Cardiology Coding Alert

HCFA has suspended edits of evaluation and management (E/M) services with diagnostic tests. In a monthly conference call with representatives of specialty societies, HCFA announced the suspension but gave no reason for it.

The edits, published in version 6.3 of the national Correct Coding Initiative, became effective Oct. 30, 2000, and bundled 66 E/M codes with more than 800 diagnostic tests and other services listed in the Medicare fee schedule as having XXX global days.

When HCFA first announced its intention to bundle E/M services with diagnostic tests in the November 1999 Federal Register, it stipulated that if the E/M service was significant and separately identifiable, it would be separately payable if modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) was attached to the E/M code.

Physicians across the nation, however including cardiologists have reported an increase in denials of E/M services when performed on the same day as diagnostic tests (such as echocardiograms, stress echoes and pacemaker checks) even when modifier -25 was attached. HCFA now says that before it reintroduces the edits, it will strengthen efforts to educate physicians and its own carriers about the appropriate use of modifier -25 and what constitutes a significant, separately identifiable E/M service.

The suspension of this new class of edits is welcome news for cardiologists and their coders, many of whom took strong issue with diagnostic tests being bundled to E/M services.

The edits were not consistent with how coding works, says Stacey Elliott, CPC, head of contracts, compliance and information systems with COR Healthcare Medical Consultants, an 11-physician practice in Torrance, Calif. When cardiologists examine a patient, ordering tests and reviewing test results contribute to the medical decision-making component of the visit, but providing the test itself is separate and deserves to be paid separately. She notes that her practice has received hundreds of denials for E/M services performed since Oct. 30, of which at least 90 percent were due to the new edits.

Append Modifier -25 as Necessary

When HCFA announced the new policy in November 1999, it stated the edits were designed to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself. As a basis for its policy, HCFA reasoned, Because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record.

Although HCFA now says that any claims involving E/M services and diagnostic tests after Oct. 30 should be resubmitted, it recommends that physicians continue to attach modifier -25 to the E/M service when refiling the claim. In other words, cardiologists are still required to demonstrate in the patients medical record that the E/M service was significant and separately identifiable.

Thus, any new E/M services performed with a variety of diagnostic tests and other services with XXX global days such as echos, stress tests, pacer checks, radiology interpretations, event monitoring and vascular injection procedures would also require modifier -25 for the same reason.

HCFAs apparent determination to pay only for E/M services deemed significant and separate is due, at least in part, to chronic double-dipping by some physicians when diagnostic tests are performed, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

Some cardiologists would automatically claim for E/M and a diagnostic test even if the test was pre-scheduled and was the only reason for the visit, Callaway explains. For example, a patient would arrive for a previously scheduled pacemaker check (9373x) and the cardiologist would bill for the routine, pretest evaluation, which is considered part of the service. By bundling E/M services to the pacer check and instructing cardiologists to use modifier -25 to override the edit only when a significant, separately identifiable E/M service is performed, HCFA is trying to end such practices, she concludes.

Recognizing Separately Identifiable E/M Services

E/M services are separately payable if the documentation indicates that the visit led to the decision to perform a procedure, such as a diagnostic test like a stress test in the cardiologists office.

For example, a new patient presents with chest pain. The cardiologist performs a full E/M workup, including history, examination and medical decision-making, and orders an echocardiogram (93307). In this case, the appropriate level of E/M (9920x) with modifier -25 attached can be billed in addition to the echo, says Gaye Boughton-Barnes, CPC, MPC, CCS-P, senior medical compliance specialist with the University of Oklahoma Medical College in Tulsa.

If the results of a diagnostic test prompt the cardiologist to perform an examination, modifier -25 should also be appended to the E/M. For example, a patient sees the cardiologist for a regular stress test, which reveals atrial fibrillation. The cardiologist examines the patient to address the new problem. When billing, the cardiologist charges for both the stress test and an established patient visit, with modifier -25 attached to the E/M code.

In both cases, the E/M service is significant and separately identifiable and can be separately billed, but documentation would need to convey clearly the development of the encounter toward the diagnostic end [i.e., taking the test or, in the second example, performing the E/M], Boughton-Barnes says. She notes that the information must be substantive enough to demonstrate the medical necessity for the encounter and avoid suspicion of double-billing.

