Although treatment has advanced leaps and bounds in the last few decades, heart disease remains the leading cause of death for U.S. adults. And with more than 20 million U.S. adults facing coronary artery disease, cardiology remains one of the busiest and highest-paid specialties.
But high demand and top-tier salaries won’t matter much if your private cardiology practice has a problematic revenue cycle. Cardiology is a complex field with ever-changing treatments and procedures. That means keeping track of new cardiology medical billing guidelines and medical coding best practices, which can sometimes vary across payers. Even a solid claim scrubbing process may not catch every slip-up.
Fortunately, following a few crucial cardiology billing tips (like those outlined in the cheat sheet below) can help your practice reduce costly errors and ensure a healthy revenue cycle management (RCM) process.
Cardiology Billing Guidelines and Coding Cheat Sheet
Keeping track of cardiology CPT codes and billing best practices is far from easy. We’ve put together this short cheat sheet with a few basics for cardiology medical billing. You can download the full cheat sheet here.
Common Mistakes and Pitfalls in Cardiology Billing and Coding
Like many medical specialties, cardiology coding, claims and reimbursement can get complex. Below are some of the common cardiology billing challenges your team may encounter.
Not Checking Coverage Guidelines Before Procedures and Tests
One of the most common mistakes with cardiology billing is forgetting to check a patient’s specific coverage guidelines for a procedure or test. Missing this important step can pose problems for the patient and the practice. Reimbursement could be at stake, and patients may feel confused or frustrated when they receive a surprise bill for their care.
Beyond insurance eligibility, it’s also important for your team to check coverage guidelines before a cardiology procedure or test. You’ll need to make sure all prior authorizations, referrals or pre-certifications are in place before the scheduled procedure. Each payer will have specific guidelines, so understanding the intricacies of the patient’s plan is critical for a smooth claim filing process.
Not Coding for Comorbidities
Cardiology patients often face more than one diagnosis, also called comorbidity. Common heart disease comorbidities include diabetes, high blood pressure (hypertension) and COPD.
When it comes to cardiology billing and coding, it’s important to document these comorbidities to help ensure your practice gets reimbursed as much as possible. You can document diseases separately or use ICD-10-CM combination codes.
ICD-10-CM stands for the International Classification of Diseases, Tenth Edition, Clinical Modification. Like CPT codes, ICD-10-CM allows physicians to speak a common language for diagnoses.
When documenting different diagnoses, check the coding instructions and read the code descriptions carefully. In some cases, you may need a combination code. A combination code helps classify multiple diagnoses, a diagnosis with a complication, or a diagnosis with a secondary manifestation. For example, a patient whose heart failure was caused by hypertension.
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Not Adding the Proper Modifiers
Cardiology codes often include modifiers at the end. Modifiers are two-digit codes that show you’ve somehow altered the service in the original five-digit CPT code.
For example, you may add modifier 25 to a patient visit where the clinician determined the patient needed a stress test at the end of the visit. Modifier 25 is for “significant and separate evaluation and management (E/M) on the same day as another procedure or service.” You would add “-25” to the end of the CPT code for the patient visit.
Not using modifiers properly could result in lost revenue for your practice. In the example above, forgetting the “25” modifier may mean you miss out on reimbursement for the patient visit. Instead, the payer may lump together the visit with the stress test procedure.
Other common cardiology modifiers include:
- 22 – Increased procedural services
- 51 – Multiple procedures done at the same time
- 52 – Reduced services
- 53 – Discontinued procedure
Not Being Specific with Your Coding
Every cardiology condition has various options for diagnosis code. Coding mistakes often happen when you choose a code that isn’t specific enough for the diagnosis.
For example, the ICD code for unspecified systolic congestive heart failure (150.2) differs from the code for combined systolic and diastolic congestive heart failure (150.4).
Coding for the Symptoms and Not the Diagnosis
Often, cardiology coders submit symptom codes in addition to or instead of diagnosis codes. For the best possible reimbursement, only submit symptom codes if they are unrelated to the diagnosis. For example, if a patient is diagnosed with angina, you don’t need to submit a code for chest pain.
How to Prevent Cardiology Claim Denials
Know Payers’ Billing Guidelines and Set Up Rules for Unique Edits
Every payer is different, so you must understand the billing and coding intricacies for each. Understanding the unique guidelines can help avoid denials and delays in payments.
If you have a payer with a unique billing protocol or code edit that your team is repeatedly entering, find an RCM tool that can automate this process. With the Gentem platform, for example, you can work with our team to create edits for specific claims or payers, which saves time and reduces the chance of manual error.
Keep Thorough Documentation
It’s always a good idea to keep detailed documentation for each patient, including symptoms, diagnoses, comorbidities, tests and treatments. Make sure you keep track of all patient encounters and avoid waiting too long between the date of service (DOS) and entering charges (also called charge lag).
Having thorough notes will help your practice with pre-authorizations or certifications, as some payers require comprehensive patient notes. The notes will also help your practice if needs to appeal any claim rejections or denials.
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Create an Accurate Eligibility Check Routine
Verifying a patient’s insurance eligibility is an essential first step in the RCM and claim submission process. Your claim may not get very far if a patient doesn’t have an active insurance plan.
It’s a good idea to set up a process where you can automatically check upcoming appointments. For example, the workflow could check eligibility for the following week’s schedule, giving your team plenty of time to reach out to patients if there are insurance issues. A tool with batch eligibility check features can save your team time, too.
Take Steps to Avoid Human Error
With so many twists and turns to cardiology billing, it comes as no surprise that simple human error is often the biggest hurdle to a clean claim process. With that in mind, make sure you:
- Work with a billing and coding team that has experience in cardiology
- Audit your RCM and billing process often to find patterns and errors that may be affecting your cash flow
- Set up a thorough review and claim scrubbing process
- Partner with a smart RCM software solution that provides automated workflows to reduce the likelihood of human error
Cardiology CPT Codes
The CPT codes for cardiovascular procedures typically range from 92920 to 93793. Some common cardiology CPT codes include:
- 93010: Electrocardiogram (ECG or EKG), routine with at least 12 leads
- 93798: Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)
- 93015: Cardiovascular stress test using treadmill or bicycle exercise, continuous ECG monitoring with supervision, interpretation and report
- 93306: Echocardiogram (Echo) where the provider uses a transducer to get a 2D picture of the heart through the chest wall (transthoracic).
Find a Partner Who Can Modernize Your Cardiology RCM and Billing Process
Efficient and accurate coding is one piece of healthy revenue cycle management and crucial to the success of your cardiology practice. Billing and coding mistakes can get expensive and ultimately affect the viability of your practice.
Keeping up with CPT and ICD code changes is helpful, as well as having experienced and knowledgeable coding staff. Efficient and effective billing processes can also go a long way in helping your bottom line.
If you’re finding it difficult to get full reimbursements for your cardiology care, Gentem’s AI-powered revenue cycle management (RCM) platform can help you improve your billing process and submit cleaner claims. We’ve helped cardiology practices increase collections, allowing them to expand staff and care for more patients.