Internal Medicine Coding Alert

Here's why 'component coding' is key

 If you report cardiovascular stress tests (93015-93018), make sure you know which codes represent the professional, technical and global components. Use the following scenarios and expert advice to accurately code the tests every time.

Know Which Code Represents All Components

1. Scenario: A patient complains of chest pain (786.50) and heart palpitations (785.1). The internist uses the hospital's equipment to perform a cardiac stress test. Your physician supervises the stress test and provides a written interpretation and report.
 
Coding solution: You should report 93016 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report) for the physician supervision.  To code the written interpretation and report, you should also use 93018 (... interpretation and report only), says Sheldrian LeFlore, CPC, senior consultant with Gates, Moore & Company in Atlanta.
 
2. Scenario: The physician administers the stress test in the office, providing the procedure's technical component (that is, the internist's practice owns the equipment) in addition to the supervision, interpretation and report.
 
Coding Solution: In this case, you should report 93015 (... with physician supervision, with interpretation and report), says Lisa Center, CPC, quality review coordinator for Freeman Health System in Joplin, Mo.
 
You should use this code because it encompasses all of the procedure's components (for example, the use of the equipment, as well as the supervision, interpretation and report), she says. "The 93016-93018 breaks out the components into the parts of the test that the physician performed if he didn't do the entire service," Center says.
 
Remember: The internist may initiate this method of "stress" by using pharmacological agents, such as dobutamine ( HCPCS J1250 , Injection, dobutamine HCI per 250 mg) or Persantine (J1245, Injection, dipyridamole, per 10 mg), Leflore says. Therefore, you should report the appropriate HCPCS code to describe the agent, she says. 

Don't Bank On Screening Coverage

If you want to ensure Medicare and commercial insurers pay for 93016-93018, you'll need more medical justification than the appropriate ICD-9 codes. You'll also need to know your payer's medical necessity and documentation requirements.
 
3. Scenario: Because the patient is obese (278.0x) and has diabetes (250.xx), he presents to your internist to make sure he doesn't have coronary artery disease. The physician performs a cardiac stress test to screen for the condition. A few months later, your Medicare carrier denies your practice's claim for 93015.
 
Coding solution: "The primary reason for denial of a stress test is the lack of medical necessity," LeFlore says. For instance, most Medicare carriers, such as First Coast Service Options of Florida, do not pay for cardiac stress tests the physician performs to screen for coronary artery disease.
 
"Billers and coders must check their payers' guidelines to ensure that medical necessity is present in the documentation for performing this service," LeFlore says.
 
Center agrees: "Many offices don't check their policies and later find out they have to write off the stress test because the ICD-9 codes they used aren't on the list of approved diagnosis codes."
 
Examples: Generally, a cardiac stress test is medically necessary if the patient presents with chest pains or has an abnormal electrocardiogram (EKG), LeFlore says.
 
You should also check with your carrier to find out what the medical documentation should contain. For instance, First Coast Service Options recommends that the medical documentation include the following: