Guide to Billing, Coding, and Reimbursement for Interventional Cardiology

The catheterization codes have lots of guidelines that can be confusing. Use these tip sheets to understand what guidelines apply to which codes.

General Coding Guidelines for Catheterizations

General Coding Guidelines for Congenital Catheterizations

The PCI codes have lots of guidelines that can be confusing. Use this tip sheet to understand what guidelines apply to which codes. 

General Coding Guidelines for PCI

Use this tool to select the appropriate PCI CPT codes and modifiers.

PCI Selection Tool

The guidelines that apply to coding peripheral interventions can be confusing. Use this tip sheet to understand what guidelines apply to which codes. 

Coding Guidelines for Peripheral Interventions—2024

The guidelines that apply to coding structural interventions can be confusing. Use this tip sheet to understand what guidelines apply to which codes. 

Coding Guidelines for Structural Interventions—2024

Current Procedural Terminology, or CPT, is the coding system for physician-performed procedures. The code set is maintained by the CPT Editorial Panel. This 21-member panel is authorized to revise, update, or modify CPT. The Panel meets three times a year to review Code Change Applications. Stay abreast of new and revised CPT codes through the CPT Editorial Panel Summary of Panel Actions released after every meeting.

ICD-10-CM codes are used to document the diagnosis for which the patient was treated. Diagnosis codes establish medical necessity in claims processing and provide key information for risk adjustment. Always select the most specific diagnosis code available that most appropriately represents the patient's condition. Avoid unspecified codes whenever possible. 

ICD-10-CM Browser Tool

Evaluation and management CPT codes fall under different categories based on place of service. There are codes for office visits, hospital visits, nursing facility visits, home or residence visits, and emergency room visits. All visit types follow the same basic guidelines and require history, an examination, and medical decision-making. A medically appropriate history and examination must be documented, but specific components are no longer required for coding purposes. Medically appropriate is determined by the provider. The level of service is determined by either medical decision-making or time.

Medical Decision-Making: The three components of medical decision-making are the number and complexity of problems addressed, assessing and reviewing data, and risk. Two out of three must meet the level of service to bill that level. 

Time: Any visit can be documented based on the total time spent on the date of the encounter. Time can include activities both before and after the actual visit as long as they are performed by the physician on the date of the encounter. Time spent must be documented in the chart note in order to bill based on time. Time requirements are listed in the CPT book under the code descriptions. 

For more detailed information on determining the correct level of service, see SCAI’s educational videos:

2021 Office Visit Coding Changes

Evaluation and Management: 2023 Changes to Non-Office Visit Codes

Moderate sedation is separately reimbursable by accurately and appropriately reporting the moderate sedation codes (99152, 99153) that went into effect on January 1, 2017. The physician's role is commonly that of an “administrator" or supervisor directing another practitioner, such as an RN. The physician doesn’t have to administer the moderate sedation drug(s); the physician can supervise the administration of the moderate sedation drug(s), and the physician is still considered to be performing the service. 

Coding Q&A—Moderate Sedation with Cardiac Catheterization

A modifier is two digits appended to a CPT code that provides additional information that can be used for payment or tracking purposes. Modifiers also enable healthcare professionals to respond effectively to payment policy requirements. For accurate reimbursement, be sure you understand how to use payment modifiers. Always review payer policy to be sure of what the payer requires.

Using Modifiers for Reimbursement

The AMA/Specialty Society RVS Update Committee (or “RUC”) makes annual recommendations to the Centers for Medicare & Medicaid Services (or “CMS”) on the relative value units (or “RVUs”) to be assigned to new, revised and existing CPT codes. This 32-member panel represents the entire medical profession, with 28 seats appointed by national medical specialty society organizations and three appointed by the AMA. The RUC process also includes specialty society representatives from each of the approximately 125 specialty societies seated in the AMA House of Delegates.

Medicare defines accountable care organizations as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated, high-quality care to the Medicare patients they serve.” Many large group practices and hospitals participate in ACOs. Even if specialists are omitted, it is important to understand how participation impacts the organization as a whole.

Accountable Care Organizations (ACOs): General Information

Accountable Care Organizations: Understanding the New Frontier of Physician Payment—Webinar

The only time a PAR or nonPAR provider can bill the patient for services is when the services are not covered by the Medicare program. To do so, the provider must give the patient an advanced beneficiary notice prior to the service being rendered. The notice must be specific to the service being rendered and clearly state why Medicare will not cover the service. A blanket ABN is not acceptable. The patient then has the choice to refuse or pay for the service. 

