Common Pitfalls in Cardiology Medical Billing

Common Pitfalls in Cardiology Medical Billing

Although treatment has advanced by leaps and bounds in the last few decades, heart disease remains the leading cause of death for U.S. adults. And with more than 20 million U.S. adults facing coronary artery disease, cardiology remains one of the busiest and highest-paid specialties. But cardiology is a complex field with ever-changing treatments and procedures. That means keeping track of new cardiology medical billing guidelines and medical coding best practices, which can sometimes vary across payers. Even a solid claim scrubbing process may not catch every slip-up. Due to high dollar value claims, cardiology practice won’t afford to receive claim denials. In this article, we listed common pitfalls in cardiology medical billing, and avoiding them would ensure the financial sustainability of your cardiology practice.

Common Pitfalls in Cardiology Medical Billing

1. Inappropriate Use of Modifier

Modifiers are two-digit codes that show you’ve somehow altered the service in the original five-digit CPT code. Inappropriate use of modifiers like modifier -22,-25, -51, -52, and -53 is one of the common pitfalls in cardiology medical billing. For example, when you submit a claim to the insurance carrier that is coded with a 25 modifier, you are telling the carrier to pay you for both the E/M visit and the minor procedure. The insurance carriers will review claims with an E/M and procedure codes for accuracy. Ensure that when you bill both codes on the same day, your documentation must support both codes. Document adequately for the E/M separate from the procedure. Typically, when these services have been audited payment was rescinded due to incorrect coding, incomplete documentation, and/or lack of medical necessity to support both codes billed on the same day by the same physician.

2. Not Coding for Comorbidities

While billing for cardiology, the billing team often forget to document one or two diagnoses. Cardiology patients often face more than one diagnosis, also called comorbidity. Diagnosis for common heart diseases includes diabetes, high blood pressure (hypertension), and COPD. It’s important to document these comorbidities to avoid claim denial as well as get reimbursed for all delivered services. When documenting different diagnoses, check the coding instructions and read the code descriptions carefully. In some cases, you may need a combination code. A combination code helps classify multiple diagnoses, a diagnosis with a complication, or a diagnosis with a secondary manifestation.

3. Absence of Eligibility Check

One of the most common pitfalls in cardiology medical billing is not checking patients’ specific coverage guidelines for a procedure or test. Missing eligibility and benefits verification can pose problems for the patient and the practice. Reimbursement could be at stake, and patients may feel confused or frustrated when they receive a surprise bill for care received. Beyond insurance eligibility, it’s also important for your team to check coverage guidelines before a cardiology procedure or test. You’ll need to make sure all prior authorizations, referrals, or pre-certifications are in place before the scheduled procedure. Each insurance carrier has specific guidelines, so understanding the intricacies of the patient’s plan is critical for a smooth claim filing process.

4. Absence of Prior Authorizations

Over-stretched office and billing staff might overlook or rush through checking for prior authorizations, pre-certs, and referrals. It could prove a costly mistake for any cardiology practice. Claim denials received due to the absence of prior authorizations are considered ‘hard denials’ which are difficult to reverse. Once you receive a claim denial due to the absence of prior authorization, most payers won’t change their decision. By doing the necessary leg work on the front end of the revenue cycle you can prevent such denials at the back end. To avoid such pitfalls, be sure to gather and verify all insurance information from the patient during scheduling. Also, review payer reimbursement guidelines for tests and procedures that require prior authorization or pre-cert. Provider portals or payer websites are a good sources of finding a list of services/ codes that might require prior authorization.

5. Incomplete Clinical Documentation

Incomplete clinical documentation is one of the common pitfalls in cardiology medical billing. Incomplete documentation will lead to claim denials and eventually could lead to an external payer audits. Proper documentation is critical to justifying medical necessity and the selection of codes for billing. It tells the story of a patient visit by recording pertinent facts, findings, and observations. Payers will use this documentation to verify coding choices, site of service, medical necessity, appropriateness, and accurate reporting of furnished services. Each office note must tell a complete story and be able to stand alone. While documenting ensure to mention why the encounter is taking place, as the coder will assign a different code for a routine visit vs. a surgery clearance vs. an initial visit. If known, it is important to document whether or not patients are compliant with their medications.

To Summarize,

Regular staff education, proper documentation, and adopting good coding practices will result in faster reimbursement, fewer external audits, and overall improved compliance. Regular internal audits will reveal common coding and documentation errors. It will show up areas where staff need to be trained. An open communication channel between physicians and the billing team is a necessity for successful revenue cycle management.

In this article, we listed only prime pitfalls in cardiology medical billing, there are a lot of other billing errors that lead to denied payments. As multiple parties are involved in painting an accurate picture of the patient’s comprehensive care and acuity level, the involvement of cardiology billing experts is essential. Legion Healthcare Solutions is a leading medical billing company providing complete billing and coding services. We assist cardiology practices to avoid billing pitfalls and secure timely and accurate reimbursements. To know more about our cardiology medical billing and coding services, contact us at 727-475-1834 or email us at

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