Cardiology Coding Alert

Learn which codes can - and can never - be broken

Identifying the cardiovascular stress test codes that include both professional and technical components is as difficult as identifying those that do not. Try your hand at coding the following scenarios to identify where your stress test coding knowledge shines, and where it needs to be polished.

Check Which Components Are Included

1. Scenario: A patient complains of chest pain (786.50) and heart palpitations (785.1). A physician uses the hospital's equipment to perform a cardiac stress test. Your doctor supervises the stress test and provides a written interpretation and report.

Coding solution: You should report 93016 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report) for the physician supervision. To code the written interpretation and report, you should also use 93018 (... interpretation and report only), says Sheldrian LeFlore, CPC, senior consultant with Gates, Moore & Company in Atlanta. Pay attention to the descriptors of these codes, which include key phrases such as "without interpretation and report" and "interpretation and report only."

Red flag: Be sure to check with your carrier to see if 786.50 and 785.1 are listed among the ICD-9 codes that lend medical necessity. Also, check their documentation requirements.
 
2. Scenario: Your physician administers a cardiovascular stress test in the office, providing the procedure's technical component (that is, the physician's practice owns the equipment, employs the staff, pays the rent, pays the utilities, etc.) in addition to the supervision, interpretation and report.

Coding solution: In this case, you should report 93015 (... with physician supervision, with interpretation and report), says Lisa Center, CPC, quality review coordinator for Freeman Health System in Joplin, Mo. Focus on the latter portion of this definition, which specifies both physician supervision with interpretation and report.

Therefore, 93015 is the correct choice because it encompasses all of the procedure's components (the equipment's use, as well as the supervision, interpretation and report), Center says. Use 93016-93018 to report the components of the test the physician performed if he didn't do the entire service, she says

Remember: The physician may initiate this method of "stress" by using pharmacological agents, such as dobutamine (J1250, Injection, dobutamine HCI, per 250 mg) or Persantine (J1245, Injection, dipyridamole, per 10 mg), Leflore says. Therefore, you should report the appropriate HCPCS code to describe the agent, she says.

Include Documentation as Justification

If you want to ensure Medicare and commercial insurers pay for 93015-93018, you'll need more medical justification than the appropriate ICD-9 codes. You'll also need to know your payer's medical necessity and documentation requirements. 
 
3. Scenario: Because the patient is obese (278.0x) and has diabetes (250.xx), he presents to your physician to make sure he doesn't have coronary artery disease. The doctor performs a cardiac stress test to screen for the condition. A few weeks later, your Medicare carrier denies your practice's claim for 93015.
 
Coding solution: "The primary reason for denial of a stress test is the lack of medical necessity," LeFlore says. For instance, most Medicare carriers, such as First Coast Service Options of Florida, do not pay for cardiac stress tests the physician performs to screen for coronary artery disease. 

"Billers and coders must check their payers' guidelines to ensure that medical necessity is present in the documentation for performing this service," LeFlore says.

Center agrees: "Many offices don't check their policies and later find out they have to write off the stress test because the ICD-9 codes they used aren't on the list of approved diagnosis codes."
 
Examples: Generally, a cardiac stress test is medically necessary if the patient presents with chest pains (786.5x) or has an abnormal electrocardiogram (EKG) (794.31), LeFlore says. However, you will find a mixed assortment of other covered indications dictated by local coverage determinations. Check your Medicare LCDs and/or LMRPs to determine what your carrier defines as medically necessary.

You should also check with your carrier to find out what the medical documentation should contain. For instance, First Coast Service Options recommends that the medical documentation include the following: