All right, well we'll go ahead and get started. Good afternoon everyone and thank you for joining us today. My name is Jamie Quimby and I'm one of the managers of Revenue Cycle Solutions Coding with MedAxiom. My colleague Angie Bolton and I actually work together reviewing all the current guidance on some of the most common cardiovascular diagnostic services that we see provided across the cardiovascular community. We'll be taking a deep dive into this topic today and we'll be covering many areas of reporting the different services that we see provided. We'll start with a little housekeeping just to touch up on. To access the slides for today's presentation, you need to click on the chat box. There will be a link located there. Please do not use that chat box for anything else, especially questions. There is a separate questions box that you can submit any Q&A that you have. As always, we ask you keep your questions on topic and know that we will answer as many questions as we can today live, but there is a lot of content to cover today, so we will compile all those questions at the end and we will add that Q&A sheet onto our MedAxiom Academy website once we get it completed. The next couple slides are just covering CEUs and how to claim them. When you log into your individual MedAxiom Academy account, you will click on the My Academy tab here and then you'll see anything that you had registered for or anything upcoming or previous. You would actually click on that actual link and then it will open up and then you will see a box like this. You would click on your claim CEU, then your screen will refresh, and then there will be another tab that you can click on that will actually download that PDF copy of the CEU certificate. You can simply just either drag that download onto your desktop or you can open it and then save it. With our CEU platform, so with it being uploaded directly to our site, we do ask that you give us one to two business days to allow time for our team to get that certificate added to your individual account. Again, you do have to launch the webinar in order to claim your CEU credits now. AAPC has become more strict over the years with their vendors, so they do periodically they will audit the vendors, so we do have to show proof that the webinar itself was launched for you to obtain that CEU certificate. All right, so we're going to start with covering some of the common coding and documentation tips for reporting the cardiovascular diagnostic services. Then we're going to go into some of the guidelines and policies, specifically on placing orders, policies that are there for supervision requirements, and then we'll talk about medical necessity. Then we're going to cover some of the carrier guidance throughout the presentation, and then we have some FAQs that we'll cover that we found from some of the specific carriers at the end. All right, so we'll start with guidelines. We'll start with the most important part of a diagnostic service is an order. This is actual guidance from Medicare on order requirements from the benefit policy manual section 80.6. Medicare defines this as an order is a communication from a treating physician or practitioner requesting that a diagnostic service be performed for a beneficiary. Typically, there will be a written document from the provider's office stating what the services ordered are along with the indications. This can be placed electronic, hand-delivered, mailed, or faxed to the testing facility. Typically, with our day and age that we're in now, it is all sent electronically for the most part, but if you're old school and been in the industry for many years like I have, you can remember, you know, having to fax an order or even seeing the handwritten documents placed. There sometimes may be a verbal order, and that's okay. Sometimes this may be done through the telephone. Typically, in that type of scenario, whomever is receiving that verbal order will then place a document in that patient's chart with the details of what the verbal order received was. The point here is there has to be an order for a diagnostic service rendered. So, how can medical necessity be supported and how you think about, like, what does medical necessity even mean? So, first, there must, again, be documentation to support the intent to order the service. There should also be documentation as to why the service is being requested. This will be your diagnosis code or your reason for the request. Then you will want to see if there are any national Medicare coverage determination policies or if your local Medicare contractor has a local coverage determination policy. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. The national coverage determination, or what we typically call MCDs, are made through an evidence-based process with opportunities for the public to participate. So, in the absence of a national coverage policy, there may be where your local Medicare contractor will make a local coverage determination. Oftentimes, too, if there even is a national coverage determination from national Medicare, most of the individual Medicare contractors will then follow suit with that and add a local coverage determination with that MCD policy from national Medicare. So, sometimes you may see both. Then, finally, you'll want to check with your patient's insurance plan also. Some of the commercial payers may have authorization requirements that you have to meet in order to even render that service to the patient. So, you'll definitely want to make sure you're following that. Most practices have a separate department that does all the authorizations and the pre-certs for services provided. So, what is that local coverage determination? Again, you definitely want to make sure if your Medicare contractor has an LCD policy for a particular service that you are reviewing those yearly. They typically are updated when the new ICD-10 codes come out in October because those are on a fiscal year, and then also they may be updated yearly in January, again, depending on if there's any CPT changes as well. So, definitely want to stay up-to-date on that, but Medicare overall defines that local coverage determination as a determination by a fiscal intermediary or carrier under Part A or Part B whether or not a particular item or service is covered. LCDs typically will outline any coverage guidance for that particular service in detail. It will cover things like the indication coverages, limitations, and the medical necessity details. Most times, there will also be reference in that LCD with related coverage documents that they call articles. That article will actually detail the CPT codes and individual ICD-10 codes covered within that policy. Now to cover some of the details of supervision guidance. General supervision means the procedure is furnished under the physician's overall direction and control, but their presence is not required during that performance. With the direct supervision, that means, I'm sorry, that was general supervision. Direct supervision means the physician must be present in the office suite and immediately available, but again, they do not have to be present in that room. So, general just means they have to, it's furnished overall under the physician's direction, but they do not have to be present. Direct means they have to be physically present in the same area or office suite as the patient, but they do not have to physically be in the room. And then last, with our personal supervision, this means the physician must be in attendance in the room during the performance of the service. So, an example of personal supervision, just offhand, a diagnostic coronary angiography service. So, typically, if you have a cath lab in your office setting or even if this is being done in a facility setting where your physician's, you know, doing the procedure and documenting their report, that will have an assignment of the 03 for personal supervision. So, again, means your provider has to be in the room during the attendance and performing a service, essentially. How you can find the supervision requirements is on the Medicare physician fee schedule. So, I actually have the 2023 physician fee schedule, so I'm going to drag it over here on top of our slides real quick. So, when you're looking at your CPT codes overall and then you click over into the columns, you can see column Z here has the list of the supervision requirements and what the code allotment is for that. So, you can see, like, with our EKG, our office EKG here, the 9300, that has a 01. So, again, that means the provider does not have to be physically in the room, but it's performed overall under that physician's direction. Let's get this back out of our way. So, again, some of our services we provide will have a global service, meaning the global code itself, that would include everything, and then sometimes they're broken out into components where you can either report just the professional component or the technical component of the service, just depending on the scenario. So, when looking at that professional part of the service, this would represent the physician's work or any of that professional work provided from the physician. It would also include the interpretation of the services rendered with the physician report and signature. So, just keep, you know, that would be the difference with just the professional side. Now, looking at the technical side, this would include all non-physician work. So, any administrative work, equipment and facility costs, all that non-physician work would be that technical aspect of it. So, if you have a situation where you're splitting your billing, and I have a couple situations we'll talk through as we go through the slides, but if you can't report that global code that would account for the technical and professional, then you would append the appropriate modifiers if they're applicable to that service. So, just a recap of tips to answer the overall medical necessity. So, what service is being requested by the physician? What is needed? Why are the services being requested? So, again, thinking about that diagnosis code and that indication. Then, next, you want to see, well, does that reason for the service meet any