Cardiology billing
Cardiology Medical Billing and Revenue Cycle Management
Quilven runs the full revenue cycle for independent cardiology practices. Collection in this specialty is decided less by whether the study was indicated and more by four structural questions: who owns the equipment, whether the device period has actually opened, whether nuclear and advanced imaging cleared a radiology benefit manager, and whether the note supports the coverage determination. We bill as a percentage of what we collect. Month to month. No setup fee. No minimum.
Most cardiology practices arrive with one of these.
Section 3
Why cardiology billing is not general medical billing
A practice that owns cameras, reads its own studies, and monitors implanted devices is running three payment models on one tax ID. Miss the model and the claim either never pays or pays and comes back later.
The four leaks that generalist billing does not usually catch:
The professional and technical split. Diagnostic cardiology is often two payments glued together: interpretation and equipment. Office reimbursement is higher than facility reimbursement because the office is supposed to be carrying the machine. Bill the wrong half and you either donate the larger share or create a duplicate that Medicare recoups.
Device intervals. Remote pacemaker and ICD checks run on 90 days. Loop recorders and hemodynamic monitors run on 30. The clock starts at the last billable interrogation, not at the start of the quarter. Bill early and it denies. Never bill and the period is gone.
Advanced imaging prior authorisation. Nuclear stress, cardiac MRI and cardiac CT usually leave the payer and enter a radiology benefit manager. An authorisation number is not a paid claim.
Cath lab bundling. A diagnostic catheterisation performed in the same session as an intervention is bundled into the intervention. Report both without a documented separate encounter and you either deny or audit.
None of that is "the biller forgot a modifier." It is specialty mechanics.
Section 4
Do we bill 26, TC, or global?
Two facts decide it: who owns the equipment, and where the study was done.
| Situation | Bill | Why |
|---|---|---|
| You own the equipment and read the study | Global, no modifier | You bear both costs |
| You read a study performed elsewhere | Modifier 26 | Interpretation only |
| You own the equipment, another physician reads | Modifier TC | Equipment, technologist and supplies |
Billing only modifier 26 gives away the larger share
Billing global on hospital equipment while the hospital bills TC is a duplicate that gets recouped.
The professional and technical pieces add up to the global payment. Not every code allows the split. The Medicare Physician Fee Schedule marks each code with a PC/TC indicator. Codes marked as physician services cannot be divided.
This is where money disappears quietly. On a complete transthoracic echo, the technical component is the larger share. A practice that owns the machine and still bills only modifier 26 is giving away the bigger half of every study, usually because that is how the last biller built the charge master.
The other direction is worse. Billing global on hospital equipment while the hospital bills TC is a duplicate payment. It gets recouped, often with interest.
If office studies look underpaid relative to the work, start here before you assume a fee schedule problem.
Section 5
Are we billing device and remote monitoring on the right clock?
Usually not, if anyone is using a calendar quarter as the trigger. CMS coverage article A56602 sets the intervals. They reset from the last billable interrogation.
| Device | Remote codes | Period |
|---|---|---|
| Pacemaker | 93294 professional, 93296 technical | 90 days |
| Implantable cardioverter defibrillator | 93295 professional, 93296 technical | 90 days |
| Implantable hemodynamic monitor | 93297 | 30 days |
| Implantable loop recorder or insertable cardiac monitor | 93298 | 30 days |
Bill early and it denies. Never billed and the period is gone.
Shorter cycle. Resets from last billable check, not the quarter.
Do not report the 90-day remote codes if the monitoring period is under 30 days (CMS A56602). For 93297 and 93298, manufacturer and CMS descriptor language uses a shorter minimum (commonly 10 days). Verify the current article before you set a rule in the charge master.
Three denials that keep coming back
Duplicate on the professional and technical pair. Medicare pays 93294 or 93295 and denies 93296 as a duplicate because the codes sit in the same range. That is claim construction, not a wrong code.
Device code mismatch. 93297 is the hemodynamic monitor. 93298 is the loop recorder. Swap them and the claim dies.
Interval errors both ways. Too early denies. Never billed is the expensive version, because a closed period does not reopen.
Track patients, not quarters. That is what the tool is for.
Free cardiology coding tool
Cardiac device and remote monitoring interval calendar
Select a device and the date of the last billable interrogation. It returns the codes, the interval, and the first date the next period can be billed. Runs in your browser. No name field, no MRN field.
Source: CMS A56602 for intervals, manufacturer coding guidance for facility modifiers.
Educational reference only. Not billing or legal advice. Payer policies vary. Verify against the current CMS article and your payer policy.
