Internal Medicine Coding Alert

Because there is a global code (that includes technical and professional components) for reporting cardiovascular stress tests along with several component codes, internists may be confused about how to report the portion or portions of the test that they have completed. Unlike many procedures that have a technical and professional component to them, Medicare does not require the use of modifier -26 (professional component) by internists who bill for the supervision or interpretation of the test. When performing the test as a preoperative examination, internists may need an alternative or secondary diagnosis code to justify the medical necessity of the procedure because the diagnosis code for preoperative cardiovascular examinations (V72.81) is not covered by many Medicare carriers.

A cardiovascular stress test is used with patients with chest pain or other symptoms of heart disease. The stress test evaluates heart action during physical or pharmacological stress to test cardiac reaction to the increased demand for oxygen and provides diagnostic confirmation that cannot be obtained from a resting electrocardiogram (EKG), explains Felecia Bernstein, CPC, EMT, an independent coding consultant in Deal, N.J., and president of the Monmouth County, N.J., chapter of the American Academy of Professional Coders.

The physical stress is exercise in the form of a treadmill, bicycle or other method. When the patient is unable to perform the exercise, pharmacological stress is created through the administration of drugs such as dipyridamole, adenosine or dobutamine.

Modifiers -26 and -TC Not Needed for Medicare

This procedure contains a technical component that represents the value assigned to the ownership and maintenance of the equipment used to perform the stress test and the use of any technicians. Two professional components represent the internists supervision and interpretation of test results. With the cardiovascular stress test, however, the standard modifiers -TC for the technical component and -26 for the professional component are not used when billing Medicare.

It is not necessary to use the modifiers -TC and -26 with this procedure, because the CPT codes are self-defining, says Jim Stephenson, billing manager for Premium Medical Management, a multispecialty physician group practice in Elyria, Ohio.

Internists who bill private insurance companies that strictly adhere to CPT coding principles may want to check with those payers about their coding requirements for stress tests. The June 1996 CPT Assistant reported that, although Medicare does not require modifiers for the stress test codes, the addition of the modifiers -26 and -TC would be acceptable for CPT coding.

Code 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) is the global code used in an office setting where the internist owns (or partially owns by being a partner in the practice) the test equipment being used, supervises the administration of the test and interprets the test results, Stephenson explains.

Component Codes Used in Hospital Setting

CPT also has several component codes that can be used when different physicians supervise and interpret the test, which is often the case when the test is done at a hospital.

Code 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) is used to report the internists supervision of the stress test.

Code 93018 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only) is used to report the internists interpretation of the test results. Both 93016 and 93018 can be billed by the same physician or by
two physicians.

Code 93017 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report) is used to report only the technical component of the stress test and is billed by the facility that provides the equipment to do the test. Code 93017 cannot be reported in combination with code 93015.

Coding in the Office Setting

In an office setting, a non-physician provider or second physician also could be involved in the administration of the stress test. Physician assistants are among the non-physician providers who may be involved in the administration of the test, says Bernstein. Those services can be billed in the name of the internist as long as he or she is providing direct supervision, meaning that the internist is in the office suite when the test is being administered, she explains. The documentation in the patients medical record must also indicate that this was a physician-initiated service and that the internist was involved in the patients treatment plan.

If a second physician or nurse practitioner administers part of the test in an office setting and wishes to bill separately for his or her services, most local carriers will accept the use of component codes 93016 and 93018 for services performed in an office.

Drug and Administration Separately Reimbursable

Although exercise is considered the preferred method for inducing stress in a patient, Stephenson says all of the above-mentioned codes can be used for the exercise or pharmacological versions of the test. In most cases, the drugs administered for the pharmacological version are reimbursable separately when the test is performed in an office setting. Many carriers will not reimburse separately for the drugs when the test is performed at a hospital. The following is a list of the J codes most commonly used to report the drugs used during a pharmacological stress test:

J0150 injection, adenosine, 6 mg
J0151 injection, adenosine, 90 mg
J1245 injection, dipyridamole, per 10 mg
J1250 injection, dobutamine HCI, per 250 mg

Because the 6-mg dosage of adenosine normally is used for the treatment of atrial tachyarrhythmias (427.89), which is a non-covered diagnosis code for Empire Medicare Services of New York, that carriers local medical review policy advises that modifier -22 should be attached to code J0150 when it is reported.

The administration of the drug to the patient for a pharmacological stress test is considered by Medicare to be included in the procedure. But many private insurance companies will reimburse separately for the administration of the drug, Stephenson adds. This can be reported with codes 36000* (introduction of needle or intracatheter, vein), 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour), 90781 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; each additional hour, up to eight hours) or 90784 (therapeutic, prophylactic or diagnostic injection; intravenous).

A 12-lead EKG (93000) usually is performed on a patient before the stress test is administered to obtain a baseline reading. But when performed in conjunction with a stress test, the EKG is not reimbursable separately, says Bernstein. If the internist, however, performs an EKG and because of the results decides to do a stress test or if the EKG is performed on the day after a stress test as a follow-up, then he or she should be able to report the service and get reimbursed, she claims. Modifier -59 (distinct procedural service) should be attached to the lesser-valued procedure.

Pre-op Diagnosis May Be Denied

Medicare reimburses only for diagnostic stress tests; it does not cover screening tests for asymptomatic patients. Stress testing is covered when the evaluation indicates that angina or ischemic heart disease is a reasonable explanation for the patients medical problem, says Bernstein. The medical record documentation for an initial stress test should include a complete evaluation of the patients symptoms and an EKG.

The stress test also can be used as a preoperative clearance tool. Because of fears that the test has been overused on asymptomatic patients for these preoperative procedures, many local carriers have revised their list of covered diagnosis codes for stress tests. Some carriers, such as the Wisconsin Physicians Services, the National Heritage Insurance Company of California and Trailblazers Health Enterprise of Texas, will accept the preoperative cardiovascular examination diagnosis code (V72.81).

On the other hand, Empire Medicare Services of New York and First Coast Service Options, the Medicare carrier for Florida, are among the payers that do not cover the preoperative examination diagnosis codes for stress tests. Internists whose Medicare carrier does not reimburse specifically for the pre-op evaluation code need to indicate with a diagnosis code that is covered by the carriers local medical policy the specific reason they have been asked to do the evaluation.

Some Carriers Require Secondary Diagnosis

Some carriers will allow the stress test to be used for a preoperative examination when the patient has a condition, listed as a secondary diagnosis, that could put him or her at high risk for heart failure in a surgical setting. Both Empire Medicare Services of New Jersey and HGSA, the Medicare carrier for Pennsylvania, will cover the preoperative exam diagnosis code when it is submitted in conjunction with either a diagnosis of diabetes mellitus (250.00-250.93) or atherosclerosis of arteries (440.20-440.9).

Nationwide Medicare of Ohio and West Virginia also allows the preoperative exam diagnosis code when it is submitted in conjunction with one of the following conditions: diabetes mellitus (250.40-250.73), atherosclerosis of extremity arteries (440.20-440.9 and 443.9-444.9), aortic aneurysm (441.00-441.9) or cerebrovascular disease (433.1-433.11 and 434.00-436).

In general, an internist should use an ICD-9 code that is listed in the carriers local medical review policy for stress tests as a covered diagnosis. The list of covered diagnosis codes is fairly short compared to some other tests such as EKGs, says Stephenson.

Note: For more on coding for EKGs, see Optimize Reimbursement for Preoperative EKGs on page 45 of the June 2000 Internal Medicine Coding Alert.