Good afternoon, and welcome to today's webinar. Today, we're going to be discussing CV diagnostic coding updates specific to our imaging leaders. My name is Jamie Warren. I am part of the CARE Transformation Team here with MedAxiom, and I am honored to be able to introduce our speaker today, Jamie Quimby, who is an expert in all things coding and will help us have a better understanding from an imaging leader perspective. Next slide, please. A little housekeeping before we get started. At the bottom of your screen, you will see a button for chat, and this is where you're able to download today's presentation. I do highly recommend that you do. There is a lot of very valuable information to be able to come back and resource. The second button at the bottom is your Q&A, and please type any questions as we go along in this presentation. If time permits, at the end, we will be able to read out some of these questions and get Jamie to answer, and if we do run out of time, no worries. We will answer these and then post them on the website. So, with that, I would like to turn it over to Jamie. Thank you. All right. Thanks so much, Jamie. All right. Welcome, everybody. We're going to start with covering some of the common coding and documentation tips for reporting some of our cardiovascular diagnostic services. Then we'll go into some of the guidelines, policies on placing orders and supervisions and medical necessity, and then we'll cover some of the carrier guidance put out with some FAQs. So, let's start with touching up on guidelines, because each Medicare contractor out there and national CMS, they all will release these guidelines. Some will be pretty similar word for word. Some will have a few differences to them, but then you also have to factor in your commercial payers, your state Medicaid policies, you know, just all the different carriers that we deal with. So, it can vary across country what coverage is, so just keep that in mind. It's important for your coding team and your billing staff to be familiar with a lot of stuff. We really depend on one another. When I was in a practice previously, I worked very closely with a lot of the imaging leaders and the physicians just updating them annually on any changes in any of the policies that would affect stuff that we report. So, just to start, this is guidance from Medicare on order requirements, and this is from the Benefit Policy Manual. Medicare defines this as an order is a communication from the treating physician or practitioner requesting that a diagnostic service be performed for a beneficiary. So, pretty standard definition. Typically, there will be a written documentation from the provider's office stating what the service that they are ordering is, along with some indications listed as to why they are ordering it. Usually, that is listed just with the diagnosis code. It could either be a known diagnosis that the patient has or symptoms that the patient is having. This can be placed either electronic, it could be hand-delivered, which doesn't happen too often anymore, mailed or faxed to the testing facility. There may be times when a verbal order via telephone is placed. Typically, in that scenario, whomever is receiving that verbal order will then place documentation in that patient's chart with those details of the verbal order that was given. The point here to stress is that there has to be an order for any diagnostic service being performed. So, you can't just, you know, perform a service without there being that order indicating that medical necessity. So, now we're talking about medical necessity. So, what is medical necessity and how is it defined? So, first, there, again, must be that documentation to support the intent of the order that for that service being placed. There, again, should also be documentation as to why that service is being requested. Again, this is typically listed with diagnosis codes, either with a confirmed diagnosis that the patient has or the signs and symptoms. Then, typically, what on the back end will happen is your coding and billing staff will look at, or either your staff that helps with doing your pre-authorizations for those studies, they will then look at the carrier policy for that patient, determine, you know, if anything further needs to be done prior to the test being completed. With Medicare, they have something called a national coverage determination policy, what we typically will refer to as an NCD. And then, from a local Medicare perspective, the contractors will list a local coverage determination, or what we typically will call an LCD. The LCDs are typically pretty similar to the national coverage determination listed, but they may have some further specific details listed in that particular Medicare contractor's policy. You would follow your LCD primarily, unless there is no LCD, and then that's when you can refer to the national Medicare policy. Again, each carrier will list that, and I'll just slide over my internet here. So, I have First Coast service options listed here. You can see on their website, this is just their homepage, they will have different tabs here, and most carriers are similar to this, but here's an LCD, which is that local coverage determination, and then you can see, you could just slide over it, and you can look at active LCDs, and, you know, just to type in right here, you can either search by a name, if you know the CPT code for that service, you can type that in, or you could just search at the different ones they have listed, but just for example purposes, I'll type in an echo code, a 93306, and you can see they have different policies listed. Sometimes there may be more than one. If the LCD is any coverage indications, stuff like that, frequency limitations, those types of details will be listed in that. Then, when you're in the LCD, at the bottom, they will list an article. What the article further details out is the specific CPT codes and the specific diagnosis codes that are covered for that service, so just wanted to point what those two differences are out to you. And again, each Medicare contractor will be set up similarly. You'll be able to look for, you know, a particular test that you're looking at, and then you can find out what that coverage will look like. Okay. Okay, so we just covered what an LCD is, so I'll go ahead and skip through this. Again, that's just what your local Medicare contractor policy would be. For supervision requirements, each type of test may vary on what the supervision assignment would be, and you can find those details out on the Medicare Physician Fee Schedule. They will list out