Advanced Search

Cardiology Coding Alert

Supply Coding Tricky but Well Worth the Effort

Published on Wed May 01, 2002

Cardiologists routinely purchase and bill for a wide variety of medical supplies and related materials. Most of these fall within one of four main categories: (1) pharmaceutical stress agents, (2) radioisotopes for nuclear scans, (3) contrast agents for echocardiography and (4) other injectable medications.

Reporting the use of supplies can be tricky, and incorrect coding may result in denials and payment delays. Among the difficulties are the following:

  • Most of the supplies used by cardiologists are reported to Medicare carriers using the less familiar HCPCS codes.

  • Not all supplies are in the same section of the HCPCS manual.

  • Codes for the same material vary based on amounts used.

  • Generic names are used even when the material is commonly known by a brand name.

    In addition, because the supplies are first purchased by the cardiologist and are then supposed to be billed with no markup to Medicare, the Part B carrier may require an explanation, and in some cases an invoice (for which a paper claim would be necessary), to verify that only pass-through charges are billed.

    Pharmaceutical Stress Agents

    If a patient cannot walk on a treadmill, the cardiologist may decide to stress the heart pharmacologically. Although the reporting of the test is the same, when stress is induced this way, the supplies may be separately reported.

    Among the most common stress agents are dobutamine, dipyridamole (Persantine) and adenosine. Dobutamine directly stimulates the heart by boosting the heart rate, coronary blood flow and oxygen requirements, and is used with stress echocardiography or nuclear scans (for example, thallium stress tests). Adenosine and Persantine are vasodilators that boost blood flow by opening up the coronary arteries. They are used for nuclear scans but not stress echos. The HCPCS manual lists these and other stress agents as follows:

  • J0151 Injection, adenosine, 90 mg (not to be used to report any adenosine phosphate compounds; instead use A9270)
  • J1245 Injection, dipyridamole, per 10 mg (Persantine IV)
  • J1250 Injection, dobutamine HCl, per 250 mg (Dobutrex)
  • J0280 Injection, aminophylline, up to 250 mg
  • J3490 Unclassified drugs.

    When adenosine is used, report J0151, not J0150, says Nikki Vendegna, CPC, a cardiology coding and reimbursement specialist in Overland Park, Kan. "J0150 is also for adenosine, but the small dosage (6 mg) is used to convert a patient out of an arrhythmia, not to induce stress," she says.

    Many carriers will cover pharmacologically induced stress testing only when the patient cannot tolerate exercise, and they may want to know why stress was induced with drugs. In addition to ensuring that the documentation supports the claim, a short explanation should be included on the claim form, says Rebecca Sanzone, CPC, coding manager for Mid-Atlantic Cardiovascular Associates, a large cardiology-based practice in Baltimore. "Paper claims and electronic claims should include a short note in the message line that states, for example, 'Patient unable to walk on treadmill,' " she says. Also, the cardiologist's documentation should highlight the medical necessity for the drugs by noting any indications that rule out exercise.

    Radioisotopes

    Like most supplies, stress agents such as dobutamine and Persantine have a long shelf life and may be stored for use on more than one patient. The materials used in nuclear cardiology, such as thallium and sestamibi (Cardiolite), differ in that they have no shelf life because they have extremely short half lives, which reduces the patient's exposure to radiation.

    "You have to order a specific number of doses of a radiopharmaceutical. For example, if you are going to perform three thallium and seven sestamibi tests, you order each the day before on a per-dose basis," Sanzone says.

    This may help explain why radioisotopes are not "medical and surgical supplies" and are not reported using HCPCS J codes. Instead, the codes for nuclear agents are considered injections, which are in the A section for "drugs administered other than oral method." The most common radiopharmaceuticals used for nuclear scans are:

  • A9500 Supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m sestamibi, per dose (often called Cardiolite)
  • A9502 ... tetrofosmin, per unit dose (known as Myoview)
  • A9505 thallous chloride TL-201, per mCi (known as thallium).

    The technetium used for MUGA scans is reported using unspecified code A4641 (Supply of radiopharma-ceutical diagnostic imaging agent, not otherwise specified). The "tagging" kit for technetium-based pharmaceuticals may also be reported separately. Unlike the radiopharmaceuticals, it is billed using an unlisted-drug code from the J section (J3490, Unclassified drugs).

    "It's important to use units when billing for radiophar-maceutical supplies," Vendegna says, noting that all three radioisotope codes are measured by the dose or, in the case of thallium, by the millicurie (mCi).

    When claims for radiopharmaceuticals are filed electronically, the message line should be used to inform the payer which isotope was used and how much, she adds.

    If a Medicare or other carrier requests the invoice for the radioisotope to ensure the cardiologist is billing a pass-through charge only, Sanzone says, "a paper claim may be necessary, and the type and amount of radioisotope should be noted in box 19 of the claim form."

    Not all commercial payers recognize HCPCS codes, which were developed for use by Medicare. Some non-Medicare carriers require that 78990 (Provision of diagnostic radiopharmaceutical[s]) be used for nuclear scans.

    Although the one code covers many supplies, it is still an effective way to report the use of nuclear supplies because the cardiologist is supposed to list the pharmaceutical and the dosage provided in the message line, Sanzone notes. Therefore, the carrier requiring 78990 receives as much information as the Medicare carrier that asks for HCPCS codes.

    Note: If stress is induced pharmacologically for a nuclear scan, the stress inducer and the radioisotope may be reported.

    Contrast Echo and Injectable Medications

    A contrast echo uses a contrast material to provide sharper images than a regular echocardiogram. The material used (Optison or Albunex) may be reported using A9700 (Supply of injectable contrast material for use in echocardiography, per study).

    As with radiopharmaceuticals, some carriers may want to see an invoice, so a paper claim may be required, and the name of the contrast agent, as well as the dosage, should be documented and noted in section 19 of the form.

    Injectable medications, meanwhile, are those drugs that must be injected to be payable. If taken orally, they will not be paid. Examples of injectable drugs include J0395 (Injection, arbutamine HCl, 1 mg) and J0460 (Injection, atropine sulfate, up to 0.3 mg).

    Note: The supplies required to administer any of the drugs (tubing and needles, for example), as well as the administration, are not separately payable. They are included in the stress test, echo or nuclear scan."You can only bill for what you put into the patient's body, not for putting it there," Vendegna says.

    • Other Articles in this issue of

    Cardiology Coding Alert

    View All