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Cardiology Coding Alert

Document ECP Codes Well for Full Reimbursement

Published on Mon Oct 01, 2001

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The 2000 HCPCS manual introduced G0166 (external counterpulsation, per treatment), which cardiologists can report when they provide external counterpulsation (ECP) services to Medicare patients. The situation is difficult when the cardiologist treats a patient with private insurance, in part because CPT does not include a specific code for ECP.
 
In the absence of a specific code, there is much confusion about how to bill for the service. The situation is further complicated because coding recommendations provided by the manufacturer of ECP devices are considered inappropriate by most carriers, says Nikki Vendegna, CPC, a cardiology coding and reimbursement specialist in Overland Park, Kan. If an unlisted-procedure code is used and is also well documented, most carriers will pay for the treatment.

Thirty-Five One-Hour Treatments

External counterpulsation is a noninvasive technique used to treat ischemic heart disease. During the treatment, the lower extremities and lower trunk are wrapped in a series of three compressive air cuffs that inflate and deflate in tandem with the patient's cardiac cycle. This reduces the pressure the heart must pump against, increases the rate of return of blood to the heart, and increases blood pressure during the filling phase of the cardiac cycle. These actions, in turn, increase the amount of blood and oxygen going into the coronary arteries and decrease the work of the heart when it beats. 
 
Many patients who undergo these treatments experi-ence increased time until onset of ischemia, increased exercise tolerance and a reduction in the number and severity of anginal episodes. A full course of therapy consists of 35 one- or two-hour treatments, which may be offered once or twice daily, usually five days per week.
 
The components of the procedure include the use of the device, finger plethysmography to follow the blood flow, continuous EKGs to trigger inflation and deflation, and optional use of pulse oximetry to measure oxygen saturation before and after treatment.
 
External counterpulsation is distinguished from intra-aortic balloon counterpulsation, which is a more familiar, invasive form of counterpulsation used as a method of temporary circulatory assistance for the ischemic heart, often after an acute myocardial infarction. Although intra-aortic balloon counterpulsation has its own code (92971, cardioassist method of circulatory assist; external), it does not accurately describe ECP, which is thought to provide a permanent effect on the heart by enhancing coronary collateral circulation.

HCPCS Code G0166

Most Medicare carriers instruct cardiologists to use G0166. When performed in a nonfacility setting, the CMS fee schedule assigns 3.76 CQ relative value units (RVUs) to each treatment, for a total of 131.6 RVUs for 35 treatments, which may be given once or twice daily, typically five days a week. (The fee schedule assigned ECP only 0.11 RVUs if the treatments are performed in a facility.)
 
Most Medicare carriers cover ECP only if the patient has been diagnosed with disabling angina and if surgical intervention, e.g., bypass surgery or angioplasty, is contraindicated. Although the Food and Drug Administration permits the use of ECP to treat a variety of conditions, such as acute myocardial infarction, stable and unstable angina pectoris and cardiogenic shock, the Medicare Coverage Issues Manual (CIM) limits Medicare coverage to patients with stable angina pectoris because, it states, only that use has developed sufficient evidence to demonstrate its medical effectiveness.""
 
Medicare will cover ECP provided by nonphysician practitioners only if the treatment is performed under the direct supervision of the cardiologist or other physician" which means the cardiologist must be in the office suite and available to assist during the ECP treatment says Sueanne Bicknell RRA CPC CCS-P compliance administrator with CPR/Heart Place in Dallas.

Billing Private Carriers

The specific HCPCS code did away with most coding dilemmas associated with ECP billing to Medicare carriers but did not resolve how to bill commercial carriers for the service Bicknell says.
 
However Bicknell says manufacturer representatives have provided cardiologists with coding and billing information that conflicts with Medicare guidelines. In a document distributed to providers the company suggests cardiologists bill private carriers as follows:
 
  • 93922 non-invasive physiologic studies of upper or lower extremity arteries single level bilateral (e.g. ankle/brachial indices Doppler waveform analysis volume plethysmography transcutaneous oxygen tension measurement) 

  • 93040 rhythm ECG one to three leads; with interpretation and report
       or
     
  • 93041 ... tracing only without interpretation and report
     
  • 99211 office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician
     
  • 94760 noninvasive ear or pulse oximetry for oxygen saturation; single determination
    or
     
  • 94761 ... multiple determinations.

