Cardiology Coding Alert

Question: A patient's primary-care physician (PCP) sent a patient straight to a heart catheterization lab without coming into the cardiologist's office. Our cardiologist provided the history and physical, the catheterization results were normal, and the patient went home six hours later. Can I bill for a new patient visit?


Ohio Subscriber


Answer: To bill for the pre-cath E/M service on the day of a heart cath, the physician should provide evaluation services, such as an exam, that lead to the decision for the cath. If another physician sends the patient to the cath lab, the physician performing the catheterization may not be able to bill for this evaluation because the decision to perform the cath was already made.

In your scenario, however, the patient's PCP referred him to the lab. Many cardiologists are not comfortable performing a heart cath based solely on the diagnosis of a PCP. They will instead evaluate the patient, determine if the indications for a cath are present, assess for any contraindications (such as hypertension or anticoagulants), and decide whether to proceed with the cath procedure.

You should ask your physician if this is his position on the issue. If your physician agrees (and the record reflects a separate evaluation and decision to catheterize), you should be safe to bill for the E/M.

You could report a new patient visit, consult, admit to inpatient or admit to observation, depending on the specifics of the encounter. If you bill anything other than a consultation, you will need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to indicate that the service is separate from the cath procedure.

Although not necessarily required by Medicare guidelines, you may need to attach modifier 25 to consultation E/M services as well.  

You Be the Coder and Reader Questions were prepared with the assistance of Jim Collins, ACS-CA, CHCC, CPC, CEO of the Cardiology Coalition and compliance manager for several cardiology groups around the country; and reviewed by Jerome Williams Jr., MD, FACC, a cardiologist with Mid Carolina Cardiology in Charlotte, N.C.