Cardiology Coding Alert

Echocardiography is among the most commonly performed cardiology services. Coding these diagnostic tests, however, can be anything but routine. There are several variations on the basic echocardiogram, each with its own particular documentation requirements. In addition, non-physician practitioners often perform the tests, and medical necessity and diagnosis code requirements vary.

As a result, cardiologists need to document exactly what they did in the operative report, and their coders need to read all of the documentation in the operative report and familiarize themselves with their carriers medical necessity and diagnosis guidelines to determine when a particular service (or combination of services) is payable.

CPT 2000 lists 14 echocardiography codes describing the following distinct procedures:

basic transthoracic echocardiogram (TTE)
Doppler echo and color flow mapping
stress echo
transesophageal echo (TEE)
contrast echo

Note: There also are separate codes for echos involving patients with congenital heart disease.

How to Code Basic Echocardiograms (TTE)

A transthoracic echocardiogram (TTE), commonly referred to as an echo, is a non-invasive study that visualizes the hearts function, blood flow, valves and chambers. Echos use ultrasound technology similar to that used to observe a fetus in the womb. The ultrasound produces real-time images that are recorded on videotape and interpreted by a technician or physician.

The following two codes describe the basic, transthoracic echo:

93307 echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; complete; and

93308 follow-up or limited study.

There is no code for only the professional component of the basic echo, so if the cardiologist doesnt own the equipment, the complete echo cannot be billed. Instead, modifier -26 (professional component) must be attached to either 93307 or 93308.

If the cardiologist also performs an examination, both services are billable. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should not be attached to the appropriate evaluation and management (E/M) code because the echocardiogram is a diagnostic test and is found in the Medicine section of the CPT manual, says Stacey Elliott, CPC, manager of contracts, compliance and information systems, with COR Associates, an 11-physician group in Los Angeles.

If the echocardiogram yields a more specific diagnosis, that diagnosis code should be associated with the test code, whereas the pretest diagnosis code should be linked to the E/M service code, Elliott says. She notes, however, that a single diagnosis is sufficient to obtain payment for both the E/M and the echo.

If a nurse or technician performs the echocardiogram under the incident-to guidelines, the physician must be present and immediately available, says Quin Buechner, MS, MDiv, CPC, a non-physician practitioner (NPP) coding and reimbursement specialist in Cumberland, Wis. When a service is performed by an NPP and is billed incident-to, 100 percent of the fee may be claimed. But if the physician was busy attending to another patient and couldnt be disturbed, then the echo should not be billed incident-to.

For nurse practitioners, physician assistants and clinical nurse specialists who bill under their own Medicare unique personal identification number (UPIN), the situation is more complicated, Buechner says. For these sorts of tests, there are two things to consider:

1) Is the NPP permitted to perform the service without
supervision under state scope-of-practice regulations?
and

2) What guidelines does the carrier have in these
situations?

Because the Healthcare Financing Administration (HCFA) has left such decisions up to individual Medicare carriers, policies vary across the country, Buechner says. Additionally, private payers may have their own guidelines. So coders need to call and request each carriers payment guidelines.

How to Code Doppler Echocardiography

Most patients who require an echocardiogram also receive Doppler echocardiography, which provides a spectral display of the information as well as color visualization of the patients blood flow. This procedure allows the cardiologist to determine how well the patients valves are functioning.

There are three CPT codes for the two types of Doppler echocardiography:

93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (list separately in addition to codes for echocardiographic imaging); complete;

93321 follow-up or limited study (list separately
in addition to codes for echocardiographic imaging); and

93325 Doppler echocardiography color flow
velocity mapping (list separately in addition to codes for echocardiography).

All three are add-on codes, which means they may not be billed on their own but only in conjunction with 93307 or 93308.

Although 93307, 93320 and 93325 are typically performed together, particularly in hospitals where providing the three services in tandem is now a standard- of-care issue, the two Doppler codes are payable only if certain diagnostic criteria have been met.

If a person has a valvular problem that shows up on the original echo, the cardiologist performs the Doppler pulse and color flow because these services visualize the blood flow, which indicates whether the valves are functioning correctly, says Rebecca Sanzone, CPC, billing manager with Mid-Atlantic Cardiovascular Associates, a 45-cardiologist practice in Baltimore.

The biggest problem in getting Doppler echocardiograms paid, Sanzone says, is that the diagnosis that prompted the test may not be covered by many carriers, including Medicare. We have a problem in the hospitals where these tests get ordered for shortness of breath, which isnt an acceptable diagnosis code for these services. She notes that although the same is true for regular echocardiograms, the list of acceptable diagnoses is much larger, which minimizes the problem.

As a result, when one of Sanzones cardiologists performs a Doppler that returns positive, she links the end, or post-test, diagnosis with 93307, 93320 and 93325. If the test returns negative, she codes the test for record-keeping purposes only, and the carrier is not billed.

Note: Many Medicare carriers, such as Wisconsin Physician Service (WPS), the Medicare Part-B carrier in Wisconsin, Michigan and Illinois, do not allow post-test diagnoses. Check with your carrier to determine if using a post-test diagnosis is acceptable.

For Medicare patients, Sanzone recommends having the patient sign a waiver and then filing the claim with a -GA modifier (waiver of liability statement on file). Otherwise, you wont get paid, she says.

Referring Physician Must Order Doppler by Name

Since late 1998, HCFA has not covered claims for Doppler echocardiography if the primary-care physician (PCP) who referred the patient to the cardiologist does not explicitly mention the word Doppler in the referral. Medicare auditors are scrutinizing such claims and if a specific reference to a doppler test is not there, the Medicare carrier may demand a refund.

