How to reduce cardiology claim denials

Why cardiology claim denials look different

Cardiology billing mixes office visits, diagnostic testing, interventional procedures and long-running device follow-up, often spread across the office, the hospital and an outpatient imaging suite.

Most cardiology denials trace back to a few predictable questions: who billed which part of a test, whether the diagnosis supports the test, whether the payer authorized it, and how procedures and visits were bundled. Our guide on how to reduce claim denials covers the general method. This article covers the causes specific to cardiology.

Professional and technical components: modifiers 26 and TC

Most cardiac diagnostic tests split into two parts. The technical component covers the equipment, the technologist and the supplies. The professional component covers the physician’s interpretation and report. Echocardiograms, nuclear stress tests, cardiac CT and MRI work this way, and some services, such as certain ambulatory ECG monitoring, use separate codes for each part instead of modifiers.

• Global billing (no modifier) is for when your practice owns the equipment, employs the staff and reads the study.
• Modifier 26 is for the interpretation only, usually because the test was performed in a hospital or another facility that bills the technical side.
• Modifier TC is for the technical side only, when someone outside your practice reads the study.

The classic denial is a global claim for a test done in a hospital outpatient department. The hospital has already billed the technical component on its facility claim, so your global claim either denies or gets paid and recouped later. The place of service on your claim should match where the test was physically performed, and your charge capture should default to modifier 26 for hospital-based reads.

Medical necessity denials: NCDs, LCDs and diagnosis linkage

Medicare covers many cardiac tests only for specific indications, set out in National Coverage Determinations and, more often, in Local Coverage Determinations published by each Medicare Administrative Contractor. Commercial payers publish their own medical policies, and they don’t always agree with Medicare or with each other.

Medical necessity denials in cardiology usually come from one of these:

• The wrong diagnosis on the line. The chart supports the test, but the claim carries a vague symptom code that isn’t on the covered list, or the right code was entered and never pointed to the test’s line item.
• Frequency. Repeat echocardiograms and stress tests are a common target. Many policies expect a documented change in symptoms or clinical status before a repeat study is covered.
• Screening versus diagnostic. A test ordered without symptoms or a qualifying condition may be treated as screening, which many plans don’t cover.

The fix starts at the order. The ordering provider’s note should say why the test is needed, in terms the coverage policy recognizes, and coders should code from the documented indication instead of the test’s usual purpose.

For traditional Medicare patients where coverage is doubtful, an Advance Beneficiary Notice signed before the service lets you bill the patient if Medicare denies. Without a valid ABN, that denial usually ends up as your write-off.

Prior authorization for nuclear and advanced cardiac imaging

Commercial and Medicare Advantage plans commonly require prior authorization for nuclear stress testing, cardiac CT, cardiac MRI and PET, and some require it for echocardiography too. Many plans hand these reviews to a radiology benefit manager: a separate company with its own portal, phone line, clinical criteria and rules.

Where imaging authorizations go wrong:

• Code mismatch. The approval covers one CPT code and a different one is performed, for example a study done with contrast when the approval was for one without. Many plans allow a short window to update the authorization after the service. Miss it and the claim denies.
• Site and provider. Approvals are often tied to the rendering provider and the location. Moving the patient to another office or facility can leave the claim without valid coverage.
• Expired dates. Approvals have validity windows. A test that slips past its window because of rescheduling needs a new or extended authorization.

More on the workflow side in prior authorization in medical billing.

Cath lab and interventional coding: bundling denials

Cardiac catheterization codes are built as bundles. The diagnostic catheterization codes already include the injections, imaging and supervision and interpretation that go with them, with the specific code depending on which side of the heart was catheterized and whether coronary or bypass graft angiography was done. Billing those parts separately on top of the bundled code produces NCCI edit denials.

Interventions add another layer:

• Diagnostic cath on the same day as PCI. Diagnostic angiography at the same session as an intervention is generally included in the PCI. The exceptions are narrow: no prior catheter-based study exists and the decision to intervene came from this one, or the prior study is inadequate or the patient’s condition has changed. The report has to say which, and the diagnostic code needs the modifier the payer expects, usually 59 or an X modifier.
• Vessel modifiers. Coronary intervention codes are reported by major vessel and branch, with coronary modifiers such as LD, LC, RC, LM and RI identifying the vessel. A missing or wrong vessel modifier, or two base codes on the same vessel, is a frequent denial.
• Add-on codes need their primary code on the same claim. If the primary denies, the add-on follows it.

Coding these cases from the full procedure note instead of a charge slip prevents most of these errors.

Device monitoring billing periods

Pacemaker, defibrillator and implantable cardiac monitor follow-up generates a steady stream of small claims that are easy to get wrong in bulk. Remote monitoring codes cover a defined period, 90 days for remote pacemaker and ICD interrogation for example, and are reported once per period. The usual problems:

• Timing. Billing a remote period before it’s complete, or reporting the same period twice.
• Overlap. Billing an in-person interrogation by the same practice for the same device inside a remote monitoring period, where the code rules don’t allow both.
• Wrong code family. Pacemaker, ICD and cardiac monitor codes aren’t interchangeable, and the professional and technical portions of remote monitoring are reported separately.

A device clinic needs a report showing each patient’s current period dates, so billing isn’t rebuilding periods from old claims.

Modifier 25 on same-day E/M visits

Cardiology patients often see the physician and have a procedure on the same day. When the visit is significant and separately identifiable from the procedure, modifier 25 on the E/M line tells the payer so. Payers scrutinize it closely.

• Separate work, separately documented. The note should show evaluation beyond the usual pre-procedure assessment: a new problem, a worsening condition, or management of other conditions.
• Different diagnoses help but aren’t required. The visit can share a diagnosis with the procedure if the work was genuinely separate.
• Major procedures use modifier 57. When the visit produces the decision to perform a procedure with a 90-day global period, modifier 57 applies instead of 25.
• Payers edit differently. Payers vary in how they treat visits billed alongside diagnostic tests, so check each payer’s policy instead of appending 25 to every same-day visit.

A routine that keeps cardiology denials down

Default hospital reads to modifier 26 in charge capture, check authorization on every imaging order, have a coder review every cath report, keep a device period tracker billing can see, and review denials monthly by root cause and payer. Our cardiology billing page explains how we handle these areas day to day.

If you’d like to see where your own cardiology denials come from, ask for a free A/R audit. We’ll look at your recent claims by payer, provider and root cause, and the findings are yours whether or not you work with us.