A: If a patient cancels or 'no shows', there is no billing to a carrier.  But medicare and other carriers have said that if the patient fills out a waiver/agreement prior to the procedure, explaining the expense of a nuclear no show and they sign it, then you could bill the patient for not showing and your cost.  This is not an insurance expense but a patient expense.

Q:  How do we bill this?  Patient saw three doctors; same tax id number and same date of service in hospital?  If we are not supposed to bill modifier -22, then does that mean the other two doctors not get paid?  Patient saw three doctors because there could be complicating factors.

A:    You can only bill for one visit per day for related services in the hospital or office setting.  The -22 modifier is NOT for E/M codes, only procedures.

Q:  I have a Medicare patient that had a pacer insert on 4/11/00.  He is billing 33212, 33207, 76000-26, DX 427.31 and 427.81.  Then on 4/16 patient was admitted to hospital (home base) by her PCP for rule out Pulmonary Emboli.  On 4/17 the physician did a consult 99253 with DX 427.81, 427.31 and V45.01 (copy enclosed).  Will that fall under the global or is there a modifier I should use?  Also, on 4/19 he did a pacer check in hospital (93734 26 V45.01) then on 4/27 he did an office visit for 42731.  Any help would be appreciated.

A:    As you know, pacers have a 90 day global.  The consult performed on 4/17 would be bundled into that global period.  If the diagnosis was for a completely unrelated problem (hypertension or peripheral vascular disease) then you could bill for it with a -24 modifier.  The hospital pacer check is unbundled.  Only after the global period are pacer checks covered.  The office visit on 4/27 is also bundled.   Tell the physician that for 90 days after the pacemaker insertion, all services relating to that diagnosis are bundled and not billable.

Q:  Will insurance pay for an office visit, a pacer check and a rhythm strip at the same appointment by the same physician and do any modifiers need to be used?  Is rhythm strip considered part of pacer check?  The analysis in description is throwing us off.

A:    The rhythm strip code is bundled into daily hospital rounds, office visits and pacer checks according to the Federal Register.  You can only bill for a rhythm strip code is no other service was done that date.  You can bill for a pacer check on the same date as an office visit only if you are after the 90-day global and if the office visit was for a new problem.  Then use the -25 modifier for the office visit code.

Q:  Billing for a two-day stress test protocol:  patient did treadmill.  He came 3 days later for the resting pictures.  Do we bill complete test as multiple studies on day test is completed or do we bill treadmill with single study then another single study on final date?

A:    You need to bill the code for complete test, multiple studies on the day the test is completed.  It is unbundling per ACC guidelines to bill for a single study and then another study on the final date.

Q:  Patients with Multiple Sclerosis need ECHO's before beginning on a drug therapy regimen.  This drug has "cardiac side effects":  (1) since 1st ECHO is screening, baseline and patient has no cardiac problems, what do we use for diagnosis -- MS?  Can we use V81.2 and/or V72.85 -- which is primary?  (2) On follow-up ECHO's, do we use MS again with V58.9 or V67.51?

A:    I would use the diagnosis 995.2 and then the V81.2 for the first test and if you have any resulting diagnoses for the second use those.  If not, use V67.51 and 995.2 for the follow-up.  You may have to appeal if it doesn't go through the first time.

Q:  The patient is at home and the visiting nurse association comes in and corresponds with us.   We adjust medication or whatever else needs to be done (protein, dressing changes, etc.)  We bill once per month on patient even though patient was seen by VNA 2-3 times a week in some cases.  We are billing 99375 and getting paid at approximately $94.  Is this correct? 

A:    Home visits and care plan oversight - home visits are only to be billed for "on-site" work done by home nurses and physicians that actually go to the patient's home/hospice site.  If you are billing the CPO 99375 then you are telling the insurance company that the doctor is spending 15-29 minutes per month (adjusting meds, home health orders, filling out orders, phone calls to other physicians, etc.) and documenting this in the chart.  If you are doing this then you are correct.  You must be able to show 15 minutes at least.  The home health nurses only get about $6-20 per visit so they are being reimbursed appropriately.

