Cardiology Coding Alert

Hint: You'll only append modifier -25 to E/M codes

There's no need to stress when it comes to coding a stress test with E/M services and EKGs as well as figuring out the technical and professional components. The following three frequently asked questions and two scenarios will you show you how to optimize your stress test claims every time.

1. On the day your cardiologist performs a stress test, must a history and physical also be billed?

Answer: No. If at the time of the stress test, the cardiologist performs a review of the patient's current status for the sole purpose of verifying that he is physically stable to undergo the procedure, that review should be considered part of the procedure itself, says Paulette Finke, billing manager at Cardiovascular Associates of Northern WISC in Wausau, Wisc. That goes for mini histories on patients prior to the procedure.

2. Are there times a cardiology practice would bill for an E/M service in addition to a stress test?

Answer: Yes. For example, a cardiologist sees a patient for an E/M service and decides to perform a stress test, having room on his schedule for a stress test on the same day. Or if the cardiologist discovers hypertension and addresses it, you would append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the correct E/M code and get paid for the office visit as well as the stress test.

Remember: "[Modifier -25] is probably the most important of all the modifiers," says Jean Ryan-Niemackl, LPN, CPC, an application specialist with QuadraMed Government Programs in Fargo, N.D. "You should always use this modifier on E/M codes and never on procedure codes."

3. When a cardiologist performs a stress test on the same day as another diagnostic test such as an EKG, should I add modifier -59 to be paid for both?

Answer: Yes, as long as the cardiologist performs the EKG diagnostically and not during the stress test, Finke says. You can use modifier -59 (Distinct procedural service) to identify procedures and/or services that are not normally reported together but that under certain circumstances are separately billable. But don't get into the habit of using it automatically.

Try 2 Stress Test Examples

Example 1: A patient complains of chest pain (786.50) and heart palpitations (785.1). A cardiologist uses the hospital's equipment to perform a cardiac stress test. Your doctor supervises the stress test and provides a written interpretation and report.
 
Answer: You should report 93016 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report) for the physician supervision. To code the written interpretation and report, you should also use 93018 (... interpretation and report only), Finke says.

Example 2: Your cardiologist administers a stress test in the office, providing the procedure's technical component (that is, the cardiologist's practice owns the equipment) in addition to the supervision, interpretation and report.

Answer: In this case, you should report 93015 (... with physician supervision, with interpretation and report), Finke says. You should use 93015 because it encompasses all of the procedure's components (the equipment's use, as well as the supervision, interpretation and report).

Note: Use 93016-93018 to report the components of the test the physician performed if he didn't do the entire service.

Remember: The physician may initiate this method of "stress" by using pharmacological agents, such as dobutamine (J1250, Injection, dobutamine HCI per 250 mg) or Persantine (J1245, Injection, dipyridamole, per 10 mg).

Therefore, you should report the appropriate HCPCS code to describe the agent, if the cardiologist performed the test in the office setting where your practice supplied the drug.