Q: What CPT code would a cardiologist use for a six-minute walk test for a patient with a diagnosis of pulmonary hypertension?
A: With the correct supporting documentation, most six-minute walk tests can be coded as a Pulmonary Stress Test, Simple - 94620. This is a test performed for pulmonary assessment. CPT Assistant indicates documentation should include heart rate, blood pressure, oxygen saturation, and liter flow of supplemental oxygen. Each of these should be recorded at rest, during exercise, and during recovery. Physician analysis of data, interpretation of the test, and a written report are included in this code.
COMPLIANCE NOTE: Medicare indicates the technical portion of this test must be performed with direct physician supervision. Non-physician practitioners are specifically excluded from qualifying to provide this supervision; only physicians can. Direct supervision is defined as "the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services." The supervision levels required for diagnostic codes including all stress tests are indicated in the Medicare National Physician Fee Schedule Relative Value File (available online at CMS) looking at the technical component listing for a particular test. Offices must be sure they are meeting this requirement of the test and are documenting the physician's supervision.
Jill M. Young, CPC, CEDC, CIMC, is president of Young Medical Consulting LLC in East Lansing, Mich., and the 2009-2010 Chair of the American Academy of Professional Coders Chapter Association.
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Reimbursement rates and CPT codes are subject to change based on region and updates to regulations. ADVANCE's Coding Q&A column is a guide only - check the specific coverage in your area to ensure accuracy.