Internal Medicine Coding Alert

Tip: Use modifier -26 when the internist performs TEB in the hospital

When your internist performs bioimpedance testing, the keys to payment are knowing how to code this procedure and whether Medicare and private carriers pay for it.

Sales representatives are increasingly pushing hemodynamic-testing machines on IM offices. So, the next time your physician is about to catch a sales pitch, be ready with the facts.

Physicians use thoracic electrical bioimpedance (TEB) devices on patients with cardiovascular disease or other heart-related problems. TEB monitors cardiac output by noninvasively measuring hemodynamic parameters, including stroke volume, systemic vascular resistance, and thoracic fluid status.

Why Knowing the Right Code Isn't Enough

If your internist performs this test in the office, you should report 93701(Bioimpedance, thoracic, electrical). Typically, when the physician performs the procedure in the hospital and the hospital owns the equipment, you should append modifier -26 (Professional component) to 93701, says Cynthia A. Swanson, RN, CPC, senior managing consultant for Seim, Johnson, Sestak & Quist LLP, in Omaha, Neb.

Heads-up: Learn your insurer's policy for reporting TEB, Swanson says. For example, CIGNA HealthCare, which is the Medicare carrier for North Carolina, states, "The global, technical and professional components of this service (TEB) may be billed in the office setting ... for Part B reimbursement."

Also, some Medicare and commercial insurers won't pay for the test - so double-check your payer's coverage before you buy a machine. For example, in Oklahoma, carriers Blue Cross Blue Shield and United Healthcare deny 93701 because they consider TEB an "investigational" procedure, says Carolyn Crawford, RN, BSN, an office manager for Michael K. Crawford, MD, an Oklahoma City internist.

Remember That All Policies Aren't Created Equal

Even if your carrier pays for TEB, you should be aware that most payers also have numerous medical- necessity guidelines for 93701. For instance, most Medicare insurers, such as First Coast Service Options of Florida, cover the test when performed for six reasons:

1. To differentiate between cardiogenic and pulmonary causes of acute dyspnea. But the physician can use TEB in these cases only when medical history, physical examination and standard assessment tools have not worked.

2. To optimize the atrioventricular (A/V) interval for patients with A/V sequential cardiac pacemakers. Again, the physician must attempt medical history, exam and standard assessment tools before relying on TEB.

3. To monitor continuous inotropic therapy for patients with terminal congestive heart failure. In this case, the patient must have chosen to die in comfort at home or is at home awaiting a heart transplant.

4. To evaluate for rejection in patients with a heart transplant as a predetermined alternative to a myocardial biopsy.
 
5. To optimize fluid management in patients with congestive heart failure after the physician has tried to manage the condition with medical history, exam and standard assessment tools.

6. To manage drug-resistant hypertension. This means the physician couldn't achieve goal blood pressure in patients who adhere to full doses of an appropriate three-drug regimen, which includes a diuretic.Typically, Crawford's physician uses TEB primarily for patients with congestive heart failure, arrhythmia and patients who can't control their labile hypertension with medication, she says.

Double-Check Your ICD-9 Coding

Medicare carriers often have contrasting guidelines on acceptable ICD-9 codes for 93701. Empire Medicare Services, for example, accepts 416.0 (Primary pulmonary hypertension) and 416.1 (Kyphoscoliotic heart disease), but First Coast does not. First Coast, however, covers 402.11 (Benign hypertensive heart disease with heart failure) and 401.0 (Malignant essential hypertension), while Empire does not.

Bonus tip: Be sure to review your internal medical record documentation so that the internist's documentation supports 93701 before submitting it for payment, and that the documentation complies with published payer policies, Swanson says.