national and local coverage guidelines from Medicare? You also want to check a lot of the commercial carriers, the big payers, will a lot of times have their own policies listed on their website as well. And then, how, who and where will the service be performed? Is it going to be performed in your office setting where you may own your own equipment, or is it going to be performed in a facility like hospital setting, you know, as an outpatient? Those types of things. So, where is your place of service? And then, do I have an accurate appropriate order and then documentation at the end to support my service even being rendered? So, again, all important aspects when you're looking at reporting our diagnostic services. Okay, so now we're going to touch up on some of the common services. So, we're going to cover a lot of different testing today. So, lots of content to cover with you. So, we'll try to pace ourself good so we're not talking too fast, but I do want to make sure I get through all the slides today so we cover everything. So, we're going to start with our echocardiogram. So, a standard echocardiogram is known as a transthoracic echocardiogram, or typically you may see it abbreviated with TTE. It uses an ultrasound to produce images of the cardiac structure and function. It allows for assessment of the chamber sizes and the function of that left and right ventricle, as well as the atrium. It also looks at the valvular assessments for stenosis and or regurgitation. It evaluates for congenital heart defects, pericardial disease, structural issues, so those types of things. It also can look at the pulmonary pressures as well. So, you may see sometimes in an echo where maybe the patient's found to be in pulmonary hypertension. So, you may see some readings like that as well documented. So, these are the standard codes that we see for reporting this service. So, when you look at that 93306, that's typically where we live the most in the cardiology world. So, that is a complete echo that also includes your spectral doppler and your color flow doppler. So, many, many years ago there used to be, well there still is separate add-on codes for the dopplers, but years ago before we had the 93306, we used to have to report that spectral and color flow separately. With some of the other echoes, you still can report those separately because they're not included. So, with the 93307, this is still a complete echo, but this is when the spectral and color flow doppler are not performed. I can tell you probably a good 90 plus percent of the time when they're doing a complete study, the spectral and color flow doppler are also being performed. Again, we'll talk through some of the next upcoming slides about documentation and how you can tell when those dopplers are performed. With the 93308, this would be a limited or follow-up study. So, if you have a Medicare LCD out for a particular service, for the echo service, and they have frequency limitations in that policy, maybe you had a patient that had an echo, I don't know, maybe a month prior, maybe they're back in the hospital and the provider wants to order another echo. So, you would have to look at that Medicare policy and what they have listed within their limitations and follow-up guidance on whether or not they would even allow you to report another complete study, or if you would have to report it as that follow-up. Even if it's a full study, if it's within that frequency limitations that they have outlined in their policy, you may have to still report it with the 93308. So, again, it would just vary depending on what exactly is outlined in the policy. 93303, that's for a complete echocardiogram for congenital cardiac anomalies. Now, this code does not include, even though it's a complete study, it does not include if the spectral doppler and color flow doppler are also completed. So, if they are supported by your documentation, you would actually add those codes on also. And then the 93304 would be another follow-up or limited study for the congenital cardiac anomalies. So, how do you know you have a complete study versus a limited? So, this is actual language in your CPT book from the guidelines that CPT has put out. So, they define a complete study as that 2D imaging, the M mode when performed. Again, you're looking at both the left and right atrium and ventricles. Then also the aortic, the mitral, and the tricuspid valves are evaluated, the pericardium, and then any adjacent portions of the aorta. So, you may sometimes see, and I probably almost, I'd say probably 99% of the time when I have a complete study done, I also see additional areas documented within the notes. So, you might see areas of the pulmonary valve, stuff like that. That's not a requirement for a complete study. But again, if it's also documented, then there's nothing additional you would report if you saw like the pulmonary valve documented. It's not a requirement for that complete study is my point. So, again, most times when I see a complete study performed, they're going to comment on the pulmonary valve as well. Now, if you have an instance where maybe the provider couldn't visualize an area well, so there is guidance out there from the ECHO society that they do allow, they say in the guidelines that if the physician documents why they cannot visualize a structure that they're, you know, as part of that complete study, and they say why they can't visualize that, then you can still get give credit for a complete study. They would need to be, you know, detailed about that in their report, though. So, next we're going to look at our transesophageal ECHOs, or TEs is where what we commonly call these. So, there's two categories, again, depending on if it's a congenital or not. So, the 93312 and this 93315 are the global codes of that service. So, this would include your probe placement, your image acquisition, and then your provider interpen report. If you have a scenario where the physician couldn't get the probe to place, or maybe the documentation does not identify that the provider placed that probe, that's a very important key factor here. If your report does not state that the probe was placed by the physician in the report, then you can't assume that they did. Sometimes there's difficulties with placing the probe, and they have to call the anesthesiologist to come in and actually place that probe. So, it needs to be clearly documented in your note that your provider did place the probe to report the 93312 or that 93315, depending on the, you know, conditions you're evaluating for the patient. Now, if there is no probe placement clearly documented from your provider, then you would have to report the 93314 or that 93317 for that image acquisition, and then the interpen report only. Structural heart TEE. So, this one is got a little bit stricter guidance on it. So, this is reported during a structural heart procedure. The 93355 is reported once per intervention, and it can only be reported by an individual who is not performing that interventional procedure. So, the service would include when performed, the measurements, that probe manipulation, any Doppler and color flow, 3D imaging, and again, that physician interpretation and report. Again, if you have a case where you're doing maybe a TAVR procedure, and you have your surgeon and your interventional cardiologist involved, you would have to have a separate provider doing that TEE service to report it. If it's your interventional cardiology provider who's doing the TAVR, also does this TEE, then you cannot bill for it. So, big strict rule with that there, it has to be a separate provider. And the reason I want to point this out is because this is actual guidance from the Medicare NCCI manual. This is language printed in that manual where they state if even a standard echocardiogram is performed on the day a structural heart, meaning these TAVRs or mitral valve replacement procedure is done, and it's done by the same provider involved in that structural heart procedure, then neither the standard echo or your TEE can be reported. So, that's why the documentation for that is so strict, or the policy is so strict for that 93355. It has to be a separate physician. So, again, if it's your same provider, your interventional provider that's doing either that TAVR or that mitral valve replacement procedure, and they also do an echo same day, you cannot bill for that echo. So, these are the Doppler services we were talking about. So, the 93320 is for a complete Doppler study. The 93321 would be for a follow-up or limited study. And then when you look at that 93325, that's for our Color Flow Doppler. There's no difference whether it's complete or limited. They didn't break that code out like they did with our spectral Doppler. So, even if you have only a limited Color Flow study supported, you can still report this 93325. Lots of questions I get about this. Well, how can you tell when the Dopplers are done? So, the best way for you to be able to tell is your provider documenting that technique was used in that report. Most times they'll pin it at the top of the study where it'll say, you know, echocardiogram. Most times we'll see it say complete echocardiogram with Doppler and Color Flow. That's the standard language that I see. But as long as the techniques are listed in the report, then that is allowable. There was actually a CPT assistant article that does state like that documenting those terms is sufficient documentation for reporting those services. But if you don't have it clearly laid out for you, so looking at the difference between the Dopplers and the spectral Doppler service with the 93320 or that limited study with the 93321, this does include both the continuous wave Doppler and or the pulse wave Doppler. So, you can see how they're broken out here. So, in that continuous wave Doppler, this is used to estimate the severity of valve stenosis or regurgitation by assessing the shape or density of the output. With the PulseWave Doppler, it's used to assess for ventricular inflow patterns or intracardiac shunts and to make precise measurements of blood flow at the valve. With ColorFlow, it uses measurements of velocity and direction of blood flow to look at the color pattern on a