Cardiology Coding Alert

Proposal #1:
Work RVUs Reduced by 50 Percent or More

Based on a formula that estimates the average number of E/M visits that occur during a procedures global period, HCFA also is proposing to reduce the work RVUs for pacer and ICD codes by more than 50 percent in some cases. HCFA also proposes to adjust practice expense inputs for supplies, staff time and equipment.

These reductions already have attracted criticism from the North American Society of Pacing and Electrophysiology (NASPE). In a letter to HCFA administrator Nancy-Anne Carle, NASPE president David Cannom, MD, writes, HCFAs proposal to ... reduce the work and practice expense values by 60 percent will have a profoundly negative and dramatic effect on practicing physicians who specialize in pacemaker and defibrillator implants.

Cannom calls the proposal unacceptable and wants it withdrawn because it will have a detrimental impact on the way these procedures are currently reimbursed. According to NASPE, the premise that reduction in work values will be fully offset by billing for subsequent visits is incorrect.

NASPE also disputes HCFAs assumption that the physician performing the pacemaker or defibrillator implant typically is the same physician expected to furnish care for the patients related cardiac disease.

Proposal #2:
Critical Care Guidelines Revised

The HCFA proposals announced on July 17 in the Federal Register also include changes to critical care and observation coding and reimbursement, as well as an advanced copy of CPTs 2001 critical care guidelines (printed early with permission of the AMA).

These three changes dominate the critical care revisions:

Physicians now will be able to bill for E/M performed on a patient before the patient required critical care services.

The number of RVUs for both critical care codes,
99291 and 99292, has increased.

The trend away from the guideline that critical care
services could be claimed for patients whose condition was unstable (begun in CPT 2000) will continue.

The CPT introduction now states critical care and other E/M services may be provided to the same patient on the same date by the same physician. This brings CPTs introduction in harmony with section 15508F of the Medicare Carriers Manual, which states, if there is a hospital or office/outpatient evaluation and management service furnished early in the day and at that time the patient does not require critical care, but the patient requires critical care later in the day, both critical care and the evaluation and management service may be paid.

Note: The earlier E/M service should be reported with a -25 modifier (significant and separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and, in most cases, should be linked to a different diagnosis code.

The CPT introduction now also explicitly rules out using time spent performing a procedure toward critical care time, whereas previously, only time spent on vaguely defined other activities could not be counted. According to CPT 2001, Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time.

Finally, HCFA appears to be moving further away from the notion that the patient had to be unstable for critical care services to be billed appropriately. Under the new guidelines, it should be easier to meet the criteria for claiming critical care services when treating critically ill patients, even those who may be ill for a long time. Services for a patient who is not critically ill but happens to be in a critical care or intensive care unit still are reported using other E/M codes.

Proposal #3:
Inpatient and Observation Changes

The most significant revision to Medicares observation /inpatient codes closes a loophole that allowed physicians to bill for an additional E/M service within the same 24-hour period as an admit if the two E/M services occurred on different calendar days. When a patient is admitted to the hospital or to observation status, no other E/M may be charged on the same calendar day. This means that if a patient is seen in the emergency department (ED) in the late evening and is admitted early the next morning on the following calendar day, the admitting physician can charge for both the E/M provided in the ED and for the admittal.

HCFAs proposed revision would eliminate the calendar- date loophole by creating three time-specific categories.

Inpatient stay of 24 hours or more. Medicare would pay for both inpatient hospital admission services (99221-99223) and hospital discharge services (99238-99239) when a patient is a hospital inpatient for 24 hours or more. The medical record must document that the patient was an inpatient for at least 24 hours for both of these services to be paid.

Inpatient or observation stay of less than eight hours. If a patient is admitted as a hospital inpatient or an observation patient for less than eight hours, Medicare would pay for only the admission service (99221-99223 or 99218-99220) on that day. The discharge service is not considered to be a separately billable service.

Inpatient or observation stay of eight or more hours, but less than 24 hours. If a patient is admitted as a hospital inpatient or an observation patient for eight or more hours, but less than 24 hours, Medicare would pay for both the admission and discharge services under codes 99234 to 99236.