Cardiology Coding Alert

Myocardial contrast echocardiography (MCE), sometimes referred to as contrast-enhanced echocardiography, is a relatively new technique that can aid in the treatment of some types of heart disease by giving the cardiologist a better view of the left ventricle than would be afforded by a routine echo. Although the federal Food and Drug Administration (FDA) approved Optison, the contrast agent typically used for such echocardiograms, on Dec. 31, 1997, both Medicare and commercial carriers have been slow to agree to reimburse this service or issue policy guidelines.

Consequently, coding and payment for this service remain unclear in many parts of the country. And even in states where the local Medicare carrier has issued a policy on the use of Optison, the policies differ widely. For its part, the Health Care Financing Administration (HCFA) has yet to issue a policy statement, which means the local Medicare carriers have free rein to determine payment as they see fit. As a result, policies range from outright denial or rolling the service in with the echo, to paying out the drug portion through an HCPCS code or using an unlisted code to bill for the service.

The procedure itself is straightforward. An ultrasound-enhancing agent (Optison) is injected into the patient, resulting in a clearer image of the left ventricular endocardial border. According to a policy statement by Trailblazer Health Enterprises, the Medicare Part B carrier in Texas, the service may augment diagnosis and treatment of selected patients ... In certain circumstances, MCE might replace radionucleide angiography or stress SPECT testing.

MCE is particularly useful for patients undergoing a stress echo, according to a similar policy statement from Xact Medicare Services, the Pennsylvania carrier. It is used most frequently during the evaluation of patients for valvular and ischemic disease.

Medicare Coding and Reimbursement Trends

Last year, the American College of Cardiology (ACC) urged HCFA officials to cover the use of echocardiography contrast agents, noting that this service can contribute significantly to the diagnosis and treatment of cardiovascular disease. ACC also asked HCFA to end the policy disarray among its local carriers.

HCFA should establish a uniform, reasonable reimbursement policy for echocardiography contrast agents, according to the ACC. To date, coverage and payment policies for contrast agents have varied widely among state Medicare carriers. Some are inappropriately denying coverage of contrast agents altogether. These denials are based on the inaccurate belief that the cost of echocardiography contrast agents is included in the current allowances for echocardiography services under the Medicare physician fee schedule. In fact, HCFA has not accounted for these agents in the current echocardiography relative value units; however, the agency is seriously considering such a bundling approach as part of the refinement process for the new practice expense component of the fee schedule. The ACC opposes this bundling approach.

One example of the bundling policy comes from CIGNA Healthcare, the Medicare Part B carrier in Tennessee, North Carolina and Iowa. According to the CIGNA policy, All [contrast-enhancing echocardiography] agents used in the performance of a procedure are included in the practice expense reimbursement for the procedure. Therefore, they should not be billed separately.

Other carriers have modified their policies recently. For example, Empire Medicare Services, the Part B carrier in New Jersey and parts of New York, including New York City, and Xact Medicare Services in Pennsylvania, decided in September 1999 to pay for Optison use. Both carriers policy statements report: Optison ... will be reimbursed for echocardiography enhancement when a conventional study (echocardiogram) has failed to opacify the left ventricle. A contrast agent is considered medically necessary when it is used to improve the delineation of the left ventricular endocardial borders. This is especially applicable during the performance of exercise echocardiographic stress testing. Submit this contrast media utilizing procedure code 90799 (unlisted therapeutic, prophylactic or diagnostic injection) and provide a narrative identifying Optison and the dosage as well as the statement Failed echocardiogram.

Trailblazer in Texas also now pays for Optison, but instead of an unlisted CPT code, it instructs providers to use HCPCS code J3490 (unclassified drugs). Interestingly, if you look up contrast agents for echocardiography in the HCPCS book index, the only entry is code S8060 (supply of contrast material for use in echocardiography [use in addition to echocardiography code]), which certainly sounds correct but, as an S-code, is categorized as a non-Medicare temporary national code. As such, it is not mentioned in any of the policy statements issued by the local carriers.

The Trailblazer policy also restricts the use of MCE, stating that notwithstanding the advantage of MCE, its use should, at present, be limited to situations in which non-contrast echocardiography is suboptimal or gives an indeterminate result. Trailblazer lists five factors that contribute to suboptimal echocardiography: adverse body habitus, lung disease, hyperventilation, tachycardia and prior cardio-thoracic surgery. Note: These are examples only. Medical necessity for using contrast echocardiography is not necessarily limited to these five situations.

Trailblazer also expects the patient record to clearly indicate the clinical necessity of MCE. Just dictating Optison enhanced echo image, is insufficient, according to Sueanne Bicknell, RHIA, CPC, CCS-P, compliance administrator at CPR-Heart Place, a group practice with 65 cardiologists in Dallas. The reason for using the contrast agent should be dictated in the operative report and in the echo report, Bicknell says.

Trailblazer has given five very specific examples of what they say will support medical necessity. If the physic-ian feels he has a sixth reasonwhich is finehe or she can document and submit a claim, which will be reviewed to determine if it supports medical necessity, she says.

To support medical necessity on the basis of prior cardio-thoracic surgery, Bicknell recommends using code V45.81 (aortocoronary bypass status) for post-CABG patients, and V43.3 (heart valve replaced by other means) and V42.2 (heart valve replaced by transplant) for post-valve replacement patients as a secondary diagnosis if appropriate, as it will help define the kind of prior cardio-thoracic surgery the patient had.

Because Optison comes in a 3-ml single-use vial, any time it is used, a complete vial may be charged and a 1 placed in the units box of the HCFA 1500 claim form. If, for example, 4.5 ml is used, a 2 should be placed in the units box, Bicknell says.

Bicknell notes that because Trailblazer pays 95 percent of the average wholesale price (AWP) of the Optison, practices must absorb a loss on the price of the agent. If the AWP is $110, for instance, Medicare only reimburses $104.50, she says.