Breaking down cardiology billing and coding can be a real puzzle. You've got to overcome the complicated nature of cardiac procedures, the ever-changing rules of the billing game, and the need to dot your i's and cross your t's for that sweet reimbursement. And let's not forget the extra layer of complexity when it comes to clinical trial procedures — denials are on the rise!
Let's dig deeper into some of the everyday cardiac procedures that often get the denial stamp, uncover how to dodge that bullet, and take a peek into how Glenwood swooped in to rescue those denied claims.
CMS categorizes major cardiac procedures such as TAVR/TAVI, TEER, and Pacemakers as Category B devices and covers these procedures under coverage with evidence development (CED) — when your claim meets the criteria.
Nevertheless, despite these provisions, some procedures frequently encounter denials. Here are four cardiac procedural codes that often face denials:
Description: Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis.
Clinical trial number: P402245763
Description: Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during the same session (List separately and code for primary procedure).
Clinical trial number: P402245763
Description: Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach.
Clinical trial number: P401737528
Description: Percutaneous transcatheter closure of the left atrial appendage with an endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision, and interpretation.
Clinical trial number: P402699957
Unfortunately, lacking supporting documentation is the primary cause of these claim denials. A simple tweak to your claim processing can avert revenue loss in your practice.
Achieving optimal reimbursement for cardiac procedures hinges on satisfying the criteria established by CMS. The key to averting claim denials lies in the thorough documentation that adheres to the precise requirements outlined by insurance providers. Furnishing essential details such as the Clinical Trial Number, Q0 modifier, and secondary DX code Z00.6 is imperative for a successful reimbursement process. It's also a proactive measure to address potential denials.
Claim denials are inevitable, yet a significant portion can be prevented by understanding and implementing the correct coding and documentation guidelines.
Here's an outline of coding steps to fortify your claims with thorough documentation.
Step 1: Procedure Code
Employ the appropriate Current Procedural Terminology (CPT) code corresponding to the specific cardiac procedure performed.
For example, CPT Code 33340 — Percutaneous transcatheter closure of the left atrial appendage with an implant, including fluoroscopy transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, radiological supervision, and interpretation.
Step 2: Diagnosis Code
Choose the relevant International Classification of Diseases, 10th Edition (ICD-10-CM) diagnosis code based on the patient's medical condition.
It could be any one of the following:
*The CMS NCD does not cover the unspecified code for LAAC (Left Atrial Appendage Closure). Nevertheless, some private insurance providers might incorporate this ICD-10 code within their coverage policies.
Step 3: Place of Service
Indicate the applicable place of service code, specifying the location where the procedure was conducted (e.g., code 21 for inpatient hospital setting).
Step 4: Secondary Diagnosis Code Z00.6
The diagnosis code Z00.6 is mandatory for all services provided in a Qualified Clinical Trial or an approved study. It applies even if the services are generally considered regular care for the patient outside the trial.
Step 5: Modifier Q0
Attach this modifier to indicate that the procedure is an investigational clinical service provided in an approved clinical research study.
Step 6: Clinical Trial Number
An 8-digit clinical trial registry number (e.g., CT 02699957) with the alpha characteristic "CT." Enter this information in field/item 19 of the CMS 1500 claim form or its electronic counterpart, the 837p, specifically in Loop 2300 REF02 (REF01=P4, corresponding to field/item 23).
At Glenwood, we have assisted several private practices in successfully recovering their denied claims. After analyzing the first denial, we figured out that incorporating specific elements — namely, the Clinical Trial Number, Q0 modifier, and secondary DX: Z00.6 was imperative for securing claim approval.
We devised a strategic approach, consolidating all outstanding claims within the pending accounts receivable, amounting to a total of $425K. After ensuring alignment with the specific requirements stipulated by CMS, we resubmitted these claims, which resulted in the successful payment of $151K.
But that's not all. We took it up a notch by configuring the claims with the Clinical Trial Number so they get filed automatically. Plus, we tightened the screws with fixed validations to weed out claims that don't cut it with CMS billing criteria.
We at Glenwood are committed to eliminating denied claims and ensuring future claims are CMS-friendly, giving private practices a solid financial boost.
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