Cardiology Coding Alert

ABNs could be your saving grace--find out how

To report clean claims for your cardiac rehabilitation (CR) services, you'll need the right documents, including the attending physician's script, the supervising physician's signature on exercise sessions, and plenty of support for separate services during rehab sessions.

Stay clear of these four pitfalls, and you'll report CR services correctly every time.

Pitfall 1: Professional Services Not Apparent

The first step is to make certain that your cardiologist's professional services are apparent to the carrier.   

Here's how: Make sure your cardiologist performs both initial and subsequent services to reflect active participation in the course of treatment. "It's very important that the treating physician provide a written prescription for cardiac rehab services," says Sheldrian Leflore, CPC, a revenue management educator with The Coding Group in Carlsbad, Calif.

Best advice: Before billing 93798 (Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring [per session]), document everything. Getting your CR documentation right will eliminate reimbursement woes. Indeed, Medicare pays about $20 per facility session for 93798, according to national averages in the Physician Fee Schedule--and for a patient on a six-week protocol, this can really add up.

Remember: Cardiac rehab services (93797-93798) have a zero-day global package. To bill for any additional physician services on the same day as cardiac rehab, you do not 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 prevent bundled-service denials.

But some carriers are slow to implement CMS Transmittal 954, released last year. This transmittal instructs you to use modifier 25 only when your cardiologist provides a significant and separately identifiable E/M service on the same day as a procedure that has a global period. (For the exact language, go to www.cms.hhs.gov/transmittals/downloads/R954CP.pdf.) In other words, you may still need to use modifier 25. Bottom line: Check with your payer.

Example: The physician might perform an interim physical exam to assess the therapy's impact and to make sure no adverse events are imminent. In this situation, you would report an established patient office visit (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient) and the cardiac rehab service (93797-93798). If your payer requires modifier 25, you would append it to 99213.

Pitfall 2: Missing Supervising Physician
 
To recoup ethical reimbursement for cardiac rehab services, you have to be very clear about documenting who the supervising physician is.

A CMS official provided Cardiology Coding Alert with the following definition of direct supervision for cardiac rehab services: "It does not require that a physician be physically present in the exercise room itself, provided the contractor does not determine that the physician is too remote from the patients' exercise area to be considered immediately available and accessible."

In other words, the supervising physician must be in the exercise program area and available for emergencies but does not have to be in the exercise room, Leflore says.

Best strategy: Have staff sign off on exercise summaries as "Provided under the direct supervision of Dr. X." In physician practices, any on-site physician can take on supervisory responsibility for incident-to services. But make sure you bill the cardiac rehab sessions under the on-site, supervising physician. Keep in mind that this physician does not need to be the patient's regular physician who ordered the cardiac rehab or provided the first service.

Watch out: "We have our own cardiac rehab clinic in two of our offices, and we've discovered that a nonphysician practitioner (NP) or physician assistant (PA) cannot supervise a cardiac rehab center. Instead, a physician must provide direct supervision--unless a hospital owns and operates the cardiac rehab center," says Sylvia Kummer, CPC, CCP, CCP-AS, a certified coder and internal coding auditor at a cardiology group in Kentucky.

Pitfall 3: Missing Documentation

Don't fall to prey to insufficient documentation to support each of the exercise sessions.

Take action: Each service you report to Medicare must be specifically documented in the patient's record. At any point following billing, you might be required to submit proof of services that you billed, which is a longstanding condition of participation, coding experts say. Although CPT provides no definitive standard for cardiac rehab documentation (as for E/M services), a nurse's summary of the exercise session should suffice. The nurse's notes may indicate exercise type, duration, electrocardiographic responses and a comparison to previous rehab sessions.

Pitfall 4: Lack of Covered Diagnoses

Your claim may return a denial if the session notes lacked covered diagnosis documentation.

Heads up: Cardiac rehab services have eight main covered indications, according to Medicare's National Coverage Determination, Leflore says:

• acute myocardial infarction within the preceding 12 months

• stable angina pectoris

• status post the following procedures: coronary bypass surgery, heart valve repair/replacement, percutaneous transluminal coronary angioplasty (PTCA), coronary stenting, or heart or heart-lung transplant.

"The frequency and duration of the program are two to three sessions per week for 12 to 18 weeks," Leflore says. The Medicare contractor may permit coverage beyond 18 weeks, not to exceed 72 sessions for 36 weeks. "Medical necessity must be provided to support additional sessions," she adds.

Indeed, if the physician does not document one or more of the above indications, Medicare will not cover the rehab.

Rule of thumb: Be sure you check your local medical review policy for covered diagnoses. Keep in mind: You must code based on the cardiologist's documentation, and not assign diagnoses merely to get reimbursement.

ABNs Cover Your Losses

Ask Medicare patients who do not meet coverage criteria but who require cardiac rehab to sign an advance beneficiary notice (ABN) before you provide the rehab services. If you must file a claim to Medicare for these noncovered services, such as when you need Medicare denial before billing the secondary payer, append modifier GA (Waiver of liability statement on file) to 93797 or 93798.