Part B Insider (Multispecialty) Coding Alert

Published on Mon Feb 02, 2004 PDF

Carrier cracks down on Adenosine claims with poor documentation

If you're not putting heart patients on a treadmill, then you'll need to do your own workout to create documentation to justify it.
 
For patients requiring cardiac stress testing who can't exercise due to an illness or weakness, Medicare covers Adenosine ( J0152 ), a drug that increases the patient's heart rate to exercise levels. But Part B carrier Regence says many providers aren't providing full enough documentation to explain why patients can't exercise.
 
Claims for Adenosine increased 169 percent from January 2001 to June 2002 nationally, the carrier states on its Web site. So Regence (and probably other carriers) is taking a closer look at claims for the drug. And they're finding vague documentation that merely states "Patient can't exercise" or "Patient is out of shape."
 
Provide more detail, Regence tells providers. If the patient can't exercise, explain if the patient is unwilling or unable, and spell out any conditions like chronic obstructive pulmonary disease that may prevent exercise. If the patient had a treadmill test and failed to reach the required heart rate, make sure to mention this.
 
"We always have trouble with Adenosine," says Deena Wojtowski, billing supervisor with Cardiovascular Associates Ltd. in Milwaukee, Wis. Usually, the carrier will deny claims and then the provider must send in extra documentation and receive payment. Because Wojtowski is billing electronically to comply with HIPAA requirements, it's impossible to attach all the needed documentation.
 
Many practices will order Adenosine without documenting why in detail, says consultant  Jim Collins with Compliant Med in Matthews, N.C. "A lot of the times they won't put down why they're doing the pharmacological stress test as opposed to the exercise stress test." Because using Adenosine increases the risk to the patient and turns a noninvasive study into an invasive one (because of the injection), physicians usually won't do it without a good reason. But they forget to write it down, Collins says.