supervision identifiers with either the one, two, or the three, primarily, if it's applicable to that service, so with general supervision, that means the procedure is furnished under the physician's overall direction and control, but their presence is not required during the performance of that service. With direct, it means they must be present in the office suite at the time the service is being performed, but they do not have to physically be in the room again, and then, again, with personal, that means they have to be physically in attendance during the service being performed, so, again, these can vary just depending on the different type of the cardiovascular tests that we provide, so sometimes, if you're not performing a service in your office where you don't own the equipment, a lot of the billing part of this will get split, so there will be a professional component and a technical component of this, so with the professional component, so, again, if you do not own the equipment and you're only reporting that professional piece of it, you would append modifier 26 if it's applicable to that code, and then that would tell the carrier you don't own the equipment and you're only reporting that professional piece to it, but it does represent the physician's work on that professional component. It would include the interpretation of the service rendered and then, again, that physician report where they sign it. The technical component is all the administrative work, the cost of the facility, those types of things, equipment, all that stuff, and then that part of the claim would be reported with a TC modifier, again, if it's applicable to that code. We have some codes, and I'll show you examples as we go through the specific codes throughout the webcast. Some are only accounting for either that technical or professional component, so then you wouldn't have to report the modifier because the code you're reporting for billing is accounting for those services specifically. So, just some quick tips on how to answer if medical necessity is met. Again, what service is needed, meaning what is the provider ordering? Why are they performing the service? So, what is the indications on that order? Does the reason for the service meet any national or local coverage guidelines? Again, so looking at those Medicare policies, again, some of your commercial payers and other payers you deal with will vary. How, who, and where is the service going to be performed? So, are you performing it in your office setting where you own your equipment, or are you performing it at a testing site or a hospital outpatient site, that type of thing? And then, again, do I have accurate, appropriate order and documentation to support reporting that service? So, again, you have to have the order in the patient's chart. You have to have a documentation from the provider of what the service was rendered, what the findings were, and their signature. So, now we'll talk about some specific CV diagnostic services that we perform. This is not going to be an all-inclusive list, but more so the most highly ones we do report in the cardiovascular community. We'll first start with our echocardiograms. Typically, we'll call these TTEs. You can see there's different reporting options just for those. It depends on whether or not you have a complete study that is also including the spectral Doppler and your Color Flow Doppler. The 93307 is a complete study, but it does not include those spectral and Color Flow Dopplers. Typically, we don't see the 93307 done too often. Normally, the two Dopplers are included in the study. Depending on the frequency limitations and the carrier policies, you know, if a patient had a complete echo done maybe three months ago, and their particular carrier says they can only have a complete study once a year, it could vary depending on if you report this limited or it's also a follow-up study. It could be a complete study, but it's a follow-up and you're reporting it within the frequency limitation allowed. Again, it just depends on that carrier policy. If you have a 93308, this is not including the Dopplers performed. If you also perform a spectral and Color Flow Doppler, you can add those services on for billing, and those we'll cover in another slide. A 93303 is a complete study for congenital anomalies. These also do not include the Doppler codes, so if those are supported in your report, you can report those additionally. And again, the 93304 is a follow-up or limited study for the congenital cardiac anomalies. So how do we define a complete study versus a limited? This is actual language in the American Medical Association, the CPT book that we pull all of our wonderful codes out of. So they define a complete study with the spectral and color flow as including that 2D imaging, the M mode when performed. Keep that in mind, that's in parentheses, so it's not fully required. It says when it is performed, it would be included as part of that complete study. The left and right atrium, your left and right ventricles, your aortic mitral and tricuspid valves, the pericardium, and then the adjacent portions of the aorta. Now, keep in mind, most times when I'm looking at an echo report, a lot of times I have findings of the pulmonary valve too. That's not a requirement for a complete study, but since it's also documented in my findings, you know, it's part of the complete study. The point is, if you don't have pulmonary valve findings, you wouldn't downcode it, you know, to a limited study. It's not a requirement in the complete study guidelines that we have. For our transesophageal echo, or TEE, there's different reporting options for this as well. So, the 93312 is including the probe placement, your image acquisition, and your interp and report. Now, if the provider did not document in the report that they placed the probe, then that requires, from a billing perspective, that we have to downcode that service and only report the 93314 for the documentation of the report with the image acquisitions and their interp and report. Now, there are rare occasions sometimes where maybe the provider only placed the probe and another provider did that interpretation piece. So, that's why these codes are split up. The 93312 is what we call a global code, so that's the full code in its entirety where everything's included. And then you have the component codes where you can kind of break it out, depending, if not, the full global part of it was supported in that note. The 93315 is similar, it's just for the congenital cardiac anomalies. So, same thing, the 93315 is that global service that includes