Cardiology Coding Alert

Hint:  Check the procedure's global period before using modifier 25

If your cardiologist evaluates a patient following a stress test, you may be wondering whether you can report an E/M code in addition to 93016. The answer is yes--but your payers may be inappropriately relying on modifier 25 to solve multi-service issues.

Are You Allowed to Report E/M, Too?

In some situations, you can bill an E/M visit separately in addition to a stress test:

• 93016--Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report

• 93018--... interpretation and report only, if performed in the hospital

• 93015--... with physician supervision, with interpretation and report, if performed in the office.

“We don’t always have E/M charges with our treadmill stress tests, but this is something the cardiologist does quite often, and charging for it is a correct coding practice,” says Jennifer Sagar, CCS-P, lead coder at Cardiologists PC in Cedar Rapids, Iowa.

Reason: “The cardiologist may need urgently to evaluate a patient following a stress test to determine if that patient’s condition warrants further care or discharge,” says Mary Caudil, CPC, ACS-CA, financial senior manager at the University of Michigan Health Center in Ann Arbor.

Another circumstance is that a cardiologist may see a patient for an E/M services and decide to perform the stress test on the same day.

In many circumstances, the diagnosis code you report for the E/M service may be the same as the diagnosis you use for the stress test. But this may cause payers to question if the E/M service was truly significant and separately identifiable. Regardless of payer suspicions, you should assign the most accurate codes for all claims.  

Caution: If, at the time of the stress test, the cardiologist merely performs a review of the patient’s current status for the sole purpose of verifying that the patient is physically stable to undergo the procedure, you should consider that review as part of the procedure and not report a separate office visit.

Bottom line: “Typically when your cardiologist is seeing a patient and orders the treadmill, or sees him after interpreting/supervising that treadmill, you’ll find circumstances that necessitate a separate E/M service,” Sagar says.

Weigh in on Modifier 25

You may be wondering if you should attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to your significant and separately identifiable E/M service code when the cardiologist performs a stress test during the same visit.

Based on current CMS guidelines, you do not need to attach modifier 25. CMS instructs you to use modifier 25 only when your cardiologist provides a significant and separately identifiable E/M service on the same day as a procedure that has a global period.

The codes associated with stress tests (93015-93018), however, have a global day indicator of “XXX,” which means that the global period concept does not apply.  
    
But you may find that many payers--including Medicare carriers--routinely and inappropriately deny claims without modifier 25 appended to the E/M code. “You need to use modifier 25 to show payers that this is a separate service,” Sagar says.

Note: The guideline that instructs you to attach modifier 25 only when coding procedures with a global period is Medicare-specific.

You’ll notice that the CMS guidance to apply modifier 25 only to E/M services provided at the same time as procedures with a global period is contradictory to the standardized code set requirement established by HIPAA. Modifier 25 is listed in the CPT book and, therefore, part of the standardized code set. This book does not, however, specify anything about CMS’ global period guidance.

So, you should check with your carriers to learn if they want you to append modifier 25 to your separate E/M code on the same day as a stress test.