ABN Instructions

An Alternative Payment Model is a value-based care model that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. APMs are part of CMS’ Quality Payment Program (QPP).

APMs Overview

Medicare does not require prior authorization. Instead, CMS has pre- and post-payment audits to ensure claims are being billed appropriately. A Comprehensive Error Rate Testing (CERT) audit is done to review for improper payment. CMS will request documentation about a billed service. The Targeted Probe and Educate program (TPE) assists specific providers with high rejection rates or unusual billing practices in correcting those errors. 

Medicare Claim Review Programs

Comprehensive Error Rate Testing (CERT)

Targeted Probe and Educate Program

The Medicare Benefit Policy Manual provides detailed information on Medicare payment policy and can be found on the CMS website.

Medicare Benefit Policy Manual

CMS is statutorily required to keep the Medicare Physician Fee Schedule budget neutral under MACRA. All increases until 2026 are to come from MIPS. Therefore, any increases to some codes must be paid for by decreases to other codes. For example, increases made to the Evaluation and Management codes reduced procedure reimbursement.

Every year, CMS creates the conversion factor, which determines the payment rate for the fee schedule for that year. Multiply the RVU for the procedure by the conversion factor to determine the payment rate for that code for that year.

The Medicare Claims Processing Manual provides more specific details about claims submission and payment and can be found on the CMS website.

Medicare Claims Processing Manual

Documentation is essential for patient care and reimbursement. Each patient encounter should be documented completely and accurately. 

Documentation Matters Toolkit

To become a Medicare provider, you must enroll. The easiest way to enroll is by using the online enrollment system, PECOS. Enrollment is required for all types of Medicare participation. 

Medicare Enrollment for Providers and Suppliers

To be a participating provider in the Medicare program, you must agree to accept assignment. That means you accept the Medicare fee schedule amount as payment in full and will file a claim for the beneficiary. In return, you will be paid at the full fee schedule rate and receive payments directly from Medicare.

Another option is to be a non-participating provider. Being non-PAR gives you the right to bill the patient up to 115% of the limiting charge. However, you must collect the entire balance from the patient because Medicare will send the payment to the patient. In addition, if you decide to accept assignment on a claim to receive direct payment, Medicare will only reimburse 95% of the physician fee schedule rate.

Opt Out: Physicians can choose to opt out of Medicare participation. This is the only option that allows the physician to bill the patient in full for services rendered. The physician must sign an affidavit on the PECOS site and sign a contract with the patient to provide services on a cash basis. The patient and the provider cannot seek reimbursement from Medicare. Opt-out lasts for two years.

Opt-Out Affidavit

Anyone knowingly submitting false claims to the government under Medicare can trigger the False Claims Act and be is liable for treble damages for each claim. The False Claims Act applies to the Medicare program and anyone knowingly submitting claims for services not provided. The act allows for whistleblowers to bring cases to the government.

Fraud and Abuse Laws

Medicare Fraud & Abuse: Prevent, Detect, Report

The False Claims Act

The inpatient-only list lists procedures published in the Outpatient Prospective Payment System (OPPS) final rule. The list is updated yearly. Medicare will not bill any procedure on the list unless billed as an in-patient service. 

Changes to the List

In 2022, the Centers for Medicare and Medicaid Services (CMS) reversed course on a previous policy to remove 298 codes from the in-patient-only (IPO) list. In the 2022 Outpatient Prospective Payment System final rule released in November 2021, CMS stated that they would be reinstating the codes to the list and they would not be moving forward with the stages removed of additional codes as previously indicated. CMS also established a new policy for removing codes from the list in the future.

The list will be reviewed annually as a part of the rule-making process, and a procedure must meet at least one of the following criteria to be considered for removal.

1. Most out-patient departments are equipped to provide the service or procedure to the Medicare population.
2. The simplest service or procedure described by the code may be performed in most outpatient departments.
3. The service or procedure is related to CMS codes already removed from the In-patient Only List.
4. CMS determines that the service or procedure is being performed in numerous hospitals on an outpatient basis.
5. CMS determines that the service or procedure can be appropriately and safely performed in an ambulatory surgical center and is specified as a covered ambulatory surgical procedure, or CMS has proposed to specify it as a covered ambulatory surgical procedure.

To find the full list, you need to download the Addenda of the final rule.  

