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Cardiology Coding Alert

Coding Diagnostic Test for Unexplained-Syncope Patients

Published on Fri Jul 16, 2004

If your cardiologist administers diagnostic tests to patients with syncope (or "fainting"), a relatively common symptom, you may find it difficult to keep track of the testing regimes he uses. Get the lowdown on all of your cardiologist's diagnostic tests with our expert tips on syncope diagnoses.

Begin With History, Exam and ECG

"I worked at a practice where they kept receiving denials for running diagnostic tests on syncope patients, with the reason for denial being a lack of medical necessity," says Heather Corcoran, manager at CGH Billing Services in Louisville, Ky. "But the fact of the matter is that syncope does have risks." The potential for serious injury particularly affects the elderly as well as patients in high-risk environments (pilots, athletes, commercial truck drivers, etc.). "So more and more carriers are paying for diagnostic testing when syncope is the main symptom," Corcoran adds.

All patients with syncope (780.2, Syncope and collapse) require a careful history, physical examination, and routine 12-lead echocardiogram, because these key elements help the physician determine whether the patient requires additional diagnostic testing. Cardiologists will investigate whether syncope relates to arrhythmias, changes in blood pressure, valvular heart disease or cerebrovascular disease, says Jerome Williams Jr., MD, FACC, a cardiologist with Mid Carolina Cardiology in Charlotte, N.C.

1. Does the Cardiologist Suspect Organic Heart Disease?

If the cardiologist knows or suspects that the patient has organic heart disease (429.9, Heart disease, unspecified), he often starts by performing an echocar-diogram or an exercise stress test to help evaluate the structure and function of the heart and also to quantify the degree of heart disease.

Cardiologists use electrocardiograms (93000, Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) as a good baseline-screening test to help assess patients with known or suspected coronary artery disease and or arrhythmias. Routine exercise treadmill testing (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) assists the physician in determining whether the patient has exercise-induced arrhythmias, Williams says.

Second-Tier Tests Include EPS, Holter Monitor

If ECGs, echoes, and stress tests return positive results, your cardiologist may order subsequent testing including the following:

  • When the patient's symptoms suggest arrhythmic syncope, cardiologists sometimes recommend that patients wear a 24-hour Holter monitor (93224-93237). This test pays about $285 based on national averages. Loop monitoring (93268-93272) may be a reasonable alternative for patients with recurrent syncope and a normal heart.

  • Code series 93600-93660 describes the arrhythmia induction, mapping and ablation procedures that cardiologists perform in intracardiac electrophysiologic studies (EPS). These expensive and invasive studies use electric programmed stimulation and monitoring to diagnose "conduction abnormalities which may lead to slow heart rates or death," Williams says. Cardiologists also use EPS to diagnose malignant arrhythmias (for instance, ventricular tachycardia [427.1, Paroxysmal ventricular tachycardia] or ventricular fibrillation [427.41]), which are other arrhythmias leading to syncope.

  • Cardiologists may perform signal-averaged electrocardiography (93278, Signal-averaged electrocardiography, with or without ECG), or T-wave alternans when evaluating patients for electrophysiologic studies when patients have coronary disease and the cardiologist suspects ventricular tachycardia (427.1).

    2. Elderly Patients May Benefit From Carotid Massage

    Cardiologists can usually diagnose almost half of an elderly patient's syncopal episodes using only a history and physical examination (99201-99215 for outpatient office visits). Physicians often confirm these diagnoses with specific tests such as echocardiography, Holter or event monitoring, or stress testing.

    A cardiologist may perform carotid sinus massage in the office on patients who do not have carotid bruits (785.9,     Other symptoms involving cardiovascular system), recent myocardial infarction (410.x, Acute myocardial infarction), recent stroke (438.2x, Hemiplegia/hemiparesis), or a history of ventricular tachycardia.

    "By pressing the carotid sinus, the cardiologist induces slowing of the heart rate," Williams says. "However, it must be cautiously used with elderly patients, as there is a risk of causing dislodgement of carotid plaque, which could lead to cerebral atheroemboli, causing a stroke." Cardiologists may order other noninvasive tests such as carotid ultrasound or tilt-table testing for elderly patients to help determine if cerebrovascular disease or neurally mediated syncope (inappropriate response of the nervous system) is the etiology of syncopal episodes.

    3. Look to Tilt Table,Loop ECG Tests

    If the cardiologist doesn't suspect that a patient has heart disease with syncope and the patient is not elderly, the physician may perform primary diagnostic tests such as long-term ambulatory loop electrocardiography, tilt-table testing, and psychiatric evaluation.

    Physicians may perform long-term ambulatory loop electrocardiography (93235, Electrocardiographic monitoring for 24 hours by continuous computerized monitoring and non-continuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient-activated; includes monitoring and real-time data analysis with report, physician review and interpretation) for 30 days or more. Cardiologists find this procedure most effective in patients with recurrent syncope events.

    Head-up tilt-table tests (93660, Evaluation of cardiovascular function with tilt-table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention) can bring your practice about $683 each, based on national averages. During passive protocols and after baseline measurements of blood pressure and continuous monitoring of heart rate while patients are supine, patients are suddenly brought semi-upright at a tilt angle of 60 degrees. Technicians and the cardiologist monitor the patient during passive tilt without pharmacologic stimulation; if the passive tilt proves undiagnostic, the technicians begin isoproterenol infusion. (See our article "4 Steps to Tilt-Table Coding Perfection" at right for more information on tilt-table testing.)

    Psychiatric disorders such as anxiety and depressive disorders can sometimes cause syncope. "If the patient is stressed, anxious, or has a history of psychiatric disorders and is found not to have cardiac problems, the cardiologist may order a psychiatric evaluation (90801, Psychiatric diagnostic interview examination)," Corcoran says. "This does not necessarily mean that the patient's insurer will pay for the service that you bill with 90801."

    Heads Up: Do not report a cardiac diagnosis code unless your cardiologist definitively finds a problem. "If the patient's only symptom is syncope, but the doctor suspects     that something cardiac-related is the underlying problem, you should only report the symptom (780.2) until you have a definitive cardiac diagnosis," Corcoran says.

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