Q:  Does the doctor have to sign the encounter forms?

A:    Regarding the signing of the office encounter forms (fee tickets), the physicians' do not need to sign the encounter forms.  The documentation rule says "...date and legible identity of the observer..." on the medical record.   So only in the chart is this necessary. 

Q:  Dr. A did a consult on a patient at 12:00 p.m.  At 5:30 that evening Dr. B did another consult on the same patient at the request of Dr. A.  Dr. B was asked to cath this patient on the following day.  The consult was done to explain the procedure to the patient and her family.  I am assuming that both doctors will not get paid for their consults.   Can one doctor (Dr. B) bill for prolonged services if both doctors are from the same practice and use the same tax id number.

A:    Since Dr. A is a "general cardiologist" and Dr. B is an interventionist, then the second consult may get paid.  As long as the criteria are met, you will be okay.  Criteria #1 noted in the medical record a request for a consult, #2 opinion or advice only (if the patient was referred for a cath and not an eval there is not consult), #3 documentation by the consulting physician says "I recommend cath" NOT "I will proceed with cath".  So if Dr. A asked Dr. B to perform a cath and Dr. B went in and saw the patient before the procedure, there is no consult since there is 24-hour global on caths.  If however, Dr. A asked Dr. B for a consult/opinion as to whether the patient needed a cath, then you have a consult.   Confusing?  It is for a lot of offices.

Q:  Last year I attended a Medicare seminar.  One of the questions raised was "Could a rythm strip (93041) be billed with a pacer check?"  I understood the answer to be only if it is billed with a telephone pacer check, not an office visit.  Is this correct?  Also, is there someone from Medicare we could send old outstanding claims to?

A:    You cannot bill the 93042 in the hospital setting on the same date as a rounding visit.  It is bundled.  So in the office setting, only bill the visit.   If you are performing TTM monitoring and then the strip, you can bill for both.   As far as a place to send old claims to Medicare, it is on an individual basis.   You can only send requests for a review or hearing in one packet.

Q:  Patient #1 had to go back to OR 10 days after pacer implant for reposition of atrial lead.  Patient #2 was going back to OR one day after pacer implant with a preoperative diagnosis or pacemaker lead malfunction and postoperative diagnosis of micro dislodgement..  Also, I want your input on coding explanting a complete unit, recapping leads, planting new pacer and leads.

A:   (1)  If the leads of a pacer implant need repositioning within the first 15 days after implant, some payers will allow the lead repositioning codes (33216/33217) to be used with modifier -78.   However, it is strictly up to the payer's discretion for payment (most often it is not paid under 15 days).  (2)  Again, same scenario, you could bill a poocket revision code (33222) if no other procedures are billed on the same day.

Q:  (1)   Cardiologist consults a patient, either in observation or an outpatient setting on one day.  Services are billed as 99244.  Cardiologist visits patient the second day (still outpatient).  Can services (day care) on second day be billed, and if so, how?  (2)  Non-Medicare patient is admitted to observation by one of our doctors on day 1.  Discharge is done on day 3.  How do we bill for outpatient care on day 2?  Some insurances allow observation up to 48 hours.  Hospital has kept patient in an outpatient setting.

A:    If a patient is in an "outpatient setting" (23 hours or less), your doctor can bill a consult code (99241-99245) for the initial consult.  If the patient is in longer than 24 hours it becomes an inpatient visit for all subsequent visits (99231-99233).  For observation codes, the same rule applies.  There is 24 and 48 hour observation patients.  If they are in longer than 24 hours, your follow-up visit is subsequent hospital (99231-99233).  If you are the discharging physician on an outpatient or observation patient, look at codes 99217, 99218 and 99220.  There are paid at lower levels than the other codes, but they give you more options. 

