston, Texas, adds to Dix’s assessment when she says that before C7, “no mechanism existed for CMS to accurately identify this category of physician for quality and payment programs.”

C7 can also reduce your risk of denials, according to our experts.

In the past, since CMS had no way to identify the different specialty for treating patients with heart failure, Medicare carriers denied these claims. Medicare’s rationale states this was duplicate billing when a cardiologist and a heart failure specialist from the same group practice billed for the patient evaluation services. Now, C7 will solve that problem and help cut denials, Dix says.

What You Need to Know About Physician Specialty Codes

Medicare physician specialty codes describe the specific/unique kinds of medicine physicians practice, and CMS uses these specialty codes for programmatic and claims processing purposes.

“CMS states that the appropriate use of specialty codes helps reduce inappropriate suspensions and improves the quality of utilization data,” Bozkurt says.

When physicians enroll in the Medicare program, they choose their Medicare physician specialty on the enrollment application (CMS-855I or CMS-855O) or internet-based provider enrollment, chain, and ownership system (PECOS).

Impact: CMS will update the CMS-855I or CMS-855O paper applications to reflect the new specialties in the future. In the meantime, physicians should pick the “undefined physician type” option on the enrollment application and specify the applicable specialty in the space provided.

Note: If your physician is already enrolled in Medicare and wants to update her specialty to reflect one of the new specialties, she must submit a change of info application to her Medicare Administrative Contract (MAC). Physicians may submit an enrollment application to initially enroll or update their specialty within 60 days of the implementation date (Oct. 2, 2017) of these new specialties.

Follow These 3 Physician Specialty Code Tips For Cleaner Claims

See our experts’ advice below to make sure you are using physician specialty codes correctly.

Tip 1: Watch out for “twos.”

Mind your evaluation and management codes.

“When coders see two evaluation and management codes being billed, they should look to see if one is for a different specialist,” Dix says. “Coders should watch for denials within their group of physicians for duplicate billing of evaluation management.”

Dix adds that you should also always take the time to link the correct diagnosis code to the visit because that will tell the story and the reason for two visits by two separate providers on the same day.

Tip 2: Double-check the details.

Don’t neglect details within the documentation when submitting your claims.

“My advice for coders would be to make sure that the physician’s credentialing is correct and up-to-date with insurance carriers,” Hodge says. “If the correct specialty codes are not updated with insurance carriers, this will result in denials.”  

Tip 3: Always review your EOB.

Never forget the important of the explanation of benefits (EOB), which tells patients what medical treatments and/or services were paid for on their behalf.

“Coders will have to check their EOBs carefully to make sure that claims are being reimbursed correctly, and they may have to check with third-party payers to make sure they are submitting their claims correctly,” Bozkurt says.