Cardiology Coding Alert

Hint: Never report 93350 in conjunction with 93015.

In the Cardiology Coding Alert volume 20 number 5 issue, you learned how to correctly report stress tests (also called treadmill or exercise tests) in the article “Omit the Anxiety from Reporting Cardiac Stress Tests,” but do you know what to do when the cardiologist performs a stress echo in addition to the stress test? Take the guesswork out of these scenarios by following these practical, easy-to-follow steps.

Read on to find out more.

1. Zero In on These Codes for Stress Tests

What happens: Cardiologists use stress tests, also called treadmill or exercise tests, to see how well a patient’s heart deals with work. When a patient takes a stress test, the cardiologist (or tech) hooks the patient up to heart monitoring equipment, and the patient walks slowly on a treadmill. Then, the treadmill’s speed increases and tilts to simulate the patient going up a small hill. During the test, the cardiologist monitors the patient’s heart rate, breathing, blood pressure, and level of tiredness.

To report stress tests, you will choose from the following codes:

• 93015, Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharma­cological stress; with supervision, interpretation and report
• 93016, ... supervision only, without interpretation and report
• 93017, ... tracing only, without interpretation and report
• 93018, ... interpretation and report only.

Difference: Look at the difference between these codes. You’ll report 93015 for the complete service, 93016 for the supervision only, 93017 for tracing only, and 93018 for the interpretation and report only.

Example: A patient has a stress test in the hospital, which your cardiologist oversees and then interprets the results. That means you would report 93016 and 93018 to capture your cardiologist’s work.

2. Add the Stress Echo Into the Situation

In some cases, the cardiologist will perform a stress echo along with the stress test. With a stress echo, the cardiologist takes echocardiographic images of the left heart before, after, and sometimes during the stress test to monitor the motion and thickening of specific walls, according to CPT^® Assistant.

Your stress echo code choices are as follows, per the 2017 CPT^® manual:

• 93350, Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report
• 93351, … including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional.

Since the guidelines for reporting 93350 and 93351 with stress tests can be tricky, let’s look at the rules in more depth.

3. Follow These Situational 93350 Guidelines

CPT^® offers the following advice for reporting 93350 and 93351 in conjunction with 93015-93018.

Appropriate to report: A note under 93350 in the 2017 CPT^® manual instructs you to report 93016-93018, when appropriate, with 93350 to illustrate the cardiovascular stress component of the test. CPT^® Assistant further explains that you would choose 93350 for the cardiologist’s performance and interpretation of the stress echo, without all the components of 93015.

Never report: Don’t report 93350 together with 93015, according to the CPT^® manual.

Setting: You can report 93350 in either a nonfacility or facility setting, according to CPT® Assistant.

Different cardiologists: When the same cardiologist who performs the professional services of the stress test does not perform the stress echo, report 93350 with the appropriate codes 93016-93018 for the components of the cardiovascular stress test the cardiologist did provide, according to CPT^®.

“Codes 93016-93018 should be reported with 93350 when the documentation allows,” says Theresa Dix, CCS-P, CPMA, CCC, ICDCT-CM, coder/auditor of East Tennessee Heart Consultants in Knoxville, Tenn. “Only report the service the physician provides.”

Dix offers the following example to illustrate her point: If the physician only interprets the test and does not provide the supervision, only use code 93018 and vice versa.

Remember: “Make sure the documentation backs up your code choice,” says Dix.

4. Overlooking These 93351 Guidelines Would Be a Mistake

Appropriate to Report: If the cardiologist performs the stress echo with a complete cardiovascular stress test, including continuous electrocardiographic monitoring, supervision, interpretation, and reporting, report 93351, according to the CPT^® manual.

Never report: You should never report 93351 with 93015-93018 and 93350, according to CPT^®.

Setting: You should only report 93351 in a nonfacility setting, according to CPT^® Assistant.

Modifier 26: If the same cardiologist performs only the professional components of the complete stress test and echo, he should report 93351 and append modifier 26 (Professional component), according to CPT^® 2017.

“A 26 modifier is applicable when you are only billing the professional component of this service — if you do not own the equipment,” says Rebecca Sanzone, CPC, CPMA, compliance administrator at St. Vincent Medical Group/Ascension Health in Indianapolis, Ind. “Another entity would be billing 93351-TC.”

Sanzone further explains her point.

“In a hospital setting, the physician would use the 26 modifier because he/she is only doing the supervision and interpretation of the service,” says Sanzone. “The facility would be billing for the use of the equipment.”

5. Ask Yourself These Questions Before Submitting Your Claim

To excel in coding for stress echoes and tests, you should get a report from the cardiologist and ask the following questions, says Sanzone:

1. Question:

Where did the cardiologist perform the stress test?

Answer:

• Do not append modifier 26 if the cardiologist performed the test in the office, since he owns the equipment.
• You will append modifier 26 if the cardiologist performed the stress test in the facility.

2. Question:

What physicians are involved?

Answer:

• If one cardiologist interpreted both the stress and echo portion, you should bill 93351.
• If two cardiologists were involved — one supervised and interpreted the stress test, and the other interpreted the echocardiogram, bill 93350 (93350-26 at a facility) for the echo physician and 93015 (or 93016, 93018 at facility) for the stress physician.

Bonus tip: 93352 (Use of echocardiographic contrast agent during stress echocardiography [List separately in addition to code for primary procedure] is an-add on code for when the cardiologist uses an echocardiographic contrast agent during the procedure, says Sanzone. Example: Definity (Perflutren Lipid Microsphere). Please note: IV saline (bubble study) is not considered a contrast.

You should never report 93352 more than once per stress echo, according to CPT^®.