How Do I Bill for Services on the IPO List?

Codes on the in-patient-only list are not subject to the two-midnight rule, but the patient must be admitted as an in-patient. If the procedure is done in an out-patient setting, the service can be billed as an in-patient if the service is provided on the date of an in-patient admission, provided within three days of an in-patient admission, or deemed related to the in-patient admission.

Does the List Only Apply to Medicare Patients?

No. Many payers, especially Medicaid, follow CMS policies. If the payer follows the IPO list, an in-patient authorization may be required. The hospital should also be aware that the status of the procedure is in-patient. 

The Inpatient Only List: What You Need to Know

Local Coverage Determinations are payment policies that apply specifically to one particular MAC or jurisdiction. Local Coverage Articles (LCAs) include additional information, such as applicable CPT and diagnosis codes.

Local Coverage Determinations

The Centers for Medicare and Medicaid Services or CMS is in charge of managing the Medicare program, but they contract out the claims processing operations to private insurers. There are 6 Medicare Administrative Contractors, or MACs, each responsible for a different region of the country. The MACs are responsible for all claims processing and payment. MACs can also make their own policies known as 'local coverage decisions'. Refer to your MAC’s website for the most up-to-date information.

Who are the MACS

Medicare Administrative Contractors by State

MIPS is a quality-based payment program with four components: quality, improvement activities, promoting interoperability, and cost measures. All physicians enrolled in the Medicare program are required to participate in MIPS if they have been a participating provider for over a year and exceed the low volume threshold. Participation is important because it affects your Medicare reimbursement. Not participating can result in up to a 9% payment penalty applied to your Medicare reimbursement two years after the reporting year. By participating, you can share in up to a 9% payment bonus. Even if you leave your current practice, the bonus or penalty for that payment year will follow the physician.

Quality Payment Program Resource Library

MIPS Value PathwaysWhat Does MIPS Participation Mean for Your Practice

National Coverage Determinations (NCDs) are payment policies established by CMS that apply nationally to all Medicare Administrative Carriers (MACs).

National Coverage NCD Report Results

The National Correct Coding Initiative (NCCI) is a program developed by the Center for Medicare and Medicaid Services (CMS) to ensure that CPT codes are used correctly when more than one service is provided on the same day. There are two types of edits: procedure to procedure (PTP) and medically unlikely (MUE) edits. PTP edits indicate when two codes cannot be billed together on the same day. MUE edits indicate the number of units that can be billed on the same day. NCCI edit changes are released quarterly. NCCI edits are specific to Medicare and Medicaid, but most payers either follow NCCI edits or have their own similar edit system.

Understanding NCCI Edits

Section 1877 of the Social Security Act prohibits referrals to healthcare entities where the physician (or their immediate family) has a financial interest in services that may be paid by Medicare. Exceptions exist, so it is important for physicians to discuss any financial arrangements with a healthcare attorney. Penalties include a $15,000 per service civil penalty as well as claims denial.

Limitation on Certain Physician Referrals—Section 1877

Audits and documentation requests can be stressful experiences if you are not prepared. Use these best practices to help you respond to different types of requests.

Most insurance companies require credentialing for a physician to become a part of their provider network. Most group practices and hospitals will have existing contracts already negotiated. But, if you are starting a private practice, you will need to review the contracts and weigh the costs and benefits of participating. Review fee schedules, billing requirements, and coverage policies to determine if participation makes sense.

In vs. Out of Network: If you decide to contract with an insurance company, you will be considered an in-network provider. That means plan members will be able to locate you in their directory, and you must accept the negotiated contract rate set by the insurance company and abide by the plan’s coverage guidelines. If you decide not to contract with the insurance company, you remain out-of-network. As an out-of-network provider, the patient remains responsible for the full billed amount, and payment from the insurance company may be made directly to the patient.

When a service is denied, either through prior auth or after claim submission, most insurance companies have a mechanism to appeal the decision. Check policy manuals for the appeals process. It usually includes up to three levels of appeal. 

Insurance plans have different levels of benefits and coverage requirements. A health maintenance organization (HMO) is more restrictive, requiring the patient to see only in-network providers and requiring referrals for specialist care. A preferred provider organization (PPO) allows the patient more freedom, usually offering both in- and out-of-network benefits and allowing the patient to see any provider within the network without a referral.

