Medicare Compliance & Reimbursement

If you fear a denial every time you choose an ICD-9 code for a "normal" study, you're in luck with pre-op evaluations. Get the scoop by learning the rule and applying it to the sample case below.

Rule: In 2001, Medicare issued guidelines for coding pre-op exams (CMS transmittal 1719, www.cms.hhs.gov/transmittals/downloads/R1719B3.pdf):

1. Report the pre-op V code first. "The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (e.g., V72.81 through V72.84)."

2. Then include the diagnosis that prompted surgery and the condition that prompted the pre-op evaluation, if your physician notes one.

3. Follow these with other diagnoses and conditions affecting the patient.

Benefit: The transmittal states that preoperative diagnostic tests are payable if they are medically necessary.

Medicare looks to national coverage determinations (NCDs) first to establish necessity. If there is no NCD, you can help prove the service is reasonable and necessary by including the ICD-9 codes for the conditions that prompt the surgery and the test, the transmittal states.

Consider the following real-life example, and determine which ICD-9 codes you would report, as well as the correct CPT codes. Assume that the hospital will code the Tc99m sestamibi.

Get started: The file indicates that during the surgeon's assessment before an incisional hernia repair, the surgeon identified an ECG abnormality, triggering the preop referral.

Procedure: Rest/stress myocardial perfusion SPECT study with gated wall motion analysis and calculation of the ejection fraction.

Indication: Preoperative evaluation.

Technique: A two-day protocol was used. 10 millicuries of Tc99m sestamibi was injected for rest images and 29 millicuries Tc99m sestamibi was injected at peak exercise.

The patient exercised for 10 minutes of the Bruce protocol achieving 86 percent of the maximum predicted heart rate, stopping due to fatigue. No diagnostic electrocardiographic changes were seen. During the test, patient experienced no abnormal symptoms.

Scintigraphic findings: Homogeneous uptake of the radioisotope is seen throughout the myocardium. The summed stress score is 0, the summed difference score is 0, and the TID ratio is normal.

Gated wall motion analysis shows normal wall motion and thickening. LV volume is normal. The calculated left ventricular ejection fraction is greater than 70 percent.

Impression: Normal rest/stress myocardial perfusion SPECT study.

What to do: "For a preoperative SPECT stress test to check the heart prior to surgery, you would list V72.81 [Preoperative cardiovascular examination] as the first listed diagnosis," says independent coding consultant and instructor Linda Templeton, CCS-P, CPC, CPC-H, who also codes nuclear medicine procedures for a large teaching hospital in southeast Michigan.

Code V72.81 is a Medicare-payable diagnosis, and most insurance companies will accept it.

The appropriate diagnosis for an incisional hernia is 553.21 (Ventral hernia; incisional), and including this code will help tell the patient's story to the payer. For the abnormal ECG, report 794.31(Abnormal electrocardiogram [ECG] [EKG]).

Finally, if the provider had documented "abnormal findings in the impression of the report, you would list that as a secondary diagnosis in addition to the V72.81," Templeton says.

Choosing the correct diagnoses will help support your CPT codes. This sample report documents a myocardial perfusion SPECT study at rest and stress, with gated wall motion analysis and ejection fraction calculation. You should report 78465 (Myocardial perfusion imaging; tomographic [SPECT], multiple studies [including attenuation correction when performed], at rest and/or stress [exercise and/or pharmacologic] and redistribution and/or rest injection, with or without quantification) for the tomographic (SPECT) myocardial perfusion imaging study.

You may report +78478 (Myocardial perfusion study with wall motion, qualitative or quantitative study) and +78480 (Myocardial perfusion study with ejection fraction) separately for the wall motion and ejection fraction (EF), says Cheryl Klarkowski, RHIT, CPC, coding specialist with Baycare Health Systems in Wisconsin.

Support: Codes +78478 and +78480 represent services separate and distinct from 78465, according to the AMA's October 2004 CPT Assistant.

Modifier tip: Remember to append modifier 26 (Professional component) if you're only reporting the professional services.

Because you're in the hospital setting (reporting professional services only), 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) and 93018 (... interpretation and report only) for the stress test portion of the protocol.