everything, including that probe placement, your image acquisition, and that final interp and report. And again, if they only place the probe, that's when you would break the codes out, and if there's no mention of that probe placement, that's when you build just the 93317. We also have a structural heart TEE code to report, this 93355. Guidelines are very strict with this code. It is only reported by a provider that is not performing the interventional procedure. So, we typically see these done a lot with our TAVR patients to be, for an example. So, say you have your interventional cardiology and your surgeon involved with the TAVR placement, you would have to have a different provider doing this TEE same day if you want to report it. Sometimes our interventional provider doing the TAVR will also perform the TEE. In cases like that, Medicare is very strict and they will not allow both to be reported. So, if you have a provider that's doing your TEE, the TEE service, and they're doing the TAVR procedure, you would not be able to report the TEE, essentially. So, again, guidelines are very strict. It has to be performed by a provider not involved with the procedure, the structural procedure being performed. It does include all measurements, probe manipulation, Doppler and color flows are also included. Any 3D imaging is also included in this code. So, nothing extra to report if a full complete study is done here. This is just actual guidance from the Medicare NCCI manual. So, Medicare updates this manual yearly. These are edits that they put in place that we have to follow from a billing perspective. So, this again is actual language and they actually reference a TTE and or a TEE and it's related to our TAVR procedure or the mitral valve replacement procedures. And again, if the same provider is reporting that procedure, then they would not be able to report the, if they perform the ECHO also, they would not be able to report. And you can see in the guidelines, they actually quote these specific CPT codes that you cannot report in conjunction with that procedure being performed. So, this is, again, one of the more stricter policies Medicare has put out there, but that is the language word for word. These are the Doppler add-on services. Now remember, if you're doing a complete ECHO cardiogram with that 9-3-3-0-6, that does include the Doppler and color flow. So, you would not report these separately. But say you have a limited study with that 9-3-3-0-8 where maybe they're only looking at maybe the mitral and aortic valve. They didn't look at all, you know, both of the atriums or the ventricles. So, you truly only have that limited study. But you have documentation that shows that the Doppler and color flows were both performed. You can report those as add-on codes. Anytime you see a plus in front of a CPT code, that means it's an add-on code and there has to be a primary code reported with it. Medicare, or not Medicare, the CPT book does list in the actual book the codes that you can add, that would be the primary code add-on for these services. From a coding perspective, there are always a lot of questions as how can you tell when Doppler and color flow are done if it's not specifically referenced in the actual note itself. So, a couple things. So, the physician really should be specific on the components that they're using to support the billing. CPT assistant does state that using terms such as Doppler and color flow is sufficient documentation for reporting those services. So, usually when you're looking at an echo report, at the top of it, it'll list what the type of study you're doing. So, it'll say, you know, echo with color flow and or it'll say echo with Doppler or color flow. That's sufficient documentation. Sometimes when you're looking in the findings of the study, it will reference, you know, something not found on color flow Doppler or, you know, just it'll list it within the findings. But it doesn't always, so that's why it's important, at least at the top of the report where you're showing the type of study you're doing to list out the techniques that are being used for that study. A common misconception that we get from the coding community is if regurgitation findings are documented and that means they did color flow. And I actually use this slide when I'm doing coding education, too, because in the spectral Doppler part of the study, you can see that regurgitation can come from that pulse wave Doppler. So, when I have coders say to me, well, there's regurgitation, that means color flow was done and, you know, my response is, well, you don't know that because from the spectral Doppler, the pulse wave portion, it also gives regurgitation findings. So, again, it's just the best advice I can give is just have the provider or the technician, whoever is inputting that data, list those techniques being used and that will help be supportive. So, myocardial strain imaging, this is definitely becoming increasingly popular that I'm seeing used during ECHO studies. So, there's not a lot of guidelines as far as policies out there. So really the best recommendation I have as far as coverage goes and documentation. Describe any abnormalities that are found during that part of the study. Sometimes they're normal and that's fine, but really listing why you're doing it, those types of details. Also, this code does not, you can see it's an add-on code too, so it has the plus in front of it. A lot of questions also get asked because there's no professional or technical modifier that is applicable. So meaning that 26 modifier or that TC modifier. So if you're doing this in a hospital setting, both the provider and the facility can report this add-on code as long as it's supported in your documentation. So there would be no 26 or TC modifier applicable to that particular code. Again, you want to document any of the clinical relevant findings. Sometimes the measurements will be listed that I see and the provider will specifically state that those measurements are either normal or abnormal. 