Cardiology Coding Alert

How to Create a Superbill That Works for Your Cardiology Practice, Not Against It

It clearly pays to maintain a well-designed superbillan outdated one can cause denials, trigger an audit, and keep your practice from receiving all the reimbursement to which it is entitled.

However, even if youre retaining the same basic design, updating the contents of a superbill takes time and effort. Often practices put it off to their own detriment.

Here are some content and design tips to help your cardiology practice. Use the following checklist to enhance reimbursement, avoid auditors, and decrease denials:

1. Are you using the most current diagnostic, procedural, and HCPCS Level II codes? If youre not updating every year when the new codes are released in the late fall, then your form is obsolete, warns Sue Moore, CCSP, CMM, CMA, business office manager at Heart Specialists of Northwest Ohio, a 15-member group of general, invasive and EP cardiologists.

Barbara J. Cobuzzi, MBA, CPC, agrees. Updating annually is the first and foremost rule of maintaining a good superbill, stresses the president of Cash Flow Solutions, a batch biller in Lakewood, NJ, who conducts superbill audits for her clients.

Ive seen practices continue to submit truncated or deleted codes for several years running, she says. [An obsolete superbill] not only causes them to experience more denials because they arent representing their services accurately, but they could also be losing money since they may be missing the opportunity to bill for something.

Cobuzzi suggests revising the superbill during the last two weeks of the year. At this time, all the new codes have been released, and the patient base is lower than usual, so the billing department isnt having to process as many payments, she explains. That way, you can find some time to work it into your schedule before the new codes take effect at the first of the year.

But Moore says that the process at Heart Specialists takes longer because she involves others in the practice. In addition to going through the code books and noting revisions, deletions, and additions, I also ask the lab and the nuclear technicians to revise their particular sections, she says. Then, I have two of the cardiologists review the rough draft.

2. Does the superbill list the complete range of Evaluation and Management (E/M) codes? Vying for first place in the update checklist is making sure the forms contain all levels of the E/M codes for new patient (99201-99205), established patient (99211-99215), and consultations (99241-99245).

Not having all five levels is a red flag for an auditor, warns Joseph Greco, CEO of Professional Systems, a healthcare printing firm in Plymouth Meeting, PA, that maintains a library of sample superbills for cardiology practices and other specialties. (For information on the design, printing and support of superbills, contact Professional Systems Corporation at 800-852-5213, ext. 211; 610-834-9400; or email: The auditors reasoning is: If the option is not printed on the form, then how will the physician check it? explains Greco.

Cobuzzi acknowledges that this is one of the first places auditors check for upcoding of E/M services, reminding readers of a recent audit that was triggered when a teaching university failed to offer a full range of E/M codes on their superbill.

Without the full range of codes available, auditors infer that the physician never bills for them, which makes them suspicious, she explains. Even if the cardiologist says I never do anything less than a level three, list the lower levels anyway, she recommends.

Susan Stradley, CPC, CCS-P, senior consultant for Medical Group of Elliott, Davis and Co., LLP, headquartered in Greenville, SC, agrees. The most dangerous thing you can do on a superbill is to start listing E/M codes at a level three office visit or consult, she warns.

However, dont let this warning keep you from listing a level five consult (99245), Stradley adds. Although most of the time the risk factors to reach a level five are such that the patient is admitted to the hospital, there are times in the office when a cardiologist can bill it, Stradley says. If you dont, youre shortchanging your practice.

For example, if a particularly complex case requires additional workups and test reviews such as labs, x-rays, EKGs and old medical records, you might be able to justify billing code 99245.

3. Does the diagnosis code match the procedure? If your diagnostic codes dont support the medical necessity of the procedures, then Medicare will deny payments. This is particularly important for cardiology procedures, such as noninvasive vascular studies, which are specific to particular parts of the body. For example, codes 93922-93971 represent studies of the extremities, so your superbill should include diagnoses related to vascular diseases of the extremities.

If the cardiologist is performing one of those codes, and you dont have a diagnosis on the billing sheet that matches the need for the procedure, the claim might be denied, explains Stradley. (Physicians often use only a diagnosis listed on the superbill.)

She knows of a cardiology practice that has had to deal with tens of thousands of dollars in medical-necessity denials because they routinely used hypertension as the justification diagnosis for their duplex studies of the lower extremities.

4. Does the narrative in the CPT manual match the abbreviated one on your superbill? Dont assume that because the procedural number hasnt changed from year to year that the code description is also the same, cautions Cobuzzi. Check the descriptions for the codes affecting cardiology to make sure your physicians are actually doing the procedure as described in the CPT. Then abbreviate it correctly for your superbill. Otherwise, you run the risk of misrepresenting the service rendered, she says.

5. Is room available on the form for the use of modifiers? Greco, Stradley and Cobuzzi all recommend including a list of modifiers on the superbill so that the cardiologist can quickly check off the appropriate ones. But rather than taking up precious space to list all the modifiers, list only the ones that typically affect office visits for cardiology:

-22 (unusual procedural services)

-24 (unrelated E/M service by the same physician during post-op)

-25 (significant, separately identifiable E/M services)

Dont forget to include the GA modifier to show an ABN (waiver) has been signed by the patient indicating the service may not be covered, Cobuzzi warns. Otherwise, you cant bill the patient.

6. Does the design of diagnostic codes encourage specificity? For example, on the Heart Specialists superbill, Moore includes a larger, separate block for the fifth digit for 410.xx (myocardial infarction).

I do not even list 0 (episode of care unspecified) as an option, but rather only 1 (initial episode of care) or 2 (subsequent episode of care), she explains. (See the insert for a sample copy of Moores superbill, judged by experts to be quite good.)

Likewise, a cleverly designed superbill can force physicians to be more specific with a diagnosis they may otherwise mark automatically as unspecified. For example, Moores form has 14 diagnoses for hypertension; the last one is unspecified.

Greco agrees. If you allow the physician the easy choice, chances are he or she is going to make it. But it may not be the right choice. Your superbills design should be used as a tool to make the superbill as specific as possible, as well as making it more audit proof, he says.

Tip: Dont include numerical codes in diagnostic headings, sources advise. By having a heading such as 401.9, you only encourage physicians to choose unspecified hypertension, warns Stradley. In fact, with the new ICD-10 system (which will require much more specificity than ICD-9) coming out in less than three years, you should use the time from now until then to get your physicians accustomed to thinking in terms of specificity.

7. Does the superbill include a space for J codes and V codes? Moore also lists J0280, J1250, J1246, along with codes for influenza, pneumococcal vaccines and B-12 injections on her superbill.

Other cardiology practices may not give influenza vaccines, but because our practice used to include internal medicine, we continue to offer them to some of our older patients, she says. Thats why its important that your superbill reflect what your practice actually does. If you merely use a superbill from another practice without modifying it, youll be overlooking charges you could have billed.

Moore also lists 15 V codes on her superbill. This has its pros and cons, she acknowledges. Yes,
occasionally a physician will mark a V code as the primary diagnosis; however, we feel its important to use a V code as a supporting secondary diagnosis.

Tip: Consider adding a column next to the list of diagnosis codes so that the cardiologists can rank the diagnoses for billing purposes, says Mirianne Sloan, lead biller at the Four Corners Heart Clinic in Durango, CO.

Note: In upcoming issues, well feature individual critiques of not only superbills but also of forms that cardiologists use to capture hospital and cath lab charges.