Clear Documentation, Accurate Coding Can Secure Stress Test Reimbursement

Cardiovascular stress tests are among the most common services provided by cardiologists. But even though cardiology coders regularly bill for this “bread and butter” procedure, obtaining correct payment for services rendered can be complicated. To do so, many questions need to be answered, such as:

• What kind of test was performed?
• How many tests were performed?
• Was there a payable diagnosis?
• What, if any, supplies were used?
• Where was the test performed?
• Was the cardiologist in the office suite?
• Is the Patient covered by Medicare or a commercial carrier?

The cardiologist's documentation needs to address these issues. However, some cardiologists may note that the patient received a “stress test” when in fact additional services, such echocardiography, pharmacologically induced stress, or nuclear scans, also were performed.

This kind of inadequate documentation can result in significantly less payment for procedures. Although CPT does not include separate codes for stress induced via exercise or via drugs, cardiologists should be able to bill for any supplies, such as drugs used to induce pharmacologic stress and/or radioisotopes used in myocardial perfusion studies, such as SPECT scans.

If the documentation notes that the stress test was accompanied either by echocardiography or a SPECT scan, both the stress test and the SPECT or echocardiography should be billed separately. Furthermore, place of service needs to be correctly noted and taken into account when choosing the appropriate stress test code (and, in some cases, modifiers).

Finally, the documentation needs to clearly indicate the level of supervision provided by the cardiologist, as the supervision requirements for these procedures differ. For example, Medicare carriers will not cover stress tests unless the physician is physically present in the practice.

Treadmills and Bicycles

Example: Stress test was preceded by an appropriate evaluation of the patient that included H&P and a resting ECG.

The results of this evaluation are important determinants in selecting between exercise or pharmacologic stresses as well as the need for stress imaging (ie., echo or radionuclide study).

Cardiovascular stress testing is a non-invasive diagnostic test given to individuals with coronary risk factors, a history of coronary artery disease (CAD), or symptoms that may indicate CAD. Stress tests are used (a) to diagnose coronary disease; (b) to evaluate existing disease to determine if change has occurred; (c) to evaluate the risk of an adverse coronary event; or (d) some of all of the above.

Typically, stress testing is performed with the patient on a treadmill, although in some cases, a stationary bicycle may be used. Readings are taken when the patient is at rest and during exercise. When the patient is on the treadmill, the heart and body respond to the stress of increased physical activity. A diseased heart responds abnormally to stress, and this can be monitored by taking the patient's blood pressure and heart rate, and by ECG monitoring. The cardiologist then makes a diagnostic determination based on the results.

CPT includes the following four codes for the basic stress test:

• 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)
• 93016 — (…; physician supervision only, without interpretation and report)
• 93017 — (…; tracing only, without interpretation and report)
• 93018 — (…; interpretation and report only)

To select the correct code, the main factor to consider is the place of service, which may be a hospital or physician clinic. If the stress test is performed in a hospital setting (inpatient or outpatient), the cardiologist may bill only for the professional component of the service, by reporting codes 93016 and 93018.

If, however, the entire test is performed in an office setting code 93015 should be used. This “global” code includes both the technical and professional components of the service.

If the cardiologist supervised the test in the hospital and also provided an interpretation and a (written) report, codes 93016 and 93018 should be used to report the service. If the physician was not present or there to supervise the test, then only the 93018 can be coded.

Note: It is unlikely that cardiologists would use code 93017, because this code describes only the technical portion of a cardiovascular stress test.

Modifiers -26 (professional component) and -TC (technical component) should never be used with these stress test codes, because the codes already are differentiated on this basis.

If the physician performs the stress test in his or her office, global code 93015 may be billed. If, however, the technical portion of the service is provided by a non-physician provider, the documentation must indicate the test was performed under the cardiologist's direct supervision.

This means the cardiologist must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. However, the cardiologist does not have to be in the same room as the procedure that was performed.

Note: Non-physician providers can provide services only if state scope-of-practice laws and/or regulations permit them to. However, even if the NPP can provide the test, some local insurers, such as WPS, the local Medicare carrier in Illinois, Michigan, Minnesota and Wisconsin, may not allow code 93016 -- the physician supervision component -- to be billed.

According to WPS local Medicare review policy CV-004, dated Jan. 1, 1999, and LCD updated 2007, “documentation in the patient's record must indicate when a physician is physically present (face-to-face) continuously during the entire procedure when billing for 93016.” This may or may not apply to global code 93015 as well, since this code includes 93016.

Documented Indication or Diagnosis Establishes Medical Necessity

Both local Medicare carriers and private payers are likely to cover cardiovascular stress tests when performed for a medically necessary reason. Most carriers publish a long list of diagnoses that justify giving the patient a stress test. Many carriers also accept a wide variety of indications, which are documented using signs and symptom codes, such as suspected or known CAD, angina, arrhythmia and syncope.

However, the indication or diagnosis must be clearly documented in the patient's medical record. If an indication, such as chest pain, is used, the key to obtaining payment is to be certain that it is noted in the medical record.

