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Internal Medicine Coding Alert

You Wont Skip a Beat If You Code Cardiac Components

Published on Sat Mar 01, 2003

When coding a heart test for a patient, you may feel as if you're being tested yourself as you puzzle over the many codes in the cardiography section of the CPT manual. But you'll pass with flying colors if you use a global code when appropriate and remember that the other codes in the series are not add-ons but individual services.

The cardiography section (93000-93278) includes codes for three tests that internists sometimes use to determine the health of a patient's heart: Holter monitoring, stress tests and electrocardiograms (EKGs). The series for each of these tests begins with a global code including hookup, scanning analysis and interpretation/report followed by codes that break out components separately.

Coders sometimes try to append modifier -26 (Professional component) to the global code to show that the physician provided only some of the services, but doing so will result in a claim denial, says Kathy Pride, CPC, CCS-P, HIM applications specialist with QuadraMed based in San Rafael, Calif.

"These codes are unusual CPT codes because you can't separate out the professional component of the code by appending a -26 modifier," Pride says.

Instead, if you perform only some of the services described in the global code, bill just those components rather than coding the global.

Know Your Holter Monitor to Code Properly

Holter monitor testing is the most confusing code series, Pride says. Patients typically undergo this testing when they have complained of heart palpitations or flutter, and the doctor wants to monitor the patient's heart constantly over a 24-hour period so he or she can see and analyze the irregular rhythms. For 24 hours, the patient wears a beeper-sized box that measures and records heart activity.

The coder's first dilemma is choosing the correct code series to use, because CPT shows three series (93224-93227, 93230-93233, and 93235-93237) that describe slightly different Holter monitor techniques.

"To know which one to use, you have to know which technology you have," Pride says.

The primary difference among the codes is in how the heart rhythms are recorded, stored and analyzed:

  • 93224 Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation
  • 93230 Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; includes recording, microprocessor-based analysis with report, physician review and interpretation
  • 93235 Electrocardiographic monitoring for 24 hours by continuous computerized monitoring and noncontinuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient-activated; includes monitoring and real-time data analysis with report, physician review and interpretation.

    If you are not sure which code describes your office's machine, ask the doctor what type of equipment he uses, says Michele Zimmerman, CPC, coder at the four-physician Florida Heart and Vascular Associates in Tampa. You can also check with the company providing the Holter monitor to determine which code criteria it meets, Pride says.

    You need to distinguish between the types of monitors both for coding accuracy and for reimbursement reasons, says Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.

    The 93230 series is the highest-paying series, with reimbursement at about $161 nationally, not adjusted for region, for the global almost $10 more than the 93224 series global, at $152. The 93235 series is the lowest-paying, with reimbursement for the global at about $117 nationally.

    Bill Only for Components Provided

    You should bill the first code in the series (for example, 93224) for Holter monitor testing if your doctor performed all of the described services, which include hooking up and removing the monitor, analyzing the scan, and reviewing and interpreting the results. If the doctor performed only some of those services, however, you will bill only for the individual services provided.

    All three of the Holter monitor code series break out the individual components separately. Let's say your office monitored the patient using the equipment described in 93224, but the physician did not do the scanning analysis. Commonly, physicians will have an outside company perform that technical component, Pride says. In that scenario, you would code 93225 for the recording, hookup and removal of the Holter monitor and 93227 for physician review and interpretation. The scanning company would bill on its own for the analysis.

    "The simplest way to look at it is: He who provides the service, bills and collects," Rappoport says.

    Don't Stress Over Stress Tests

    Stress tests are another heart procedure that internists sometimes order for their patients. This test measures how well the heart handles exertion and can show if blood supply is reduced in the arteries leading to the heart. The patient typically walks on a treadmill or pedals a stationary bike at increasing speeds while hooked up to heart monitoring equipment. He or she then undergoes monitoring again after the test for heart rate, blood pressure and other vital signs.

    The exercise stress test is set up the same way as the Holter monitor codes, with a global followed by breakouts of the components:

  • 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.

    Most internists'offices will never use 93015 because they typically do not have the equipment to conduct stress tests in their offices, Rappoport notes. Usually, they will send a patient to the hospital or to a cardiologist for a stress test.

    If the internist sends the patient to the hospital for the stress test, sometimes the internist will also go to the hospital to monitor the test. Use 93016 in this scenario. If the internist doesn't supervise the stress test but interprets the results, use 93018. If the doctor does both, you should code both 93016 and 93018.

    Electrocardiograms Follow Pattern

    An EKG is a routine heart test that internists often use as the first test for a patient having symptoms of heart disease. The physician attaches electrodes to the patient's chest and uses them to record heart rhythms. Unlike stress tests, internists often perform EKGs in their offices.

    If you remember the pattern for the above codes, choosing a CPT code for an EKG is simple. Use the global code 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) when the patient has the EKG in the office and your physician interprets the results. If the doctor sent the patient elsewhere for the EKG but performed the interpretation and report, use 93010 (... interpretation and report only). You likely won't use the other code in this series, 93005 (... tracing only, without interpretation and report), because it is used when a facility performs the EKG but does not provide the physician report and interpretation.

     

     

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