Cardiology Coding Alert

Hint: Be very careful when reporting an E/M service with 93660.

If your cardiologist treats patients who experience unexplained episodes of syncope (fainting), he may perform tilt table tests to figure out what’s causing the syncope so he can prescribe the right kind of treatment.

Test your tilt table coding skills with the following scenario to make sure you submit clean claims in your cardiology office.

Scenario: A patient has been experiencing recurrent, unexplained episodes of syncope. The cardiologist evaluates the patient’s past medical history and performs a physical exam. However, the cardiologist cannot determine the cause for the patient’s syncope from the history and exam. The patient has no history of heart disease. The cardiologist performs a tilt table test to determine the cause of the patient’s syncope symptoms. The cardiologist owns the tilt table equipment.

Step 1: Pinpoint Procedure and ICD-10-CM Codes for Tilt Table Test

In a tilt table test, the patient lies strapped to a special table while the cardiologist slowly tilts the table slowly upward. This “tilt” simulates suddenly transitioning from a lying down position to a standing up position, helping to trigger the patient’s symptoms of syncope.

During a tilt table test, the cardiologist monitors the patient’s electrocardiogram (EKG) for any changes in heart rate, and he also monitors the patient’s blood pressure. The patient should let the cardiologist know if she experiences any light-headedness or faintness during the test. If the patient does feel symptoms of syncope, the cardiologist will lay the table flat to help her regain consciousness. However, if the patient does not experience any signs or symptoms, the cardiologist may need to administer isoproterenol or perform mechanical manipulation of peripheral blood flow with a variety of compression devices to produce the symptoms of syncope.

CPT^® code: When your cardiologist performs a tilt table test, you should report code 93660 (Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention).

Don’t miss: From the code descriptor, you can see that 93660 includes continuous ECG monitoring, intermittent blood pressure monitoring, and administration of medications, so you cannot report these services separately.

ICD-10-CM: The diagnosis code for this scenario would be R55 (Syncope and collapse) for the syncope.

Step 2: Know If Cardiologist Owns Tilt Table Equipment

Code 93660 is split into professional and technical components. You must check the medical documentation to see if your cardiologist owns the tilt table equipment or not. If your cardiologist does own the tilt table equipment, report the global code 93660.

However, if your cardiologist does not own the tilt table equipment, you should report 93660 with modifier 26 (Professional component), and the hospital will bill their portion with the TC modifier. So, in our example above, there would not be a modifier appended to 93660 since the cardiologist owns the tilt table.

Step 3: Cardiologist Performed Tilt Table Study With EP? Follow This Advice

Your cardiologist may perform a tilt table study alone or along with other services.

For example, in some cases, your cardiologist may perform a tilt table test along with a comprehensive electrophysiologic (EP) study. “Because tilt table testing is a separate and distinctive service from a comprehensive electrophysiologic study, code 93660 is listed in addition to the code for the comprehensive electrophysiologic study (93619, 93620, +93621, +93622), when both are performed on the same date,” according to CPT^® Assistant Vol. 22, No. 11.

Example: The cardiologist performs a comprehensive EP study with right atrial pacing and recording, right ventricular pacing, and recording, His bundle recording, and the insertion and repositioning of multiple electrode catheters. He does not induce or attempt induction of an arrhythmia. The cardiologist also performs a tilt table test on the same date as the EP study. You should report codes 93660 and 93619 (Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia) with modifier 26 appended on your claim.

Step 4: Approach E/M Services With Caution

You can only bill a separately payable evaluation and management (E/M) code on the same day that you report a tilt table test if your cardiologist’s documentation supports the separately identifiable service.

If the E/M service is unrelated to the tilt table test, is medically necessary, and your cardiologist appropriately documents it, then you can append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the code for the E/M service your cardiologist performed on the same date as the 93660 service.

Take a look at this example from Robin Peterson, CPC, CPMA, Manager of Professional Coding Services, Pinnacle Integrated Coding Solutions, LLC:

Example: A patient with known coronary artery disease (CAD) comes into the office for a check-up. The cardiologist performs a pertinent history and physical exam, and the patient informs the cardiologist he has had some syncopal episodes. The cardiologist talks with the patient about his CAD and verifies the patient is not experiencing any new symptoms of chest pain or shortness of breath, reviews an electrocardiogram (EKG), which shows no new arrhythmias, reviews current medications, and decides not to make any changes to the current medication therapy. The cardiologist decides to schedule an outpatient tilt table study at the facility to try to identify the source of the patient’s syncopal events. You should separately report the E/M service with modifier 25 for the evaluation of the patient’s CAD and medication management. Report the tilt table study performed later that day in the hospital with code 93660 and modifier 26.

Remember: Code 93660 has a global period indicator of 000 on the Medicare Physician Fee Schedule (MPFS). That 000 indicator means: “Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.”

So, before you report an E/M with modifier 25 on the same date as the tilt table test, you should be sure to confirm that documentation shows the E/M is separately identifiable from the work usually required for 93660.