certain section they're looking at. It also can show regurgitant flow as well. So this is why it's important for the provider to document those details with the techniques that they use during the study. A common argument that I get is if regurgitation is documented, then that means the ColorFlow is done. I've heard that a lot. Well, as you can see, that's not true because during the spectral Doppler part with the PulseWave, that does also give us regurgitation readings. So you can't make that argument that if I see regurgitation findings in one of the valves and that means they did ColorFlow, it could have came from the PulseWave and I can't assume it. So that's why it's important for that provider to document that technique that they're using clearly in their report. Myocardial strain is actually, I'm starting to see this reported more frequently. So the need for it is definitely there. So when they're looking at this, it's looking at any strain imaging or deformation of that ventricle. So typically you're gonna see your findings documented in the LV portion of your echo report. So what they're doing is they're looking, it's used in conjunction with an echocardiogram. And again, they're looking for left ventricular deformation. Usually you might see certain documentation or verbiage talking about pixels that are documented or speckles. So with that, they're looking to see if there's any abnormalities within that LV portion of the echo report itself. So again, this is the code reported. This does not have the modifier 26 or TC applicable to it. So even if you are reporting this in the, say they're in the hospital itself, you don't own the equipment, but they did do this myocardial strain imaging, you have the findings supported in your note, then you would just report that 93356 as is. So again, no modifier 26 or TC applicable to this service. With 3D. So in 2022, we received a new code, the 93319. I have not seen it used a whole lot in the general cardiology community because it is specifically referenced to congenital cardiac anomalies. So if you are doing 3D imaging with your echo services and it's not for congenital issue, then you're most likely still reporting these two options here. The 76376 is with 3D that is not requiring independent workstation. And then the 76377 is when there is an independent workstation documented. So most times I'm seeing the 76376 reported the most when there is 3D. The thing about the 3D imaging is the medical necessity has to be documented with this. So let me see if I can pull this up real quick. So with Medicare, and I see this a lot with most carriers. So let me drag this over here. So I have an LCD pulled up for the 3D imaging. So you can see what their policy is here with their covered indications, their limitations. So most times when you're looking at an LCD, when you scroll down towards the bottom of the report, it's gonna have any associated documents. So here they're gonna have articles. And the nice thing about the articles is they actually list out the CPT code itself. And then they list out the applicable ICD-10 codes that are payable with that service. So as you can see here, I have my 3D imaging. And then down here, it'll list group one, which is our ICD-10 codes applicable to these services here. And look at the only things payable per this Medicare policy. It doesn't give us anything that we would be reporting with our echo findings. So if it had valve disease or maybe left ventricular hypertrophy, something like that, none of those codes are payable here for this 3D portion. So really it has to show that that echo was abnormal. Your physician needs to document that clearly that the 3D portion of the study was abnormal for you to even be able to report it to get it paid for medical necessity. So again, very important why you wanna be checking your local coverage determination and any relevant articles related to it to see what they may be saying for that particular service. So I'm finding a lot of the 3Ds, depending on what's in that documentation, sometimes they may not be getting paid. Now, a lot of times if you are seeing a patient and you're evaluating them for toxicity, say they have active cancer and they are getting chemotherapy, that is very common for the patient to come in routinely multiple times a year to get an echo because they're monitoring for the heart toxicity for the chemotherapy. A lot of times they're doing 3D imaging and that myocardial strain because of that toxicity potential. So a lot of times those particular cases, I'm seeing a lot of the contractors and the carriers do reimburse for that. But again, it can vary depending on your particular carrier. So the point is here, they can't just do 3D imaging without having some kind of documentation as to why it's needed. So bubble study, if you see these, I see them still periodically. So bubble study echocardiogram is the same as an echocardiogram. The only difference is an IV is placed in the patient's arm and during certain portions of that imaging, they inject saline with bubbles into that part to get a better picture of it. Usually they might do this if they're looking to see if there's a tiny hole between the upper chambers of the heart, either with a PFO or an ASD. There is no separate code for billing purposes though. Bubbles or saline is not considered a contrast material for an echocardiogram. So if you see a bubble study done, just report whatever you can for your echo being performed itself. If it's a complete study, then report that, or if it's a follow-up or limited, you would just report that. Definity study. So this varies again, depending on your facility location and where this is being done. So if it's being done in an office setting where your practice owns the equipment, then you can bill for this Q9957 service. If it's done in a facility setting or where you don't own the equipment, then the facility is who reports the service. So that's the difference here. You have to own your equipment to report the definity with your echo. If you do not own the equipment, then there's nothing additional for you to report from a professional perspective. So again, it's just gonna depend on the situation and where that service is rendered. But if you do own it, again, you can report this definity service. Most carriers are gonna require you to add the NDC number to it, and then the amount of contrast that is administered. All right, moving to our stress echoes. So sometimes you might have a physician or a stress echo to evaluate the motion of the heart's walls and pumping action when that heart is stressed. This will help the provider to better determine a lack of blood flow that isn't always apparent on some of the other tests we provide. During a stress echo, the images are recorded before, after, and sometimes during that stress portion of the study. The patient's EKG, the heart rate and blood pressures are also monitored before, during, and after a test. The goal is to evaluate that hemodynamic, the EKG, and the echo responses to the patient being stressed. If the patient is unable to exercise, then the provider may use a medication such as dibutamine to stress the patient's heart. We'll cover what some of those medications are because they're kind of, they're common sometimes in our nuclear studies too. So we'll cover what some of those codes look like. So when a stress echo is performed with a complete cardiovascular stress test and the supervision is provided by the same provider interpreting that study, then we can use the 93351. So say we have a situation where the patient's in the hospital setting though, so we don't own the equipment, but the same provider supervised and interpreted the study. The guidelines, even though it's done in a facility setting, we don't own the equipment, the guidelines will allow us to still build the 93351 with the 26 modifier appended in the facility setting. But again, you have to have the same provider supervising the stress portion. So this 93351 includes the stress portion also. The 93350 is only the stress echo, but you can report separately the cardiovascular stress test portion. So say you don't supervise the study and you're only doing the professional interpretation. So you would report in that instance, the 93350 with your 26 modifier, and then you can also report your 93018, which is your interpretation of the stress. So again, differences with the reporting depending on who supervised the study. All right, so now we're gonna move into stress testing and nuclear study. So we'll start with our stress test code. So this is just when the patient has a standard stress test. A lot of times this will be done first before they do maybe a stress echo or a nuclear stress test. And if this study is abnormal or they don't get the findings, they don't think the findings are adequate, then they may go ahead and order either that stress echo or the nuclear stress test. But just a standard stress test, this evaluates the patient's heart during physical or pharmacologic stress and is generally performed either where the patient's sitting on a bicycle or they're walking on a treadmill. During a stress test, the patient will usually exercise until symptoms occur or the patient reaches a maximum heart rate of 85%, depending on that predicted heart rate based on the patient's age. The heart rate, the breathing, the blood pressures, all that's monitored during a stress test. They also have an EKG hooked up to you as you're stressing your heart. I had one done a few years ago and I walked on the treadmill. So I had all these wires all hooked up to me and so it was a little interesting, needless to say, you're trying to like run on a treadmill and you've got EKG also hooked up to you. So they do monitor all that throughout the entire study. So the 93015 is the global code. That's when you own your equipment and you're reporting 100% of that global component, that code itself. Now, if for any reason you don't support the full global code, say maybe you don't own your equipment, so maybe it's done on a facility setting and so you're only doing the professional aspects of it. The 93016 is when your provider is doing supervision. So they're in there supervising the patient, walking on that treadmill