Q:  A surgeon at a hospital performes pacemaker insertion on a patient.  The patient's follow-up care was then turned over to one of our cardiologists.  This doctor changed the patient's dressing and wants to know if we can charge for the service along with the follow-up visit.  I need to know if there is a code for this, what it is and if we can bill for these types of services.  Also, is there a time frame attached to this service?

A:    When another physician performs procedures and/or surgery on a patient and then transfers the care to another physician, the second physician can bill for office services with a -55 modifier on the E/M or visit codes, if the procedure that was performed has "global days" attached to it.  (See your Federal Registry.)   If there are no global days then you can charge for your office or clinical services without any modifiers.  But use box number 19 on your HCFA form that is for remarks and give the date of the procedure and type in that you were not the performing surgeon.

Q:  Are we billing the following correctly:  Stress test:  93015.   Thalium Stress test:  93015 & 78465. Pers Stress test:  93015, 78465, J1245.  Stress Echo:  93350 & 93015.  Echo:  93307, 93320, 93325.

A:    Yes, you are billing 100% correctly.  A suggestion: when you are coding for these diagnostic tests, make sure that you are coding the signs, symptoms and indications for a patient and not CAD (Coronary Artery Disease).   This will enable you to show "medical necessity" for your diagnostic tests.  Indications include:  chest pain 786.50, abnormal EKG 794.31, murmur 785.2, abnormal heart sounds 785.3, etc.  The CAD, if any, is coded on the follow up visits.

Q:  What are the correct codes to use for initial stent and subsequent angioplasty on two distinct vessels (example given)?

A:    You will use code 92980 (single vessel), 92981 (additional vessel) then for the stenting, you will code 92982 and/or 92984 for each additional vessel.  Because the CPT book describes the procedures as being performed at the same same session, a modifier is not necessary.

Q:  When a patient is referred to our physician in the hospital for a consultation and then care is transferred to that doctor at a later date, is that patient considered a new or established patient upon induction into the office?

A:    According to the AMA's CPT guidelines and all Medicare guidelines:   "...a new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years."  This definition does not have a place of service differential attached to it.  It basically means that if any physician of the same specialty in your group sees a patient in the hospital setting, hospice, E/R, office, home visit, rehab, (i.e. anywhere), that the patient is considered an established patient for any follow-up care.

Q:  Patient has dual transtelephonic pacer.  Check with another company's equipment.  However, report is sent to cardiologist for interpretation:  What code do we use for interp.?

A:    93733-26:   Same code no matter who does the interp.

Qn:  When billing a bubble study with a full echocardiogram done in the office, can any added components be billed (example:  start of the IV)?  Presently I am billing procedure codes: 93307 M26, 93320 M26, 93325 M26 (all the components of the interpretation of a full echocardiogram).  Description of a bubble study:  After the echo is completed an IV line is started.  10 cc syringe of normal saline are agitated and rapidly introduced into the IV with specification of the right atrium/right ventricle.  This is repeated at least 3 times with maneuvers to alter intrathoracic pressure.  The bubble study allows us to assess for right to left shunting (and left too right intercardiac shunting.)  The study not only adds time to a regular echo but adds expense (line, saline, etc.)  Can we bill for anything else?

A:    You are billing all of the components of the echo correctly, however, for your saline you can bill 90784 to private carriers and put your ml for the saline.   If it is Medicare, the HCPCS code is J7042 for 500 ml of saline.  (If less is used then append the modifier -52 to the HCPCS code.)  You cannot bill for extra time with an echo.

Q:  How do I bill for aortic arch angiography and subclavian angiography?  Also, I would like to check the proper coding for subclavian Percutaneous Translumianal Angioplasty of the subclavian artery and subclavian artery stenting.

