Cardiology Coding Alert

A stress test is one of the standard tools a cardiologist uses to evaluate patients with signs and symptoms of ischemic heart disease; however, coders shouldnt become complacent about billing for them, say billing and reimbursement specialists.
Here are several reader questions that point out the difficulty in coding and documenting this mainstay of a cardiology practice.

1. On the day a stress test is performed, must a history and physical also be billed?

Heres a good rule of thumb, advises says Susan Stradley, CPC, CCS-P, senior consultant for the Medical Group of Elliott Davis and Co., LLP, headquartered in Greenville, SC. If at the time of the stress test the physician performs a review of the patients current status for the sole purpose of verifying he or she is physically stable to undergo the procedure, that review should be considered part of the procedure itself.

The amount of work done in this type of review varies by physician, with some preferring a simple review of vital signs, while others perform a more detailed exam, she says. However, in all cases, if the review is just to confirm and document the patients current condition before performing the procedure, then the E/M should not be billed separately.

The National Correct Coding Initiative (CCI) considers the stress test procedure to inherently involve some degree of physician involvement or supervision, she explains.

2. Are there times a cardiology practice would bill for an E/M service in addition to a stress test?

Yes. For example, if the cardiologist discovers hypertension and addresses it, you would append modifier -25 to the correct E/M code and get paid for the office visit as well as the stress test.

Its used to bill for an E/M with a procedure or service where otherwise the E/M would be considered part of the procedure or service, explains Stephanie Servy-Gajic, director of coding management and education at Cardiology of Georgia in Atlanta.

Remember that modifier - 25 only goes on E/M codes, says Thomas Kent, CMM, seminar leader for McVey and Associates, Nevada, CA. A lot of people get confused and try to put it on a procedure code.

The rationale is that the E/M service is over and above, and unrelated to, the performance of the stress test, adds Servy-Gajic.

Be sure that the clinical office note can stand alone for the new diagnosis (hypertention) and that the history, exam, and medical decision making components are documented.
Vicki Williams, accounts receivable manager at Charleston Cardiology Group in Charleston, WV, adds that billing for an office visit and a stress test would also be appropriate if the physician discovered abnormalities in the stress test that required additional decision making.

Check with your carrier to see if they require modifier -25 for an E/M service with a stress test, says Stradley.

3. When a stress test is performed on the same day as another diagnostic test such as an EKG, should I add modifier -59 to be paid for both?

Modifier -59 can be used to identify procedures and/or services that are not normally reported together, but that under certain circumstances are separately billable. However, coders should be cautious when using this modifier, warns Servy-Gajic.

Dont get into the habit of using it automatically, she says. Like modifier -25, modifier -59 has been overused in the past. You may get the claim paid by attaching it, but you also may find yourself repaying it back in the future.
Modifier -59 applies to codes that are bundled under the CCI and designates the following:

That the procedure or service was provided at a different session or patient encounter;

That it was a different procedure or surgery;

That it was performed on a different site or organ system;

That it was a separate incision/excision, a separate lesion, or a separate injury that is not ordinarily encountered or performed on the same day by the same physician.

A Web site posting by the American College of Cardiology (www.acc.org) states that if the interpretation of a three-lead EKG in the morning shows abnormalities that leads to the performance of a cardiac stress test later that day, a -59 can be attached to the stress test in order to be reimbursed for both the EKG and the stress test.

However, if you use modifier -59, be prepared to appeal. I believe it could be won on appeal by explaining that when you did the EKG first, it warranted a stress test. You could also argue that you performed the procedures separately, why they were both justifiable, and show your documentation, Stradley says. Ultimately, however, it depends your carrier.

Kent agrees. Using modifier -59 in this case is going to be a tough one to argue, he says. Its easier if you can document that the procedures were performed at two separate times of the day, and you can show that the EKG was legitimate because it preceded the stress test. Otherwise, you may have a difficult time convincing the carrier to pay.

OIGs position, he says, is that in the past too many physicians have used the modifier to bill for an EKG in addition to a stress test when the EKG was actually a part of the more complex procedure.

South Carolinas Medicare carrier is now actively auditing physician charts for modifier -25 inappropriate usage and I expect -59 will follow, Stradley says.

The biggest problem with automatically using either modifier -25 or -59 is that they allow payment that may not be appropriate, warns Stradley. Medicare does not review either of them before payment, she explains. In other words, if the modifier is there, you are paid whether it is correct usage or not. The problems arise later if you are audited.

So to avoid attracting the attention of auditors, should you make it a policy to bill for stress tests only, and never for EKG and/or an E/M service on the same day?
You could, but youd be losing money, agree Kent and Servy-Gajic.

Talk to your physicians and find out what type of service they are actually providing during a stress test, Kent says. It may be that they are doing enough to justify the additional code of an E/M service but dont know that they can bill for it.

Peruse office notes carefully, advises Stradley. If the patient is presenting with other signs and symptoms unrelated to the reason he is in for the stress test, and you have documentation that these were addressed, then you can bill for an office visit in addition to the stress test, she says.

Kent also advises coders and physicians not to be intimidated by the threat of auditors. If you are honest and you have the proper documentation, then you can prove you have not set out to willfully defraud the government, he says. You want to capture all the reimbursement you are ethically entitled to.