Even if the basic echo reveals a valvular problem that indicates the need for a Doppler echo, Medicare will not pay for the Doppler if the referral did not specifically mention Doppler echocardiography. Therefore, cardiology offices need to monitor such referrals and instruct primary-care physicians to resubmit referrals that inadvertently left out the Doppler portion and include the Doppler in subsequent referrals, just in case.

In some rare cases, the PCP may explicitly want only a 93307. But most of the time, they want the patient to get a thorough test and that means the Doppler echo as well, Sanzone says.

How to Code Stress Echocardiography

When a basic echocardiogram is taken at the same time as a stress test, the usual code (93307) is not used. Instead, 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) should be billed to report the echocardiogram portion of the session only, whereas the stress test portion is reported separately.

Just beneath the descriptor for 93350, CPT 2000 also states: The appropriate stress testing code from the 93015-93018 series should be reported in addition to 93350 to capture the stress portion of the study.

This service is similar to the basic echo (93307) in that it provides two-dimensional, or real-time imaging. The main difference is that 93350 includes both a baseline echo that is taken when the patient is at rest and another when the heart has been stimulated by exercise or drugs.

Medicare has assigned 5.41 relative value units (RVUs) to 93307, whereas 93350 is assigned only 3.00 RVUs, even though it includes two echo readings. If only the professional component is billed, 93307-26 (1.33 RVUs) pays more than 93350-26 (1.12 RVUs).

Higher reimbursement has prompted some cardiologists to bill 93307 instead of 93350 when a stress echo is performed. This kind of inaccurate billing is a red-flag issue, however, warns Terry Fletcher, BS, CPC, CCS-P, a cardiology coding and reimbursement specialist in Dana Point, Calif.

Coding a lesser procedure to get paid more is very poor strategy because it focuses on one side of billing reimbursement but ignores the other, equally important side compliance, Fletcher says.

Cardiologists need to be careful and code what they actually performed instead of worrying about reim-bursement when choosing their CPT codes, Fletcher continues. Sure, their bottom lines are involved, but they need to focus on accuracy. If there is a code that specifically describes what theyre doing, they have to use it in this case, the 93350, she says.

Doppler typically is not used in a stress echo setting, says Mark Lundin, a registered diagnostic cardiac sonographer (RDCS) who is technical director and supervisor with Summit Cardiology, an 11-cardiologist practice in Seattle. When you do a stress test, usually you arent expecting to use Doppler. Sometimes, however, you may find something valvular that requires a closer look via doppler.

When that occurs during the course of a stress echo, Lundin says, the Doppler may be turned on and used, but it is rarely billed unless the referring physician specifically requested it.

Transesophageal Echocardiography (TEE)

Sometimes a regular echocardiography is technically inadequate. In other situations, it may demonstrate pathology but may not provide enough data to allow the cardiologist to make a definitive therapeutic decision in the best interests of the patient. In these cases, trans-esophageal echocardiography (TEE) is appropriate, according to local medical review policies published by most Medicare carriers.

When a TEE is performed, the ultrasound generator is placed in the esophagus, allowing the cardiologist to obtain additional cardiovascular information. Compared with TTE, TEE is a relatively invasive procedure with potential for morbidity because the instrumentation lies within the esophagus. Therefore, Medicare carriers restrict its use to patients for whom TTE is inadequate.

Most carriers will cover TEE examinations in cases where its clinical utility has been demonstrated. For example, TEE has become a quick, reliable tool in diagnosing and defining aortic dissection and aneurysm, with sensitivity and specificity in the range of 97 percent consistently reported. In suspected aortic dissection, the application of bedside biplane or multiplane TEE is frequently considered the diagnostic study of choice.

Although aortic ulceration, atherosclerotic plaque and mural thrombotic material are identified by TEE with increasing frequency, particularly in older patient populations, using TEE to probe for these pathologies still is not considered routine. If emboli occur repeatedly and aortic surgical intervention is being considered, however, the surgeon may use TEE to locate and characterize remediable aortic lesions.

The procedure may also be required occasionally for the following conditions: native valvular heart disease, endocarditis, valvular prostheses (mechanical and bioprostheses), suspected cardiac thrombi and emboli, congenital heart disease, pericardial disease, cardiac tumor and mass assessment, and pre-cardioversion. It also is sometimes used when TTE images are inadequate (for example, to assess left ventricular function in a critically ill intensive care unit patient with poor ultrasound windows).

Note: Significant pathology of the esophagus, such as tumor, stenosis varices or diverticula, usually contraindicate use of TEE, as the expected information that can be obtained via this technique must exceed any potential risk.

Coding Myocardial Contrast Echocardiography (MCE)

This relatively new technique, also known as contrast-enhanced echocardiography, aids in the treatment of some types of heart disease by giving the cardiologist a better view of the left ventricle than would be afforded by a routine echo.

Myocardial contrast echocardiography (MCE) is particularly useful for patients undergoing a stress echo, according to a policy statement from HGSA Administrators, formerly Xact Medicare Services, the local Medicare carrier in Pennsylvania. The service is used most frequently during the evaluation of patients for myocardial and ischemic disease.

HCFA has created a new Q code, Q0188, that is for the supply of injectable contrast material for use in echocardiography, per study. The code is expected to become effective Oct. 1, 2000.

Although Optison, the contrast agent typically used for such echocardiograms, received Food and Drug Administration (FDA) approval on Dec. 31, 1997, both Medicare and commercial carriers have been slow to reimburse this service or issue policy guidelines.

By adding the new code, HCFA will recognize that the cost of the contrast agent used during echocardiography is separate from the payment for the procedure itself.