Getting reimbursed correctly in cardiology involves understanding clearly how specific procedures such as Nuclear Stress tests are performed.

Consider a cardiologist who performed a Nuclear Stress test on a patient suffering from chest pain with history of hypertension. The cardiologist chooses to administer a new drug such as Lexiscan (that received a permanent HCPCS code only in January 2009) to monitor blood flow and evaluate blood supply to the heart. During the test, the patient’s ECG is measured. When it’s time to bill, the insurance wants to know whether the patient was authorized to undergo this procedure. Furthermore, while the cardiologist might receive a certain reimbursement, the payment might not compensate for the cost of Lexiscan.

At NextServices, we combine clinical skills with those of business to utilize the best of both worlds in getting our clients reimbursed accurately.

Assume further that the patient needs to go through a cardiac catheterization. While performing the cath, the cardiologist decides to perform an angioplasty after discovering a blockage in multiple vessels. The insurance now wants to know if a physical examination, bloodtest and EKG were performed prior to the procedure. When two cardiologists perform this procedure (one for placing the catheter and the other for monitoring flow), how are reimbursements distributed? Will the multiple vessels be bundled and denied for payment? Is the patient considered a high-risk or low-risk patient?

Each of the above variables determine how much the cardiologists get reimbursed. Billing without understanding can put the practice at extreme risk. Given the expected 40%+ drop in Medicare reimbursements for cardiology, such risk can be disastrous for the financial well-being of a cardiology group.