or riding that bicycle. The 93017 is actually the technical aspect of it. So this will be, your facility would be reporting this code. And then the 93018 is for your provider's interpretation and report. So again, if you don't own your own equipment, you cannot report this 93015, you would then report the component codes depending on what is supported by your documentation. So here's just some scenarios for consideration. So looking at our stress test and this can apply to our stress echoes too or the nuclear studies that we'll be covering next. So really we're just thinking about the stress portion of the study and the global code versus how to break out the component codes. So if you're in place of service 11, you own your equipment, your provider provides that supervision during the study, you own your equipment and the same provider also interprets the study, then you build a global code 93015. Now say you're done in a facility setting where you're in the hospital and the hospital obviously owns that equipment. You have one doctor supervise the stress test, then a different doctor in the group is the one that's actually going to interpret and do the report. So Dr. A would get the 93016 for that supervision because they supervise the study. Your Dr. B would then get the 93018 for that interpretation and report. Same kind of scenario, like if you have a APP that's doing the direct supervision, then you could build that depending on the state scope of practice. And again, your carrier's credentialing requirements and all that stuff. But say all that's met, then you can build that supervision under your APP. And then again, your physician who interprets and reports would get that 93018. All right, so looking at our nuclear studies. So there's two different types. The most commonly reported, again, the nuclear studies at rest and stress doing that imaging protocol. This study looks at how the coronary arteries perfuse the actual heart muscle. Typically the test is administered once while the patient's resting, then they do the results, they take images, and then later they actually start stressing the patient's heart. They'll either put them on a treadmill or if the patient's unable to exercise on that treadmill, they'll induce a pharmacological agent, stress agent that will mimic the heart doing physical exercise. So there's multiple different types of medications they could use. A common one we see is what we call Lexi scans. So they'll induce that into the patient and then that starts stressing the patient's heart out and it kind of mimics that patient doing physical exercise. So again, once that patient's heart rate reaches 90 to 95% of that predictive maximum, they then take additional images. So they're taking the rest images first and then they typically will take images after they've stressed that patient's heart out. So there are two different types, the spec and then that planar. It depends on the type of equipment that you're dealing with. Most practices that I see and work with all use the spec imaging. It produces more detailed quality. You got 3D imaging versus only 2D. So again, the camera does rotate on both of them around the patient during the stress portion. But again, a lot of times you're getting a more clearer picture with 3D imaging versus just 2D. I probably in my 15 plus years in cardiology reporting, I've maybe reported this one maybe twice. So again, it's not very common that I see that type of equipment being utilized. So these are the codes for reporting. Now on occasion, there may only be a single study done. So there may be times where the patient only has the rest portion done only. So if you only have a single study, then you're gonna build the 78451 for the spec or the 78453 for the planar. Now, commonly this is where we live in nuclear imaging, the 78452. This is when a multiple study is supported and that means it's done at rest and or stress. So that's where they're getting multiple readings from that patient. They'll get the rest readings first and then they stress the patient's heart and then they take the additional images. So that would be your multi-study. And again, the 78454 would be a multi-study too, depending if they still utilize that equipment there. Now, say you own your equipments and you're able to report these codes. So these codes are reportable by the facility. So again, if you're doing this in the hospital setting and you do not own your equipment, then any injections done during that study are not reportable by the provider. So this is when you're doing it in your own facility, you own your equipment, then you can report these codes here. As you can see, there's different contrast agents that they can use to stress that patient. This is not an all-inclusive list even. So these are just the more common ones that we see used during a stress test itself. So again, just different codes to choose from depending on what they're utilizing there. But again, if you don't own your equipment and it's done in a facility setting, then the facility would report these services. Again, other additional injections that they commonly do during a nuclear stress test, again, not an all-inclusive list. These are the typical ones we see. But again, if you do not own the equipment and it's done in a facility setting, then the facility reports this code. You would only report the professional aspects of the service. So again, at hospital setting, you're not reporting these codes regardless. So this is an example. It's kind of small here, but you can see here, I blacked everything out so we don't have, you know, PHI or anything. But the monitored by is showing that this provider supervises study. Sometimes they'll put monitored by, sometimes it'll say directly supervised. Sometimes it may be within the meat of the note where they're talking about that. Sometimes it may be at the bottom. There's no set place where it has to be documented. As long as you can clearly see that there was direct, that there was supervision during the stress portion of the study, then you're fine. So here, this is the same provider that's interpreting the study. So you could see we have that part supported. They took resting images and then they stressed that patient's heart and then they took additional images. So this will be a multi-study. So depending on the setting and where this is performed is gonna vary on how our billing is. So if it's in the office setting, you own your equipment. You can see here, we're gonna have the 78452 for that multi-study. We then can build our complete global code for our stress, the 93015. And then we have the medications that were administered here in the myo views here. So, and the number of units based on the guidelines with those services. So again, place of service 11, you own all your equipment. You can report these services. Now, facility-wise, now you can see we're in the hospital with place of service 21 or 22. You can see now we can only report the professional aspects of the study. So we have the 78452 with our 26 modifier and then we can build that 93016 and the 93018. So we can't build the global because we don't own that equipment. So the facility is gonna build that 93017 and then they also get the injection codes and then they can build their 78452 with that TC modifier. All right, so cardiac blood pool imaging is a technique used for evaluating ventricle function. Currently, there are two techniques for assessment of the ventricle performance. The first is the first pass technique and the second is the gated blood pool imaging. Information that can derive from these studies include assessment of the left and or the right ventricle ejection fraction, the regional wall motion, the volumes and diastolic function. The first pass technique utilizes a high count rate gamma camera and involves sampling for only seconds during the initial injection through the central circulation. The high frequency components of this radioactive passage are then recorded. I don't see a lot of the first pass studies done. Typically, I see these types of studies done. So this is that second technique. So this is the gated blood pool imaging studies. You might also see it referred to as a MUGA scan or a MUGA study. So again, these are the codes available for that service just depending on, again, what is supported by your documentation, whether it's a multi-study, if it's just a single study. So again, just gonna vary depending on what you have supported. All right, CTA and PET services. So these are starting to gain more popularity over the last several years now. So what is a cardiac CT? It uses advanced CT technology along with intravenous contrast material to then obtain high resolution and 3D pictures of the moving heart and the great vessels. These images enable physicians to determine whether there's plaque or calcium deposits that may be present in the artery walls. This is a non-invasive method for detecting blockages in the coronary arteries. So you might see sometimes where prior to a coronary angiography being performed or a left heart cath where the patient had a CT or a CTA performed. Sometimes if those images are not clear, that may be why the provider's bringing the patient into the hospital for that more invasive service with the cardiac cath. So here are the available codes for this service. The 75572 includes the 3D image processing assessment of cardiac function and evaluation of the venous structures if they are performed. The 75573 would be for any congenital anomalies that they're looking for. And then that 75574 is a CTA and they typically evaluate the heart, the coronary arteries, and if there are any bypass grafts that are present. So noninvasive coronary fractional flow reserve, or what we commonly call FFR. So when we're in a cath lab and we're doing a diagnostic cath or even an intervention, sometimes the providers will utilize the FFR in the cath lab. This is a newer technology that they're, which is why these are category three codes. So this service here can be performed in conjunction with a CTA. So the FFR process creates a personalized digital 3D representation of the patient's coronary arteries. And then it employs algorithms to help determine and replicate coronary blood flow. So