Another way to document that an E/M service is significant and separate from any procedure or service, including a diagnostic test, is to provide separate diagnosis codes for the E/M service and the test. This can be difficult for cardiologists, however, because cardiac patients often present with several related problems, Boughton-Barnes says.

Take, for example, a patient who sees the cardiologist in the office for arrhythmia. The cardiologist examines the patient and conducts a pacer check, which is the reason for the visit. But the cardiologist also discusses other cardiac rhythm-related problems with the patient, which do not involve the pacer check and for which there is no separate diagnosis, Boughton-Barnes explains. She stresses that although Medicare no longer requires two diagnoses when billing services with modifier -25, a relationship between diagnoses and services must still be demonstrated.

She notes that although a patient with angina may complain of chest pain, if the cardiologist knows the cause of the pain is angina, a diagnosis of chest pain (786.5) should not be associated with an E/M service simply to
differentiate it from a diagnostic test (such as an echocar-
diogram), which would be associated with the angina.

Note: In this situation, the ICD-9 code for chest pain may be included on the HCFA 1500 claim form, but it should not be linked to the E/M visit unless the cause of the chest pain is unknown.

You need to distinguish between chest pain and angina, and demonstrate a clear understanding of why youre seeing the patient and performing the test, argues Boughton-Barnes. In cardiology, sometimes the symptoms are the same, because the underlying symptomatology or etiology of the problem is the same. So what do you do? You can use a catch all diagnosis like chest pain, but that can be a problem because the payer may review the claim and decide it isnt valid.

Instead, she says, cardiologists should carefully document the visit in a way that clearly describes why the cardiologist performed both an examination and a diagnostic test. If there is no separate, associated diagnosis code for the E/M service, the claim will likely be reviewed. Therefore, she recommends either sending a paper claim that includes the supporting documentation or using the comments box in the electronic form to describe the reason for the evaluation which could be a minor technical difference that is not separately listed in the ICD-9 manual.

If the cardiologist is uncertain about the cause of the patients chest pain (or another sign or symptom), which the test later determines to be caused by angina, linking the chest pain diagnosis to the E/M service and associating the angina diagnosis with the echo would be appropriate.

Defining Significant Services

To be billed at the same time as a diagnostic test (or any other procedure or service), an E/M service must also be significant. This means the visit should be more than a level-two encounter, Boughton-Barnes says.

Significance relates to the purpose of the patient encounter, including the context of the visit [i.e., the chief complaint] and the medical decision-making involved, Boughton-Barnes says. All the components taken into account when determining the level of the visit time, effort, complexity and treatment options need to be documented to indicate a significant visit.

This requirement is particularly important for E/M services provided at the same time as a diagnostic test because the pretest evaluation built into the tests relative value is typically not substantial. Documentation indicating a significant service was provided offers additional evidence that double-dipping has not occurred.

HCFA Will Watch Modifier -25 Claims

Since the Balanced Budget Act of 1997, modifier -25 claims have been considered red flags prompting carrier review.

Some physicians have reported receiving warnings from carrier representatives about attaching the modifier to E/M services performed with diagnostic tests, even though the use of modifier -25 in such circumstances was mandated by HCFA. This emphasizes the importance of accurate documentation in the event of an audit.

Physicians and their specialty societies also report receiving erroneous instructions from carriers, including:

Automatic denials for E/M services performed on the same day as diagnostic tests;

Being told to attach modifier -59 (distinct procedural service) to the E/M service; and

Being told that two diagnoses are required for both services to be paid.

Faced with such apparent poor understanding of the new edits by its own carriers, HCFA has pledged to work with the AMA and specialty medical societies to continue educational efforts on the use of appending modifier -25 to E/M services when billed with diagnostic tests and other services with XXX global days performed on the same day.

HCFA claims it will develop a program to guide and educate carriers, and will direct the carriers to publish clear and accurate information about the edits in local Medicare bulletins. Finally, HCFA says it will attempt to ensure its carriers implement existing national policy that allows the same ICD-9 code to be associated with both the E/M service and whatever service or procedure has been provided on the same day.

Coders, however, should not wait until HCFA fulfills its pledge, Callaway says. Instead of taking the word of the first Medicare customer service representative they are able to reach on the phone, she says, coders should locate someone at a higher level (in South Carolina, Callaways home state, Palmetto Government Benefit Services, the local Medicare carrier, has an education consultant who fills this role) who can appropriately answer questions about medical and surgical coding and billing practices.