3D echo services. So we did get a new code last year, this 93319. It's only related to 3D echocardiograms for congenital cardiac anomalies. So if you're not doing the 3D imaging for a congenital anomaly, then we are instructed to report either this 76376 or the 77, just depending on if that independent workstation is documented in the note. Most times it's not, so then we just report this 76376. I can tell you carrier coverage for the 3D is very, very strict. Some of the carriers on the 7000 series, they want an abnormal diagnosis code reported. So for cardiology, it would be an R93.1. So if the 3D imaging is abnormal, then that would be the diagnosis that would be supportive in the medical necessity policy that Medicare has. Again, it can vary depending on your carrier, but I do know from a Medicare perspective, they are quite strict with the coverage on the 3D reporting. Bubble study. Again, sometimes we see a bubble study performed. There is nothing separately reportable from a billing perspective. Medicare doesn't pay anything extra for this, so it would just be included in the primary code you're reporting, the primary echo code that you're reporting. Echo enhancement agent study. So sometimes DFINITY is used. Again, this is only reportable if you own your equipment. So if you do a DFINITY echo study in the hospital setting, the hospital billing would actually report the DFINITY code itself. But if you're in your office setting where you own your equipment, you can report this Q9957. Most carriers, you have to add the NDC number, which is the drug number assigned to it, and then you have to fill out the units and the MLs and all that wonderful stuff on the claim. All that stuff's done on the back end, but it's very important to document that specific detail in your echo note, though, with documenting the amount of contrast that was used, so that way we know. If you're using Lumison, the Q9957, it's excluded from the Medicare physician fee schedule or that Optuson, which is Q9956, that is also excluded from the Medicare physician fee schedule. So from a professional perspective from physician reporting, Medicare would not cover those two Q codes. But DFINITY is covered, so that's listed here on the slide. That is the code that supports that. Stress echo. So sometimes you may... We'll see a stress echo done. Sometimes a stress echo and a traditional echo is done, and we'll cover that in some of the FAQs later. But with the stress echo, these are broken up depending on, again, if you own your equipment or not. So the 93350 is your stress echo. It's rest imaging and stress imaging both included, and that's with your provider interpretation and report. If you don't own your equipment and you're breaking your billing up, then you would use the 93350 along with your component codes of the stress test portion itself. Now, if you're in your office setting, you own your own equipment, the same provider supervised, and they're doing the reading of the study, the 93351 is your full stress echo. That also includes the stress portion. Now, the billing can get tricky with this if you say you're doing it in a hospital setting. So we know you don't own your equipment. So the interpretating provider would report the 93350 with the 26 modifier to show that professional component. Then they would also report a 93018. That's for the stress test interpretation part of the study. Now, if that same provider also was physically in the room supervising during that stress portion, they could also report the 93016. So the 93015 through the 18 is our stress test reporting codes. The 93015 is that global code that we were talking about. So there's always a global code. The global code reports everything. So that's you owning your equipment. So that includes that technical and professional aspect of it. And then the 93016, the 17, and the 18 are the component codes if you have to break the billing up. So again, sometimes in a hospital setting, it may be a different provider supervising. So that provider would get to report the 93016 for the personal supervision. And then your interpretating provider would report the 93350 for the report. And again, you're going to pin that 26 and then that 93018, which is that stress test interpretation. So again, it just depends on your scenario and where the study is being performed and what the ownership of the equipment is. 93352 is if any agent is used during that stress echo. That, again, it has a plus sign in front of it. So that would be an add-on service. It would have to be reported in conjunction with one of these codes. All right. So stress testing and nuclear studies. So again, these were the stress test codes that we just covered. So again, that 93015 is your global code, so that includes everything. The 16 is the personal supervision only. So that's without the interpretation and report. That's the provider physically being in the room during the stress. The 93017 is the tracing only. 93017 is the tracing only. So this is that technical aspect of the service. So again, if it's done in a hospital setting, the hospital would report this 93017. And then your provider interpretation or report is with the 93018. But again, if you own the equipment and you're doing all the components, you just report the 93015, and that accounts for all three of these below. Here's just some scenarios for billing. Because, again, this can get kind of complex just depending on ownership of that equipment, place of service, all that stuff. So here we have a place of service of 11, which is our office setting. The provider provides the supervision, they own their equipment, and they're going to personally interpret that study. So again, you bill that global code with the 93015. Now, in this scenario, we have a place of service hospital. So it could be inpatient or outpatient with your 21 or 22. A hospital owns their equipment. Dr. A is supervising the stress test. Dr. B is the one interpreting it and documenting it. So Dr. A would report the 93016, and Dr. B would report the 93018 for that interpret and report. Same scenario, but it's the documentation, the supervision done by the physician assistant or the APP. Depending on the state scope of practice and what those laws are in that state, a lot of them have gotten relaxed, especially since COVID. They have started allowing supervision, personal supervision of the APPs. So if you have a scenario like that and your state allows for the billing, your APP could bill for that supervision that they provided, and then your provider that did the professional interpretation would then bill for their portion of that. Myocardial perfusion imaging are what we typically just call our nuclear stress test. So the 78451, this is for a single-spec study. And you can see here, that's the difference. I don't see a lot of the planar studies done anymore. Most of the equipment that I see done in the hospitals across the country are with that spec imaging. So the 78451 would only be a single study. It could either be at rest or stressed. These aren't too common. Typically it's a multi-study where they're going to do both. They're going to image at rest and then they'll stress the patient and do additional