Cardiology Coding Alert

Cardiovascular stress tests are common procedures, but obtaining correct payment for them can be complicated and depends on several factors:

What kind of test was performed?
How many tests were performed?
Was there a payable diagnosis?
What, if any, supplies were used?
Where was the test performed?
Was the cardiologist in the office suite?
Is the patient covered by Medicare or a commercial carrier?

Poor documentation can result in reduced payment. For example, some cardiologists may note merely that the patient received a stress test, when, in fact, additional billable services such as echocardiography (echo), pharmacologically induced stress or nuclear scans were also performed. But if, for instance, documentation specifies that the stress test accompanies either an echo or a single-photon emission computerized tomography (SPECT) scan, both the stress test and the SPECT or echo may be separately billed. The place of service must also be noted and taken into account when choosing a stress test code (and modifiers, when necessary). And because supervision requirements for these procedures differ, documentation should clearly indicate the level of supervision provided. Medicare carriers, for example, will not cover stress tests unless the physician provides direct supervision (i.e., is in-clinic and accessible while the service is performed).

Treadmills and Bicycles

Cardiovascular stress testing is a noninvasive diagnostic test given to patients with coronary risk factors, a history of coronary artery disease (CAD) or symptoms that may indicate CAD. The tests are used (a) to diagnose coronary disease, (b) to evaluate existing disease to determine if change has occurred, (c) to evaluate the risk of an adverse coronary event, or (d) in some combination of the above, says Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in private practice in Seattle.

Typically, stress testing is preceded by an evaluation of the patient that includes history and physical (H&P) and a resting electrocardiogram (ECG). This evaluation aids in the selection of exercise or pharmacologic stresses and helps determine the need for stress imaging (i.e., echo or radionuclide study).

Stress testing is usually performed with the patient on a treadmill, although a stationary bicycle may be used. Readings are taken when the patient is at rest and during exercise. During exercise, the heart and body respond to the stress of increased physical activity. A diseased heart responds abnormally to stress which can be evaluated by monitoring the patients blood pressure, heart rate and electrocardiogram (ECG). The cardiologist makes a diagnosis based on the results, Yakovlevitch says.

CPT includes 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.

If the test is performed in a hospital setting (inpatient or outpatient), the cardiologist may bill only for the professional component of the service by reporting 93016 and/or 93018, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

If the cardiologist supervises the test in the hospital and also provides an interpretation and a (written) report, use both 93016 and 93018.

If a nonphysician practitioner (NPP) performs the technical portion of the service, documentation must indicate the test was performed under the cardiologists direct supervision. This means the cardiologist must be present in the office suite although not necessarily in the same room and immediately available to assist and direct throughout the procedure.

Note: NPPs can provide services only if state scope-of-practice laws and/or regulations permit. Some local insurers, such as WPS, the local Medicare carrier in Illinois, Michigan, Minnesota and Wisconsin, never allow NPPs to bill 93016. According to WPS local Medicare review policy CV-004, dated Jan. 1, 1999, Documentation in the patients record must indicate when a physician is physically present (face-to-face) continuously during the entire procedure when billing for 93016. This may apply to global code 93015, as well, because it includes 93016.

If the entire test is performed in an office setting, use 93015. This global code includes both the technical and professional components of the service.

Modifiers -26 (professional component) and -TC (technical component) should never be used with these codes. They are already differentiated on this basis.

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

Indication or Diagnosis Establishes Necessity

Local Medicare carriers and private payers are likely to cover medically necessary cardiovascular stress tests. Most carriers publish a long list of diagnoses that justify a stress test. Many carriers also accept a variety of indications which are documented using signs and symptom codes such as chest pain, respiratory distress and syncope.

If an indication (e.g., chest pain) is used, it must be noted in the medical record, Callaway says.

For example, a patient with autonomic neuropathy may not show anginal symptoms the only sign of CAD may be ECG abnormalities. In this case, sign or symptom ICD-9 code 794.31 (abnormal electrocardiogram [ECG] [EKG]) may be an acceptable diagnosis for payment of a stress test claim.

The payer wants to know why the patient was tested. If the patients record shows that the indications justified the test, payment should be easier to obtain, Callaway reasons. The cardiologists documentation should note that the stress test was preceded by an appropriate evaluation of the patient, including an H&P and resting ECG.

Note: Medicare will not pay for stress tests performed to screen for coronary disease, even if risk factors are present.

Pharmacologically Induced Stress

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

Adrenergic stress agents, such as dobutamine, stimulate the heart, increasing the heart rate, oxygen demands of the heart and coronary blood flow. These properties make dobutamine an effective agent to induce stress along with stress echos or nuclear scans, Yakovlevitch says.

Dobutamine stress testing is contraindicated for early post-myocardial infarction (MI) patients. In these patients, the heart is too sensitive for standard treadmill exercise; similarly, the heart cannot tolerate being flogged by the dobutamine to increase blood flow.

In these cases, cardiologists use drugs such as adenosine and Persantine, which act as vasodilators to open the coronary arteries directly, rather than flogging the heart to increase blood flow. Adenosine although appropriate for nuclear scans should not be used with a stress echo, Yakovlevitch says.

To know, for example, that the left anterior descending artery is stenosed, you must observe that the anterior wall is not squeezing properly under stress, Yakovlevitch explains. Adenosine, he notes, does not stimulate the heart muscle and therefore does not increase oxygen demand. An abnormal response to adenosine is simply a failure to increase coronary blood flow (i.e., supply) appropriately. Additionally, because it can cause bronchospasm, adenosine is contraindicated for patients with severe intrinsic asthma.

There is no separate CPT code for a pharmacologically induced stress test, and the descriptor for 93015 specifically includes pharmacologic stress. If, however, the test is performed in the cardiologists office (as is most typically the case), most carriers will pay for the drug used to induce the stress.

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

J0151 injection, adenosine, 90 mg (not to be used to report any adenosine phosphate compounds; instead use A9270)

J1245 injection, dipyridamole, per 10 mg [Persantine IV]

J1250 injection, dobutamine HCl, per 250 mg [Dobutrex]

J0280 injection, aminophyllin, up to 250 mg

J0395 injection, arbutamine HCl, 1 mg

J0460 injection, atropine sulfate, up to 0.3 mg

J3490 unclassified drugs.

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

IV administration of the drug is part of the stress test and should not be billed separately. According to the national Correct Coding Initiative, infusion codes 90780-90784 are bundled with 93015. Most private payers follow this HCFA policy.

Establish Medical Necessity for Drugs

Medicare carriers will not cover the use of pharmacologic agents in cardiovascular stress testing unless exercise is not possible. Therefore, the cardiologists documentation must explain why testing was necessary and why exercise was not possible by providing indications and/or diagnoses to describe the patients 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.

If the claim is submitted to obtain a denial (so the patient or a third-party payer can be billed), many carriers instruct cardiologists to report V81.0 (special screening ... for ischemic heart disease).

Finally, to ensure patient safety during a pharmacologic stress test, the immediate availability of the cardiologist is required and should be documented.

Note: Treadmill testing is a reasonable standard of care for patients with a low likelihood of disease. But for higher-risk patients or patients with some pre-existing conditions, treadmill testing alone may not be sufficiently accurate. For these patients, stress tests may be combined with other diagnostic services that involve imaging, such as myocardial perfusion imaging studies (SPECT scans, wall motion and ejection fraction analyses) or stress chocardiography. Coding, billing and documentation for these services will be examined in the next issue of Cardiology Coding Alert.