Health care in the United States has dominated the social, political, and financial arena in the past decade. Although we have assumed that because health care in the United States is very expensive it is the best medical care, the facts do not bear that out. In the United States, our health care costs are indeed the highest in the world, but the overall health of our population lags far behind other countries that spend much less. An analysis comparing health care spending, supply, utilization, prices, and health outcomes across 13 high-income countries shows that in 2013, the United States spent far more on health care than these other countries, and, despite this, Americans had poor health outcomes, including shorter life expectancy and higher rates of chronic conditions.¹ As a comparison, the United States spends 17.1% of the gross national product on health care, and the United Kingdom spends 8.8% with worse outcomes.² That model of increased spending with worse outcomes is not sustainable.

While the debate as to why we spend so much and have worse outcomes is going on, the government has been trying to change not only the way we practice (focusing more on evidence-based guidelines) but also restructuring the payment system that was spiraling out of control. Each year, the government relied on the Sustainable Growth Rate to hold down costs. Year after year, as spending increased, the House of Medicine would descend on Capitol Hill and lobby for a real fix for the problem. The result was the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that moved the focus from fee-for-service to value-based payments. This change has proponents and detractors, but it makes sense that to be the best custodian of health care dollars, we must focus on providing the best care for our patients at the lowest cost. The "value" of our work is publicly reported and accessible by consumers as well as payers.

An issue that we as providers are facing is that because the data collected are assessing outcomes as "value," the data will ultimately reflect financially in the new reimbursement model, both as bonuses and penalties. Many cardiologists in the United States are integrated and work for a health care system. Some of those physicians feel that they are no longer responsible for data, for coding, or for documentation that supports a level of service and that it has become the system's problem. That may seem correct, but if the physicians do not code or document appropriately, the billing will be suboptimal, and patients cannot be cared for with low cost and good outcomes as expected. In addition, without appropriate and accurate documentation, we will continue to see reductions in both staffing and services. Providers need to understand how their data are reported and how they can view their publicly reported data and see where there may be gaps in documentation.

MACRA was enacted with the express purpose of supporting a four-pronged approach to health care reform. Also known as the "quadruple aim," this transformative environment of reform mandates lower per capita costs while managing our population health in a more efficient and successful fashion that also enhances the patient and provider experience. To achieve that goal, MACRA (now called Quality Payment Program [QPP]) supports two tracks:

1. Participation in advanced alternative payment models
2. Merit-Based Incentive Payment System (MIPS) for quality and financial reporting

Data collection started in 2017 and will be used for payment adjustments or incentives in 2019. There are several components that make up MIPS, and there are several ways to participate.

MIPS

If you participate in traditional Medicare, your performance-based payment adjustment will most probably be through MIPS, where there is a possible "score" of 100 points. The weighting of MIPS categories is shown in Figure 1.

Figure 1

For 2018 MIPS, providers are eligible if they bill more than $90,000 a year, provide care to more than 300 Medicare fee-for-service patients per year, and are not first-year participants in the Medicare program. For cardiology, this is likely all-inclusive; physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists are eligible. Clinicians can report as an individual clinician or as a group. Clinicians need to report performance date for the Quality, Advancing Care Information, and Improvement Activities categories. Cost will be calculated through Medicare claims data. Clinicians can choose to report the categories using one reporting mechanism or select a different reporting mechanism for each category.

It is important to understand that if the clinician is part of a multispecialty group that decides to report as a group, the reporting metrics (specifically in the Quality category) will all be the same and may not be cardiology-centric. By contrast, for those reporting individually, the measures are chosen individually, providing the opportunity to utilize quality metrics that relate to the specific patient populations managed. Heart failure is one of the most common patient populations managed in cardiovascular medicine, and heart-failure-related reporting metrics may often be chosen even in large multispecialty groups.

The Impact of QPP on Cardio-Oncology Care

Identifying opportunities for cardio-oncology care delivery should be a win-win. Taking full advantage of the QPP program will be important to maintain and improve reimbursement. Utilizing the portions of the program that directly measure cardio-oncology processes and outcomes will also ensure appropriate therapy for this patient population.

One of the objectives of the QPP is to provide clinicians with flexibility to choose the activities and measures that are most meaningful to their practice. Of the 4 categories outlined, 2 of the areas—Quality and Improvement Activities—provide the opportunity to optimize clinical care specifically for this patient population. For the Quality category, clinicians must choose 6 out of about 300 quality measures; one of these must be an outcome or high-priority measure. The Quality category carries a 50% weight for 2018 data year for MIPS.

Quality Measures

For a clinician who is looking to directly impact cardio-oncology care and take full advantage of MIPS QPP, Table 1 lists good choices for Quality measures and their corresponding domains. The Centers for Medicare and Medicaid Services has also developed an informational online tool that allows clinicians to explore the various measures that may best suit their practice. It is available at https://qpp.cms.gov/measures/quality.

