Cardiology Coding Alert

Question: Our physician is interested in performing enhanced external counterpulsation in the office. The sales representatives claim that reimbursement for the procedure is excellent. Are they correct? Which codes are used to bill for the service?

California Subscriber

Answer: As of April 1, 2000, Medicare instructs physicians to bill for external counterpulsation (ECP: Medicare has dropped the word enhanced from its description) using HCPCS code G0166 (external counterpulsation, per treatment session), says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

During an ECP treatment, the patient is placed on a table and his or her lower trunk and extremities are wrapped in a series of three compressive air cuffs. The cuffs inflate and deflate in synchronization with the patients cardiac cycle. As a result, most patients are said to experience increased time until onset of ischemia, increased exercise tolerance and a reduction in the number and severity of anginal episodes.

When performed in the office, this service has 3.76 relative value units per treatment. According to section 35-74 of Medicares Coverage Issue Manual (CIM), a full course of therapy usually consists of 35 one-hour treatments, which may be offered once or twice daily, usually five days per week.

ECP is covered for patients diagnosed with disabling angina (class III or class IV, Canadian Cardiovascular Society classification or equivalent classification) who in the opinion of a cardiologist or cardiothoracic surgeon are not readily amenable to surgical intervention, such as percutaneous transluminal coronary angioplasty or cardiac bypass, because: (1) their condition is inoperable, or at high risk of operative complications or postoperative failure, (2) their coronary anatomy is not readily amenable to such procedures, or (3) they have comorbid states that create excessive risk.

Although ECP and similar devices are approved by the Food and Drug Administration for treatment of many conditions, including stable or unstable angina pectoris, acute myocardial infarction and cardiogenic shock, Medicare coverage is limited to patients with stable angina pectoris, since only that use has developed sufficient evidence to demonstrate its medical effectiveness. The CIM also states that:

1. Noncoverage of hydraulic versions of these types of devices remains in force; and

2. ECP must be done under direct supervision of a physician (i.e., the physician must be in the office and readily accessible but does not have to be in the room where the service is performed.

Ask private carriers for their coverage policies and code preferences. CPT code 92971 (cardioassist-method of circulatory assist; external) most closely describes an ECP-type treatment.