imagings of the stress part of it. So that would account for the multi-study. So this is the most common one we see. Again, if the facility is using this type of equipment, that's when it's the same thing. It would either be a single study or a multi-study report. If you're in your office setting where you own your equipment, you can report the stress agents also being done. If it's done in a hospital setting, the hospital actually is the reporting provider for the stress agent. So again, just depending on the ownership part of the equipment would depend on if you can report these or not. So if you're doing it in your office setting and you own your equipment, then you can report these codes. Again, the coverage just varies as far as like how many units and all that stuff you would report just depending on what was used. This is not an all-inclusive list because there are many. These are just kind of the most common ones that we see. For Alexa scan, you know, the J2785, the adenosine is another common one I see done. So just depending on how much is done depends on the units that you report. Again, the radiopharmaceutical supply also. So this is an addition. If you own the equipment, you can also report these two. Cardiolite and the myo view are the two common that I see common. Again, these are done per study dose. So the units could change if you're doing a rest study and a stress study and they do two doses of it, you could change that to the two units since it was used at rest. And then again, at stress. So again, if you don't own the equipment, you're doing in a hospital setting, for instance, you wouldn't report these because the hospital would report them. So this is just a nuclear stress test case example here. So you can see our indications is listed for the atypical chest pain and palpitations. It has the risk factors document. You can see the, the pharma logical agent was documented here along with the, the stress, the rest and stress dose with the mild view. You can see that was done twice. Here's our documentation. And then down here, we have our findings. So for professional reporting with the place of service 11, and we have the same provider, they would report the 7, 8, 4, 5, 2 for that multi-study report, the 9, 3 0 1 5 for the stress portion. And then you have your mild view and then your Lexus scan with the units. And then if it's done in a hospital setting, you can see how those codes come off. And then we also have to break up the, the stress reporting. So I obviously blocked out patient information and provider details, but the provide this case had the same provider supervising. You see, it was monitored by the provider. And they also did the interpret and sign the report. So they are able to report the 9, 3 0 1 6 and that 9, 3 0 1 8. For the, what we typically call just the mug of studies. These aren't too commonly used, but that these are the coding options available. Again, you can see the plus sign here. So this will be an add on code. That would have to be reported in conjunction. CPT again would list this, the specific CPT codes that are approved to be listed as the primary reporting options. So again, it just depends on the 7, 8, 4, 7, 2 is that, that planar study for a single and then you have your multi-study and that, you know, they just break them down. So again, we don't see these too commonly anymore. Most common is either our nuclear stress test or the pet services that we'll be covering now. So for pet reporting, we're going to spend a little more time discussing these as there were so many reporting options. Now depending on what would be supported in the note we're looking at, there are three major types of pet myocardial imaging services. There's the metabolic studies, the perfusion studies, and then there's a combination. Each type has an additional code to report the services as an option when that concurrent transmission CT is also performed. So we'll cover all these specific codes in the next three slides. So these are the CPT codes for the pet, for the metabolic evaluations, the 7, 8, 4, 5, 9, and the 7, 8, 4, 2, 9, again, describe only the pet metabolic evaluation. The 7, 8, 4, 5, 9 includes the ejection fraction and the ventricular wall motion when performed and to specify just a single study. The 7, 8, 4, 2, 9 is exactly like the 7, 8, 4, 5, 9, except it includes that concurrent acquired CT transmission scan. So if there is no supportive or it wasn't performed, the CT part of it, then you would just report the 7, 8, 4, 5, 9. Guidelines further do allow with these two specific codes that if a CT is done for coronary calcium scoring, so that would be reported with 7, 5, 7, 7, 1, and we'll cover that again in the upcoming slide, you can separately report that with one of these codes if it's supported. All right. So these are the pet codes available for our perfusion evaluations. There's four options available. The 7, 8, 4, 9, 1 is a perfusion study. That's a single study. So it's either at rest or stress. The 7, 8, 4, 9, 2 is your perfusion study. That's multiple. So it'd be at rest and stress. And the 7, 8, 4, 3, 0, and 3, 1 are identical to these two codes, except they include the acquired computed transmission scans. So again, if those are supported in your notes, then you would report one of these two codes, depending if it's a single or multi-study. And then these are the last reporting options. So code 7, 8, 4, 3, 2 reports a combination of that perfusion and metabolic evaluation. So these are the combinations that would include both. And these would combine the previous codes we just covered with the 7, 8, 4, 5, 9, that 7, 8, 4, 9, 1, or that 7, 8, 4, 9, 2, depending if it's that single or multi-study. Your 7, 8, 4, 3, 3 is the same as the 7, 8, 4, 3, 2, except it includes that CT scan, if done. And finally, on the 7, 8, 4, 3, 4, you can see, again, this has a plus in front of it, so it cannot be reported by itself. It is an add-on code. So this reports pet myocardial absolute quantification of myocardial blood flow at rest and with that pharmacologic stress. Guidelines state that this service includes separate computer processing to generate measures of global and regional myocardial blood flow. This does require a separate technologist's work, typically on a separate computer system, and then with validation of the computer data by the physician or the other qualified healthcare professional. This service is reported in conjunction with either that 7, 8, 4, 3, 1 or that 7, 8, 4, 9, 2. So that's where CPT lists, those are the only two codes this can be reported with. So those are our two pet perfusion