I haven't seen a whole lot of these performed, but not saying they can't, which is why it has, it had the need to get a category three code. So if you have a provider that does a lot of CTAs and they're utilizing this, this service, just depending on what they have documented would depend on what all, you know, which one you would be most appropriate for that service. All right, PET scan. So a PET scan of the heart is an imaging test that uses specialized dye to allow your doctor to view problems with your heart. The dye contains a radioactive tracer, which concentrates on areas of the heart that may be injured or diseased. The PET study has become increasingly more popular over recent years. We have a lot of more codes to choose from when recording the service. Now it used to only have like two codes and now you can see we have more. So again, just depending on what you have documented being supportive in your note is going to vary on which code you, you would append depending on, you know, what you have supported there. Additional guidance for coding PETs. So again, you want to capture the correct CPT code because we do have different options now. Definitely check any policies that may be out there with your carrier on what is considered to be supportive from your diagnosis reporting. Code for any add-on services that might be appropriate. So your stress test, any supervision, all that stuff. And again, if you're able to report the injection codes, then make sure you're appending those as well. All right. So non-invasive peripheral studies now. So we're going to start with duplex scans. So overall, when you're looking at a policy or the CPT guidelines with the duplex scans, the American Medical Association does state that both the spectral and color flow dopplers are required. It's not separately billable, so it's included in the primary code you're reporting. So it's a little different from our ECHO services. So they are required. That is the key thing. So at least one of the following in section two here should be documented in your report to support. A complete duplex has arterial inflow and venous outflow, and then that color and spectral doppler being documented. So we'll start with our carotid duplexes. So these are reported based on whether or not it's a complete bilateral study or a unilateral or limited study. Again, just depending on what you have in your documentation. So this is actually an LCD from WPS. So it's an example to show you on the frequency allowables with their carotid duplex reporting. So first, they state each patient's condition and response to treatment must medically warrant the number of services reported for payment. Essentially, medical necessity must be supported in the patient's chart. Second, they will monitor the frequency of follow-up studies for that medical necessity. Third, only one preoperative service is considered reasonable and necessary for bypass surgery. So sometimes you may see, you know, patient came into the hospital, they had a coronary diagnostic cath done, it showed severe disease, they're referring the patient to have bypass grafts put in by a CT surgeon. And so part of that workup sometimes will include some preoperative testing. So this could be a scenario where they may order a carotid duplex just as a preoperative situation. So again, this policy is saying they will allow one preoperative service as reasonable and necessary when it's related to bypass surgery. So fourth, any reevaluations of existing carotid stenosis coverage state that the patients that demonstrate a diameter reduction of greater than 50% with symptoms or less than 60% with no symptoms are followed on an annual basis. If the patient does become symptomatic, they will allow a repeat study. So again, it's just going to depend on what's in your documentation. So that's a perfect example to point out that frequency. So patient has known existing stenosis in their carotids. They're not symptomatic, depending on the percentage of the disease that they have is going to depend whether, you know, it should for the most part just be done on an annual basis. Now, if that patient does become symptomatic, that's where they will allow it to be done more frequently within that annual time frame. And then last, any follow-up studies that are done outside of a global period for a carotid endarterectomy, those are typically done once that procedure is done and you're outside of your global period. They're typically done at that six-week mark, then they do them again six months, and then thereafter they're just done annually unless that patient becomes symptomatic again. So again, perfect example of reviewing your LCDs, looking at the frequency allowables and seeing how many times in a year you can report this service, you know, for maybe a patient that's not, you know, complaining of symptoms. All right, with extremity arterial duplex scans, we have different reporting options just depending if they're looking at your upper extremities or your lower extremities. So again, the 93925 is going to be for your lower extremities and that's going to be a complete bilateral study. The 93926 is going to be for either one side or a limited study. And then your 93930 is going to be for that complete bilateral upper extremity study. And then again, your 3-1 is going to be for an upper extremity, but it's unilateral or limited. Venous duplex, so same thing here, like with your arterial, you have a complete bilateral study, you've got your 93970, and then your 93971 for a unilateral or limited. Sometimes with the limited, like maybe the patient had a procedure or something and they're complaining of pain where that access site may have gone through, sometimes I see them do a follow-up study on that just to make sure the patient doesn't have like a hematoma that had formed since the catheter had been removed from the procedure. So again, just looking, check your LCDs if there is one, or check the National Medicare, check your commercial payers, just see what kind of policies they have on these services. So these are the codes for the aorta, the IVC, or the iliacs or bypass grafts that may have been performed there. Again, this goes off of whether it's complete study or unilateral or limited, depending on what you've got in your documentation. So this is an org too, so they can review the aorta, the IVCs, or the iliacs, or the bypass grafts. So again, it just depends on what you've got in your documentation, how much was imaged, whether or not you can report that complete study versus that limited. All right, ABI. So these can get a little confusing because the rules vary depending on if it's upper versus lower extremities. So these apply to both. So say they do an ABI on both the upper and the lower in the same day, depending, say they did a complete study of both, you can report this 92923 twice. It does have an MUE of two units, so you could essentially report it two times. Again, it would vary depending on what your carrier, if they want, what modifier they want appended with it if you have a upper and lower study done same day. It's not that common that they would do that, but it can happen. I have seen it happen. So again, just depends. But overall, looking at your ABI, it looks at the functional measurement procedures. It does include, again, that Doppler ultrasound studies, blood pressure measurements, oxygen tension measurements. It involves the measurements also in recording by one of the several methods of changes in the size of a body part as modified by the circulation of the blood. So again, they're looking at all that part of the report. They're looking at those components in that. So we're going to cover what each one is. Thing to point out with the 92924, this would be a complete study where they're doing stress with it. So this would include stress with it. So if they're stressing the patient on a treadmill as they're doing the study, then that would be your 92924. Looking at a lower extremity requirements with, or a limited lower extremity requirements. So these are the three areas that one of these three have to be met to support. So looking at it, all three, it does include the distal posterior tibial, the anterior tibial, dorsalis, pedis, artery. So again, they're looking at one to two levels. So, and the levels that they identify in the guidelines itself are the high thigh, the low thigh, the calf, the ankle, the metatarsal, and the toes. So you'd have to have one to two levels documented, um, you know, to meet that limited study. And then upper extremity, it's the same thing. There's the three areas, whether or not they're doing, you know, the Doppler measurements, um, you know, the oxygen tension measurements just depends, you know, one of these three techniques that they're doing. Again, it has to have the one to two levels documented for the upper and, um, the levels they recognize in the upper part are the arm, the forearm, the wrist, and then the digits. So when you're looking at a complete study, again, it's, it's broken up with the same, whether or not, you know, you have your Doppler again, your oxygen tension. Um, so one of the three levels has to be met. So not all three, um, but again, you're looking at the different levels that they're taking. So again, the levels here for the lower, they're going to be that high thigh, the low thigh, the calf, the ankle, the metatarsals and the toes. So they have to do three or more levels to meet that nine, three, nine, two, three. And if you're looking at that code, it's for a complete study. Um, so again, they would have to have the three levels done, um, for the lower extremity and then upper is same thing, three or more levels. And then again, they're looking at the arms, the forearm, the wrist, and the digits. So you'd have to have at least three of those levels documented to support that complete study. All right, now we got cardiac arrhythmia monitoring. So ambulatory monitors are small, portable, electrocardiograph machines that are able to record the heart's rhythm. There are multiple types of monitors available. As you can see, each has unique features related to the length of the recording time and the ability to send the recording. So we'll go over the specifics with