Part B Insider (Multispecialty) Coding Alert

Tip: Make sure your physician documents direct supervision

You may think you-ve got stress test coding down pat, but you could be missing important details that can boost your practice's bottom line. Here's a quick way to tell for sure.

First, Review Stress Test Codes

You should take into account the place of service (POS) when choosing stress test codes. According to Tammy Judd, CPC, hospital coordinator at Spokane Cardiology in Washington, CPT in-cludes four codes for the basic stress test:

- 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.

How to use these codes: If the entire test happens in an office setting, use 93015. This -global- code includes both the technical and professional components of the service. You won't be using modifier 26 (Professional component) and TC (Technical component) with any of these codes. In other words, if your physician performed only the professional interpretation, you will report 93018.

Note: A physician would not likely report 93017 because it describes only the technical portion of the test.

If the test takes place in a hospital setting (inpatient or outpatient), the physician may bill only for the professional component of the service by reporting 93016 and/or 93018. Also, you won't be coding for any supplies the physician uses because the physician didn't purchase them--the hospital did.

Indication or Diagnosis Establishes Necessity

Local Medicare carriers and private payers likely will cover medically necessary cardiovascular stress tests. And most carriers publish a long list of diagnoses that justify a stress test. Many carriers also accept a variety of indications--which you would document using signs and symptom codes--such as chest pain, respiratory distress and syncope.

If you use an indication (such as 786.50, Chest pain, unspecified), your physician must note it in the medical record. -The physician needs to document a valid reason for doing a stress test,- says Robin Yazell, CPC, billing manager at Cardiology PC in Syracuse, N.Y. The physician's documentation should also note that an appropriate patient evaluation preceded the stress test , including a history and physical (H&P) and resting ECG.

For example, a patient with autonomic neuropathy may not show anginal symptoms. The only sign of coronary artery disease (CAD) may be ECG abnormalities. In this case, sign or symptom code 794.31 (Abnormal electrocardiogram [ECG] [EKG]) may be an acceptable diagnosis.

Make the Pharmacologic Stress Test Difference

Some patients may not be able to use the treadmill or bicycle for a stress test. In these cases, physicians use pharmacologic stress to simulate the effects of exercise.

Catch this: You won't find a separate CPT code for a pharmacologically induced stress test. The descriptor for 93015 specifically includes pharmacologic stress. If, however, the physician performs the test in the office (as is typically the case), most carriers will pay for the drug your physician uses to induce the stress, Judd says.

Supply codes for specific pharmacologic agents, found in HCPCS, include:

- J0152--Injection, adenosine for diagnostic use, 30 mg

- J1245--Injection, dipyridamole, per 10 mg (also called Persantine)

- J1250--Injection, dobutamine HCI, per 250 mg.

Typically, local Medicare carriers pay only a -pass-through charge- for such medications. The carrier will reimburse only the amount the physician paid for the pharmaceutical.

Watch out: IV administration of the drug is part of the stress test, meaning you should not bill it separately. According to the Correct Coding Initiative (CCI), infusion codes 90760-90779 are components of 93015. Most private payers follow this CMS policy.

Don't miss: Medicare carriers will not cover the use of pharmacologic agents in cardiovascular stress testing unless exercise is not possible. Therefore, the physician's documentation must explain why pharmacologic stress testing was necessary and why exercise was not possible by providing indications and/or diagnoses to describe the patient's condition.

For example, documentation should specifically note that the patient could not walk, was severely obese or had significant degenerative joint disease. Carriers may also want documentation to include physical examination findings that demonstrate that the patient could not reasonably be expected to perform exercise stress testing.

Avoid Documentation Pitfalls

Warning: If your physician provides poor documentation, you can expect reduced payment. For example, some physicians may note merely that the patient underwent a -stress test,- when, in fact, he may have performed other additional billable services, such as echocardiography (echo), pharmacologically induced stress or nuclear scan. To report them, however, your physician must note these in his documentation.

For instance, if his documentation specifies that the stress test accompanies either an echo or a single-photon emission computerized tomography (SPECT) scan, you can report both the stress test and the SPECT (78465, 78478, 78480, 93015) or echo (93350, 93015 and possibly 93320
and 93325).

Supply supervision proof: Also, because supervision requirements for these procedures differ, your physician's documentation must clearly indicate the level of supervision provided.

Why: Medicare carriers, for example, will not cover stress tests unless the physician provides direct supervision.

This means the physician must be present in the office suite--although not necessarily in the same room--and immediately available to assist and direct throughout the procedure. If a nonphysician practitioner (NPP) performs the service's technical portion, documentation must indicate the NPP performed the test rather than merely supervised the test.