Cardiology Coding Alert

Code V72.81 (preoperative cardiovascular examination) has been the textbook ICD-9 code to use when billing for tests and/or examinations performed on patients about to undergo surgery. But increasingly, Medicare carriers are denying such claims if V72.81 is the only diagnosis or the first one listed on the HCFA 1500 claim form. Coders should use the diagnosis code that describes why the cardiologist was asked to see the patient.

Typically, what happens is that other physicians send patients with a history of heart problems who are about to have surgery to a cardiologist for an exam and tests. But many Medicare carriers now view such preoperative clearances as screenings, for which it does not pay. And an increasing number of carriers will not pay for it unless there is a payable diagnosis or symptom. Many hospitals require clearance, however, citing good medical practice and liability concerns.

As a result, says Terry Fletcher, BS, CPC, a coding and reimbursement specialist in Laguna Beach, Calif., some carriers now only cover V72.81 for the exam, not for the tests, and sometimes, depending on the carrier, not even for the exam. A lot of offices are having problems getting reimbursed for the tests, and sometimes even for the exam, when they use V72.81 as their only diagnosis code. Another option is to code the surgical diagnosis, but if the patient is having gallbladder surgery, for example, and requires car-diac clearance, coding 574.00 (calculus of gallbladder with acute cholecystitis, without mention of obstruction) is not a covered diagnosis for labs or EKGs, only for the exam.

List Diagnosis First

What Medicare wants is a diagnostic reason for the pre-op clearance, such as previous heart surgery, says Denise Reckers, a coder with Cardiology Consultants, an 11-member cardiology practice in Abilene, Texas. For Medicare to cover it, you need a sign or symptom code or a diagnosis as to why the patient requires pre-op clearance, Reckers explains.

And that diagnosis should be listed first on the HCFA claim form, ahead of V72.81, Fletcher says. Because many carriers computers accept only one diagnosis code, V72.81 should be added as a second diagnosis code, particularly for lab tests, Fletcher notes.

What has been helpful is that offices have been coding V72.81 for exam portion only and including a comprehensive history on the patient to verify a covered diagnosis such as family history, heart disease or hypertension, which would cover labs, EKGs, etc., Fletcher says, as Medicares screening guidelines apply more for tests than other services.

Even if an established patient is coming in for the clearance, offices still have to go back and look at the patients history, Fletcher notes. Quite often, lab services will be paid by signs and symptoms rather than diagnoses.

If a payable diagnosis is available both for the exam and the lab tests, that should be used ahead of V72.81 when billing for both services. For example, an 82-year-old female is scheduled for hip replacement surgery (27130, arthroplasty, acetabular and proximal femoral prosthetic replacement [total hip replacement], with or without autograft or allograft). The patient is taking Coumadin, an anticoagulant blood thinner, and needs to be taken off the medication three days before surgery, so preoperative clearance by a cardiologist is medically necessary. The cardiologist should list the ICD-9 code (V58.61, long-term [current] use of anticoagulants) first, both for the evaluation and management (E/M) exam and any lab tests he or she orders. The secondary diagnosis would be V72.81.

In short, cardiologists should use the diagnosis code that describes why they were asked to see the patient. Presumably, there will be an indicator of some sort of cardiac abnormality, such as an abnormal EKG or chest pain. Or the patient may be post-CABG (V45.81 aortocoronary bypass status) or have had a myocardial infarction years earlier (414.01, coronary atherosclerosis of native coronary artery). In most cases, the diagnosis code for the prospective surgery is incidental and should be listed after both the reason the cardiologist was consulted and the V72.81.

Consult Codes Should Be Used

Because the cardiologist has been asked to see a patient by another physician, the visit qualifies as an office consult (9924x, as appropriate), which reimburses at a higher rate than a new or established patient visit (99201-99215). This is true even if the cardiologist previously has seen the patient. If the consult is performed on an inpatient, codes 9925x (initial inpatient consultation) should be used.

To bill a consult, the cardiologist needs to ensure that:

the cardiologist has received a request (in writing) from the referring physician;
medical necessity for the consult must be
documented in the patients record; and
the cardiologist must provide a written report of his or her findings to the requesting physician.

In addition, the fact that the consult was performed to clear a patient for surgery must be documented in writing and sent back to the requesting physician, Reckers says.

Reckers also notes that if the patient is referred to the cardiologist because of a sign or symptom or a medically necessary diagnosis, the exam and/or tests may be performed the day before or the same day as the procedure without being caught up in the procedures global period. For example, a general surgeon schedules a 70-year-old man for a partial colectomy (44140). The patients primary-care physician (PCP) performs a work-up and finds he has shortness of breath and a heart murmur. The PCP decides to have this checked before the surgery and sends the man to the cardiologist, who examines the patient and performs the necessary tests the day before the colectomy. Because the heart problems are unrelated to the diagnosis that prompted the decision to perform the colectomy, the cardiologist can bill both for the consult and any tests or lab work that are performed.

In some areas, cardiologists are the primary-care physicians for some patients more than 50 years of age, and in that capacity, they are asked to perform routine pre-op clearances for their patients. In those situations, they must ensure the exam and any tests are performed at least 48 hours before the surgery, Fletcher says. Otherwise, they may not be reimbursed because the pre-op is considered part of the surgerys global package. The exam should be billed 9921x (office visit, established patient), as appropriate.

When cardiologists are asked to preoperatively clear an inpatient, Fletcher recommends coding with the signs or symptoms that prompted the request for the consult (for example, chest pain [786.5] or shortness of breath [786.05]). Code V72.81 should not be included in these claims because the carrier will want to know why an inpatient consult was performed if there was no acute problem, Fletcher says.

If a patient visits the cardiologist before surgery and they talk but no exam is performed, then no consult may be billed because V72.81 requires an element of an examination. Similarly, a preoperative clearance is deemed not to have occurred if the patient goes to the cardiologists office to pick up admitting orders for the hospital and sees a nurse but not the physician.