multi-studies, one that is either being, one of them includes that CT transmission scan, if supported. So just to recap, guidance for coding our pet services, again, capture, correct CPT and ICD-10. The ICD-10 is our diagnosis reporting to support that medical necessity. Again, each Medicare contractor will have policies out on these pet services. A lot have further defined the coverage for these because there's so many codes to choose from now. Code for any add-on services, so for that stress portion, like we did with our nuclear stress test, you can report those stress codes separately, if they're supported. And then, again, if you own your equipment and you're doing it in your office setting, you can report your medication or the injections being done. All right, cardiac CT. So these are the available CPT codes we have for our cardiac CT reporting options. So 75571 reports the CT of the heart. It does that quantitative evaluation of the calcium deposits in the coronary tree. High levels of calcium deposits in the heart's triple, triples a person's likelihood of suffering, again, that adverse cardiac event. So this is our coronary calcium scoring that we typically call. The 75572 includes the 3D image processing assessment of the cardiac function and evaluation of venous structures if performed. This study includes the quantitative assessment such as the coronary percentage stenosis, the ejection fraction, the stroke volume, and the ventricular volume when performed. On the 75573, this is for a CT of the heart with congenital anomalies. Again, it also would include assessment of the left ventricle cardiac function, the right ventricle structure and function, and again, any evaluation of the venous structures if performed. When they say if performed, it means it's not a requirement, but if it's performed, it's included. So there will be no separate reporting essentially. These also include the quantitative assessments such as that coronary percentage stenosis, the ejection fraction, the stroke volume, and that ventricular volume, again, when performed. And then finally, on our 75574, this is a CTA. So this would be done to evaluate the heart function of the heart, the coronary arteries, and any bypass grafts present. As with the last two codes that we just covered, it also includes the quantitative assessments such as that coronary percentage stenosis, that ejection fraction, the stroke volume, the ventricular volume, again, when performed. These are the FFR codes. Sorry, I'm going to get a sip of water real quick. These are the FFR codes that are reportable now with that coronary CTA. So if you're doing that 75574 and they also are doing this FFR imaging, you can report just depending on the, you know, how much of it they are looking at. So these are what we call a category three code. So these are not graduated yet to a full CPT code like that 75574 is. So with the category three code, coverage is definitely carrier specific, carrier price. So it's not going to be listed on the Medicare physician fee schedule. You'll have to go to that particular, your particular carrier itself and look up the code to see what their coverage would be. Some may cover it and list a fee reimbursement attached to that specific code. Some may say it's not covered yet because of it being a new code. So again, coverage does vary. I do know from talking with the coding community across the country that some carriers for them do pay, some are denying. So it's just going to depend. Best thing I could say recommendation wise is just have that medical necessity documented. You are able to try to appeal claims when they are denied, you know, and sometimes that will help get these carriers to start covering services like this. So again, if this is used frequently, they will look at this code and decide at that time, you know, it could be two years from now, for example, if they see a lot of these being reported, they may go ahead and graduate it to an actual full CPT code, which is a category one code. But for now we have it as a category three code. So again, that coverage is going to vary just depending on the carrier and the area you live in. Okay, so non-invasive peripheral studies now. So again, documentation guidelines for our duplex studies. So they do require spectral and color flow Doppler are required for these studies. Guidelines states it's needed for assessment of both flow and color and recording of that spectral waveform. Include at least one of the following, either that spectral, that flow velocity, the resistant index, the wave or the pulse. For a complete duplex, it must include the arterial inflow and the venous outflow. And again, with that color and spectral Doppler, a limited duplex must have at least color and spectral Doppler still documented. There's different types of studies, just depending on what area you're looking at. So these are our codes available for our carotid duplexes. Again, if you have a complete bilateral study, you're able to report this 93380. If it's a unilateral or a limited study, or maybe you're within the frequency limitations of reporting, it's going to just depend on the 93882 being reported or not. This is just, this is actually an LCD, a local coverage determination example from a Medicare contractor, a WPS on the carotid duplex frequency reporting. Now remember, a lot of those LCDs do list the frequencies allowable for those particular tests. So this is again, just as an example of the carotid one from that WPS carrier. So first they say each patient's condition and response to treatment must be medically warranted, and it must warrant the number of services reported for payment. Essentially medical necessity must be supported in that patient's chart. Second, they will monitor the frequency or follow-up studies for medical necessity. Third, only one preoperative service is considered reasonable and necessary for bypass surgery. Fourth, the re-evaluation of existing carotid stenosis coverage does state in this policy that patients demonstrating a diameter reduction of greater than 50% with symptoms and less than 60% with no symptoms are followed up on an annual basis. So again, just depending on that degree of the stenosis, whether they have symptoms or not will, you know, depend on how often you can report that. If the patient becomes symptomatic, a repeat study is allowed. Last, any follow-up studies outside a global period for a carotid endarterectomy are done at six weeks, six months, and then annually thereafter, again, unless that patient develops symptoms. So again, this is just an example of the details that are listed in