Legion Healthcare Solutions

Unique Challenges of Cardiology Medical Billing

Unique Challenges of Cardiology Medical Billing

Nature of Cardiology Medical Billing

Billing and coding for any medical speciality offers unique challenges due to billing guidelines and constantly changing reimbursement policies from various insurance carriers. Cardiology medical billing offers unique challenges as various sub-specialities of cardiology are involved. Different sub-specialties like interventional cardiology, echo-cardiology increases the need of expert coders and billers. MACRA rules for cardiology are complicated and coders must know in-depth guidelines for interventional and endovascular procedure coding. Cardiac cauterization including bifurcation intervention versus branch interventions leads charting to the highest level of specificity (systolic or diastolic CHF compared to CHF unspecified). Also, frequent revisions of codes happen in procedures like iliac repair, angioplasty, stent replacement, ECG recording, making it difficult to receive accurate insurance reimbursements. Let’s understand unique challenges of cardiology medical billing from insurance reimbursement point of view.

Unique Challenges of Cardiology Medical Billing

Some of the unique challenges of cardiology medical billing are listed below:

  • Provider cannot render more than one cardiology treatment per day, if so technical component of the lesser expensive cardiology procedure will be reduced by 25 percent which means only 75 percent of the technical part will be paid.
  • For cardiology coding, a lot of combination codes are available with ICD-10-CM. Based on the patient’s conditions accurate combination code need to be used. For example, the ICD code for unspecified systolic congestive heart failure (150.2) differs from the code for combined systolic and diastolic congestive heart failure (150.4).
  • Cardiology patients often face more than one diagnosis, also called comorbidity. When it comes to cardiology billing and coding, it’s important to document these comorbidities to help ensure your practice gets reimbursed as much as possible. 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.
  • Provider should know whether the codes they submit are accepted and have medical necessity to be performed. They should also know which modifiers to be used and component coding etc. CMS gives an exhaustive list of CPT codes for cardiology and it monitors whether the provider is correctly coding.
  • Commonly used modifiers in cardiology coding are modifier-22, modifier-25, modifier 51, modifier-52, and modifier-53. Not using modifiers at all or inaccurate use of modifiers leads to reduced reimbursements or claim denials. For example, you may add modifier 25 to a patient visit where the clinician determined the patient needed a stress test at the end of the visit. Not using modifiers properly could result in lost revenue for your practice. In the example above, forgetting the ‘25’ modifier may mean you miss out on reimbursement for the patient visit. Instead, the payer may lump together the visit with the stress test procedure.
  • Cardiology charges are billed differently based on whether patient was treated in patient or outpatient or same day surgery or in the office location.
  • Preauthorization of cardiology procedures is mandatory before billing to avoid authorization denials.

Addressing Unique Challenges of Cardiology Medical Billing

Above mentioned unique challenges of cardiology medical billing will increase claim denials, reduce insurance reimbursements and might attract external payer audit. There are few things your practice can do to address these billing challenges, mentioned below:

  • Get well versed with billing and coding guidelines for various payers. Know these payers’ billing guidelines and set up rules for unique edits. Every payer is different, so you must understand the billing and coding intricacies for each. Understanding the unique guidelines can help avoid denials and delays in payments.
  • It’s always a good idea to keep detailed documentation for each patient, including symptoms, diagnoses, comorbidities, tests and treatments. Make sure you keep track of all patient encounters and avoid waiting too long between the date of service (DOS) and entering charges. Having thorough notes will help your practice with pre-authorizations or certifications, as some payers require comprehensive patient notes. The notes will also help your practice if needs to appeal any claim rejections or denials.
  • Verifying a patient’s insurance eligibility is an essential first step in the RCM and claim submission process. Your claim may not get very far if a patient doesn’t have an active insurance coverage. As lot of population has lost its employment due to pandemic, its always advisable to check insurance coverage for every patient visit. Your billing workflow could check eligibility for the following week’s schedule, giving your team plenty of time to reach out to patients if there are insurance issues.
  • Form a team of cardiology billing and coding experts. Internally audit your billing and coding process often to find patterns and errors that may be affecting your practice collections. Set up a thorough review and claim scrubbing process. Look for automation opportunities to avoid any human error.

Legion Health Care Solutions is a leading medical billing company providing complete billing and coding services to ensure accurate insurance reimbursement for your practice. Outsource your billing and coding operations like cardiology coding, prior authorization, charge entry, payment posting, denial management, eligibility verification, and Accounts Receivable (A/R). To know more about our cardiology billing and coding services, contact us at 727-475-1834 or email us at info@legionhealthcaresolutions.com

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