Internal Medicine Coding Alert

Watch out: Stress test is not part of Medicare's preventive service package.

Avoid making coding for cardiovascular screening a chamber of horrors with these quick tips on identifying and coding your internist's cardiac tests.

When your internist screens a Medicare patient for cardiovascular disease, there are several tests she might perform. Medicare covers some heart screening procedures for asymptomatic patients; other types of tests, however, need to be prompted by medical necessity. Avoid miscoding and denials by using these tips for identifying the different types of cardiovascular screens your physician might perform in the office.

"There are multiple options for evaluating the electrical activity in the heart," relayed Christina Neighbors, MA, CPC, ACS-CA, of Franciscan Health Systems in Tacoma, Wash., during her recent audioconference, "Coding and Billing Best Practices for Heart Rhythm Procedures" (www.audioeducator.com).

EKG clues: One of these tests is an electrocardiogram (EKG or ECG). During an EKG, the physician places six leads on the patient's chest and additional leads on each extremity, and then gets a printed readout of the patient's heart activity. Coding for this procedure will depend on the level of your internist's involvement, Neighbors said.

When the internist performs an EKG, choose from the following codes:

• 93000 -- Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report

• 93005 -- ... tracing only, without interpretation and report

• 93010 -- ... interpretation and report only.

Coverage tip: EKGs must be prompted by specific symptoms in order for Medicare to cover them. Check with your individual payer to see what ICD-9 codes will prove medical necessity for EKGs/ECGs; specific diagnosis codes may vary
by payer.

There are dozens of diagnosis codes that might prove medical necessity for your EKG claims, including hypertension and myocardial infarction. According to National Government Services' local coverage determination (LCD) for ECG/EKG (L28189), these are some of the diagnosis codes you could report for 93000-93010:

• 174.0-174.9 -- Malignant neoplasm of female breast ...

• 250.00-250.93 -- Diabetes mellitus ...

• 396.0-396.9 -- Diseases of mitral and aortic valves ...

• 404.00-404.93 -- Hypertensive heart and chronic kidney disease ....

The internist can also perform an exercise stress test to check for cardiac disease; during this test, the patient performs a physical activity while undergoing a 12-lead EKG. However, these are not covered for asymptomatic Medicare patients.

Stress test clues: Internists "conduct this test while the patient uses a treadmill, exercise bike, or a drug to induce stress on the heart," Neighbors explained.

When the internist conducts an exercise stress test on a patient, choose from the following 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 -- ... physician supervision only, without interpretation and report

• 93017 -- ... tracing only, without interpretation and report

• 93018 -- ... interpretation and report only.

Don't miss: If the internist uses drugs to induce heart stress, remember to code separately for them, Neighbors said. Some of the drugs the physician might use include adenosine (J0152, Injection, adenosine for diagnostic use, 30 mg), persantine (J1245, Injection, diphryidamole, per 10 mg), or dobutamine (J1250, Injection, dobutamine HCI, per 250 mg).

According to TrailBlazer Health's LCD for cardiovascular stress testing (L26582), these are some of the ICD-9 codes that prove medical necessity for stress tests:

• 410.00-410.02 -- Acute myocardial infarction ...

• 424.0-424.3 -- Other diseases of endocardium ...

• 785.0-785.2 -- Symptoms involving cardiovascular system ... .

While Medicare requires medical necessity for EKGs and treadmill stress tests, it will cover cardiovascular screening blood tests for asymptomatic patients, confirms Sean M. Weiss, CPC, CPC-P, CMPE, CCA-P, CCP-P, senior partner at The CMC Group LLC in Atlanta.

There are four codes to choose from when the internist performs a blood test to screen for heart disease.

Blood test clues: Use the most comprehensive code, 80061 (Lipid panel ...), when the internist performs cholesterol, lipoprotein, and triglycerides checks during the same screening, says Weiss. If, however, the internist performs only one of these tests, choose one of the following individual test codes:

• 82465 -- Cholesterol, serum or whole blood, total

• 83718 -- Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)

• 84478 -- Triglycerides.

Frequency guidelines: The patient can receive only one of the four above services every five years. So if the internist performed a whole-blood cholesterol screening (82465) on Oct. 1, 2005, the patient would not be eligible for another covered cardiovascular blood screening (82465, 80061, 83718, or 84478) until Oct. 1, 2010.

"If you perform the test even one day prior [to 5 years], Medicare will deny it due to frequency. They are sticklers for dates," Weiss says of Medicare payers.

According to The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals: "Medicare provides coverage of cardiovascular screening blood tests for all asymptomatic beneficiaries every 5 years (i.e., at least 59 months after the last covered screening tests). The screening blood tests must be ordered by the physician or qualified non-physician practitioner treating the beneficiary for the purpose of early detection of cardiovascular disease. The beneficiary must have no apparent signs or symptoms of cardiovascular disease."

(Check out the guide at www.cms.hhs.gov/MLN
Products/downloads/mps_guide_web-061305.pdf.)

V code alert: Provided frequency guidelines are met, Medicare does not require a medically necessary reason for the patient to have a cardiovascular blood test. However, you will need to include required V codes, according to Weiss.

When submitting a Medicare claim for a covered blood screening, you must append one of the following diagnosis codes:

• V81.0 -- Special screening for ischemic heart disease

• V81.1 -- ... hypertension

• V81.2 -- ... other and unspecified cardiovascular conditions.

For more information on coding for Medicare patients' preventive services, see www.cms.hhs.gov/MLN
Products/downloads/Preventive_Services_Eligibility.pdf.

To perform (and be paid for) the cardiovascular blood screening tests, the practice must have a Clinical Laboratory Improvement Amendments (CLIA) waiver on file. Also, you must append modifier QW (CLIA waived test) to the test code when you code the claim.

Example: A Medicare patient receives a lipid panel test to check for ischemic heart disease on Oct. 4, 2009. The medical record indicates that he had a Medicare-covered lipid panel on Dec. 22, 2003. On the claim, report the following:

• 80061-QW for the lipid panel

• V81.0 appended to 80061-QW to indicate the purpose of the screening.

(Note: For more information on CLIA waivers, please see "Discover How Waived Status Can Impact the Bottom Line" in Internal Medicine Coding Alert, Vol. 10, No. 10.)