that local coverage determination policy, and again, you could just go to that Medicare contractor in your region and look this information up. They do vary, you know, they can vary by the different contractors, and again, they will vary by the different types of tests too. For our extreme extremity arterial duplex scans, you can see we have different reporting options, whether it's a lower extremity or an upper extremity. So the code 93925, just to start, this is a bilateral lower extremity procedure. It requires imaging of at least the entire common femoral, the superficial femoral, and the popliteal arteries. The deep femoral, arteries, the deep femoral, and the tibial peroneal arteries may also be imaged, but they are not required for a complete study. So again, a complete lower extremity study would include the common femoral, the F, the superficial femoral, and the popliteal. Report code 93926 when either a unilateral or limited study is performed. And then on our upper extremity, again, if it's a bilateral complete study, they define that as imaging of the subclavian, the axillary, and the brachial arteries. If you do the radial and the ulnar arteries, those are not required as a complete study, but they would be included if they are also imaged. Again, and then the 93931 is when a unilateral or limited study is performed. Sometimes they may do studies of both the upper and the lower extremities on the same day. Again, just having that clinical documentation supporting that medical necessity is important. You know, whether the patient's having, you know, symptoms in both the upper and lower extremities, just those types of details should be documented. Extremity venous duplex codes. So a complete lower extremity study does include imaging of at least the common femoral, the deep femoral, the popliteal, and the great saphenous veins. Any other veins that are also imaged on that study, like the tibial or the peroneal, would still be included, but they're not required for that complete study. So that's for lower. So this code actually does not specify whether it's upper or lower, so it would apply to both. So if you do an upper and a lower extremity study same day, there is a medically unlikely edit, meaning how many units we can bill. It's only assigned one unit, but most have success adding two units and appealing if necessary. So again, it's just going to depend on that medical necessity if you do have to do an upper and lower extremity study same day. For the upper study, though, the requirements that would be for the complete study would be the jugular, the subclavian, the axillary, the brachial, and the basalic and cephalic veins. So again, any additional veins on the upper from that would be just part of the study. For our aorta, the IVC, iliacs, or bypass grafts, so this code, it doesn't require all to be done for a complete study. It just has to be a full study of one. So again, the 93978 includes imaging of the abdominal aorta, the IVC, and the iliacs or grafts that may be involved. It's used whether the entire course of just one of these vessels or all of the vessels are imaged. So again, if you only do a full study of your iliacs and you do bilateral, that's still supportive of the 93978. The 93979, again, is just a limited study. So if they only do one side or don't do a full, complete study of both sides, then you would report that. Our ABI reporting, there's lots of reporting options here, too, with the three codes available. So these do require, they have the functional measurement procedures that include the Doppler, the ultrasound studies, blood pressure measurements, oxygen tension measurements. It also involves the measurements and recording of one of the several methods of changes in the size of the body part as modified by that circulation of the blood. There's different coverage options depending. So with the 93922, this is a limited study. The requirements of limited study are one of the three above. So right here on the slide, one of these has to be documented. So for all three, it includes the distal posterior tibial, the anterior tibial, dorsalis, pedis, arteries. The ABI is to be done at at least one to two levels to support this 93922. The levels themselves are the high thigh, the low thigh, the calf, the ankle, the metatarsal, and the toes. So they would have to at least have two of those levels documented. For the upper extremities, you must meet one of the three above. Again, they are all included, the Doppler determination, the systolic pressures, and the recordings, again, at one to two levels. For the upper extremities, the levels they define include the arm, the forearm, the wrist, and then the digits. So you'd have to have at least two of those levels documented there. For a complete lower extremity with that 93923, so first, for the first three, you would have the ABIs of the distal posterior tibial, the anterior tibial, the dorsalis, pedis, arteries. In the fourth example, you can report a single level if the functional maneuvers are performed, which are measurements with the posterior test or the measurements with the reactive. Again, the levels are described, again, by the high thigh, the low thigh, that calf, the calf, the ankle, the metatarsals, and the toes. Again, same, similar for our upper extremity. Again, just remember with the levels, again, are your arm, your forearm, your wrist, and then your digits. All right, I know we're coming up on time here, so I'll try to go a little bit quicker. So our ambulatory monitors, so the EKG reporting is pretty straightforward. I know there's some, we get a lot of questions sometimes on the monitors, like with your holters and the zeo patches and stuff, so we're going to kind of break those down. Again, ECHO report, our EKG reporting is pretty standard. If you own the equipment, you would report your global code with the 9300. If you don't own it and you're only doing the interpretation, again, that's just done with your 93010. Coverage for a rhythm strip are very strict. If you're reporting an evaluation and management service same day, they will bundle the service in with that, and they will not pay it separately. So again, just typically we see these one to three leads done in the hospital setting, and they will bundle it if an E&M is done same day. Cardiovascular monitoring services, so we got some new codes a few years ago with these, and we used to have the zeo patch codes, which were a category three, and like I had mentioned earlier, if the reporting frequency is pretty high with these, like meaning you have your patient population or using a lot of those, they will