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Cardiology Coding Alert

Get Your Dx Right for 93798 and Cash in on Cardiac Rehab

Published on Mon Mar 22, 2004

Don't forfeit $10 per session by overlooking ECG monitoring

If your practice offers cardiac rehabilitation services, you'll need to report the right diagnosis codes, give the "event date" for the patient's condition, and establish that your cardiologist recommended the service or you'll reap only denials for your claims.
 
Watch ECG monitoring: Typically, cardiac rehab programs include a series of physician-supervised exercise sessions with continuous electrocardiograph (ECG) monitoring. So check the note for ECGs, or you could be forfeiting about $10 per rehab session.

You should report 93797 (Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring [per session]) when the patient has rehabilitation without continuous ECG monitoring. Expect about $23 for in-office cardiac rehab sessions and about $10 for facility-based rehab sessions, according to the 2004 Medicare Physician Fee Schedule.

Use 93798 (... with continuous ECG monitoring [per session]) when the note indicates ECG monitoring during the session. This year's fee schedule indicates that Medicare pays a national average of $29 for each in-office cardiac rehab with ECG session and about $15 for each facility-based session. At the in-office rate, if your office performs 10 cardiac rehab with ECG sessions per week ($290) for a year, you could be receiving $15,000 for these services, coding experts say.

Keep in mind that 93798 includes ECG monitoring and physician interpretation, so you would not bill any additional codes, says Maureen Purcell, a coding specialist with Long Island Cardiovascular Medical Associates of Deer Park, N.Y.
 
Know What to Look for in the Note 

Most Medicare and private payers want to see clear documentation of several specific criteria for cardiac rehab services before they'll pay claims. When you bill 93797-93798, make sure the report shows the following, according to the American College of Cardiology's (ACC) Guide to CPT 2003:

  • a prescription for the rehab services from the attending physician;
  • the patient has a documented diagnosis of acute myocardial infarction within the preceding 12 months; or
  • the patient had coronary bypass surgery and/or stable angina pectoris.

    Indeed, having the right diagnosis codes is critical for cardiac rehab claims, Purcell says. For instance, Empire Medicare Services, carrier for southeastern New York state and New Jersey, only accepts acute myocardial infarction (410.00-410.92), coronary artery bypass graft (V45.81), old myocardial infarction (412) and stable angina (413.9) with 93798 claims, Purcell says. Empire does not reimburse for non-ECG sessions (93797).

    For Blue Cross and Blue Shield Senior Care (HMO Medicare Plan), the same diagnoses apply, Purcell says. Empire BCBS plans also accept post-percutaneous transluminal coronary angioplasty (V45.82), and most commercial plans will accept a coronary artery disease (414.00-414.04) diagnosis, she adds.

    Don't miss: Medicare also requires that you specify when the physician diagnosed the patient with the condition that made the cardiac rehab necessary, or you'll get denials. Make sure that you assign a "qualifying event date" for each diagnosis (myocardial infarction, coronary artery bypass graft, or nuclear study) on your 93798 claims, Purcell says.

    Red flag: If your cardiac rehab note does not indicate that a physician saw a patient periodically during the exercise program and supervised the rehab services when nonphysician staff administered the exercise program, you could attract an HHS Office of Inspector General audit. The OIG includes cardiac rehabilitation services in its 2004 Work Plan and has recently audited several outpatient facilities for "incident-to" violations. 

    "Medicare covers cardiac rehabilitation incident-to as a physician's professional services benefit, which requires that the services of nonphysician personnel be furnished under the physician's direct supervision," says Don White, OIG spokesman with the Office of Public Affairs. This means that a physician must be in the exercise-program area and immediately available and accessible for a medical emergency at all times during the exercise program, he says.

    In recent outpatient facility audits, the OIG could not identify in the cardiac rehabilitation reports that the facilities had designated a physician to supervise the cardiac rehabilitation services and could not identify the physician's professional services related to the program, White says.

    So, cardiology coders in facility and office settings should make sure that the notes indicate a supervising physician and describe any involvement the physician has with the patient participating in the cardiac rehab program.

    Don't Hold Your Breath for 93668 Pay

    Although Medicare will pay for cardiac rehabilitation, CMS hasn't assigned RVUs for peripheral arterial disease rehab, according to this year's fee schedule.

    So you'll get denials if you submit 93668 (Peripheral arterial disease [PAD] rehabilitation, per session) to Medicare and many private payers that follow Medicare's lead.

    This leaves billing staff wondering how to get paid when their cardiologists perform arterial peripheral vascular rehab services, says a cardiology coder in Joplin, Mo.

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