Be sure your diagnosis code supports medical necessity for the heart test you code.
"If you want to know why your electrocardiogram was denied, look first to your ICD-9 code," says Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.
Sometimes the physician will inadvertently code using a noncovered diagnosis, Rappoport says. The doctor may note that the patient has hypotension (458.0-458.9), or low blood pressure, for example, which is not a covered diagnosis for an electrocardiogram (EKG) in Florida, says Michele Zimmerman, CPC, coder at the four-physician Florida Heart and Vascular Associates in Tampa. In that scenario, the coder should seek out the doctor and ask about signs and symptoms that prompted the order for an EKG.
"The coder should ask the doctor, 'Was the patient having chest pain? Or shortness of breath? Or is he going on a medication that can affect the heart? Or is the EKG for a pre-op?'" Zimmerman says.
Those are all examples of conditions that may be covered diagnoses for an EKG and often, one of them is noted in the patient's record, Zimmerman says.
If you don't find a covered diagnosis in the physician's documentation, however, you should not change the diagnosis code to a covered one, because that would constitute fraud. You must code based on the physician's documentation.
When selecting a diagnosis code, be sure to check your local medical review policies to determine covered diagnoses in your state for EKGs, Holter monitoring and stress tests, Zimmerman says.
Carrier interpretations of covered diagnoses vary from state to state. For example, Cahaba the Medicare carrier in Iowa and South Dakota considers 345.00-345.91 (Epilepsy) a covered diagnosis for Holter monitor testing, but First Coast Service Options, the Florida carrier, does not. In Florida, 423.1 (Adhesive pericarditis), 423.2 (Constrictive pericarditis), 424.0 (Mitral valve disorders) and 425.0-425.9 (Cardiomyopathy) are covered diagnoses, while they are not with Cahaba in Iowa and South Dakota.
Many coders also have questions about how to code the diagnosis if the test shows no problems with the heart.
"A lot of people are confused and think that if you have a normal test you have to code it as a screening," says Kathy Pride, CPC, CCS-P, HIM applications specialist with QuadraMed based in San Rafael, Calif.
That is incorrect. "If the diagnostic test did not provide a definitive diagnosis or was normal, the testing facility or the interpreting physician should code the sign(s) or symptom(s) that prompted the treating physician to order the study," according to Section [...]