The CardiologyBiller.Com “EP & CRM Superbill”

Jim Collins, CPC, CCC, President, CardiologyCoder.Com, Inc. CardiologyBiller.Com
Jim Collins, CPC, CCC, President, CardiologyCoder.Com, Inc. CardiologyBiller.Com

One of the first things I do for new billing clients is implement effective charge capture tools like this “EP & CRM” Superbill (Figure 1). The form provides a guided tour of itself. 

We first planned to keep this form as a proprietary tool – something that only our active clients could use in practice. Then I trained a physician, who was not a client, on how to code a-fib cases. It was painful to see him ask the same question in different ways in order to try and get a different answer: “Can I bill left atrial pacing and recording if I do it before the AF ablation?” “What if it was not confirmatory, but truly diagnostic — can I bill for it?”

These were nagging questions that I know would have been resolved if I could have just placed the form in front of him and showed him how the “Ablations” section is structured. I withheld the form as long as I could, but ultimately I gave in and walked him through the form. The relief I saw on his face was compelling enough to put an end to the concept of us keeping this form to ourselves. It was kind of like when a clinical trial is stopped prematurely, because the data is so overwhelmingly positive.

 After some horse-trading with my partners, I am able to share this form with you in EP Lab Digest®. As established in the copyright notice, certain organizations may copy and use this form for billing purposes after their doctors have attended my associated training program. In the training program, I will provide critical information that must be understood by each physician using this form. I’ll provide a few examples below.

Almost in the very center of the form you’ll see the statement “Secondary prevention – remove Q0 Mod.” This check box helps us eliminate one of the most common errors associated with billing for defibrillator implants: not assigning the Q0 modifier when indicated. The story behind this modifier is obscure.

When Medicare last updated the National Coverage Determination for defibrillators, it mandated that all primary prevention defibrillator implants be enrolled in a Medicare-specified data registry. By populating a registry, Medicare hoped to identify a more appropriate subset of patients who would most benefit from a defibrillator implant. In January 2005, the Washington Post wrote that this registry requirement “represents the most aggressive effort yet to use [Medicare] as a backdoor way to learn more about what works and what does not in medicine.”1

Originally, the only qualified registry was QNet’s ICD Abstraction Tool. On April 1, 2006, the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) replaced QNet as the Medicare-mandated registry.

Modifier QR (Item or Service Provided in a Medicare Specified Study) was originally required on all primary prevention defibrillator implantations that were enrolled in the registry. This modifier was deleted on January 1, 2008 and replaced with modifier Q0 (Investigational clinical service provided in a clinical research study that is an approved clinical research study). Make sure to note that this is a “Q-Zero” not a “Q-Oh” — there is a difference between the two.

In addition to requiring the hospital to enroll all primary prevention implants in the specified data registry, they require physicians to affix the Q0 modifier to the CPT code used to report the device being implanted. Many superbills require the physician to check off that the Q0 modifier should be appended. However, we require the physician to check off this box when the Q0 modifier should be omitted from the claim. 

In the rows above this Q0 modifier check box, you’ll see that the Q0 modifier is already listed as applying to each of the defibrillator implant codes: 33264-Q0, 33263-Q0, etc. We took into account that over 90% of defibrillator implants are performed for primary prevention indications. Rather than having the physician check a box nine out of ten times in order to accurately code his services, we have the physician only check a box one out of ten times. I’m sure that errors will still occur, but our form will reduce errors, physician administrative burden, and the number of claims that have to be re-worked. Collectively, the dozens of nuances we worked into this form will add a lot of revenue to the bottom line for most EPs and NEPIs.

We applied a similar convention with the check box that says “No DFT – remove 93641-26.” We listed the DFT code with each of the defibrillator generator change out codes assuming that doctors will perform DFTs most of the time when performing a generator change out. If they happen to omit this portion of the procedure, they check off the box, and that code (93641-26) gets removed from the claim.

The “Ablation(s)” section of the form achieves the most with the least amount of real estate. The left column of the form contains the names and codes for each of the ablation procedures. The columns to the right are for each of the add-on services one could potentially perform at the time of an ablation procedure. The CPT book says that only certain add-on services can be reported with each of the ablation procedures. It required a spreadsheet with a pivot table to determine which add-ons could be reported with each ablation code for about six months after the codes were first introduced. Everything has settled now, and the Ablation section of the form illustrates which add-on services can be reported with each ablation. 

The “Device Checks” section of the form tackles a lot of topics in a compact format. Codes 93288 and 93289 should stand out as device checks that do not involve performing threshold testing at the time of the service. Traditionally, these services would be the rarity — device technicians would almost always check the thresholds during the device service. In recent years, the devices have evolved to do threshold testing automatically — a process called “auto-threshold.” If the device technician refers to the auto-threshold data rather than perform a demand threshold test, codes 93288 or 93289 should be used instead of the other device testing codes. 

The financial difference between codes 93288 and 93289 and the other device check codes is substantial. If the patient is being remotely monitored, codes 93288 and 93289 will not be compensated at all. The “interrogation” service described by these two codes is considered to be an included part of the remote monitoring service. 

In the “Other” section of this form, you’ll see the listing of NIPS – 93724-26. I left this listing on the form with some reluctance. Code 93724 is officially defined as “Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings).” Nothing about the definition suggests that it is appropriate for non-invasive programmed stimulation. However, the abundance of reference material from specialty societies and others suggesting that 93724 is “the code” for NIPS is undeniable. I’ve long felt that an unlisted code would be more accurate. However, unlisted codes don’t pay, and they create a lot of administrative burden.  

App Launch

If you like the CardiologyBiller.Com EP & CRM Superbill, wait until you see our iPhone/Android app. The app will be launching March 30th in booth 707 at ACC.14. Like a good superbill, the app tackles a lot of challenges in an elegant and foolproof manner. Doctors who use our app will secure more compensation, have considerably less administrative burden, and experience fewer denials.

When a doctor goes to the hospital in the morning, he or she will take a picture of the schedule for the day. That picture will automatically be routed to our field of U.S.-based data entry professionals, who will instantly add each patient to your schedule in the app. Each patient will be a bubble in a stream of bubbles for the day. As you see each patient, you simply tap on their bubble, assign the level of service and the diagnosis code. Your charges go real time into a work cue for your billing staff. The claim for one patient can be entered before you begin seeing the next patient. 

If you get an add-on patient during the day, you simply add a new bubble to your schedule, take a picture of the demographic/registration paperwork, and move on with your day. The picture you took removes the need to write down anything like insurance information or patient identifiers. Your billing staff can just key it in directly from the high-resolution picture(s) you took.

Unlike the EP & CRM superbill, the billing app we developed applies to physicians of all specialties. EPs will get just as much use out of the application as an internal medicine physician.

For more information, please visit:


  1. Weiss, Rick. “Medicare To Cover Cardiac Device.” Washington Post. 20 Jan. 2005. <>