Navigating Cardiology Billing and Reimbursement

Understand the complexities and regulations in the cardiology billing landscape. Discover expert tips and best practices to navigate these issues and optimize reimbursement.

Cardiology billing and reimbursement involves multiple and challenges and complexities, highlighting the need for specialized support. 

Coronary artery disease represents the leading cause of death worldwide. The most prevalent cardiovascular diseases, such as coronary artery disease (CAD), atrial fibrillation, heart failure, hypertension, and stroke, are complex, and caused by a combination of genetic and environmental factors. As cardiologists strive to provide the best care to control the symptoms, they need to follow proper billing and coding practices to ensure optimal reimbursement. In the ever-evolving healthcare landscape, outsourced medical billing services are a practical way to streamline claim submission and get paid for services rendered. 

In the U.S., the numbers of men and women who are affected by and die from coronary artery disease (CAD) exceed all other conditions including all forms of cancer. The prevention, diagnosis and treatment cardiac diseases remain a great challenge despite the advancements in medical care, state-of-the-art medical technologies, and health awareness measures. 

Cardiology billing and coding presents unique challenges and complexities due to the specialized nature of cardiovascular care, evolving technology and complex diagnostic protocols. To code intricate and complex procedures, such as angioplasty, stent placements, ECG recording, lilac repair, and electrophysiology studies, requires an-depth knowledge of cardiology terminology and medical procedures as well as the latest ICD-10 and CPT codes. Additionally, complying with federal rules, and varying guidelines and regulations of both private and insurance payers is also difficult.  The complexity of the entire process can have a huge impact on cardiology practice reimbursement if not handled correctly.  

Cardiology departments require specialized teams with expertise in the intricacies of cardiology billing and coding. The cardiology medical billing process involves many steps:

Coding: Cardiology procedures and services described in the clinical documentation need to be reported using the right codes and modifiers. This requires assigning the appropriate ICD-10 codes to indicate diagnosis and CPT codes to describe the procedures and services performed. Care should be taken to avoid overcoding and undercoding. Cardiology patients often have more than one medical condition and it’s important to document and code these comorbidities. Cardiology procedures involve multiple components, and understanding and navigating the rules for bundling and unbundling codes is crucial to prevent coding errors. 

Claim creation: After code assignment, claims are generated and submitted to the appropriate payers – private insurance, government programs and patients.  As insurance payers impose strict deadlines for claim submissions, timely filing is essential maintaining for avoiding penalties and maintaining a steady revenue stream. Providers also need to also adapt billing and coding practices to support new payment models that focus on quality outcomes rather than volume of services.

Handling insurance verification and prior authorization: Insurance verification plays a key role in the billing process. the process of checking the patient’s health payer coverage and benefits prior to the encounter is necessary to confirm if the patient has active insurance coverage, what procedures/services are and are not covered, and how much of each procedure the insurer will cover and the patient’s financial obligation

Insurance companies usually require prior authorization for select cardiology procedures: For instance, UnitedHealthcare’s cardiology prior authorization program applies to certain instances of these diagnostic and interventional cardiology procedures: diagnostic catheterizations, electrophysiology implant procedures, echocardiograms, and stress echocardiograms. Handling insurance verification and obtaining prior authorizations is a time-consuming and challenging process.

Staying informed about regulatory changes and payer guidelines: Keeping up with the regulatory environment governing cardiology billing is another challenge.  Cardiologists must comply with HIPAA, CMS and ACA guidelines, and stay informed about any changes or updates to these regulations to maintain compliance. However, ambiguities and major changes in Medicare coding policy, Evaluation and Management documentation guidelines revisions, and complexities in insurer payment policies have made accurate coding difficult, according to an article published the Journal of the American College of Cardiology. Even unintentional mistakes in coding could lead to prosecution for Medicare fraud. 

To avoid these pitfalls, a thorough knowledge of codes and coding policy is critical. 

As indicated above, thorough and up-to-date knowledge of cardiology CPT and HCPCS codes is essential to categorize services and procedures. The appropriate ICD-10 codes for diseases or diagnosis codes should be paired with CPT codes to demonstrate medical necessity of the services provided. With changes in technology, procedure codes are often updated. Furthermore, appending the correct modifiers to codes is necessary to identify a variation from the usual service described by that code. Here are the CPT codes for cardiovascular procedures: 

* 92920-92998 Therapeutic Cardiovascular Services and Procedures

* 93000-93050Cardiography Procedures

* 93224-93278 Cardiovascular Monitoring Services

* 93279-93298 Implantable, Insertable, and Wearable Cardiac Device Evaluations

* 93303-93356 Echocardiography Procedures

* 93451-93598 Cardiac Catheterization Procedures

* 93600-93662Intracardiac Electrophysiological Procedures/Studies

* 93668-93668 Peripheral Arterial Disease Rehabilitation

* 93701-93790 Non-invasive Physiologic Studies and Procedures

* 93792-93793 Home and Outpatient International Normalized Ratio (INR) Monitoring Services

* 93797-93799 Other Cardiovascular Procedures

The ICD-10 codes for cardiology billing include codes for cardiovascular and ischaemic disease, circulatory system diseases, hypertensive disease, metabolic and nutritional diseases, and abnormal glucose. Here are some ICD-10 codes for this specialty:

* I20.9 Angina Pectoris, NOS 

* I21.09 Myocardial Infarction, Acute, Anterior (initial episode of care) 

* I21.3 (initial episode of care)

* I25.10 Cardiovascular Disease Unspecified

* I25.10 ASHD Coronary Artery

* I25.10 ASHD Unspecified

* I25.10 CAD (Coronary Artery Disease)/ASHD

* I25.2 Old Myocardial Infarction

* I25.84 Coronary Lesion

* I25.9 Chronic Ischaemic Heart Disease

* I48.91 Atrial Fibrillation

* I50.9 Congestive Heart Failure 

* I63.9 CVA

* I63.9 Stroke

* I65.23 Carotid Artery Occlusion, Bilateral

* I65.23 Carotid Artery Stenosis, Bilateral

* I65.29 Carotid Artery Occlusion

* I65.29 Carotid Artery Stenosis

* I67.2 Cerebral Atherosclerosis

* I67.9 Ischaemic Cerebrovascular Disease

* I73.9 Peripheral Vascular Disease

* I10 Essential Primary Hypertension, Includes: high blood pressure

hypertension (arterial) (benign) (essential) (malignant) (primary) (systemic)

As cardiology billing depends heavily on accurate and detailed documentation, physicians should focus on ensuring comprehensive documentation of procedures performed as well as the medical necessity for each service. For billing and coding compliance, both Medicare and private insurance require cardiology practices to maintain accurate and complete medical records.

* Ensure you have a team that specializes in cardiology billing and coding, including modifier usage.

* Make sure your team stays up-to-date on the latest codes, payer guidelines, and industry regulations.

* Provide accurate and complete documentation of procedures and services rendered.

* To avoid errors in claim submission, perform internal medical billing and coding audits to identify and correct any mistakes.

* Establish a proper insurance eligibility verification process to check patient coverage and benefits before services are provided

Keeping up with the ever-changing healthcare regulations and coding updates requires specialized knowledge Outsourcing ensures access to professionals with the necessary skills. Experts stay well informed about changes in regulations and adopt best practices for effective cardiology billing. Medical billing outsourcing companies have specialized teams with expertise in the intricacies of cardiology billing and coding. They also have insurance verification specialists who will properly verify patient benefits, minimizing risk of claim denials due to eligibility issues.