The government is spending approximately $1.8 billion to audit and prosecute healthcare fraud this year. You minimize your risk of being penalized by becoming familiar with the top ten regulatory landmines faced by electrophysiologists when billing for their services.

#10: Claiming that you performed a procedure that is not fully supported by your operative report.

   The National Correct Coding Initiative Policy Manual for Medicare Services specifies that “Physicians must avoid up coding. A HCPCS/CPT code may be reported only if all services described by that code have been performed.” Electrophysiologists should keep this standard in mind when reporting comprehensive EP studies (CPT codes
93619, 93620) and left atrial pacing and recording (CPT code 93621).

   A comprehensive EP study (93620) is one that includes six distinct sub-component services; each of these is listed in the code’s official description: “Comprehensive electrophysiologic evaluation including insertion and repo- sitioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His
bundle recording.” CPT also contains a “five component” comprehensive EP study code (93619) which includes all of the components of code 93620 except for the attempted induction of an arrhythmia.

   When the operative report does not support that all five or six of the components asso- ciated with one of the comprehensive studies were performed, the limited EP study can more accurately be reported with a collection of the CPT codes assigned to each of the subcomponent services: 93600 (Bundle of His recording), 93602 (Intra-atrial recording), 93603 (Right ventricular recording), 93610 (Intra-atrial pacing), 93612 (Intraventricular pacing), and 93618 (Induction of arrhythmia by electrical pacing).

   Code 93621 is defined as “Comprehensive electrophysiologic evaluation including insertion and repo- sitioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure).” Unlike the comprehensive EP study codes, there are not associated sub-component codes for the two elements of this code: left atrial pacing and left atrial recording. Therefore, if the report does not support that both left atrial recording and left atrial pacing were performed, it would be necessary to attach the reduced service modifier (52) to the CPT code.This will probably result in a 50% reduction in compensation.

#9: Reporting confirmatory tests as diagnostic.

Diagnostic tests performed strictly and routinely to confirm the success of a surgical procedure are considered to be a component of the surgical procedure and not separately billable. For example, diagnostic EP studies and attempted induction of an arrhythmia following drug infusion should not be reported when performed strictly to confirm the success of an ablation procedure.