For example, a patient with autonomic neuropathy may not have anginal symptoms and the only sign of CAD may be ECG abnormalities. In this case, using sign or symptom ICD-9 code 794.31 (abnormal ECG) may be an acceptable diagnosis for payment of a treadmill claim.

The payer wants to know why the patient was tested, so if the patient's record shows that the patient's indications justified the test, reimbursement should be easier to obtain. In addition, the cardiologist's documentation should note that the stress test was preceded by an appropriate evaluation of the patient that included history and physical (H&P) and a resting electrocardiogram (ECG).

Note: Medicare will not pay for stress tests performed to screen for coronary disease, even if risk factors are present.

Pharmacologically Induced Stress

For a variety of reasons, some patients may not be able to use the treadmill (or a bicycle) for a stress test. In those cases, cardiologists use pharmacologic stress to simulate the effects of exercise on a patient's heart.

Typically, drugs such as dobutamine, adenosine and dipyridamole (also known as Persantine) are used. There are two kinds of pharmaceuticals used to increase blood flow much the same as exercise would.

Adrenergic stress agents, such as dobutamine, stimulate the heart, increasing heart rate, oxygen demands of the heart, and coronary blood flow. Dobutamine and the other adrenergic stress agents also may be used to induce stress in conjunction with stress echos or nuclear scans.

However, these drugs are contraindicated for post-MI patients. In these patients, the heart is too sensitive to go on a treadmill; similarly, the heart cannot tolerate being “flogged” by the dobutamine to increase blood flow.

In such cases, cardiologists use drugs such as adenosine and Persantine, which act as vasodilators to open the coronary arteries direct, rather than flogging the heart to increase blood flow. However, adenosine, while appropriate in conjunction with nuclear scans, cannot be used if a stress echo is done because it doesn't affect the muscles in the heart wall directly.

For example, if the left anterior descending artery is stenosed, you need to be able to see that the anterior wall is not compressing properly. Adenosine cannot stimulate the heart wall precisely because it affects blood flow without impacting the heart. Additionally, because it can cause bronchospasm, adenosine is contraindicated for asthmatic patients.

Since there is no specific CPT code for pharmacologic stress cardiologic procedures versus exercise stress cardiologic procedures, the pharmacologic stress procedure will be indicated by the billing of the drug plus the procedure. If the use of a pharmacologic stress agent is determined to be unnecessary, denial of the drug used will occur.

There is no separate CPT code for a pharmacologically induced stress test, and the code descriptor for 93015 specifically includes pharmacologic stress. If, however, the test was performed in the cardiologist's office (as is most typically the case), most carriers -- though not all -- will pay for the drug used to induce the stress.

The supply codes to bill for the specific pharmacologic agent are found in the HCPCS book. They include:

• J0152 — (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 [various])
• J0395 — (arbutamine HCl, 1 mg)
• J0460 — (injection, atropine sulfate, up to 0.3 mg [various])
• J3490 — (unclassified drug)

Typically, local Medicare carriers only pay a “pass through charge” for such medications, which means that the carrier will only reimburse the cardiologist whatever he or she paid for the pharmaceutical.

The IV administration of the drug is considered a part of the stress test and should not be billed separately. According to the National Correct Coding Initiative (CCI), infusion codes 90765-90779 are bundled with 93015. Most private payers, furthermore, follow CMS's lead in this matter.

Medical Necessity for Pharmaceuticals

Medicare carriers will not cover the use of pharmacologic agents in cardiovascular stress testing except when exercise is not possible. Therefore, the cardiologist's documentation must be able to justify not only why testing was necessary, but also why exercise was not possible, by noting indications and/or diagnosis codes to describe the patient's condition.

For example, the documentation should specifically note that the patient could not walk, was severely obese, or had significant degenerative joint disease. Carriers also may want the documentation to include physical examination findings that demonstrate that the patient could not reasonably be expected to perform exercise stress testing.

If the claim is being submitted to obtain a denial (so that the patient or a third-party payer can be billed), many carriers instruct cardiologists to report code V81.0 (screening for ischemic heart disease).

Finally, to ensure patient safety during a pharmacologic stress test, the continuous presence of the cardiologist is required (SOUNDS RIGHT, BUT IS THIS ALWAYS THE CASE?) and should be documented.

Stress Tests and Visual Studies

Stress testing is a reasonable standard of care for patients with a low likelihood of disease. However, for higher-risk patients or patients with some existing conditions, stress testing alone may not be an efficient indicator.

For such patients, it may be necessary to combine stress tests with other diagnostic services that involve imaging, such as myocardial perfusion imaging studies (SPECT scans, wall motion and ejection fraction analyses) and stress echocardiography.

Terry A. Fletcher, BS, CPC, CPC-Cardio, CPC-E/M, CMSCS, CMC, CCS-P, CCS
Healthcare Coding and Management Consultant
AAPC Local Chapters Board of Directors, Executive Chair 2007-2009 (AAPCCA)
27881 LaPaz Road, G156
Laguna Beach, CA 92677
800-805-8056
http://www.TerryFletcher.net