Cardiology Coding Alert

Question: If a patient presented in the office on one day for CAD (414.01) and comes back another day to see an electrophysiologist for tachycardia, can we charge for a consult code even if the patient is already an established patient in our office?


Tennessee Subscriber

Answer: Although considerable differences separate electrophysiologists (EPs) from other cardiology subspecialties, Medicare has not established a separate designation for EPs. On the credentialing paperwork (such as the CMS-855), EPs must designate themselves as "cardiologists." This lack of specificity on registration forms works against EP physicians because they are in the same group, in the same specialty, and may not be able to secure reimbursement for services that they report as consultative if a cardiologist within the same practice requests the consult.

Many practices, however, have reported success collecting consultative reimbursement for their EP physicians when group-member cardiologists request consultations. Because many cardiologists characterize electrophysiology as a distinct subspecialty of cardiology, relatively few diagnostic or therapeutic scenarios overlap. So when your cardiologist refers his patient to your EP to render an opinion and report back on the electrical portion of the patient's heart, you can report a consult.

Caution: In general, intraspecialty consults can be more difficult to obtain reimbursement for, but Medicare guidelines do say that if a consult is within the same specialty and is medically necessary, it will pay for it.

Tip: To avoid problems, note in the report that the consulting physician is subspecialized in a unique part of his field.

You should also be sure your documentation meets the consult requirements, which include (a) medical necessity, (b) the request from an appropriate practitioner seeking advice or an opinion, and (c) the EP's results or opinion, which he reports back to the requesting physician.

Watch out: On the rare occasion when your EP (or other subspecialist) is able to work in a same-day consultation, you should prepare yourself for administrative burden and payment delay. The reason is that your report will likely be pitted against Section 15501(H) of the Medicare Carriers Manual (MCM). The MCM states that a physician in a group practice who performs an E/M service for another physician of the same specialty should report only one E/M service per day. The exception is if the E/M visits are for unrelated problems.