Cardiology Coding Alert

Cardiologists and electrophysiologists may perform tilt-table testing to evaluate patients with syncope (780.2) and other diagnoses. The test, which is typically performed in a cath or EP laboratory, changes the patient's position from 0 to 60 degrees in fewer than 10 seconds. During that time, they monitor the patient's blood pressure and pulse, and observe if syncope (fainting) occurs. The response of the patient's heart rate and blood pressure to the tilting while strapped to a table may disclose the cause of fainting spells.

Although there is only one code for the tilt-table testing performed by cardiologists and EP physicians 93660 (Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention) reporting this procedure can still be tricky, says Savanna Siens, CPC, CCS-P, a cardiology coding and reimbursement specialist in Kansas City, Mo.

Cardiologists frequently question the following:

The cardiologist's documentation should clearly indicate the medical necessity for the test.

The guidelines do not apply to physician assistants, nurse practitioners and clinical nurse specialists, who require only general supervision for the diagnostic tests listed in the memo, including tilt-table testing, says Michael Powe, director of reimbursement with the American Academy of Physician Assistants in Bethesda, Md.

Note: The American College of Cardiology recommends that an experienced nurse or laboratory technician be present with a physician in attendance or immediately available.

Note: Medicare assigns 4.36 relative value units (RVUs) to global code 93660. The professional component is valued at 2.74 RVUs; technical, 1.62.

These codes, according to WPS policy no. CV-013, 93660, are "separate from the testing of autonomic nervous system function [codes 95921 to 95923], which are more neurologic, and not cardiovascular, in nature."

Note: Some carriers, including WPS, only pay for tilt-table tests performed in a hospital facility.

Medicare Supervision Guidelines

In April 2001, Medicare transmittal B-01-28 introduced a new set of guidelines for physician supervision of diagnostic tests performed by allied healthcare personnel. It included three levels of supervision for tests:

General supervision. The procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

Direct supervision. The physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not have to be present in the room where the procedure or service is performed.

Personal supervision. The physician must be in the room during the performance of the procedure.

Note: The direct personal supervision requirement for incident to billing is equivalent to direct supervision for a diagnostic test.