Cardiology Coding Alert

Appealing a Third-party Payer's Inappropriate Test Denial

The following letter is an example of the sort of written communication you can send a third-party payer to appeal its decision to deny reimbursement for a stress test that returned negative, even though signs/symptoms were included as the diagnosis to support the decision for the test.


To: Any American Healthcare Insurance Co.
From: Wendy Jones, CPC
Re: John C. Smith, ID # 000-00-0111-1; Group # 0000vg; DOS: 01-12-99

Attention, Board-Certified Cardiologist:

Please find a copy of the Explanation of Benefits (EOB) we received on the above-named patient for date of service
01-12-99, denying benefits.

The EOB stated that the medical need was not established ... for the services that were performed. The service in question is a Stress Echocardiogram, CPT code 93350 (echocardiography, transthoracic, real-time with image documentation [2D], with or without M-mode recording, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report [the appropriate stress testing code from the 93015-93018 series should be reported in addition to 93350 to capture the exercise stress portion of the study]).

The indication for this test for Mr. Smith was chest pain, palpitations and shortness of breath. The test was performed to establish the presence of heart disease as the underlying condition for the symptomatology.

In this patients case, the test came back essentially negative for ischemia. Thus the indications for the test (symptomatology) were coded, not the ischemic heart disease. To code for a condition that is being ruled out would go against the coding guidelines set forth in the ICD-9 Code Book for Physician Payment, as well as the HCFA provider manual issued by the Federal Registry.

Enclosed, please find the history and exam documentation available to support the medical necessity for performing the stress echocardiogram. Should you require any additional information for your review, please dont hesitate to contact my office.

We are sure that this was just an unfortunate error on your part and not a deliberate attempt to deny this claim in bad faith. We anticipate a prompt response for reimbursement and will follow up in 10 days to verify receipt of this appeal.

Thank you in advance for your cooperation.