A:  The rules for coding peripherial arteriography changed, effective January of 1999.   Prior to this year, you could bill for each component of peripherial arteriogram/PTA/Stent.  Now you can bill only for the most distal and the most "extensive" procedure performed on a given artery, similar to the method required for cardiology interventions.  The code that you list for the subclavian artiogram is correct for both arch and subclavian arteriogram:  36215.  If you perform an arch aortogram and a subclavian arteriogram at the same time, only the subclavian can be billed but the code is the same for both.  Additionally, you should bill 75710-26 for the supervision/interpretation of the resulting x-rays/cineangiograms.   The proper codes for subclavian PTA, unilateral is 35475 and 75962-26; 35475-50, 75962-26 and 75964-26 for bilateral subclavian PTA.  37205 and 75960-26 are the correct codes for subclavian stent.  37205; 37206; 75960 for bilateral stents.  Remember again that, effective this year, you can't bill for a PTA and stent of the same vessel.  Only the most significant service performed (the stent) should be billed.

Q:  How do I code for chambers implants?

A:
Single Chamber (Ventricular):  33207 - Insertion Implant (exploration); 71090 - Fluoro
Single Chamber (remove old generator): 33223; 71090 - Fluoro
Implantation of lead:  33249 Placement of device leads; 71090 Fluoro; 93641 Testing device; 93618 - Induction/Attempted Induction.
On HCFA Form: 33207; 71090-26; 33223-51; 71090-26-59; 71090-26-59; 93641; 93618.
Dual Chamber Pacer on HCFA Form: 33208; 71090-26; 33223-51; 71090-26-59; 71090-26-59; 93641-93618.  (FYI:  If the leads needs repositioning within the first 15 days, some payers will allow the lead reposistioning codes (33216-33217) to be used with a -78 modifier.  It is strictly the payer's call to be approved.  Your Medicare payer in Massachusetts will pay for this once.  Pocket revision (33222) is only billed if there is no other procedure performed at the same time or for the above procedures when the generator site must be moved due to extenuating circumstances.)

Q:  Regarding frustration of physician with MI fifth digit and need for detail.

A:    While physicians are frequently frustrated with the detail necessary in reporting diagnosis codes, their use to the level of detail mentioned in the article is required and quite important.  The specification of which wall has infarcted may seem to be minutia but payers will frequently delay payment of claims if "unspecified" codes are used.  The "episode of care" fifth digit, while frustrating, is also essential.  Let's try to simplify its use.  Use fifth digit "1" if the patient is being cared for in the immediate, post - in fact hospitalization.  Use fifth digit "2" for any services after the initial MI hospitalization for office visits or procedures until six months post MI, when the "412 - old MI" diagnosis code is used.  While the ICD code states fifth digit "1" is to be used for the first 8 weeks and the "2" therafter, until the six month time frame, these definitions are not truly vital to correct payment/coding.  They were created as a tool for statistical analysis at hospitals and don't have any bearing on payment beyond their absence or use of unspecified digit "0" causing payment delays.

Q:  A 47-year-old female with the diagnosis of recurrent syncope.  Extensive cardiac testing was done to include EP studies, Cardiac cath, Head-up Tilt studies, and loop monitoring.  Now an implantable loop recorder (IRL Medtronic Reveal) is the current treatment plan.  How should we code for this procedure?

A:    Since this patient is not a Medicare patient, your reimbursement probability will be better after the past testing you have done.  We recommend that you try and get a specific authorization for this.  Code this as follows:  9326822 - (implantable event recording with presymptom loop) per 30 days; 93270 - recording, hook-up, and disconnect; and 93271 - monitoring, receipt of transmissions and analysis.  Only code the patient's signs, symptoms, and/or indications for this recorder.  (For postsymptom recording, see 93012, 93014.)

Q:  How do you bill for critical care codes?  They are unclear as to where critical care services can be rendered and paid.

A:    Typically, critical care services are attached to a place of service code 21 or "in-patient."  They can also be billed with 23, or emergency department location.  Outpatient location 22 rarely covers cc time.  It is almost impossible to get paid with the office place of service.