graduate that code to a category one, so that's what happened with those zeo patches. So just to start, our holter monitors includes up to 48 hours of continuous recording, and then depending on, most practices don't, they work with a third party company on them monitoring it while the patient's, you know, has the device on, and they'll send the provider any incidents that pop up, or they'll send them that final report for them to review and interpret. So most time you won't be billing the global code with these. You'll break them out with the component codes, so the 93227 is for the professional interpretation only. Again, and that's up to a 48-hour study. Now with your zeo patches, what we typically call, these get broken up between the 93241 and the 48. So your 93241 through your 93244, and I probably should have listed these codes out in more detail, those are a monitor that is greater than 48 hours and up to seven days. Your 93245 through your 48 are, if it's greater than seven days, but up to 15 days. If you do your hookups in the office, say you have one of your medical assistants or your nurse actually hook the patient up to the monitor, you can bill that hookup code as well. Typically the hookup code is going to be a different date than the the interpretation of that study. So that's a big thing to point out there. You bill the interpretation to date the physician does the interpret and report and signs it. So that that's the date you report for that. So again, just goes based off of the monitoring period that they wore these. Your mobile cardiac monitors or your MCOTs, what we typically call those, those can be up to 30 days. There is no hookup code reportable with this service specifically. So if they do hook the patient up to that monitor, there's nothing for billing there. On your event monitors, again, these are up to 30 days. Also there is the 93268 is that global code. So again, most times it's a third party that is kind of monitoring it on the back end while the patient's wearing it. So, but you can report the hookup if you do hook the patient up with the device and then you report the 93272 for that provider interp. Again, your dates are going to be different. Your date of the hookup will be the date that happened to the patient. And then your interpretation date will be, you know, maybe 30 days later when the provider analyzed all the recordings and stuff and then did their report. Oh, well, here's the breakdown of the codes. So again, these are our Holter codes. These are what we typically called our ZO patch up to seven days. Again, additional, but up to 15 days. These are MCOT codes. Again, technical aspect, and then you only have your professional interp. So there's no hookup code. And then here's our event code. So this is the hookup code, the 93270, and then your provider interp would be the 93272. Okay. So some FAQs we'll cover, and these are just common questions that we see. So, can I perform and bill for strain on every echo I do? Well, only if that medical necessity is supported. And then of course you have to have documentation in the echo itself of what the strain measurements were. So all those details need to be documented. Carrier coverage is going to vary. There's no Medicare local coverage determination listed on these. So it's just going to vary across the different carrier coverage. Can I perform and bill 3D echo on every echo? Same thing. Only if medical necessity is supported. I did cover this earlier. Carrier coverage is very strict on this. So you definitely want to make sure you check with that policy specifically. If you don't, from a Medicare perspective, if you don't have that R93.1, which is the abnormal cardiovascular imaging study, they will not pay this 3D imaging. So it is important to specifically list in the report to what the 3D findings were. They want to see that documented in the note. How do I bill for a TEE if performed in conjunction with the TAVR? So again, we covered that earlier. If the TEE is done by the same provider performing the TAVR, then you cannot report it. If it's done by a different provider not performing the TAVR, then they can report that 93355 for that structural TEE code. Can a stress echo and a TTE for our traditional echo be reported same day by a single physician? Yes, they will allow you. But again, you're going to have to, you'll have to append modifier 59 to show that they are true separate services. And you will have to have medical necessity for reporting both. So again, very important that that medical necessity piece is there. Can I perform and bill for a stress test and a cardiac pet MPI on the same day? If stress test is performed with the pet study, then yes, you can report that separately with your 93015 through the 93018. Again, just depending on if you own that equipment or if you're breaking it up by the component codes. Can I bill for a calcium score? That is reported with that 75571. Again, if the practice owns that equipment, then you would report the global. Most commonly it's done in a hospital setting. So the provider would just append that modifier 26 for that professional interpretation. We see frequent denials for that CT and the FFR. Are there any tips? Again, I mentioned that earlier too. We do see that's pretty common because that FFR is listed with a category three code. Carrier coverage is going to vary because of it being a new technology. So it really just depends. When can I bill for a venipuncture? So this, without having a report right in front of me specifically, but most likely it would crosswalk to the CPT code 36415. And in the Medicare physician fee schedule, this is listed as a statutory exclusion. So that means that this code is not payable on the Medicare physician fee schedule for those purposes. So if you do it, you can try and report it depending on the carrier. If it's Medicare, they will not pay it. These are just some resources of where some of this detail came from that you can refer back to. And again, feel free to reach out if you have any additional questions. I know we are about five minutes over, so I will go through all the questions that were asked in the questions box. And we will put, once I compile everything and answer it, we will put that on our MedAxium Academy, where you'll also be able to find the slides if you weren't able to download those when we started presenting. But with that, I thank everybody for their time today and hope you found this information helpful. Again, if you have any further questions, feel free to reach out and we will be happy to help.

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