Ensure medical necessity before reporting common cardiology diagnostic procedures
August 25th, 2014 - Lisa EramoMedical necessity is important in any specialty but particularly in cardiology where physicians perform diagnostic tests frequently. It’s important for coders to ensure that medical necessity is clearly documented before they report common diagnostic procedures, said Linda Hallstrom, CPC, CPMA, CPC-I, CEMC, during the AAPC’s 22nd annual HEALTHCON conference in Nashville, TN earlier this month.
The volume of cardiology diagnostic procedures performed in the United States is high, and coders working in this specialty must think about medical necessity constantly, she said. “More Americans suffer from heart disease than a lot of other conditions,” Hallstrom told attendees. “Heart disease and stroke are two of the leading causes of death in the United States for both men and women.”
An EKG is one of the most common diagnostic tools that cardiologists use to diagnose and treat heart disease, she said. However, physicians tend to over-use it, which can raise potential red flags, she added.
“Some cardiologists think of this as the patient’s ‘vital sign,’ and it’s hard for them to think about medical necessity,” Hallstrom said.
However, an EKG is not a mandatory test for every patient. Instead, it’s actually used to assess the heart’s rhythm as well as conditions such as ischemia, a heart attack, or other abnormalities (e.g., enlarged heart), she told attendees. Carriers want to see evidence that the test is necessary—whether it be a positive cardiac finding or a specific sign or symptom that warrants the test. She said she’s aware of at least one carrier that requests a copy of the EKG and interpretation before rendering payment.
Coders should also consult Local Coverage Determinations, National Coverage Determinations, and individual carrier policies to identify a list of signs and symptoms that meet medical necessity for EKGs, Hallstrom said. Some examples include ischemia, hypertrophic heart disease, heart murmur, tachycardia, altered mental status, or even metabolic abnormalities.
For EKGs performed as a part of a preoperative evaluation, report ICD-9-CM code V72.81 (Preoperative cardiovascular exam) followed by a diagnosis code that denotes the reason for the anticipated surgery, she advised.
One audience member stated many cardiologists don’t document whether an EKG is ‘preoperative,’ making it difficult to understand why the test was performed—particularly when the test results are normal.
Hallstrom says this is a challenge and that physicians should ideally document ‘pre-op’ in their order.
During her presentation, she also spoke about echocardiograms—tests that provide an ultrasound image of the heart in real time. Clinical indications for this test could include murmurs, chest pain, heart attack, heart defect, or family history. Other indications could include endocarditis, exposure to cardiotoxic agents, native valvular heart disease, cardiac tumors and masses, and a variety of other diagnoses.
Sometimes patients undergo an echocardiogram before starting chemotherapy, Hallstrom said. “There are some chemotherapies that are very harmful to the heart, so they want to get a status or baseline,” she said. “Sometimes during the chemo, the patient will be sent for interval evaluations to see if there is any heart damage resulting from that chemotherapy.”
She noted that at least one payer has begun to require prior authorization for echocardiograms for Medicare Advantage patients. Any and all information that cardiologists can provide is helpful, she added.
Hallstrom also discussed the importance of medical necessity for stress tests used to evaluate the heart’s response to stress. Cardiologists use this test to evaluate whether there is adequate blood flow, the effectiveness of medications or previous procedures, and the likelihood of the presence of coronary heart disease, she said.
“There’s a lot of value in comparing the resting heart to the stressed heart to see how it reacts differently,” she said.
For example, a treadmill EKG is often performed after a patient has an abnormal EKG or when he or she experiences chest pain.
“If the patient is unable to exercise, then they’ll pharmacologically stress the patient with medication that has a short shelf live or that reverses when the test is done,” she said.
Many of the same conditions that justify medical necessity for an echocardiogram also justify medical necessity for a stress test. It’s important for coders to capture the HCPCS code for the medication used to stress the patient, Hallstrom advised.
Physician documentation of medical necessity is important today, and it will be even more so in ICD-10-CM, she said. “Medical necessity is the drive force behind getting our claims paid,” she said.
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