The No Surprises Act went into effect on January 1, 2022, despite litigation in multiple states. In Texas, a federal judge ruled in favor of the Texas Medical Association’s case regarding the appropriate out-of-network rate for arbitration. The Department of Health and Human Services (HHS) is moving forward with updating guidance on the arbitration process to meet the requirements of the court’s decision.

What Does it Mean for My Practice?

Overall, the No Surprises Act applies to out-of-network providers practicing in in-network facilities. Therefore, if your practice participates in the same health plans as your facility, the act does not apply to you. However, the second interim final rule included a provision that applies to all providers in all settings. A good faith estimate must be given to all self-pay patients.

Good Faith Estimate

The good faith estimate (GFE) must be given to all uninsured and self-pay patients (who elect not to use insurance for services). The estimate must also be provided for all other providers involved in the procedure. So, the interventional cardiologist is also required to request an estimate from the facility and any other treating providers.

A notice of the availability of a good faith estimate should be posted both in the office and online in accessible formats for all patients. Uninsured patients should also be told verbally of the availability of the GFE, but the estimate must be provided in writing. 

The GFE must be given to the patient no later than three business days after an appointment is scheduled if the appointment is more than ten days out. If an appointment is scheduled between three and ten days out, the GFE must be given no later than one business day after an appointment is scheduled. When requested without an appointment, the response should be no more than three business days after the request is made. If changes to the expected services occur, a new GFE must be provided no later than one business day before services are rendered. 

The Written Document

The written GFE requires the following components and CMS has provided a template.

1. Patient name and date of birth
2. A clear description of service and date scheduled (if applicable)
3. List of all items and services (including those to be provided by co-providers)
4. CPT code, diagnosis code, and charge per item of service
5. Name, NPI, and TIN of all service providers and the state where the services will be rendered
6. List of items from other providers that will require separate scheduling
7. Disclaimer that separate GFEs will be issued upon request for services listed in number six and that items in number four will be provided in those separate GFEs
8. Disclaimer that there may be other services required that must be scheduled separately during treatment and are not included in the GFE
9. Disclaimer that this is only an estimate and actual services, and charges may differ
10. Disclaimer informing the patient of their rights to a patient-provider dispute resolution process if actual billed charges are substantially above the estimate, as well as where to find information on how to start the dispute process
11. Disclaimer that GFE is not a contract, and the patient is not required to obtain services from the provider

Patient-Provider Resolution Process

If billed charges exceed the GFE by $400, the patient may initiate a dispute resolution process. The patient has 120 days from receipt of the bill to initiate the dispute process with HHS. 

Good Faith Estimate for Patients with Insurance
The Act also requires a good faith estimate to be provided for patients with insurance, but this provision has been deferred to future rule-making. Additional information will be provided as it becomes available.

Out of Network Provisions
The following provisions only apply to out-of-network providers performing services in participating facilities for patients with commercial healthcare plans:

• Cannot balance bill the patient for emergency services
• Cannot balance bill the patient for non-emergency services performed in a participating facility unless requirements for notice and consent are met
• Must disclose protections against balance billing
• Ensure continuity of care when provider ends contract with payor

These provisions do not apply to Medicare, Medicaid, Indian Health Services, Veterans Affairs, or Tricare beneficiaries.

Most insurance plans require some type of prior authorization or precertification. What services require prior authorization are plan-specific and usually addressed in the plan’s benefit manual. Services that require prior authorization must be reviewed by the insurance company prior to the service being rendered. Failure to obtain prior authorization results in zero payment for the service.

Relative Value Units (RVUs) were established as a means to value services based on the resources required. RVUs are established for the following three categories of resources:

Physician Work: The physician’s individual effort in providing a service, which includes time, technical difficulty of the procedure, severity of patient’s condition, and the physical and mental effort required to provide the service. 

Practice Expense: There are direct and indirect practice resources involved in furnishing each service. Direct expense categories include clinical labor, medical supplies, and medical equipment. Indirect expenses include physician practice overhead and all other expenses.

Professional Liability Insurance: Insurance to protect a physician against professional liability.

When a physician signs an employment agreement with a hospital, the physician agrees to re-assigning all payment for services rendered to the hospital, so an employed physician may be unaware of RVUs. However. RVUs are also used as a means of tracking productivity in employment agreements.

Each insurance company has its own policy regarding the use of telehealth. Be sure to review the policy for the originating site location (i.e., may the patient be in their home), the requirement for synchronous audio and visual communication, and which services are allowed.