    • In its reimbursement literature the manufacturer says the average payment for each treatment totals more than $250 which multiplied by 35 treatments equals $8 750. The document also states that "the national average reimbursement for a standard ECP treatment session is $203 or $7 100 for a standard 35-session treatment course."
     
    Note: These figures are based on reimbursement experiences from ECP centers in the Midwest.
     
    Unfortunately most carriers will not pay for all these codes for the one treatment Vendegna says: "The information cardiologists are receiving is inappropriate and ECP treatments coded this way will be denied by most private carriers."
     
    For instance she cites the 2001 CPT manual professional edition page 339 to illustrate why 93922 should not be reported for ECP treatments. It states: "The use of a simple hand-held or other Doppler device that does not produce hard copy output or that produces a record that does not permit analysis of bidirectional vascular flow  is considered to be part of the physical examination of the vascular system and is not separately reported." ECP does not come close to meeting this definition Vendegna says.
     
    The rhythm strip ECG codes 93040-93041 are not payable separately because monitoring during a service is always included in the service as are the pulse oximetry codes 94760-94761.
     
    "The only code that even comes close is 92971 which describes an external circulatory-assist method. In this case however close is not good enough. After all the procedure that 92971 describes is usually performed during a heart cath or open heart surgery as part of efforts to keep the patient alive whereas ECP is a therapeutic series of treatments that generate new vessels (collaterals) on the myocardium revascularizing it " Vendegna warns.
     
    Note: In the literature the manufacturer also states that "not all insurance carriers will reimburse for each code. They may reimburse for any combination of the submitted codes which may reduce the overall total collected revenues."
     
    Before the introduction of G0166 some local Medi-care carriers told physicians to report ECP with 97016 (application of a modality to one or more areas; vasopneumatic devices).
     
    As for the nurse visit 99211 Bicknell says Medicare guidelines specifically rule out separate payment for E/M services and there is no reason to believe private payers have not followed suit. If the nurse's visit or a more complex E/M service is unrelated to the ECP treatment and medical necessity for it is documented append modifier -25 (significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E/M code which should also be linked to an ICD-9 code that reflects the reason for the separate evaluation.
     
    Vendegna agrees that in most instances a nurse visit is unlikely to be paid even though the nurse meets and checks the patient. "If there is no diagnosis no evaluation and no management other than that considered part of the ECP the 99211 is no different from 93922 and 93040-93041 it's included in the service " she says.
     
    Bicknell and Vendegna recommend billing 93799 (unlisted cardiovascular service or procedure) instead. Any amount may be billed because the code is for  an unlisted procedure but don't be surprised if you don't get 100 percent of what you billed. "You may get $200 out of $350 or you might get $350 " Vendegna says.
     
    A diagnosis of angina (413.x) provides medical necessity for the ECP billed with the unlisted-procedure code. Some carriers may also pay for ECP treatments linked to ICD-9 codes 411.1 (other acute and subacute forms of ischemic heart disease; intermediate coronary syndrome) and V64.1 (surgical or other procedure not carried out because of contraindication).
     
    Note: A diagnosis of angina pectoris also provides medical justification for all the incorrect codes listed above with the exception of 93922. But these codes should not be used unless you are specifically instructed to do so in writing by the carrier Vendegna says.

    Carrier Policies

    Private-carrier policies on ECP vary dramatically. For example some carriers not only accept all the codes listed by the manufacturer but may also pay for an additional E/M code e.g. 99354-99355 (prolonged services).
     
    Citing a 1999 Blue Cross Blue Shield Association Technology Evaluation Center assessment in a local medical review policy revised in August 2000 Regence Group the Blue Cross carrier in Idaho Oregon Utah and Washington state appears to include prolonged service codes 99354-99357 as billable (when appropriate) for ECP treatment.
     
    Other carriers ask to see 97016 or unlisted-procedure  code 93799 and 97016 together. With such wide variability of payment policies and practices many cardiologists hope CPT will clear up the situation by creating a new CPT code for use by everyone (except Medicare carriers which most likely would continue to use the G code). Until then ask private carriers which codes should be used.
     
    Some carriers such as Trailblazer Health Enterprises the Medicare Part B carrier in Delaware Maryland Texas Virginia and the District of Columbia require the cardiologist to submit an ECP report along with the claim for the treatment numbers 1 10 20 and 30 and will withhold payment on additional ECP treatments until those reports are received.
     
    Trailblazer also allows only 35 treatments within a two-year period although authorization may be obtained for additional treatments if the cardiologist requests more in writing that includes documentation of the medical necessity for the additional treatments Bicknell says.
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