Cardiology Coding Alert

Although routine evaluations are considered part of heart catheterizations, certain E/M services performed before the procedure may be billed separately.

Usually, E/M services, such as history and physical (H&P), performed before a heart catheterization would be considered part of the procedure. But if the catheterization is unplanned, reporting an E/M service separately may be appropriate.

Under certain conditions, cardiologists may report taking a patient's history and physical before performing a heart catheterization. For example, a male patient arrives in the hospital emergency room with chest pain. A cardiologist examines the patient and admits him after determining he is having a myocardial infarction and needs a cardiac catheterization.

When reporting this scenario, you should bill the heart catheterization as appropriate, and you also may charge for a suitable hospital admission code (e.g., 99223, Initial hospital care, per day, for the evaluation and management of a patient ). You should append the inpatient E/M code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Although the signs or symptoms (in this case, chest pain) prompted the heart catheterization, "the evaluation of the problem to determine the need for the procedure is considered separately identifiable from the performance of the catheterization, and the cardiologist clearly performed 'significant' E/M services that should be reimbursed," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

"Because the procedure was not planned in advance, the required H&P must also be documented during the admission process. Since this is combined with the documentation for the evaluation of the patient's problem, it is not considered a bundled service," Callaway maintains.

On the other hand, if the patient had been seeing the cardiologist for palpitations, intermittent chest pain and shortness of breath and the doctor performs an H&P in his or her office and determines a heart catheterization should be scheduled, that procedure will be considered elective, i.e., planned. Any further routine H&P performed on the day of the catheterization (including an evaluation performed because of hospital admission guidelines) cannot be reported separately because it is considered part of the procedure. Of course, the original H&P performed in the cardiologist's office should be billed as an outpatient office visit (99201-99215). Because the office visit preceded the heart catheterization and took place on a different day, you should not use modifier -25.

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?

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

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

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

Occasionally, a physician asks a cardiologist to see a patient who has already been admitted to the hospital. After the cardiologist evaluates the patient, he or she determines the patient requires a heart catheterization. The cardiac physician may even have seen the patient previously. But if the patient now shows signs and symptoms requiring a previously unplanned procedure, then the cardiologist should report the appropriate inpatient consultation code (99251-99255) with modifier -25 appended.

You should keep in mind, however, that you should not append modifier -57 (Decision for surgery) to heart catheterization codes because they are classified as medical procedures. Only surgical codes should use modifier -57 when appropriate.

And, although CPT no longer requires a second diagnosis when reporting an E/M service with modifier -25, some private carriers may still ask for one. The CPT manual specifically states, "The E/M services may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date." If your claim is denied because the procedure and E/M services are supported by the same diagnosis, you should include the CPT guidelines for using the modifier in any appeal.

Although Medicare will reimburse for an E/M service and heart catheterization performed on the same day, some private carriers may refuse, says Judy Richardson, MSA, RN, CCS-P, a senior consultant at Hill and Associates Inc., a coding consulting firm in Wilmington, N.C. "Private carriers could be a mixed bag. They may follow Medicare's rules, or they may pay for either the catheterization or the E/M, but not both. And they should pay for both."

When you report these services to a private carrier, Richardson suggests attaching the cardiologist's documentation for the E/M service and the catheterization and submitting a paper claim to the carrier. "This will force them to review it manually," she says. "If the private carrier still denies the claim, you should appeal."