Cardiology Coding Alert

Cardiologists are often unable to determine if a patient they are seeing face-to-face for the first time should be classified (and coded) as a new or established patient. The problem potentially occurs when they are called on to read echos or electrocardiograms (ECGs) in the hospital. In many cases, the cardiologist may not know the patients name, because the test is identified by a bar code only.

Subsequently, the same patient may visit the cardiologist in his or her office. Until now, CPT guidelines stipulated the visit would have had to be billed as an established patient visit, because a test interpretation constituted a professional service. CPT defined a new patient as one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

Payers reimburse at a higher rate for new patient visits (99201-99205) than for established patient visits (99211-99215) because of the more extensive nature of a patients initial visit. For example, a level-three new patient visit (99203) has been assigned a value of 2.19 relative value units (RVUs). The same level visit for an established patient (99213) reimburses 1.20 RVUs. This policy was considered unfair to cardiologists and other specialists who read test results at the hospital, says Terry Fletcher, BS, CPC, CCS-P, an independent cardiology coding and reimbursement specialist in Dana Point, Calif.

Fletcher notes that had cardiologists followed CPT guidelines, established patient visits would have to be billed for patients they had never met before. Cardiologists who were unaware of the identity of the patients whose tests they interpreted may have billed a new visit through no fault of their own when one of those patients visited their office, she says.

For 2001, however, the introduction to the evaluation and management (E/M) section of CPT contains an important change, and now reads:

Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s).

The change in wording means that even if the cardiologist happens to be on staff at the hospital to read echos or ECGs, and the patient later visits the cardiologist in his or her office for followup for a cardiac condition, the patient should be considered new, because no face-to-face services were performed, Fletcher advises.

Change Aligns CPT With Other Carriers

The change may not affect billing for Medicare or private carriers who differed with the previous CPT on this issue. Fletcher notes that there is no national Medicare policy regarding test interpretations and new patient visits, meaning that individual Medicare carriers have to establish their own guidelines. The same applies to many private carriers. Fletcher recommends that cardiologists check to see how their local carriers interpret the issue.

If you could show a strong rationale for billing a new patient visit [i.e., the cardiologist read an unidentified ECG, and didnt know it was the same patient] even though the cardiologist provided a professional service within the last three years, a Medicare carrier was unlikely to penalize you, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

Callaway notes that the change is important, even though the introduction of new CPT guidelines may have no impact on a Medicare carrier that had already issued a similar policy. Physicians [now have] more ammunition with which to argue with carriers whose policies are similar to the old CPT guidelines. Some payers may claim youve already rendered a service to the patient, which in their view makes the visit an established patient visit. The new CPT guidelines, however, make the distinction between a service such as reading a test in the hospital and a face-to-face encounter. And that can be a useful distinction, she concludes.

Defining Face-to-Face Encounters

During a nuclear study performed in the hospital, for example, the cardiologist may have a face-to-face professional encounter with the patient. Subsequently, the patient may visit the same cardiologist for a different problem within three years. In such cases, an established patient visit would have to be billed, because the cardiologist had face-to-face contact with the patient within the past three years, Fletcher says.

Similarly, a cardiologist may join another group practice and carry his or her patients to the new practice. These patients are considered established patients, even though the group practice has changed (and so has the groups tax ID number), because the cardiologist has personal medical knowledge of these patients and has performed face-to-face services for them during the past three years.

If, however, a practice is purchased from another cardiologist who does not follow his or her patients, all subsequent office visits provided to these patients by the purchasing cardiologist should be coded as new patient visits if the purchasing cardiologist did not provide face-to-face professional services to these patients in the past three years.

Know When a Subspecialist Can Code a New Visit

Although many cardiology coders believe that a patient who has seen a cardiologist two years earlier and returns to the same practice to see a subspecialist (for example, an electrophysiologist) about an unrelated issue can be billed as a new patient, that is not always the case, Fletcher and Callaway say.

For example, a patient is referred to a cardiology practice for evaluation of undifferentiated chest pain. A general cardiologist performs an examination and prescribes medication for the patient, who responds well and is asymptomatic. Two years later, however, the patient begins to have runs of paroxysmal atrial tachycardia (PAT), and is referred by his internist to an electrophysiologist who belongs to the same practice.

Medicare employs seemingly conflicting guidelines for such a situation. Although Medicare regulations state, Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician, other guidelines specify Physicians in the same group practice but in different specialties must bill and be paid without regard to their membership in the same group.

Callaway notes, however, that Medicare does not include subspecialties among its approved specialties, so all the cardiologists in the practice have the same Medicare classification.

The key to billing in this situation is the tax identification number, Callaway advises. Typically, specialists in the same practice use the same ID number, so if a patient of one cardiologist sees another cardiologist in the same practice within three years, regardless of subspecialty, the visit would have to be billed as an established patient visit.

Nonetheless, some local Medicare carriers now claim discretion over whether to allow specialists (and subspecialists) within the same group practice to bill a new patient visit in such circumstances. Coders should check with their local Medicare carriers to get a definitive answer.

If the subspecialist has a different tax ID number which sometimes occurs even if he or she is operating under the umbrella of the same cardiology practice the visit can be billed as a new patient visit.

Fletcher notes, however, that the intent of the new patient visit designation is to compensate the physician for the workup of a new patient. If the subspecialist works in the same practice as another physician the patient has seen, all the subspecialist (or different specialist, for that matter) needs to do is pull the patients chart: The rationale for the added compensation no longer applies. In other words, even though physicians with different tax numbers or in different specialties may be able to bill for a new patient visit, the intent of the guideline has been breached.

Properly Code for Consultations

Although the above scenario involving the general cardiologist and the electrophysiologist would have to be billed as an established patient visit, similar situations may reimburse at a higher rate if they meet the qualifications for a consultation and are billed using consult codes for the office or outpatient services (99241-99245).

Many physicians do not realize that they can use these codes for established patients, Fletcher says. For example, if the general cardiologist sends the patient directly to an electrophysiologist in the same practice (or if an internist outside the practice requested the visit), the electrophysiologist can bill for a consult, as long as the requirements for such a visit are met and documented.

If, in another example, a surgeon requests that a cardiologist perform a preoperative clearance on a patient, the cardiologist can appropriately bill for a consult. According to Medicare Carriers Manual section B3 15506E, even if the patient is an existing patient of the cardiologist, a preoperative clearance can be billed as a consultation if all of the criteria for a consult are met.

These criteria include:

A written request for an opinion or advice by the requesting physician;

A record of the request in the patients record;

A written report from the consulting physician to the requesting physician; and

No complete transfer of care for the condition or problem to the consulting physician.

In this example, the cardiologist is giving an opinion to a referring physician as to whether the patient is ready (cleared) for surgery. As long as the cardiologist puts his or her opinion in writing, he or she may bill a consult. Cardiologists who choose to code the established patient visit codes instead are losing revenue, Fletcher says.

Of course, if the consulting cardiologist assumes treatment of the patients PAT at a later date, all subsequent visits would be coded as established patient office visits, Fletcher adds.