that next. But again, as you can see, we have our EKGs, oops, sorry, I clicked too fast. Um, we have our external systems, we have our event monitors, and then we have our, what we call them MCOTs. So we'll cover in detail what all that is. So to start with our EKGs, we probably see more of these than anything. Um, these are done in our hospital setting. A lot of times you're, you know, looking at the professional side of that. If you own your equipment in the office setting, um, you know, we do tons of these on patients in a calendar year. Um, so again, most commonly we see this abbreviated as EKG or ECG. It's the same thing as, um, so no difference with the type of test there. Um, so overall it's a simple noninvasive procedure or diagnostic study, I guess I would call it, um, that checks the, for signs of heart disease. It's a test that records the electrical activity of your heart through small electrode patches that a technician will place in multiple areas. Typically it's on your, um, your chest, your arms, and sometimes your legs. Um, a common question I get with this type of EKG service, um, especially when done in like the office setting is, what if I have a patient that came in and had an EKG and they had a, uh, say they have a pacemaker put in and they had a pacemaker check same day. So again, it depends on the medical necessity as to why they're doing the pacemaker review and then why they're looking at that EKG too. If they're related, then no, you can't bill for them both because they, there's an NCCI edit. Now the edit does allow you to report, append a modifier to override that edit. So let's just talk about an example real quick of where you might bill the EKG with the device check. So say you have a patient coming to the office for regular follow-up with their EP provider. Um, they're being seen for follow-up. Maybe they have AFib and they, um, it was causing bradycardia being managed on their medication. So they, um, met the indications to have a pacemaker put in. Well, now the patient's coming in, um, and they're complaining of chest pain, which is new for them. So the provider already had, you know, scheduled to evaluate their pacemaker, you know, due to them having that, um, that AFib with the bradycardia. Well, now you have a patient coming in and that's complaining of new onset of chest pain. So the provider also decides to order an EKG to show if it's showing any ischemic abnormalities. So because you have separate related, you know, indications for your test, you can bill for both. You would bill your chest pain and any finding, you know, if there's findings of the EKG that are abnormal, you would bill that over your chest pain. Um, but if, and then you would bill your indications for your pacemaker check too, with, you know, if it's just for your AFib and bradycardia, or, you know, if that pacemaker showed any kind of abnormal, anything, you would report that too with your diagnosis. So again, um, you can append that modifier 59 or the X modifier, depending on your carrier to the EKG. Um, and then that will allow the NCCI edit to clear. So again, it's just going to depend if it's related or the provider's not clear on the report, like say we have the AFib history. Um, well, they can see the AFib on the device check itself. So you can't just do the EKG for the AFib history. Like if it's going to be related, the patient got the pacemaker because of the AFib and the bradycardia. So again, just going to depend on what you have documented in your report for that medical necessity. So these are our codes for reporting our EKGs. The 9-300 is our global code. So that's when you own your equipment and you're going to report, you know, the full global code with the tracing and your provider enter and report. Now, if you don't own your equipment, say you're doing a interpretation of a hospital EKG, then that's where you're only going to build a 9-3010 for your professional component part of that. And then your, the hospital would build a 9-3005 in that instance. Um, so this is done when with at least 12 leads, again, being documented in the report. Now the 9-3040, that's typically what we hear called a rhythm strip. Um, these most times I'd probably say 99% of the time, these are going to be done in your hospital setting. It's when they get a quick, you know, EKG read, it's one to three leads. So it's not as extensive as the 12 lead reading. Um, again, it's broken up into the component code. So if for some reason you do one of these in your office setting, you own your equipment, all that, you could build a global. Most times it's done in the hospital, like I said. Um, so you would only be doing the, looking at the interpret report. Now, the thing to point out here though, is with the rhythm strip, most carriers that I see, they bundle this code in with an E&M service provided same day. So if you have a situation where they did provide an E&M service same day, and you only have a one to three lead reading, definitely check with your payer to see if it's even worth reporting, um, or even trying to fight. The reimbursement for this is very low. And if you have a payer that specifically states they're going to bundle that in with your E&M, then you don't want to waste your time reporting it. But again, can vary. So again, you want to definitely check with your carriers. If they do allow for the billing, just make sure, you know, um, you're meeting the medical necessity and all that. Um, obviously with most of our EKG services, they are considered diagnostic services. And we do find most carriers do want the 25 modifier on the E&M done same day. There are some carriers that I do know of that don't require it. So again, very important for you to check with your payers specifically and see if they want that modifier 25 appended if an E&M and an EKG is done same day. All right, let's get into some additional monitoring services and a little bit more detail. As you can see, we got four categories here. So we'll start with our Holter monitor. That's been our most common that we've seen, um, if you've been in cardiology for many years. So with the Holter monitor, the purpose of the study is to evaluate the patient's heart rhythm, rhythm during a full daily cycle. Um, a technician will place, um, the system itself on the patient. Most times I'll have it placed in the office and then the patient will go home. They can wear it for up to 48 hours. And during that time there's continuous rhythm recording and storage that's being sent back to the facility as doing the monitoring of it. Usually, um, that, that facility or that company will then take all that information and they will send a report to the physician to review and interpret. So again, just going to depend, um, again, I don't see the global code with the nine, three, two, two, four being reported often. Um, unless you have an agreement with the company that's doing that continuous monitoring of the device, um, most times you're going to just be reporting the component codes. Um, so again, the, the nine, three, two, two, four is that full global code. But if you're not providing that continuous reporting, um, then you're going to break it down with that component service. So, um, the nine, three, two, two, five is the recording only. And that does include connecting the system to the patient. So I do see that reported a lot. If you're doing that connection and hooking the patient up to the system, the nine, three, two, two, six is that technical aspect. So that's where, where that facility is doing that scanning and analysis of the readings that it's getting while the patient's wearing that system. Um, and then the nine, three, two, two, seven is when you're doing your provider review and interpretation, um, guidelines from, um, the American medical association do state that if it is worn less than 12 hours that we have to append the modifier 52. Um, so again, this can be 24 to 48 hours, but if it's less than 12 hours, you can report it still, but you have to append modifier 52. Um, and then next, if they were for greater than 40 hours, then you, we got these long-term monitor codes added a couple of years ago. Um, these are what used to be called the Zio patch system. That was a category three code for quite a while. It did graduate thankfully, but when they graduated it to a CPT category one code, they actually split the service up. So it depends on the monitoring period on which service you would report. So the, the nine, three, two, four, one is the global code. And that's when the system is worn, um, greater than 48 hours up to seven days. So anything you have in that timeframe, you would look at that service area. So the four, one again is the global code. So if you're not providing that continuous monitoring from that technical aspect, you're going to break the service up. So your nine, three, two, four, four is actually your provider interpretation and report for the greater than 48 hours up to seven days. So again, these are bright. These are broken up based off of how long they have the monitoring. So Holter is 24 to 48 hours. Your next step would be greater than 48 hours up to seven days. And then your, um, your last category here is, um, when it's worn greater than seven days up to 15 days. So again, it's just going to depend on the monitoring timeframe that the patient had on the monitor. Again, global code two. So your nine, three, two, four, five is the global code for that period. But if you're not providing that continuous monitoring, then you're going to look at the nine, three, two, four, eight for your physician interpret and report. Now looking at our MCOTs, those allow continuous heartbeat monitoring as a patient would go about their daily activities. Most people are on the service from anywhere from 7 to 14 days, can be up to 30 days, so again just going to depend. This device itself consists of a small sensor that's attached to three electropaths. The sensor then sends each heartbeat to a handheld monitor that can be tucked into the patient's pocket or they can carry it in their purse. When the monitor detects a heart rhythm, whether the patient feels it or not, it will automatically transmit to the center. So it'll automatically send a reading of anything it catches