Cardiology Coding Alert

Overlooking add-on codes may cost you

You can collect the $550 you deserve for transthoracic echocardiography (TTE) services -- but only if you identify and properly assign your base code and add-on codes.

Cardiologists frequently use TTE with Doppler echocardiograms to evaluate heart function and great-vessel anatomy. Because of these services' rapid proliferation and noninvasive testing approach, carriers fear that practices might overuse these codes, and therefore subject them to separate, specific policies.

Typically, when the cardiologist performs a TTE that uses ultrasonic signals and two-dimensional imaging to examine potential valvular and chamber disorders, you should report 93307 (Echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; complete), says Sheldrian LeFlore, CPC, a cardiology coding consultant with Gates, Moore & Company, a medical consulting firm in Atlanta.

Although Medicare covers the physician's TTE services for patients with a number of conditions, Medicare and many private carriers exclude routine or screening TTE from coverage. For example, if you use a screening ICD-9 code, such as V70.0 (Routine general medical examination at a healthcare facility), with 93307, the carrier will likely deny the claim.

But if a physician uses TTE to examine a patient's chamber size or wall thickness, or to evaluate left ventricular function after a myocardial infarction, most payers will cover the service, says Lisa Center, CPC, quality review coordinator for Freeman Health System in Joplin, Mo.

Remember not to confuse 93307 with other TTE codes, such as 93303 (Transthoracic echocardiography for congenital cardiac anomalies; complete) and 93350 (Echocardiography, transthoracic, real-time with image documentation [2D], with or without M-mode recording, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report).

You should report 93303 when the physician performs a complete echocardiography on a pediatric patient to assess septal defects (745.4, Ventricular septal defect; and 745.5, Ostium secundum type atrial septal defect) or other cardiac congenital anomalies, LeFlore says.

If the physician performs a TTE with a cardiovascular stress test in the office, you should assign 93350, Center says. And, you should list the appropriate stress-test code, according to CPT guidelines.

Specifically, you should report 93015 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report) to represent the stress test. If cardiovascular stress is induced by pharmacologic means rather than physical exercise, you should also report the appropriate supply code (such as J0152, Injection, adenosine, 30 mg).

You should append modifier -26 (Professional component) to 93350 to indicate that the physician performed the service in the hospital (and that your cardiologist does not maintain the facility in which the testing was performed). You should report the stress test with codes 93016 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision only, without interpretation and report) and 93018 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only).

Heads Up: You should not append modifier -26 to either 93016 or 93018, because both codes already describe only the professional component of the stress test. In the facility setting, you should not report the supplies that the cardiologist uses to pharmaceutically stress patients, because the facility will bill for those supplies.

Some cardiologists order a Doppler echocardiogram (+93320, Doppler echocardiography, pulsed wave and/or continuous wave with spectral display [list separately in addition to codes for echocardiographic imaging]; complete; and +93325, Doppler echocardiography color flow velocity mapping [list separately in addition to codes for echocardiography]) in addition to a TTE. You should use the local carrier's approved ICD-9 code that specifically indicates why the physician needs to use the Doppler described by add-on codes 93320-93325, LeFlore says.

Example: AdminaStar Federal, Indiana's Medicare carrier, requires you to submit a clinical indication that establishes medical necessity for each component of the echocardiogram. Without established medical necessity, you must bill a routine screening diagnosis code.

Solution: If the patient has an additional heart problem along with the underlying condition that led to the TTE, you can use the other condition as justification for the Doppler. For example, the physician orders a TTE for an alcoholic patient with benign hypertension and heart failure (402.11).

But the patient also has shortness of breath (786.05), and because the physician suspects alcoholic cardiomyopathy (425.5), he orders a Doppler study (93320) and color flow mapping (93325). When coding this scenario, you should use 93307, 93320 and 93325, linking 402.11 to 93307, and linking 786.05 to 93320 and 93325.

Payoff: If you submit 93307, 93320 and 93325 to Medicare, you could expect $220 for 93307, $100 for 93320, and $130 for 93325 (based on national Medicare payment rates), as long as your documentation supports medical necessity.

When the cardiologist performs a TTE and Doppler in the hospital, you should append modifier -26 (Professional component) to the codes. The modifier signifies that the physician interpreted the test results but does not maintain the facility in which he performed the test (office space, utilities, technical staff, etc.).