This tool also lives at its own address: /tools/device-monitoring-interval-calendar/.
Section 7
Nuclear stress and advanced imaging prior authorisation
Nuclear stress, cardiac MRI and cardiac CT need authorisation from most commercial and Medicare Advantage plans. The review usually sits with a radiology benefit manager, not the payer's own desk.
orders study
routes to RBM
eviCore / Carelon
CARC 197, authorisation not obtained, is the usual denial. It is a process failure. Front-end capture is the only reliable fix.
eviCore and Carelon are not the payer with a different logo. They run their own criteria engine and their own peer-to-peer path. Treat them like ordinary payer authorisation and you will lose cases you could have won.
Routine exercise treadmill testing is often exempt. Nuclear and pharmacologic studies are not. Cardiac MRI is authorised almost everywhere, and reviewers want a written reason that echo or nuclear imaging would not answer the question. Appropriateness of MRI is not enough. You have to show the cheaper study is not enough.
The American Medical Association's 2025 physician survey found physicians completing an average of 40 prior authorisations a week, using about 13 hours of physician and staff time, with 94 percent saying it contributes to burnout. Cardiology sits near the top of that burden by volume.
The federal appropriate use criteria mandate for advanced imaging was paused and its regulations rescinded effective 1 January 2024. The associated G-codes and modifiers were retired after 31 December 2024. Do not put consultation information on Medicare fee-for-service claims.
AUC did not leave the building. Commercial plans and Medicare Advantage still apply the same clinical logic through benefit managers. Medicare Advantage has tightened, not loosened. Celebrating the end of the federal mandate does not change what eviCore asks for.
The CMS interoperability and prior authorisation rule became operational on 1 January 2026 for Medicare Advantage, Medicaid and marketplace plans: 72 hours for urgent requests, seven calendar days for standard ones, specific denial reasons required. Faster answers. Not fewer authorisations. It does not cover ordinary commercial plans outside those categories.
An authorisation number is still not a guarantee of payment. Claims deny after the fact when the note at the time of service does not match the criteria used at review.
Section 8
Why echo and stress claims deny for medical necessity
The procedure code can be perfect and the claim still dies. Coverage looks at whether the diagnosis matches an accepted indication in the LCD or NCD, and whether a complete study actually documented the elements a complete study requires.
Echo
One code, one payment
Already included — denied
93306 is a complete transthoracic echocardiogram with spectral and colour flow Doppler. Those Doppler services are already inside 93306. Billing 93320 or 93325 next to it is unbundling. A complete study that misses a required structure downcodes to limited or denies. Missing wall motion is a recurring audit miss. A routine echo billed against a screening diagnosis denies every time.
Stress testing
| Code | Service |
|---|---|
| 93015 | Global: supervision, tracing and interpretation |
| 93016 | Supervision only |
| 93017 | Tracing only |
| 93018 | Interpretation and report only |
Do not bill 93015 with its own components for the same test on the same date. In a facility the hospital bills the tracing and the cardiologist bills supervision and interpretation. Billing 93015 in a facility where you do not own the equipment is a standard error.
The stress-inducing code and the nuclear imaging code are two halves of one study. They are not an NCCI bundled pair. Some contractors deny the combination anyway. The answer is documentation and appeal, not recoding. Practices that treat the denial as correct write off money they are owed.
Heart failure needs type and acuity, not I50.9. Specific codes also carry HCC weight in Medicare Advantage and shared savings that unspecified codes do not. Chest pain should be specific. Unspecified chest pain as the lead diagnosis on monitoring is a known audit trigger. Where hypertension and heart failure coexist, ICD-10-CM presumes a causal link and sequences accordingly.
Section 9
What actually moved in the 2026 fee schedule
CMS estimates cardiology payment up about 1 percent overall (ACC analysis of the CY2026 final rule). That average hides the split that matters if you own equipment.
Two conversion factors for the first time: $33.5675 for qualifying APM participants (+3.77 percent) and $33.4009 for everyone else (+3.26 percent), up from $32.3465 in 2025 (CMS CY2026 PFS final rule).
A 2.5 percent efficiency adjustment cuts work values and intra-service time on nearly all non-time-based codes. Procedural and diagnostic work, which is most of cardiology, takes the hit. It offsets a large part of the conversion factor increase.
The material change is practice expense. CMS reduced the allocation of indirect PE for facility services, on the theory that hospitals already carry those costs. ACC and ASNC project facility-based cardiology services down about 7 percent and non-facility services up about 5 percent. The cut applies even if the physician is not hospital employed. If hospital reads look lighter this year, this is why.
hospital-based reads
indirect PE reduced
office-based imaging
you carry the equipment
That changes the arithmetic on bringing imaging in house. Model it. Do not assume last year's comparison still holds.
