Cardiology Coding Alert

Question: I need CPT coding information regarding tilt table testing. I have been given two codes 95921 (testing of autonomic nervous system function; cardiovagal innervation [parasympathetic function], including two or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio) and 93660 (evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention). Can you give me more information because the cardiologist spends at least one hour with the patient?

Janet Ostinelli, Administrator
Capital Heart Associates, PA,
Raleigh, N.C.

Answer: The tilt table is used to evaluate the autonomic nervous system control of cardiovascular function in patients who have presyncope and syncope (sudden loss of consciousness associated with a loss of postural tone, i.e., fainting), according to Xact Medical Services Policy M-33A, issued in April 1997.

Tilt table is a fairly involved test that requires constant electrocardiogram (ECG) and physiologic monitoring of the patient, says the policy directive from Xact, Pennsylvania's Medicare carrier. The response of the patients blood pressure and pulse to progressive tilting while he or she is strapped to a table helps to indicate the cause of fainting spells. If the tilt table does not produce symptoms of syncope, a drug such as isuprel may be administered to dilate the peripheral vessels, dropping the blood pressure to produce symptoms of syncope. Various tilts and drugs are used to determine if the syncope is caused by autonomic dysfunction.

The correct CPT code for the evaluation is 93660. The only payable diagnosis for tilt table evaluation is syncope (780.2), according to Xacts policy and a similar directive from Palmetto Government Benefits Administrators, the Medicare carrier in South Carolina. The Palmetto directive, policy number 99-0018-L, which becomes effective on Feb. 2, 2000, also lists the following indications and limitations of coverage for 93660:

1. Evaluation of recurrent syncope or a single syncopal event accompanied by physical injury when the clinical history and exam are suggestive of vasovagal episodes.

a. Patient without evidence of a history or suspicion of cardiovascular disease, or

b. Patient with evidence of cardiovascular disease, but other causes of syncope have been excluded by appropriate testing.

2. Evaluation of the patient in whom the cause of the syncope has been determined, but the demonstration of susceptibility to hypotension and/or bradycardia of a neurally mediated origin will affect treatment plans.

3. Evaluation of recurrent exercise induced syncope when a thorough history and physical examination, 12-lead ECG, echocardiogram and formal exercise tolerance testing demonstrate no evidence of organic heart disease.

Palmettos policy also notes that:

CPT code 95922 (vasomotor adrenergic innervation [sympathetic adrenergic function], including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least five minutes of passive tilt) should not be billed in conjunction with 93660 when autonomic function testing is performed at the same visit with a tilt table test.

Codes 95921 (testing of autonomic nervous system function; cardiovagal innervation [parasympathetic function], including two or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio), 95922 and 95923 (sudomotor, including one or more of the following: quantitative sudomotor axon reflex test [QSART], silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential) are not separately billable on the same date of service, because 95921 is considered an integral component of 95922 and 95923.