that it thinks is abnormal to the center. At that point in time, the center that's operating around the clock, they usually have certified cardiac technicians that are analyzing and transmitting those events to the provider in a report. So it may be a case where your provider is getting multiple reports during the patient wearing that monitor over the period of days that it's wearing it, so again can just vary. The 93228 is for the provider review and interp and the 93229 is just for that technical aspect, so again that's going to be the the company that is doing that continuous monitoring while the patient's wearing it. With an event monitor, these are more commonly done. So this is a small portable battery-powered machine. Again, just like your MCOT, the patient can wear it for several weeks up to 30 days typically. When the patient feels like they're experiencing an episode, then they can press a button on the recorder and then that will record the episode as itself. So again, these vary a little bit, but patient can actually push a button on this one and then it'll send an alert and then it'll start recording. Again, up to 30 days. These are broken also up into component codes, so the 93268 is that global service, so most oftentimes you're not providing that continuous transmission or review and analysis. So the 93270 is where you are hooking the patient up to the system. The 93271 part of that code, that's your technical aspect, so that's that transmission, the download, and analysis. And then your 93272 is your physician review and report, so that's their interpretation and report that they do. This is just a helpful snapshot or we put this together just to kind of breaks down the codes, the reporting periods here, as you can see, just a helpful cheat sheet for you to have. There is no technical or the hookup aspect to an MCOT, so if the patient is hooked up to the MCOT in your office setting, there's nothing additional you can report for that. As there is with the event monitor itself, there is a hookup code here for the 93270, so it just depends on the type of system they have. All right, cardiac device implants and monitoring services. So we have different categories. If your patient has a pacemaker, a defibrillator, a loop implant, there's different categories depending if the patient's coming in the office for an in-person service or if it's going to be a remote service. So we'll cover what these are. Interrogations are defined as an evaluation of a patient's implantable device. Stored details about the system are then retrieved. The information is evaluated to determine the current programming of the device and to evaluate certain aspects of the device's function, such as the battery voltage and, again, any rhythm treatment settings that it may have. So these are the components of an in-person interrogation, and it depends greatly depending on the type of system that they have. So with a pacemaker and a defibrillator, they're going to be looking at the program parameters, the leads, the battery, any capture and sensing function, and they're going to be looking for the heart rhythm on the pacemaker. Your defibrillator, they're going to be looking for the presence or absence of any therapy for venous infection. For the presence or absence of any therapy for ventricular tachycardia and any additional underlying heart rhythm. With your ICMs, they're just looking at the parameters and analysis of at least one recorded cardiovascular data element. And then with your loop implants, again, they're looking at both the patient-initiated and device algorithm that's detected during an event. So again, just different components depending on the type of system the patient has. Remember, this is going to be an in-person interrogation. These are the codes available. Again, going to vary based off of the type of system the patient has. So if you have a leadless pacemaker, also, it's still going to fall into the same category with your pacemaker. So again, just varies depending on the type of system the patient has. CPT reporting instructions. So the guidance from CPT on in-person interrogations is you may report this per data service performed. It cannot be reported at the same date as a programming change, and it cannot be reported on the same date as a remote interrogation. Guidance also states that an in-person interrogation is included in the time period established by a remote monitoring period. So if you have a patient come into the office and they are on a remote monitoring period also where you're billing maybe the pacemaker every 90 days, because that is what the allowable is for remote, but the patient comes in and they do just a quick interrogation of their device, but they've had a remote service reported within that 90-day window. So what they're saying here is you cannot report the in-person interrogation because you've reported a remote monitoring service within that window allowed. So it would be if there's no remote service provided and there was no programming changes needed, then you can report the in-person interrogation only. Now looking at our programming evaluation, so there's a little bit more work involved versus just doing an in-person interrogation. So we'll cover the specific components that are required in the next slide, but these are one thing to point out is that these are billable within a remote device service period. So if you have that 90-day window in effect, that patient had, you know, a remote check done recently, but now they're coming in the office and you're having to do program changes to the system, you are allowed to bill for that even within that remote monitoring period allowable. So that's the difference between the interrogation versus the programming services is one's not allowed during the remote monitoring period, the other one is. So these are the components for the programming. As you can see, it's very, it's similar to our interrogation categories that we just covered with the first five bullets here, but these additional ones below the first five are the additional parameters that are reviewed during a programming evaluation. So again, going to depend on the level of detail you have documented in your report to depend, you know, what is supported in your note. Now saying all that, we'll cover first is these are billed based off of the type of system and then if the number of leads. So it's a little different than our interrogation only services. So like with our pacemaker defibrillator, we know sometimes they may only have a single lead. They could have only two chambers where they have leads in, or they may have a multi-lead system where three chambers have a lead. So again, just depends on what you have supported in your documentation for the programming. Now, some of the rules with this, these are allowed to be reported per data service, as long as your medical necessity is being met. They are also allowed to be reported during that remote monitoring period allowed just depending on the type of system they have. These can only be done in person. So again, make sure your documentation is clear. It's up to your providers and your device technicians to understand the required components and make that distinction, whether or not that just traditional interrogation is supported or if a programming evaluation is supported. And the reason I point that out and a big key difference with this is they're actually interacting with the device, not just simply downloading the data like they would be for an interrogation. So sometimes with the programming adjustments are made to the device if it's medically necessary, but a lot of times the changes are not needed. So some people think, well, if there's no changes done, then it's just an interrogation. Well, no, that's not true. If they've evaluated all those components, then it is still appropriate to report that programming evaluation. So that's why I point out the difference. So I made this chart here. This is actual CPT guidance with the components that are required. So you have your interrogation box here with the number of leads. So this is just applying to our pacemakers and defibrillator codes. So if you have the first five done only, then you know you only have an interrogation supported. But if you have these additional parameters that are documented in your note, even if there are no changes made, but all of this is documented in your note, then you can still build that programming evaluation service. So again, if you got more than the five bullets, so you have all of these and no changes are needed, that's still okay. You can report the programming still. Now with our remote monitoring service and how that works, these are on a monitoring period basis. So it's important to stay within those guidelines applied depending on the type of device they have. You want to make sure you're able to capture the clinic schedule to keep the patient on a period date allowable. The device information is sent automatically or it's manually downloaded by the technician, just depending on the type of system the patient has. And then again, that information is then downloaded and reviewed and finalized with the provider interpretation. Now, these are the components of a remote interrogation. They're the same exact as an in-person interrogation. So there's no changes as far as the parameters that are evaluated and reviewed. The difference would be whether it's in-person interrogation or that remote interrogation. With the remote services, the codes that are reported are broken into a technical component and a professional. So with the technical, this includes receipt of the transmitted data from that device, the technician review, such as if you have a registered nurse that's on staff. A lot of practices do have like a device nurse that they keep on staff that evaluates all these. Or you could have a person from the device company itself, so a device representative that is downloading the data for you. Any of that technical support though would then be distributed into a report for the physician to review. Now, if you have a device rep that's involved, they're going to build the technical aspect of this. But if it's somebody on your staff, like a device nurse or a