Cardiology Coding Alert

Telemedicine has experienced rapid growth in recent years, with cardiologists, payers and code writers scrambling to catch up. Most people, physicians and their staff included, tend to view telemedicine as long-distance consults via computer and television screen. But there are several other kinds of telemedicine that cardiologists, in particular, utilize more than most physicians, though they may refer to such services by another name. For example, cardiac monitoring, which CPT refers to as event recording, is a form of telemedicine.

According to John Linkous, executive director of the American Telemedicine Association in Washington, DC, services that fall under the telemedicine category include teleradiology, which allows physicians to store x-rays on diskette and then view results on their computers at home; and monitoring patients in their homes with portable units, such as ECG monitors and pacemakers.

Telemedicine utilization has grown very rapidly. However, so have the regulations regarding its coding and reimbursement, making it difficult for cardiologists to keep up and get paid properly.

A variety of codes already exist for telemedicine, though the descriptions tend to be vague, making it difficult to be certain which one to use. In addition, many cardiologists may be unaware that HCFA has created a new group of HCPCS codes (in the G section) that replace existing CPT codes. In a similar vein, one important CPT code (see below) awaits revision because its description in CPT 1999 is at variance with HCFA regulations, due to the introduction of the G codes.

In short, individuals billing for telemedicine consults of any kind need to understand all the ramifications of the technology and associated coding issues to obtain fair and correct payment for such services.

Currently, says Linkous, the following CPT codes can be used by cardiologists for telemedicine activity involving portable ECGs and pacemakers. These are:

93012- Telephonic transmission of post-symptom electrocardiogram rhythm strip(s), per 30-day period of time; tracing only.
93014- Physician review with interpretation and report only. Codes 93012 and 93014 should be used to report phone transmissions of ECG rhythm strips from patients with old-fashioned patient event recorders that do not incorporate memory loop technology. These codes are used when a physician is interpreting an ECG strip which has been done in a distant area by a physicians assistant or nurse practitioner because no physician is available at the source.
93733- Electronic analysis of dual chamber internal pacemaker system (may include rate, pulse amplitude and duration, configuration of wave form, and/or testing of sensory function of pacemaker), telephonic analysis.
93736- Electronic analysis of single chamber internal pacemaker system (may include rate, pulse amplitude and duration, configuration of wave form and/or testing of sensory function of pacemaker), telephonic analysis.

Another set of codes93268, patient demand single or multiple event recording with presymptom memory loop per 30-day period of time; includes transmission, physician review and interpretation; 93270, recording (includes hookup, recording and disconnection); 93271, monitoring, receipt of transmissions, and analysis; 93272, physician review and interpretation onlyhave been supplanted, to some extent, by the following Medicare Level II HCPCS codes:

G0004- Patient demand single or multiple event recording with presymptom memory loop and 24-hour attended monitoring, per 30-day period; includes transmission, physician review and interpretation.
G0005- Patient demand single or multiple event recording with presymptom memory loop and 24-hour attended monitoring, per 30-day period; recording (includes hookup, recording and disconnection).
G0006- Patient demand single or multiple event recording with presymptom memory loop and 24-hour attended monitoring, per 30-day period; 24-hour attended monitoring, receipt of transmissions and analysis.
G0007- Patient demand single or multiple event recording with presymptom memory loop and
24-hour attended monitoring, per 30-day period; physician review and interpretation only.
G0015- Post-symptom telephonic transmission of electrocardiogram rhythm strip(s) and 24-hour attended monitoring, per 30-day period; tracing only.
G0016- Post-symptom telephonic transmission of electrocardiogram rhythm strip(s) and 24-hour attended monitoring, per 30-day period; physician review and interpretation only.

Note: With codes G0004-G0016 in place, HCFA has redefined CPT code 93268 for attended monitoring of less than 24 hours a day.

Include ICD-9 Codes to Prove Medical Necessity

Guidelines published by Palmetto Government Benefits Administrators, which administers Medicare benefits in South Carolina, say that documentation supporting the medical necessity of the [event recording] must be submitted with each claim. Claims submitted without such evidence will be denied as not being medically necessary.

In other words, to receive fair and correct compensation for such procedures, physicians need to provide accurate diagnosis codes to show medical necessity.

For example, a patient visits the physician complaining of palpitations (785.1). The physician performs a cardiovascular exam and takes an appropriate history (99204, new patient, office or other outpatient visit, comprehensive history, comprehensive exam, moderate medical
decision-making). Based on the patients history and an ECG during the exam, the physician feels the patients condition is not life-threatening, but still wants to know what is causing the problem.

