Cardiology Coding Alert

Question: When we perform echocardiograms for a primary care physician, is it appropriate to code our findings rather than the ordering physicians diagnosis? Similarly, if the primary physician requests an echo to rule out amyloidosis but we find an old MI, which diagnosis code should we use?

Gregory Fazio, MD
York, PA

Answer: According to HCFAs coding regulation of October 4, 1995, the diagnosis of the receiving physician (i.e., the cardiologist) must be consistent with the diagnosis of the requesting physician (ie. the primary care physician) because HCFA wants to know the reason service was ordered or rendered.

For instance, suppose a family physician sends a patient with syncope (780.2) to your office for an echo. However, your test discovers an ischemic cardiomyopathy or aortic stenosis.

Regardless of the findings, you still must use the original diagnosis of syncope (780.2). Unfortunately, this is not a payable diagnosis for Medicare. Even though Medicare will pay for an echo with the diagnosis code of ischemic cardiomyopathy or aortic stenosis, you cannot use it because it does not reflect the reason the echo was ordered. To change from a non-payable to a payable diagnosis based on findings is to commit fraud.

In the second example, both amyloidosis (277.3) and the old MI (412) are Medicare-acceptable diagnoses to justify the medical necessity for your echo. Again, as the receiving physician, you are bound to report the ordering diagnosis (i.e. amyloidosis) even though the findings of the echo would tend to discourage the requesting physicians tentative diagnosis and support the diagnosis of old MI.

However, cardiologists are also caught between fulfilling Medicares regulations and the liability of labeling a patient as having a non-existent condition. Thats why you should discourage your requesting physicians from using the words rule out and urge them to give you symptoms codes instead. (Medicare also interprets rule out as screening and wont pay.)

Become proactive in communicating with your referring physicians about signs and symptom codes versus diagnosis codes. Encourage them to be more specific. Ask them, for example, What besides syncope made you think an echo was an appropriate diagnostic procedure for this particular patient? As the cardiologist, you are in a position to suggest signs and symptoms of cardiovascular diseases that may not have occurred to the primary care physician.

In some practices, echo or scheduling techs have a list of Medicare-approved diagnoses and will not schedule an echo for a nonpayable diagnosis. However, some of our coding experts felt that to supply the requesting physician with such a list could be taken by Medicare as encouraging the other physician to commit fraud -- although we could not find any Medicare policy on the written sharing of payable diagnosis codes.

Whatever you do, make sure the patient has signed a waiver explaining that Medicare will not pay for this diagnosis and he or she is responsible for the bill. Use the modifier -GA on the claim form. Otherwise, Medicare will send the patient a EOB stating that he or she is not responsible for the bill and you will not be able to collect.