Cardiology billing and revenue cycle, 50-state coverage.

It is decided by who owns the equipment and who performed the interpretation. If the practice supplies the equipment, the staff and the supplies, it bills the technical component. If the physician only reads the study, it bills the professional component with modifier 26. Only when the practice does both does it bill globally. Each code on the Medicare Physician Fee Schedule carries a PC/TC indicator that states whether the code can split at all, and site of service is what should drive the decision. A practice that reads studies inside a hospital and bills globally out of habit is billing for equipment it does not own.

Yes, for most of your volume. CMS paused the Appropriate Use Criteria program for advanced diagnostic imaging in the CY 2024 Physician Fee Schedule final rule, so the consultation and G-code reporting requirement that program carried is not in force. That is a separate question from payer prior authorization. Commercial plans and Medicare Advantage plans continue to require authorization for cardiac MR, cardiac CT and nuclear stress imaging under their own utilization management rules, and those denials are as expensive as they ever were.

Vessel by vessel, from the operative report. Interventional cardiology is built on a base code plus add-on codes that carry the additional vessels, branch work, intravascular imaging and physiologic assessment. The base code alone almost never represents the case. The failure mode is a coder who reads the header of the report rather than the body, reports the base code, and leaves the add-on work unbilled. The second failure mode is reporting add-ons that bundle because the vessel detail supporting them is not in the note, which turns a revenue problem into an audit problem.

The follow-on program rather than the implant. The implant procedure is a discrete event with an operative note behind it, so it gets billed. The monitoring that follows is a recurring reporting period for a pacemaker, ICD, implantable loop recorder or cardiac monitor, and recurring work with no trigger event is exactly what falls off a billing calendar. The fix is a device registry tied to the billing calendar so every implanted patient has a reporting period with an owner and a due date. Device credit reporting on replacement cases is the second common miss.

Nearly all of the high-volume ones. Professional and technical split errors are decided by site of service, which is known before the study runs. Advanced imaging authorization is knowable at scheduling. Bundling and multi-procedure modifier disputes are visible in the code stack before the claim goes out, because the operative report is already written. Medical necessity denials on stress testing and imaging turn on whether the indication in the order matches the coverage policy, which is also a pre-service question. What remains after those controls are in place is a small set of genuine payer disputes, which is what an appeals function is actually for.