The patient is hooked up to a portable ECG (G0005) that monitors the patient at home and runs ECG traces and is attached to the patient much in the same way as a Holter monitor. When the patient feels symptoms coming on, he or she presses a button, triggering the machine to record the heart rhythm.

The data from the unit is then transmitted (usually by telephone) to a trained technician who provides 24-hour-a-day service (G0006) and can read it on the spot to determine if there is a problem that requires a speedy review and interpretation by the cardiologist (G0007).

Without including code 785.1 or another approved diagnosis code, the claim would be denied as medically unnecessary. (See box on this page for acceptable diagnosis codes for patient demand monitoring.)

Note: Transmission from patients instructed to transmit an ECG recording scheduled at a predetermined time, unrelated to symptoms, should not be reported using these codes, according to Medicare guidelines, which also warn physicians not to use the patient demand recorder to diagnose and treat suspected arrhythmia as a routine substitute for more conventional methods of diagnosis such as history, physical examination, and standard ECG.

24-Hour Event Recording Required

Because portable ECG equipment is much less expensive than it used to be, some cardiologists may wish to buy the units and operate them from their offices. However, because of the way the codes and guidelines governing event recorder use are currently structured, the physician will likely have great difficulty obtaining the correct reimbursement.

In order to bill for these codes, the physician must provide 24-hour-a-day monitoring by a technician trained to respond to the recordings who will contact the physician to give the patient the care he or she requires.

But if the physician contracts with an outside service to provide the technician for 24-hour monitoring, the doctor cannot bill for the 24-hour-a-day technical component. Instead, the outside service will bill for such services.

Another problem relates to splitting the technical component of such a service. Because the G-codes are billed in 30-day increments for 24-hour service, Medicare requires that the physician must indicate in the claim who provided the technical services and how much those services cost.

If the physicians office provides technical services when the practice is open but contracts for such services the rest of the time, Medicare has no way of correctly splitting the fee. If the physician gets the fee and pays the technical firm from his or her own pocket, Medicare says the physician must disclose how much he paid the company for the purchased service, and they will only pay you what you paid them.

If the cardiologist paid out only $100 for monitoring services, that is all Medicare will reimburse for all technical services performed during the entire 30-day period. There is no way to indicate and collect reimbursement for the portion performed by the physicians staff separately from the monitoring service.

In principle, too, Medicare expects a certain consistency in the level of care provided to its beneficiaries, and may not look favorably on patients bouncing back and forth from physician to technical company.

Note: The cardiologist can bill for the use of such a monitoring system with code 93268 if attended monitoring is less than 24 hours a day and the documentation shows that round-the-clock monitoring was unnecessary.

HCFA Rural Pilot Program

Another reason telemedicine guidelines and codes need to be updated is the fields growing importance. In 1997, Linkous says, 2 million line items for claims involving such telemedicine procedures were filed, claiming a total of $150 million. Of that, only $70 million was reimbursed.

On January 1, 1999, HCFA, which funds and administers Medicare, began a demonstration program aimed at designated Health Professional Shortage Areas (HPSAs), mainly rural areas with shortages in healthcare personnel. Physicians are now able to refer and consult using a broad array of telemedicine services, including live interactive video. The program, which has been operational since April 1999, marks the first time that physicians have been able to bill for interactive video consults.

According to HCFA guidelines issued in January 1999, Consultations rendered in this way are titled teleconsultations [and] apply to consultations for rural beneficiaries whether or not the consultant and primary care practitioner are located in the same area.

Patients from full or partial county HPSAswhich are listed in section 332(a)(1)(A) of the Public Health Service Actare now entitled to receive teleconsultation services. Medicare will pay the teleconsult 100 percent what it pays for a face-to-face consultation, with the referring (i.e., requesting) physician receiving 25 percent and the consulting physician, 75 percent.

An HCPCS modifier, GT (via interactive audio and video telecommunication systems), should be attached to the consultation claim (99241-99245, office consultation, new or established patient; 99261-99263, follow-up inpatient; or 99271-99275, confirmatory consultations, new or established patients), filed by the consulting physician.

Note: The referring physician is not allowed to bill for his role in the teleconsultation. Instead, he must receive his 25 percent payment from the consulting physician, who is paid the entire reimbursement and is responsible for disbursing it to the referring physician.