Cardiology Coding Alert

Many cardiologists are uncertain about billing evaluation and management (E/M) visits on the same day as a cardiac catheterization. That is not surprising because in some situations, E/M services performed either before or after the procedure may be billed separately, even though routine evaluations are considered part of the service.

Although E/M services such as history and physical (H&P) before a heart cath normally would be considered part of the procedure, it may be appropriate to bill the H&P separately, particularly when the heart cath is unplanned. Similarly, although routine follow-up care also usually is included in the procedure, an unexpected cath may require special attention by the physician, which could be billed separately.

Non-routine Follow-up Care Is Billable

John OMeara, MD, a cardiologist in Portland, Maine, explains, I spend time reviewing cath films, making a decision about what therapy to recommend to the patient (e.g., percutaneous transluminal coronary angioplasty [PTCA], coronary artery bypass graft [CABG]), discussing options with the patient, and then starting a new medication, arranging for subsequent admission for revascularization or even admitting the patient to inpatient unit. OMeara is uncertain, however, whether he can bill an E/M code because everything has been done on the same day.

If the follow up is not what was expected when catheterization was performed, the answer is yes, says Susan Callaway-Stradley, CPC, CCS-P, a coding specialist and educator in North Augusta, S.C. The E/M should be billed at the appropriate level with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). The supporting documentation must indicate that the catheterization results were different from what the cardiologist expected, and that a great deal of time has been spent reworking the patients treatment plan (e.g., the patient may require a bypass operation).

Bill H&P Separately

Under certain conditions, cardiologists also may bill for taking a patients history and physical before a heart catheterization is performed. For example, a male patient arrives in a hospital emergency room with chest pain. He is seen by a cardiologist, who admits him after determining he is having a myocardial infarction and needs a cardiac catheterization.

The cardiologist bills for the heart catheterization as appropriate and also may charge for a 99223 (initial hospital care, per day, for the evaluation and management of a patient, which requires these three components: comprehensive history and examination, and medical decision making of high complexity) with modifier -25 attached. Even though the signs or symptoms (in this case, chest pain) prompted the heart catheterization, they are not considered related, and the cardiologist clearly performed significant E/M services that should be reimbursed.

Because the procedure was not elective, meaningful H&P previously has not been performed on the patient. Consequently, the cardiologists exam is the first evaluation the patient has had for the condition, and therefore extra reimbursement for the examination is warranted.

If the patient already has been seeing the cardiologist for palpitations, intermittent chest pain and shortness of breath, and the cardiologist does an H&P in his or her office and determines that a heart catheterization should be scheduled, however, that procedure will be considered an elective (i.e., scheduled) procedure. Any further, routine H&P performed on the day of the heart catheterization (including an eval-uation performed because of hospital admission guidelines) cannot be billed separately because it is considered part of the procedure. Of course, the original H&P performed in the cardiologists office should be billed, and because the office visit preceded the heart catheterization and took place on a different day, modifier -25 should not be used.

The H&P you did in the office setting led to the scheduling of the surgery. And youve already been paid for that evaluation, says Callaway-Stradley.

Answering a few key questions is a simple way to determine if the H&P is billable:

1. Was the procedure scheduled from the office (i.e., is it elective)?

2. Did you see the patient and determine that a procedure was needed from that initial new or established patient visit?

3. Did the patient show up for the procedure at the elective (scheduled) time?

If the answer to these questions is yes, do not bill for H&P performed on the day of the procedure.

Billing for Hospitalized Patients

Occasionally, however, a cardiologist is asked to see a patient who already has been admitted to the hospital by another doctor. After the cardiologist does a history and physical, the physician determines that the patient requires a heart catheterization. Admittedly, this is not common, but it does happen. The cardiologist may even have seen the patient previously, but if the patient now shows signs and symptoms requiring an immediate admission for a procedure, then the cardiologist should bill for an admit with modifier -25 attached.

Stacey Elliott, CPC, business office manager with COR Healthcare Medical Associates, an 11-cardiologist group practice in Torrance, Calif., cautions that modifier -57 (decision for surgery) should not be used for heart catheterizations, which are classified as medical procedures. Only procedures with surgical codes should use modifier -57 (when appropriate).

Elliott also notes that CPT 1999 eliminated the biggest problem in charging for E/M visits on the same day as proceduresrequiring a second diagnosis. Some private carriers, however, still may ask for a second diagnosis. If that happens, CPT guidelines on using modifier -25 should be included in any appeal.