Top Ten Regulatory Landmines in EP

The government is spending approximately $1.8 billion to audit and prosecute healthcare fraud this year. You minimize your risk of being penalized by becoming familiar with the top ten regulatory landmines faced by electrophysiologists when billing for their services.

#10: Claiming that you performed a procedure that is not fully supported by your operative report.

   The National Correct Coding Initiative Policy Manual for Medicare Services specifies that “Physicians must avoid up coding. A HCPCS/CPT code may be reported only if all services described by that code have been performed.” Electrophysiologists should keep this standard in mind when reporting comprehensive EP studies (CPT codes 93619, 93620) and left atrial pacing and recording (CPT code 93621).    A comprehensive EP study (93620) is one that includes six distinct sub-component services; each of these is listed in the code’s official description: “Comprehensive electrophysiologic evaluation including insertion and repo- sitioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording.” CPT also contains a “five component” comprehensive EP study code (93619) which includes all of the components of code 93620 except for the attempted induction of an arrhythmia.    When the operative report does not support that all five or six of the components asso- ciated with one of the comprehensive studies were performed, the limited EP study can more accurately be reported with a collection of the CPT codes assigned to each of the subcomponent services: 93600 (Bundle of His recording), 93602 (Intra-atrial recording), 93603 (Right ventricular recording), 93610 (Intra-atrial pacing), 93612 (Intraventricular pacing), and 93618 (Induction of arrhythmia by electrical pacing).    Code 93621 is defined as “Comprehensive electrophysiologic evaluation including insertion and repo- sitioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure).” Unlike the comprehensive EP study codes, there are not associated sub-component codes for the two elements of this code: left atrial pacing and left atrial recording. Therefore, if the report does not support that both left atrial recording and left atrial pacing were performed, it would be necessary to attach the reduced service modifier (52) to the CPT code.This will probably result in a 50% reduction in compensation.

#9: Reporting confirmatory tests as diagnostic.

Diagnostic tests performed strictly and routinely to confirm the success of a surgical procedure are considered to be a component of the surgical procedure and not separately billable. For example, diagnostic EP studies and attempted induction of an arrhythmia following drug infusion should not be reported when performed strictly to confirm the success of an ablation procedure.    There are certainly exceptions to this general restriction as is illustrated by coverage for defibrillation threshold testing following the implantation of a defibrillator and intravascular ultrasound (IVUS) following stent deployment. Therefore, if there is a separate indication for diagnostic testing following a surgical procedure, make sure to clearly document the indication in the report.

#8: Reporting device-based cardioversion or overdrive pacing with a listed CPT code.

   It can take four or five years to establish a listed CPT code for frequently performed, new services. Procedures that are performed only rarely may never have a listed CPT code developed. Currently, there is no listed CPT code that accurately reflects cardioversion or overdrive pacing performed through an implanted pacemaker or defibrillator. According to the instructions in the front of the CPT book, we should not report a CPT code that merely approximates the service provided; if no CPT accurately describes the service, we must use an unlisted code such as 93799 (Unlisted cardiovascular service or procedure).This is the code that should be used to report cardioversion and overdrive pacing performed through an implanted device.    It is inappropriate to report these procedures with codes: 92960 (Cardioversion, elective, electrical con- version of arrhythmia; external), 92961 (Cardioversion, elective, electrical conversion of arrhythmia; internal [separate procedure]), or 93724 (Electronic analysis of antitachycardia pacemaker system [includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings]).    External cardioversion involves the application of external patches, internal cardioversion involves the percutaneous insertion of electrodes, and code 93724 is only appropriate if the patient has an “antitachycardia pacemaker system.”

#7: Billing for road mapping with device implants.

   According to CPT book instruction, diagnostic venograms should not be reported when performed for road map- ping purposes to facilitate a therapeutic procedure.    When performing left ventricular lead implants, it is common for EPs to perform occlusive coronary sinus venograms. These are not separately reportable since they are being performed for road mapping purposes. Make sure to not report the venogram with the code that is only appropriate for cerebral sinus venography, 75860 (Venography, venous sinus [e.g., petrosal and inferior sagittal] or jugular, catheter, radiological supervision and interpretation).    Similarly, some doctors routinely perform extremity venography to road map the advancement of electrodes through the subclavian vein and superior vena cava; these venograms should not be separately reported either. Make sure to not report extremity venography with code 36005 (Injection procedure for extremity venography [including introduction of needle or intracatheter]) and/or 75820 (Venography, extremity, unilateral, radiological supervision and interpretation).

#6: Reporting diagnostic echocardiography for AV optimization.

