Cardiology Billing Requires Focus and Deep Expertise – How is this Justified?



One of the very complex and challenging disciplines’ in medicine is ‘Cardiology.’  It deals with the treatment of the cardiovascular system – illnesses and abnormalities of the heart and blood vessels. This includes procedural and diagnostic services performed by cardiologists. As complicated as the specialty, so is its billing process.

The financial strength of cardiologists is related to accurate reimbursements. Even though the average Medicare fee shows an increase of 1.1%; for cardiologists, it has gone down by 2%. Hence expertise and experience is essential for managing the complexities and intricacies of this field, else due to the complex rules used by insurance companies cardiologists tend to lose around 20% of their income.

Cardiology billing specialists are usually aware of codes and guidelines that are to be used for this billing process. A few issues that need to be well understood in cardiology billing for it to be effective are:

a) The understanding of specific CPT codes such as 93451, 93456, and 93503 which are not to be attached with modifier 51.

b)  A single code is to be used by cardiologists for reporting non-congenital procedures.

c) Usage of modifiers which could be associated to reimburse denied claims.

d) Accurate documentation as per procedures performed especially for claims that need to be made necessary by cardiologists else it is often looked upon with suspicion by insurance providers.

Due to the unique terminology used or the complex protocols such as endovascular surgery, electrophysiology cardiology billing and computerized tomography angiography (CCTA), it is essential that trained and knowledgeable specialists manage this billing process.

Billers and coders also need to understand the specific billing and coding formalities for multiple procedures, valve replacement and bypass surgeries. Tracking underpayments and nuclear camera rules are more complicated than normal billing services. The software systems used for reporting by tend to be different from that of a physicians’, hence trained specialists are required who are aware of such systems.

Due to constant changes in services such as in-office imaging, modifier applications, echo services (Doppler and colour flow), and follow ups on implanted and external devices the cardiology billing specialist needs to be aware of such changes to reduce errors. Billing specifics also include verifying on the medical necessity, usage of correct modifiers, selective/non-selective catheterization and component coding that require billing proficiency and familiarity.

‘Bundled’ CPT codes are yet another important aspect of cardiology billing. Often, cardiologists (interventionalists) tend to perform more than one procedural treatment during the same visit. Therefore for billing purposes, one procedure’s cost maybe ‘bundled into’ another procedure, creating errors unless a billing expert works on the reimbursement process. Further, changes in rules by CPT, global periods or other insurance providers rules and regulations cause uncertainty in cardiology billing. Continuous education is required to be updated on new rules.

The need for patient collection specialists also increases due to sizeable patient balances and the usage of weighty cardiovascular terminology on patients’ bills. Patient collections tend to get difficult at times as many patients do not understand the large cardiology bills generated.

Without skills and training in cardiology or cardiovascular billing rules, billers will lack the profundity to answer questions posed by insurance companies. Hence apt training and skills will minimize errors and the chances of denied claims, resulting in a higher turnaround time and proceeds for the practice.

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