The decline of revenue in your cardiology practice is most likely due to bad billing practices rather than low volumes of patients. Healthcare providers in the U.S. lose over $125 billion a year due to billing mistakes; cardiology practices bear a disproportionate share of this loss because of the high cost of procedures, the complexity of CPT codes, and the continued scrutiny from payers, resulting in a very high cost per error in cardiology compared with other medical specialties.
We have analyzed the revenue cycles of many cardiology groups and have consistently identified five common errors that continue to drain thousands of dollars from your revenue cycle every month. In this article, we will identify these errors and explain the impact they have on your practice financially, and how you can fix them.
Why Cardiology Billing Mistakes Hurt More Than in Other Specialties
To give you an idea of the complexity of a cardiology visit, let’s examine what a “typical” cardiology encounter may look like. To illustrate, the course of a single patient visit may include an office consultation; 12-lead ECG, echocardiogram, and possibly a stress test, with each test having its unique CPT code, documentation requirements, and payer rules. If you then add a cardiac catheterization or implantable devices to that visit, you could have claims that involve hundreds of dollars for every CPT code line item, in addition to the actual cost of the service.
The vast complexity in cardiology leads to expensive medical billing mistakes. A wrong code for placing a stent or a missing modifier on a nuclear imaging procedure could cause you to lose thousands of dollars on just one denied claim.
Now, think about how many of these claims your office processes every month. This adds up to astronomical amounts of money.
Mistake #1: Using the Wrong CPT Codes for Cardiac Procedures
The most prevalent and costly mistakes that practices make with billing in cardiology are related to the hundreds of procedure-specific (CPT) codes used in cardiology. Many of these procedure-specific codes for cardiology can be similar in appearance, but the rules to bill those procedures can be quite different.
The Echocardiogram Coding Trap
Consider echocardiograms as an example. In echocardiography, there are many different CPT codes for echocardiography based on how the echocardiogram is performed: transthoracic (93306, 93307, and 93308), transesophageal (93312–93318), and stress (93350 and 93351). Many offices incorrectly bill one of these echocardiography codes, either forgetting to add the contrast code or incorrectly billing for completed versus limited studies, leading to denials and significant reductions in reimbursement.
Nuclear Cardiology and Cardiac Catheterization Codes
Nuclear stress testing has similar pitfalls. The technical (93015) and Professional (93016, 93017, and 93018) components for nuclear stress tests are usually billed separately based on the ownership of the equipment (with modifiers -26 or -TC). Every time your practice fails to properly apply these modifiers, it loses revenue.
Add-on codes are extremely important in both cardiac catheterization and PCI procedures; if you are not consistently capturing coronary angiography add-on codes or correctly using the add-on codes for complex multi-vessel stenting, you are likely under-billing your cath lab revenue by 20–35%.
How to Fix It
To ensure you are receiving the right revenue, conduct a quarterly coding audit of your top 10 highest volume procedure codes. Pull 15 to 20 charts for each of your 10 procedure codes and compare what you billed against what was documented. Most practices will uncover two to three systemic coding errors within the first audit error, and by correcting these errors immediately, recover revenue for the practice.
When it comes to hiring coders for cardiology specialty procedures, work with qualified coders who specialize in cardiology, rather than with generalists. A coder who specializes in family medicine is not going to be able to accurately and efficiently handle the billing processes involved with EP study billing or billing for complex device implants, period.
Mistake #2: Missing or Incorrect Modifier Usage
Even though modifiers are relatively small (two digits or one letter attached to a CPT code), they hold a considerable amount of financial weight in cardiology billing. Missing or incorrectly used modifiers account for a large number of denials for cardiology claims.
The Most Dangerous Modifier Errors
The most common misuse of a modifier in the specialty is Modifier -59 (Distinct Service Procedure), which informs the payor that two services done on the same day were performed as separate and distinct services. When Modifier -59 is used without appropriate documentation, it raises a flag for fraud. When it is not used when needed, it will result in the claim being denied because it will be considered bundled.
Modifiers -26 and -TC (professional and technical components) pertain to the billing of diagnostic services (echocardiograms, nuclear studies, vascular ultrasound) when they are billed under shared equipment arrangements. Whether these modifiers are billed correctly or incorrectly could result in either an outright denial from the payor for the claim or payment at an incorrect reimbursement rate.
How to Fix It
Integrate modifier decision trees into your billing processes. Document the specific modifiers for each high-volume procedure alongside the conditions for their use. Couple this with automated claims scrubbing tools that identify absent or mismatched modifiers before they are sent out. This implementation can lead to a reduction of 40 to 60 percent of modifier-related claim denials.
Mistake #3: Inadequate Documentation for Medical Necessity
Since the payout has increased over prior years, Payers, especially Medicare Advantage plans, have made their medical necessity criteria more rigid than in recent years. At the same time, cardiologists are under tighter scrutiny than other specialties because the diagnostic tests they do are costly, and most payers recognize that documentation flaws are common in cardiology.
What “Inadequate Documentation” Actually Looks Like
Payers often deny payment for medical necessity due to issues with the physician’s documentation. For example, an order for a stress test will typically not pass a medical necessity review if it does not have an accompanying reference to the specific symptoms of the patient, the patient’s risk stratification score, and/or previous test results, even if the physician had a justifiable clinical reason for ordering the Stress test.
Classic examples of this are around Heart Failure coding (e.g., HFpEF and HFrEF); under ICD-10, there is a difference between the two as well as their classification between acute, chronic, and acute-on-chronic presentations. Therefore, if the classification on the claim form is provided as “HF” vs. “HFpEF” or “HFrEF”, the coder must revert to an unspecified code classification that may result in a medical necessity denial or decreased reimbursement.
