How To Code or Bill A Heart Catheterization

My brother just began life in the private world as an interventional cardiologist last month. I asked him today, "How do you code and bill a heart catheterization?  And how much does Medicare pay for a heart catheterization?". His answer was, "There are five components." We sat down and looked at them all.

Anyone reading my blog knows how complicated CPT® medical coding  is. Go here if you want RVU explained. 

We sat down and looked at his billing data that comes up nicely compiled on his computer phone. The following are the codes that are billed to the Medicare National Bank every time a heart catheterization is performed. Remember, there are fees paid to doctors and fees paid to hospitals. And they are completely separate from each other. These fees will change based on a geographic modifier (what part of the country you live in) but assume normal cost of living cities.

1) CPT® 93510: Left heart catheterization, retrograde (sticking the needle in the groin and guiding the catheter to the heart). The physician collects about $220 ( 4.3 work RVUs, and 2.6 malpractice RVUs). The hospital collects about $1,300 in facility fees (about 40 RVUs) (And exactly how is this determined?)

2) CPT® 93545: Injection procedure during heart catheterization (squirting some dye in the arteries), physician collects about $20 (0.4 work RVU) . Hospital collects about $110 in facility fees (3 RVUs) (How much does that dye really cost?)

3) CPT® 93543: Left ventricular angiography (squirting dye into the heart's left ventricle), Physician collects about $15 (0.3 work RVU's) and the hospital collects about $50 bucks in facility fees (about 1.5 RVUs) . (Again, how much does that dye really cost?)

4) CPT® 93555: Interpretation and report of injection procedure during cardiac catheterization, ventricular and/or atrial angiography ("What's my ejection fraction doc?"). Physician collects about $40 (0.8 work RVU and 0.4 malpractice RVU). Hospital collects about $150 (3.6 RVU in facility fees) (What exactly costs the hospital $150 while the physician dictates their report. Is it the IT/EMR/Computer system they are collecting for? Why is the hospital collecting anything for this?)

5) CPT® 93556: Interpretation and report for injection procedure of the arteries ("Are my arteries blocked doc?") . Physician collects about $40. (o.8 work RVU and 0.5 malpractice RVU). Hospital collects about $220 (See above. This is a fast track on the RVU gravy train. Why is the hospital collecting money because the physician dictates the report?)

He said start to finish for a heart cath including procedural, documentation and time spent talking with  family  is about one hours time from start to finish. So let us see how hat plays out:

Left heart catheterization with left ventriculogram and arteriogram with interpretation and report.

Time spent: 60 minutes

Physician payment (Medicare): $335 (6.6 work RVU and 3.5 malpractice RVU=10 RVUs) (this may be assuming the 10% cuts went through since 10 RVUs pays about $380 today, or $38/RVU)

Hospital payment (Medicare): $1,830 (about 50 RVUs).

I couple of thoughts here: Hospitals collect a gazillion dollars in facility fees for procedures. I understand that it costs money to run a cath lab. Supplies, labor, overhead. And volume rules the day. With fixed labor and facility costs, your only real fluctuating cost is the supplies like catheters and the iodine. So the more heart caths you do, the less your over head as you drive down your cost as a percentage of revenue. It's amazing how economics works in the real world. Incentive? Drive procedures into your state of the art facility to drive revenue as a percentage of your fixed costs. Look at it like this, if you do 1000 caths at your hospital, your overhead will be much less than if you only do 100. The economics force you to drive your paying patients to your privately owned hospital and your uninsured to the community hospital to eat the cost. Thus the explosion of specialty hospitals and the skimming off the top on these invitation only hospitals.

Note also that each heart cath pays the physician about $130 to cover malpractice costs (about 3.5 RVUs). If a physician does 100 caths a year, that's $13,000 a year that Medicare pays for their malpractice coverage. Is paying $130 per cath for malpractice right? I have no idea. I find it hard to believe that 35% of the cath fee paid to a physician is necessary for the malpractice risk of a cath. I place central lines all the time with a risk of collapsing a lung, but I don't get 3.5 RVUs to pay for my malpractice. I would love to know how that number was created. The actual calculated physician work RVU for a heart cath is about 6.5 RVUs. Tack on the 3.5 malpractice RVUs and the total RVUs to the physician for a cath is about 10 RVUs.

Let me put that in perspective for you. One heart cath, or ten RVUs in one hour is the equivalent of seeing seven mid level in-patient hospital follow up visits (9 minutes a patient) in one hour. It's the equivalent of seeing five highly complex in-patient hospital follow up visits (12 minutes a patient) in one hour. A complex, critically ill patient in the intensive care unit, on pressors, a ventilator and multiorgan failure will pay 4.5 work RVUs for 74 minutes of work and 0.2 malpractice RVUs. I don't understand the rational behind paying 3.5 RVUs in malpractice for a heart cath but paying 0.2 malpractice RVU for a critical care ICU visit.

There are many, many decisions that go into taking care of a critically ill patient. Medication adjustments. Interpreting data. Manipulating drugs. Ordering radiology testing and laboratory. The ability to screw up at any point in the process is constant. You have to know exactly what you are doing across multiple organ system evaluations in critically ill patients. And yet, it pays 0.2 RVUs for malpractice. I would suggest that the complication rate of ICU management is far higher than the 2-3% seen with heart caths, yet Medicare pays the malpractice for ICU care at a rate of 1/20 the rate of a heart cath. It makes no sense to me, no matter how you look at it.

A heart cath pays the cardiologist about 50% more on a work RVU basis than it does for a similar time based ICU visit (6.5 RVUs vs 4.5 RVUs). That number jumps to 85% more for a similar rate of payment for high complexity in-patient follow up visits. But, if you include what Medicare pays for malpractice coverage, a heart cath jumps to 10 RVUs for one hour of work, or about 110% more when compared to a similar time of ICU work, and almost 200% more of complex in-patient follow up care.

These are the stark realities of the current payment system. It drives medical students into specialties that guarantee procedural payment systems far superior to the cognitive based specialties.

When you simply break down the numbers and look at it with an objective mind, it's easy to understand why there is an implosion of primary care in this country. Everyone is heading to cardiology with their $100 five minute stress test interpretations and their $350 heart caths (and that's just Medicare, private will pay much more). The large financial incentives are built into the system.

On the surface of things, I have no problem with heart docs making that much for a heart catheterization. In fact, if you look at it from a financial standpoint, I think it should be more. Being a cardiologist is a very difficult thing. Four years of college. Four years of med school. Three years of residency training in  internal medicine opportunities. Three years of cardiology fellowship. And possibly one year more for subfellowship. Fifteen years after highschool of education, training and opportunity cost. That's a lot of lost financial compounding that is lost during training. The market would say that they are worth every penny. And probably much more.

My problem is that the payments to a cardiologist suppress the payments to primary care in the zero sum game known as Medicare Part B. Since the pot is fixed, and all encounters are created equal, any increase in payment for one group of doctors means other groups will decrease. And right now, cardiologist services are valued much more highly than primary care on an RVU basis. And when you are a medical student trying to decide what field to enter, the prospects of three years of fellowship leading to 200-500% increase in income is a no brainer.

Cardiologist make more and they should make more on their own merits. But they don't. They make more at the expense of primary care. And that's entirely due to the zero sum RVU game. If you want to value primary care and all the cost savings that come with it, you will have to value it independently of the zero sum game known as RVU/RUC/Medicare Part B.  You almost need an EMR to figure it all out.  There's help here with an EMR comparison. 

Addendum:  Go here for an add on post on this and corrections to some bad math above.

You can learn more about coding here in my coding lectures

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