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Cardiology Coding Alert

Heart Cath Discharge:

Contact Hospital To Determine Patient Status Before Billing

Published on Mon Oct 01, 2001

Cardiologists can bill for discharges performed after left heart catheterizations only if the discharge occurred on the next calendar day. The precise code to be billed may differ depending on the place of service reported by the cardiologist (inpatient or outpatient) and the status given to the patient by the hospital (inpatient, outpatient or observation). Therefore, practice coders need to communicate with their hospital counterparts to find out how the hospital classified the patient.
 
Evaluation and management services provided on the same calendar day are included in the heart cath unless they are performed for a significant, separately identifiable reason and modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is appended to the appropriate E/M code. In some cases, when a patient has a heart cath, he or she could stay past midnight. Because heart caths have a 0-day global period, any E/M service provided on the next calendar day should be separately payable.
 
Choosing the correct code can be difficult. "It all depends on how the hospital defined the service," says Kathy Mueller, RN, CPC, CCS-P, a general-surgery coding and reimbursement specialist in Lenzburg, Ill. "Hospitals do not all follow the same protocols in these matters. Some hospitals consider heart caths as outpatient procedures, whereas others classify them as inpatient or observation." The hospital's classification of the service is important because different codes may be used depending on whether the service is considered outpatient, observation or inpatient. For example, if the patient is discharged on the same day as the heart cath, no E/M service should be billed because it would be included in the heart cath.
 
If the hospital assigns observation status to the heart-cath patient, it may be possible to bill 99217 (observation care discharge day management) if the discharge occurs on the next calendar day. If the heart-cath patient has inpatient status and is discharged on the next calendar day, use 99238 (hospital discharge day management; 30 minutes or less) or 99239 (... more than 30 minutes).
 
Note: Some hospitals automatically classify a patient as inpatient if an intervention, i.e., angioplasty, stent, atherectomy, is also performed.
 
If the hospital considers cardiac catheterization as an outpatient (but not an observation) procedure, use the appropriate code for an established patient visit (99211-99215) because CPT does not include a separate code for outpatient discharges.
 
To bill successfully in such cases, the cardiologist must also indicate the place of service, using Box 24B on the CMS 1500 claim form. For example, if the patient was admitted as an inpatient, code 21 should be entered. If the service is performed on an outpatient basis, the correct code is 22. From the perspective of the coder filling out the CMS (formerly HCFA) claim form, observation services also should be coded 22 because there is no specific "place-of-service" code for observation services, which are considered outpatient.

Communicate With the Hospital

When determining the correct code to bill for the discharge, the most important step is to communicate with the hospital to find out the patient's status, Mueller says. For example, if the hospital files its own claim for the catheterization and indicates that the service was an outpatient but not an observation procedure, the carrier may not pay for an observation discharge (99217) because the patient did not have observation status.
 
Such communication is critical, she says, because if the patient's status at the hospital is not in accordance with the claim received from the cardiologist, the carrier may deny the claim or, if it has already been paid, demand a refund. The only way to know how the hospital is going to classify the service is to ask, Mueller says. "Before billing a discharge for a heart cath, coders should communicate with the hospital and find out how the patient was categorized. Otherwise, you don't know anything," she says.
 
Such communication should occur for any service, such as electrophysiologic (EP) studies, provided to patients who may be classified differently by other hospitals.
 
Note: With the introduction of ambulatory payment classifications (APC) and the outpatient prospective payment system (OPPS) by CMS, hospitals are supposed to have only two categories for patients inpatient and outpatient. The situation is still in flux, however, and although many hospitals no longer have a separate designation for observation, others still confer observation status on some patients. Whether the hospital recognizes observation or not, if the patient is classified as outpatient, the appropriate established patient code not observation discharge code 99217 should be billed.

To Bill or Not To Bill

Even when the discharge is performed on a different calendar day, some practices may not bill for the discharge unless a separate diagnosis warranted the cardiologist's additional attention which is often the case with cardiology patients, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C.
 
"Even though heart caths have a 0-day global period, it doesn't necessarily mean that a discharge performed on a different calendar day should be billed," she says. "There are certain pre- and postoperative services associated with performing a heart cath, and just because, through a scheduling quirk, the postoperative follow-up is performed at, say, 12:05 instead of 10:45 does not mean you should automatically get paid for it," she says, citing surgery guidelines in the 2001CPT Manual: "Listed surgical procedures include the operation per se, local infiltration, metacarpal/digital block or topical anesthesia when used, and normal, uncomplicated follow-up care ..."
 
Therefore, she says, discharge services may not be appropriate unless there was a separate diagnosis that required additional E/M on the day of discharge or a good reason why additional discharge services were provided.
 
Mueller notes, however, that the number of days in the global package (0) is the determining factor, not the reason the service is performed. She also notes that heart caths and EP studies are medicine, not surgery codes.  Sandy Rubio, RN, CPC, a cardiology coding and reimbursement specialist in Omaha, Neb., says that although her own practice interprets the heart cath's 0-day global to expire on midnight on the day of the cath, a decision was made not to bill for a discharge if the cardiologist only provides follow-up for the cath, even if the discharge occurs on the next calendar day.
 
"We don't feel it's proper to bill it if there are no other issues, even if this is theoretically permitted," she says. "The cardiologist may get a follow-up visit the next day, but if the documentation indicates the follow-up relates to the heart cath only, we won't charge for a discharge summary."
 
Rubio also says that patients who receive a left heart cath often exhibit other problems that may warrant the attention of the cardiologist. For example, if the patient has high blood pressure or requires medication management, e.g., for coumadin or prothrombin times, her practice will bill for the discharge. She says cardiologists in the practice are required to summarize any care the patient will receive after the heart cath. For example, the documentation may state that "Dr. Jones will follow the patient's lipid levels," or "Dr. Smith will check on prothrombin times." Doing so, she says, makes it easier to justify an E/M code following the heart cath.

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