Cardiology Coding Alert

Although some insurance carriers bundle cardiovascular stress tests in evaluation and management (E/M) codes, many cardiologists, depending on the carrier, can be reimbursed for the procedure using certain ICD-9 codes for signs or symptoms instead of approved diagnosis codes. But the physician will have to show the indications clearly in the medical record, says Terry Fletcher, BS, CPC, CCS-P, a cardiology coding consultant in
Dana Point, CA.

A new policy announced by Nationwide, the Medicare carrier in Ohio12 other states have similar policies with more working toward that goaldefines stress testing as one of the standard tools used to evaluate patients with signs and symptoms of ischemic heart disease and certain types of valvular disease. The tests may be exercise or pharmacologic and include electrocardiograms (ECGs), echocardiograms and radionuclide studies.

The new policy applies to the following CPT and HCPCS codes:

93015 (cardiovascular stress test using maximal or
submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and 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)

93017 (cardiovascular stress test using maximal or
submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring and/or pharmacological stress; tracing only, without interpretation and report)

93018 (cardiovascular stress test using maximal or
submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only)

J0280 (injection, aminophyllin, up to 250 mg)

J0460 (injection, atropine sulfate, up to 0.3 mg)

J1245 (injection, dipyridamole, per 10 mg)

J1250 (injection, dobutamine HCl, per 250 mg)

J0151 (injection, adenosine 90 mg [not to be used
to report any adenosine phosphate compounds, instead use A9270])

J3490 (unclassified drug)

The new policy by Nationwideone of several carriers to revise their stress test policybecame effective Nov. 1. Previously, Medicare carriers would reimburse stress tests only if the patients diagnosis matched one of a list of approved ICD-9 codes.

In the past, it didnt matter what the signs or symp-toms were because all Medicare would accept before you would get paid was an approved diagnosis. Now, if you just use signs or symptoms, your claim may still be denied at first, but because of the updated guidelines, they will look at the patients full documentation on appeal, Fletcher says.

Medical Necessity Is Key

According to the Nationwide policy, Medicare covers cardiovascular stress testing when medically necessary to guide management of patients with known or suspected coronary artery disease (CAD), some cardiac rhythm disorders, and certain types of valvular disease:

1. To aid in the diagnosis of patients with signs or
symptoms of myocardial ischemia;

2. To evaluate patients after myocardial revascular
ization or procedures to relieve coronary artery
obstruction;

3. To evaluate patients referred for covered cardiac
rehabilitation;

4. To establish prognosis and make management
decisions following uncomplicated myocardial infarction;

5. To evaluate patients with certain types of valvular
disease when surgical intervention may be appropriate;

6. Pre-operative evaluation of selected patients who
are to have major surgery and are at moderate risk
for CAD;

7. To assist in the management of patients with known
or suspected exercise-induced arrhythmia, and
identification of appropriate settings in patients
with rate-adaptive pacemakers.

Initial cardiovascular stress tests must be preceded by an appropriate evaluation of the patient, including history, physical and resting ECG, according to Nationwide. A
12-lead ECG and/or rhythm strip performed in conjunction with a stress test is not separately payable. Medicare coverage may be allowed when the evaluation indicates that the study will provide a reasonable explanation for the patients symptoms and/or significant information needed to make management decisions. The results of this evaluation are important determinants in selecting between exercise or pharmacologic stresses as well as the need for stress imaging (i.e., echo or radionuclide study).

In addition, the policy provides, The most common presentation of ischemic heart disease is effort-induced angina. In some patients, the symptoms may be atypical. Unless cardiac catheterization is planned, stress testing should be performed on low or intermediate risk patients hospitalized for angina when they have been free of angina and congestive heart failure for a minimum of 48 hours. Patients with autonomic neuropathy may lack anginal symptoms and have ECG abnormalities as the only sign of CAD.

Therefore, using ICD-9 code 794.31 (abnormal ECG) may be an acceptable diagnosis for payment for a treadmill (93015), Fletcher says.

Nationwide also says that for those patients who are unable to reach 75 to 100 percent of their age-predicted maximum heart rate by physiologic exercise, pharmacological stress agents (J0280, J0460, J1245, J1250, J0151 and J3490) may be used. However, cardiologists should check with their own carrier to determine when their guidelines indicate the drugs are contraindicated.

Finally, repeat stress tests must have specific clinical indications, regardless of the ICD-9 code submitted. And more than one kind of stress testing (e.g., treadmill, ECG, echocardiogram, myocardial perfusion imaging) for the same clinical event is covered only when the first test was inconclusive or uninterpretable.

Note: Asymptomatic patients who undergo stress testing are not covered, regardless of the number of risk factors that may be present. Medicare policy prohibits coverage for screening services. In addition, stress testing always is contraindicated for the following conditions: acute myocardial infarction (within 2 days); unstable angina not previously stabilized; uncontrolled cardiac arrhythmia causing symptoms of hemodynamic compromise; symptomatic severe aortic stenosis; uncontrolled symptomatic heart failure; acute pulmonary embolus/infarction; acute myocarditis/pericarditis; and acute aortic dissection. Depending on the circumstances, stress testing also may be contraindicated for the following conditions: left main artery stenosis; moderate valvular heart disease; electrolyte abnormalities; severe arterial hypertension; tachyarrhythmia/bradyarrhythmia; hypertrophic cardiomyopathy or other forms of outflow obstruction; inability to exercise adequately; and high degree atrioventricular block.

Full Documentation Is Critical

The key to getting reimbursed by reporting signs and symptoms is making sure these indications are actually in the medical record, Fletcher says. Your Medicare carrier wants to know the steps that led to the patient being tested. So if documentation supports the fact that indications warranted the test, you can get paid.

Merely indicating the signs or symptoms, however, is not enough, Fletcher says. The medical recordi.e., the narrative that includes the indicationhas to be complete because Medicare says you need a clear indication of why the test is necessary. A note in the chart that says: Plan: echo scheduled is not a clear indication, she explains. In other words, a cardiologists note that his or her plan for the patient is an echo is insufficient; the record must clearly state that due to the indications stated in the subjective and objective stress test findings (for example, palpitations, shortness of breath and/or chest pain), the patient is scheduled for an echo doppler.

Note: As stated in the November Cardiology Coding Alert on page 88, the doppler portion must be included in the order for an echo, or reimbursement will be denied for the color flow (93325) and doppler portion (93320).

Fletcher notes that even with the proper diagnosis coding, the stress test claim still is likely to be rejected initially because of software edits used by insurance carriers. But there is a good chance the cardiologist will be reimbursed when the patients record is submitted on appeal and it is complete.

If the patients diagnosis is on the list of approved ICD-9 codes, the echo will be paid without recourse to an appeal, Fletcher says, adding that post-test diagnoses should be used if they are on the list, with the signs and symptoms added as a secondary diagnosis.