Two remote physiologic monitoring codes were added for 2026 and are now in the final rule text: 99445 for device supply with 2 to 15 days of data in a 30-day period, and 99470 for shorter-duration treatment management (first 10 minutes). They are not billed with 99454 or 99457 in the same period. Confirm descriptors and billing rules against the current CMS text before you load them.
Section 10
What we handle
Section 11
Should you outsource cardiology billing or keep it in house?
If you already have someone who understands the split, tracks device intervals by patient, and works authorisation denials instead of adjusting them off, keep them. That combination is uncommon. It exists. A practice that has it does not need us.
Find out in an afternoon.
- 1Pull twenty studies performed on your own equipment and read in house. How many were billed global rather than professional only?
- 2Pull a quarter of device monitoring. How many patients had an open billable period that nobody billed?
- 3Pull CARC 197 denials. Appealed, or written off?
Those three answers beat any vendor conversation, including ours.
In house is right when
- The biller understands ownership and place of service
- Intervals are tracked per patient
- Denials are worked
- Volume is stable
Outsourcing makes sense when
- Any of those checks fails
- One person holds the whole map with no cover
- You are adding providers or cameras faster than billing capacity
- Prior authorisation has become someone's unspoken full-time job
Test any vendor, including us, on four things: a cardiology-specific coding credential rather than a generic CPC; denial reporting by provider, not only in total; the ability to name the LCDs that apply in your jurisdiction; a first-pass acceptance rate measured at the payer, not the clearinghouse. We would rather you asked than took our word for it.
What we cannot do
Make a benefit manager approve a study, rewrite a coverage determination, or recover a device period that closed unbilled last year.
What we can do: get the split right, track the intervals, and work the denials.
Section 12
Get a free 48-hour AR audit
We look at claim data and tell you what is not being worked, where denials cluster, and what it is costing. For cardiology that usually starts with the three checks above. No obligation. If the billing is clean, we will say so.
How many providers?
Do you own imaging equipment?
Do you monitor implanted devices?
You told us
providers not set providers · Imaging: not set · Devices: not set
Section 13
Common questions
Do we bill 26 or global for a study we performed and read ourselves?+
Global, no modifier, if you own the equipment and the study was done in your office. Modifier 26 only when you interpreted a study on someone else's machine. Modifier TC when you own the machine and someone else interprets.
Medicare is denying our technical device code as a duplicate. What is happening?+
93294 or 93295 paid, 93296 denied as a duplicate of a code in the same range. Construction problem, not a wrong code. Work it. The technical piece is not trivial across a monitoring panel.
Is the stress-inducing code bundled into the nuclear imaging code?+
No. 93015 (or its components) and 78452 are two halves of one nuclear stress test and are not an NCCI pair. Some contractors deny them together anyway. Appeal with the documentation. Do not recode to make the denial comfortable.
Does prior authorisation guarantee we get paid?+
No. Authorisation means the request met criteria on the information sent. It does not certify the encounter. If the note at service does not match the criteria, the claim can still deny.
Is appropriate use criteria still a requirement?+
Not federally. The mandate was paused and the regulations rescinded effective January 2024. Commercial and Medicare Advantage plans still apply the same logic through benefit managers.
What ICD-10 detail do heart failure claims need?+
Type and acuity. Systolic, diastolic or combined. Acute, chronic or acute-on-chronic. I50.9 looks like missing clinical detail, draws denials, and carries less risk-adjustment weight.
Do you handle credentialing?+
Yes. Application fees pass through at cost. Start at offer signature, not start date.
Is our data safe with a global team?+
One business associate agreement covers every person who touches the file, US and international. Check whether any payer contract or state rule restricts protected health information leaving the US.
What does it cost?+
A percentage of collections, quoted after the free audit. No setup fee, no platform fee, no minimum, month to month with 30 days' notice.
Section 14
Sources
- CMS Physician Fee Schedule, CY2026 final rule
- CMS Medicare Coverage Database, article A56602, cardiac rhythm device evaluation
- CMS Medicare Coverage Database, article A52850, cardiac catheterisation
- CMS Interoperability and Prior Authorization Final Rule, CMS-0057-F
- CMS appropriate use criteria programme status
- American Medical Association, 2025 Prior Authorization Physician Survey
- American College of Cardiology and American Society of Nuclear Cardiology, 2026 fee schedule analysis
- MGMA Cost and Revenue Survey 2024
- Kodiak Solutions revenue cycle data, 2024