   The medical necessity for diagnostic tests is commonly defined in coverage policies at the national or Medicare contractor level. Most Medicare contractors have a limited coverage policy for echocardiography which specifies the conditions that warrant the performance echocardiograms; none of these policies list the AV optimization of a biventricular device as a valid indication. Therefore, reporting a diagnostic echocardiogram when echocardiography is used to guide AV optimization is not covered. Reporting a diagnosis code that is covered but which is not the main reason for the test on the date it is performed could be interpreted as a false claim.    An alternative approach to achieving AV optimization involves using thoracic electrical bioimpedance. In addition to the safety offered by a national coverage policy, this approach is generally less time and resource intensive. After familiarizing yourself with the national coverage indications, you can report this form of AV optimization with code 93701 (Bioimpedance-derived physiologic cardiovascular analysis).

#5: Claiming heart cath reimbursement for trans-septal puncture.

   It is tempting to secure additional reimbursement for the complexities associated with atrial fibrillation abla- tion by reporting code 93527 (Combined right heart catheterization and trans-septal left heart catheteriza- tion through intact septum [with or without retrograde left heart catheterization]) in addition to your ablation procedure code. However, in virtually all cases this would be incorrect.    The introductory notes to the EP section of CPT indicate, “Intracardiac electrophysiologic studies (EPS) are an invasive diagnostic medical procedure which include the insertion and repositioning of electrode catheters...” and “catheter insertion and temporary pacemaker codes are not additionally reported.”    Several heart catheterization coverage policies add to the clarity of this issue with verbiage like “There is no additional reimbursement for a right heart catheterization performed in conjunction with electrophysiologic tests or interventions, HIS bundle studies, pacing studies, temporary pacemaker insertion, pulmonary angiography, endomyocardial biopsy or interventional cardiac procedures, when done for reasons other than a hemodynamic evaluation.”    The complexities associated with performing atrial fibrillation ablation should be reported by attaching the complex procedure modifier (22) to the supraventricular tachycardia ablation code (93651) and/or by reporting the unlisted procedure code 93799. Making sure that the operative report clearly reflects the complexities of the proce- dure and that your billing staff tracks every claim filed in this manner will maximize your chance of securing com- pensation in excess of the typical SVT ablation payment amount.

#4: Non-compliance with “inci- dent to” and “shared visit” rules.

   Medicare publications dictate that you must meet specific requirements in order to secure 100% of the physician fee schedule amount for the work performed by mid-level providers. In the office setting, you must be in the suite when your mid-level sees an established patient for an established problem. In the hospital setting, the mid-level provider and the physician must both have face-to-face visits with the patient and each provider must personally document what his/her visit consisted of. The physician can then bill for the combined work supported by both visit notes.

#3: Billing for a visit on the day of an elective procedure.

   The Medicare Claims Processing Manual specifies that pre-operative visits provided after the decision for surgery was made are included in the surgical reimbursement and not separately billable. Because of this restriction, electrophysiologists should not report any evaluation and management services on the day of or the day before a device surgery. Similarly, physicians should not report any visits on the day of a scheduled EP study or ablation.    While attaching certain modifiers to the evaluation and management service code may secure reimbursement, it would be false to attach these modifiers if the decision for the procedure was made on a prior date.

#2: Claiming compensation for the work of device company representatives.

   Device interrogation services consist of professional and technical components. The electrophysiologist’s contribution (supervision, interpretation, and report) constitutes the professional component of the service. The technician who operates the programmer and the overhead expenses for the facility in which the device interrogation was per- formed constitute the overwhelming majority of the technical component. Because of this, it is never appropriate for a physician to request reimbursement for the technical component of device interrogations performed by device company representatives or for any tests performed in a hospital. Instead, the physician should attach the professional component modifier (26) to the appropriate device interrogation code.    By attaching the 26 modifier, you will only see a reduction of around $26 in compensation. However, the frequency with which these services are reported, and the array of applicable regulations, magnify the intensity of this regulatory landmine.

#1: Hospital follow-up visit documentation.

   The most mundane of tasks (documenting progress notes) is the number one regulatory landmine faced by electrophysiologists. These services are provided with great frequency and they are typically documented in an expeditious manner. However, a level three hospital follow-up visit (99233) has a higher documentation standard than a level four follow-up office visit (99214).    Government auditors have stumbled onto the fact that a high percentage of these follow-up visit notes do not support the levels of service reported and have initiated thousands of audits focused on hospital follow-up visits. It is very important for physicians to understand the applicable documentation guidelines for these services. After an extensive peer-review initiative, I was able to condense the most critical of the documentation guidelines into a 19- minute video, which can be viewed at CardiologyCoder.Com.    The most common documentation requirement that causes hospital follow-up notes to fall short is the history of present illness.To support a level three follow-up hospital visit, your note would need to contain at least four recognized descriptors of the HPI: location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms. Alternatives include documenting the status of three chronic or inactive conditions, establishing that history could not be obtained from the patient due to their condition (such as being intubated), or to bill based on time rather than the amount of history, exam, and complexity documented in the note.