medical assistant that you have managing the device clinic, they're on your staff, then you can report the technical aspect of this service. So these are the codes allowable. Again, the pacemaker does also include a leadless system, if they have that. So the professional reporting are these top codes here, and then your technical reporting, if you're meeting those requirements, say it's not a device technician from the company, then you can also report these technical codes as well. So an interrogation is an interrogation, whether it's done in person or remote. So the parameters are still the same for either. Again, it's just going to depend how your report shows, whether or not it's an in-person service or a remote service. So once a remote interrogation has been built, any in-person interrogations that are performed within that reporting window are not any in-person interrogations that are performed within that reporting window are not separately reportable. So with your pacemaker and defibrillators, those have a 90-day reporting period. With your loop implants, those are actually on a 30-day reporting period. So again, it's just going to depend on the type of device the patient has and that reporting period. But keep in mind, if an in-person interrogation only is done within those reporting periods, you cannot report the in-person interrogation. Now, if they're meeting the requirements of the programming, say they did all the evaluation of all the parameters and that's fully supported, you can report that even within the remote monitoring period. This is just, again, highlighting the ICM services. Those are like your loop implants. Those are on a 30-day reporting period, not a 90. CPT language does state it has to have a minimum of 10 days documented in that service period. So again, these are typically implanted on patients with CHF management or pulmonary hypertension and stuff. I don't see a whole lot of these with some of the groups that we work with across the country. See a lot of the loop implants, obviously. Those are where you're monitoring the patient for possible arrhythmia. Maybe they had an event monitor they wore for 30 days, but it was benign. But the patient's still complaining of symptoms. So sometimes they may go ahead and implant what they call a loop recorder. It's about the size of a paperclip. It's very small. These can actually be placed in the office setting now. So again, these are on a 30-day remote monitoring period as well, same language as the ICM service. So it has to have a minimum of that 10 days recorded. All right. So now we're going to cover a couple FAQs that we found. So first one to point out, we've covered this multiple times over the years, but Medicare released this MLN Matters back in 2019. And it really kind of clarified some things for us in a sense on when we're looking at the monitoring services, well, how do we append, what data service are we picking? Some carriers will say it's when the service is completed, depending on the service, whether or not you're billing the global code or not. Some say just the date it was provided to the patient. So again, varies depending, but let's apply this scenario to like a Holter monitor review. So typically if you're hooking the patient up to that Holter, you're going to build that hookup on the date the system was put on the patient, but your provider's interpretation is going to be the data service that they interpreted and signed the study. So again, that's where this kind of helped clarify some things from national Medicare. Same thing if you're looking at your device services. So sometimes the technician on a remote service may download the system, like maybe they downloaded it on the 10th of the month. Well, the provider didn't do their interpretation and report with their signature until the 15th. Well, your technical aspect of that code can be built on the 10th because that's when that service was completed, but your provider professional interpretation would have to be split and build on the date that they completed that. So that would be on the 15th of that month that they did it. So again, just depends on the type of service you're looking at. I know some carriers, when you're looking at some of your diagnostic services, like your echocardiograms that are done in the facility setting, sometimes those are not always signed and interpreted and finalized the day the study's performed on the patient. Well, if you're only appending the professional aspect of that because you don't own the equipment, some carriers are wanting the data service to be billed when the physician finalizes that study. So when they're basically completing the interpretation and signing the report. So that that data service may differ too, depending whether or not you're owning your equipment or not. Now, if you own the equipment, most carriers want you to report that service the date it was given to the patient. So it would be the true date of service that it was performed on the patient. So again, check with your carrier policies. These can vary sometimes across the country, but this is an article from National Medicare that you can reference in case you're having difficulties with a particular carrier. Some vendor FAQ. So some vendors may give other guidance as to the date of service reported. As always, again, we highly recommend you check directly with your carrier. Sometimes vendors might not give accurate information for your particular carrier. So again, just definitely, I know we stress that a lot on all of our webcasts, but it's very important that you stay in touch with your local big payers and just follow any policies that they may have. Another FAQ. So the question here was, can a stress echo and a regular echo be reported on the same data service by a single physician? So there is an NCCI edit with these services, but it does state that if the traditional echo was reported on the same date as a stress echo for different clinical circumstances, then a modifier 59 should be appended to the applicable traditional echo service, the TTE. Furthermore, the AMA CBT introductory language does state the stress echo codes includes the acquisition of the echocardiographic images before, after, and in some protocols during. But again, if it's for different clinical circumstances, then you could possibly report them separately. Again, they do bundle with NCCI. So you definitely want to make sure you're meeting the requirements to append a modifier to unbundle those services. Another FAQ. I have a provider who billed a 93015 for a stress test performed in the outpatient hospital setting and the hospital billed the 93017. So obviously if your provider billed a global code and it was done in a hospital facility setting, they do not own that equipment. So that was incorrect to report on the provider side. So your provider again would have to report the component codes depending on what's supported in that documentation. If it shows that they supervise the stress test, then they can bill that 93016. And then they would also bill that 93018 for that provider interpretation and report. Some other frequently asked questions. We kind of touched up on this a little bit. Is it permissible to bill an office E&M and a device interrogation during the same patient encounter? So if there is a separate and distinct medical reason for the E&M encounter, then yes, you can bill for both. You would have to append your modifier 25 to your E&M service. Most times if you're bringing a patient in that has a device, they're going to evaluate the device, but usually they're addressing multiple conditions with that patient. So it's not strictly they're seeing the patient for management only of the device. A lot of our patients that we treat across the country have multiple conditions that we're addressing. So as long as it's not just for the device itself, then yes, you can bill that E&M service. But again, you do have to append that modifier 25 as it's supported. And then can we bill for device monitoring services during a surgical global period? So yes, you are allowed. Any diagnostic service, even if provided during a global period is allowable, again, depending on that carrier policy, it's a diagnostic service. So it's not like an E&M where they may be falling under that global period and you're having to append that the E&M global service, the 99024. So again, diagnostic services can be appended within a global surgical area. Again, it's just going to depend on what you have documented for your medical necessity and that frequency limitation. So if it's like if you had that carotid end arterectomy and you're bringing the patient in within that global period and doing another carotid, well, that's probably not going to be billable because they're not outside that global period like that policy I showed you guys. So again, it's just going to depend on the type of test, the type of surgery that they had, what that global period looks like and why they want to do another test. These are just some helpful resources where a lot of this information was provided. This intersocietal echocardiography, this is a really good resource for any of the echo studies provided that includes your traditional echoes, your stress echoes, your TEEs, your dopplers, your color flows. There's a lot of really helpful information in that from a clinical aspect and a reporting aspect for coding. So I want to definitely point that one out because I find that one very, very helpful. And then now we are at the end and I see it is 2.30. So I am going to compile everybody's questions that were asked. Please give us about a week because there were quite a few questions. I will definitely review everybody's questions in full and then I will get up that Q&A document that we will then put on our website. So I definitely appreciate everybody's time today. I know we covered a lot of content. I hope everybody found it valuable and we will see you next month for our next webinar. All right. Thanks, everybody.

video

coding

documentation

cardiovascular diagnostic services

echocardiograms

stress echoes

nuclear studies

cardiac CT

noninvasive coronary FFR

clear documentation

supervision requirements

medical necessity

coverage determinations