Cardiology Coding Alert

Case Study:

Coding for Stress Tests During Long-term Follow-up Care

Coding Dilemma

The scenario is a common one in cardiology practices: The patient returns for a stress test as part of his or her long-term follow-up care after an interventional procedure such as angioplasty, PTCA, and coronary bypass. But how should the service be billed if the patient has had no symptoms after an incident? Automatically appending a modifier -25 (separate significant services) to the office visit could get you a visit from the Office of the Inspector General, whose auditors began examining overuse of this modifier in the fall of 1998. Whether you can ethically bill Medicare for follow-up office visits depends greatly on the documentation.

Lets take a look at an actual office note and see whether modifier -25 is appropriate.

Office Note #1

Subjective: The patient comes in today for follow-up, a year from his last visit. He has had no symptoms of angina. He has a lot of dietary indiscretion and has gained weight. He exercises very little. He has stopped smoking. Medications are listed in the chart. Mevacor has been changed to Lipitor. Continues on Norvasc 5 mg day, aspirin and Colace.

Physical Examination: Blood pressure is 142/90 at rest. With exercise, he is able to do six minutes and have a heart rate of 125, which is better than his heart rate from a year ago. Exercise tolerance is the same.

Conclusion: I dont think there is any evidence of ongoing ischemia. Clearly, his triglycerides and cholesterol need to be improved and he needs to lose about 30 pounds.

Plan: I told him that we will leave his blood pressure medicines where they are now. I put the burden on him to lose weight as a method of treating his blood pressure, cholesterol, and trigclycerides at this time. Follow-up with Dr. X in this regard. See me in one year.

Documentation Critique
The note does not clearly specify the reason for the follow-up, or the date of the original diagnosis or intervention (i.e., history of present illness). Therefore, it would be difficult to determine a diagnosisan important fact since diagnosis determines medical necessity.

I also question, from this documentation, whether he did anything except a stress test for this follow-up, says Susan Callaway-Stradley CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., in Augusta, GA. For example, the documentation indicates a problem-focused exam. Basically, they took a limited history by asking questions such as Have you had chest pain? The examination shows nothing but the blood pressure reading and weight, she points out. All of which would have been done before they put him on a treadmill anyway.

Coding Tips

Callaway-Stradley offers this question to determine whether an office visit should be billed by appending modifier -25: Is there enough evidence that a significant, separate service occurred? Speaking to the patient about the link between blood pressure, cholesterol, and triglycerides does not necessarily justify billing an office visit with a stress test, she says.
Also, check with your top five payers as to how they re
imburse for stress tests for asymptomatic patients. For example, South Carolinas Medicare carrier says, Patients who are asymptomatic post-PCTA or post-CABG may subsequently require follow-up study. Two such follow-up studies per year would be reasonable. Additional testing in the absence of symptoms will be denied as not medically necessary unless accompanied by supporting documentation.

However, Xact, a Medicare carrier in Pennsylvania, says, Stress testing is not covered for screening of asymptomatic patients regardless of the number of risk factors which may be present. Yet, Xact also lists diagnosis codes V45.81 (aortocoronary bypass status) and V45.82 (percutaneous transluminal coronary angioplasty status), which indicate that the patient has had a previous cardiac procedure.

Thats why you need to specifically ask your carrier if the term asymptomatic means the same thing before a heart attack as after, says Callaway-Stradley.

The most important tactic is to stress to physicians that they must write better notes. Tell them to be more explicit in what they are monitoring on a given day, she says. Or this one could come back to haunt you.

Coding Solution

You cannot use 99401-99404 (preventive medicine, individual counseling) because the patient has an already established condition. CPT says, These codes are not to be used to report counseling and risk factor reduction intervention provided to patients with symptoms or established illness.

An established patient visit with modifier -25 attached is questionable based on the documentation. Many carriers would not view this documentation as a significant service beyond the performance of the stress test.

Your options are as follows.

1. If stress testing is covered, bill Medicare 93015
(stress test).

2. If it is not, have the patient sign a waiver stating he or she will be responsible for fees not covered by the carrier, and append a -GA modifier to the stress test code. Otherwise, you will not be able to collect from the patient. (For more information on the GA modifier,
see page 6 of the January 1999 issue of CCA.)

"The question is not whether the physician performed enough work to bill an office visit but if it was done, he or she did not write it down, Callaway-Stradley explains.