How to Fix It
Create a Clinical Documentation Improvement (CDI) program with a focus on cardiology by working directly with your cardiologists to establish templates that will capture the information search engines use to pay. They will be looking for the following: onset of symptoms, risk assessment, treatment history, and how that treatment is linked to clinical decision-making. The goal here is not just to write longer notes, but rather, to write more intelligent notes.
In addition, incorporate a pre-auth checklist as an element of your scheduling process, so that before any cardiac imaging, stress testing, or invasive procedure is scheduled, you will have verified whether the necessary documentation has been included in the patient’s chart for pre-approval by the payer.
Mistake #4: Ignoring Claim Denials Instead of Working Them
That’s painful because it gives an impression that this is done on purpose when, in fact, it is very much done on purpose by denial management, which takes a lot of time, effort, and is not often rewarded for its work. In addition, when a claim is denied within a busy practice, the usual process is to flag the claim for follow-up, and before you know it, the claim will age beyond the timely filing limit. The revenue associated with those claims simply will not be recovered.
What Drives Cardiology Claim Denials
The team at The Medicator identified four reasons that contribute to cardiology-related denial claims:
1) Medical necessity (about 35%): The medical records do not support the procedure submitted to the insurer for coverage.
2) Incorrect codes/missing codes (about 28%): The submitted coding does not match the procedure performed (e.g., incorrect CPT/ICD-10 codes or missing modifiers).
3) Prior authorization issues (about 22%): The procedure could not be reimbursed because a prior authorization was required and was either not provided or expired, or the wrong procedure was authorized.
4) Documentation gaps (approximately 15%): Missing or inadequate medical records.
How to Fix It
In order to address the various causes of denials, practices must develop a denial tracking system that allows them to categorize their denied claims according to each root cause. A well-structured spreadsheet can be an effective way to manage denials, but having purpose-built denial management software is preferable for large-scale facilities. Practices should gather denial data by root cause rather than simply by payer, every week, rather than on a monthly basis. There should be a policy in effect that no claim over $500 will age past 45 days without active follow-up.
For practices that do not have sufficient staff time to manage denials internally, outsourcing denial management to a billing team specializing in this task is typically a high-return investment. The revenue recovered through their services typically exceeds the cost of their services during the first 60 to 90 days.
Mistake #5: Failing to Stay Current With CMS and Payer Policy Updates
Many rules and regulations govern how to bill for Medical services. One of the areas of healthcare with a high level of regulatory complexity includes billing for cardiac care. It is not uncommon for a healthcare provider to not keep current with the latest changes and regulations that affect cardiac billing.
What Changes Most Often in Cardiology Billing
When providers do not keep abreast of these changes and regulations, there are a number of negative consequences. For example, practices that have unrecognized billing errors, such as coding errors, will incur an increased amount of claims denials during the course of the year.
As a result, many healthcare providers do not keep current on the global surgery rules that are applicable to many cardiac procedures that have a 90-day global period. When a provider submits a claim for a follow-up appointment that occurs during a global period without using the appropriate modifier (-24, -25, and/or -57), the claim will be denied automatically. Additionally, practices that submit claims but do not have the appropriate modifier will be flagged by the Medicare program as being at-risk for an overpayment recovery due to improper billing of the procedure.
How to Fix It
It is important to subscribe to CMS local coverage determination notifications and check for changes in local coverage determination on a quarterly basis. Additionally, it is a good idea for a practice to utilize a billing professional who has experience and who specializes in billing for cardiac services. The cost of ongoing education for compliance is minimal in comparison to a single-time recoupment due to a billing audit.
The Medicator maintains multiple specialty-specific billing guidelines that are updated as soon as there are any changes to CMS or major payer policies, so practices we assist with will never be caught unaware by a policy change.
How Much Are These Mistakes Actually Costing You?
Let’s get some figures to help us quantify this. A mid-size cardiology practice generating $3 million per year would logically expect to lose anywhere from:
- 5-8% of revenue due to avoidable claim denials = $150K – $240K.
- 3-5% due to underbilled claims as a result of coding errors and missed claim modifiers = another $90K – $150K.
Losses due to uncollectible patient balances, write-offs on aged receivables, and compliance-related recoups. Hence, the combined probable annual loss to billing process failures as opposed to clinical quality is in the range of $300K – $400K. Now, when framed this way, investing in a superior billing infrastructure is not an overhead, but rather one of the highest return decisions a cardiology practice can make.
Final Thoughts
The 5 largest mistakes in cardiology billing relate to the use of incorrect CPT codes, the use of incorrect modifiers, insufficient medical necessity documentation, not working the denials, and lack of compliance with current policies; however, many practices have these issues regularly. All of these issues are common, can be corrected, and are major causes for loss of revenue for the practice. If the practice were to add up the amount of revenue lost due to all of these errors, it would total up to over $100,000 year.
The good news is that fixing these problems don’t take a practice overhauling their entire office process; rather, it just requires getting organized and having the right people and processes used. If the right staff are in place and work together to correct the errors and increase collection, the practice can reduce the losses and capture all of the money they are owed.
At The Medicator’s, we are experts in the area of cardiology billing and operations management. We perform coding audits and offer full revenue cycle management to help cardiology practices eliminate billing errors and collect as much money as possible. If your cardiology practice has a denial rate greater than 10% and/or AR ageing greater than 60 days, it is time to look at your current billing workflow.