Table 1: Key QPP Measures Relevant to Cardio-Oncology Management³

Measure	Domain
Discuss and provide a care plan	Shared decision-making
Transmit specialist reports	Coordination of care
Control high blood pressure Screen for tobacco use and provide cessation intervention	Manage comorbidities

Improvement Activities

The second set of measures that may directly affect cardio-oncology care is contained in the Improvement Activities section. For this category, several options are available:

• Provide 24/7 access to clinicians who have real-time access to patient's medical record
• Use Qualified Clinical Data Registry for feedback reports that incorporate population health
• Engage new Medicaid patients and follow up
• Participate in research that identifies interventions, tools, or processes that can improve a targeted patient population
• Manage medications to maximize efficiency, effectiveness, and safety

Looking Toward the Future

As the QPP is ramped up over the next several years, the penalties and incentives will increase. There is no real option for not participating; therefore, engaging with the program is a clinician's best option for success. For those clinicians who manage a significant number of cardio-oncology patients, the alignment of care delivery with the Quality measures ensure there is better care and smarter spending, leading to a better outcome for all.

As our Medicare patient population and cardio-oncology population increase, our ability to provide high-quality care in a cost-effective manner will continue to grow in importance. The QPP, whether engaged through MIPS or an alternative payment model, can provide a venue in which success means a financial incentive to those providing care. For specifics on both programs, please refer to the information at https://qpp.cms.gov.

Coding and Documentation Guidelines for Cardio-Oncology

As with every medical record, documentation a key factor. Accurate documentation of your patient's condition for each visit will help to get your claims reimbursed. When advocating for your reimbursement, accurate coding is essential. We have had some guidance from a local Medicare carrier that suggested using the following codes when treating your cardio-oncology patient. This advice may differ from other payers; you should check each payer for their guidance regarding cardiology-oncology coding:

• Report ICD-10 code Z01.818 when the test is performed as a baseline study before chemotherapy.
• Report ICD-10-CM code Z51.81 for subsequent monitoring while the patient is receiving chemotherapy.
• Report ICD-10-CM code Z08 for testing when chemotherapy is completed.

And we have found the following paragraph in an LCD for Echocardiography, Transthoracic and Transesophageal guidance:⁴

Exposure to Cardiotoxic Agents (Chemotherapeutic and External)
Measures of myocardial contractility, thinning and dilatation are important in the titration of therapeutic agents with known myocardial toxicity. When echocardiography is used to monitor cardiac toxicity of chemotherapeutic agents, an initial complete TTE may be performed prior to the first administration of the agent with the frequency of repeat studies determined by the patient's clinical course and the toxicity profile of the agent being administered.

Working closely with all your payers can be extremely beneficial for proper coding and reimbursement.

Please note that this coding guidance is current as of June 2017 but could be subject to change yearly and with any further guidance from payers regarding the science of cardio-oncology. It is to your benefit to work with your third-party payers regarding each plan's individual coding guidance and preference.

Table 2: Case Examples With Coding

Case Question	Case Answer	Coding Tips	Example Coding
An oncology patient is sent to you for a cardiovascular evaluation prior to starting cardiotoxic drugs for treatment of breast cancer. This patient is otherwise healthy and presenting with no risk factors for coronary artery disease. You perform an evaluation and management (E/M) visit and order an echocardiogram with strain to assess left ventricular function. What is your diagnosis?	Report ICD-10 code Z01.818, Encounter for other preprocedural examination (is defined as Encounter for preprocedural examination NOS and Encounter for examinations prior to antineoplastic chemotherapy), when the test is performed as a baseline study before chemotherapy.	List Z01.818 as your primary diagnosis code. This code can stand alone as the only diagnosis for this visit. You can list the neoplasm as a secondary diagnosis, for example code C50.51, Malignant neoplasm of lower-out quadrant of breast, *female. It is recommended to always code the cancer for each encounter. Check with each payer for their preference if you notice any problems with reimbursement. Some payers may want the oncology diagnosis listed first and the Z code listed second.	99243 (Consultation); Z01.818, C50.51 (attach modifier 25 to E/M) 93306 (Echocardiography); Z01.818, C50.51 (may need mod. 26) +0339T (strain)* Z01.818, C50.51
Today you are seeing a survivor of Hodgkin’s lymphoma who has a prior history of cardio-toxic drugs and radiation to the chest and is now in surveillance mode for 10 years. This patient is asymptomatic. You perform an E/M visit, stress test to access ischemia and aerobic capacity, and an echocardiogram. How would you code for this outpatient visit?	Code for your E/M visit, stress echo code 93350 or 93351. For the diagnosis codes, preferably you would want to code any cardiovascular symptom that you may find during the visit first. If there are no cardiovascular symptoms, code the reason that she came in, for example Z08, Encounter for follow-up examination after completed treatment for malignant neoplasm Z85.71, Personal history of Hodgkin Lymphoma Z92.21, Personal history of antineoplastic chemotherapy Z92.3, Personal history of irradiation (Personal history of exposure to therapeutic radiation) Z91.89, Other specified personal risk factors, not elsewhere classified (at risk for cardiomyopathy, as example)	If during your examination with the patient you discuss any cardiovascular symptoms such as shortness of breath, fatigue, and/or decreased exercise capacity that the patient experienced, feel free to code these documented symptoms prior to listing Z codes. Per ICD-10-CM guidelines you list as many ICD-10 codes per visit that are warranted (you will only be limited by your billing system’s capacity). List any co-morbidities that you have addressed and documented during your visit. When using ICD-10 code Z08, make sure you read the notes for this code. The guidelines state to 1) use additional code (the phrase “use additional code” signals the coder that an additional code should be reported to provide a more complete picture of that diagnosis) to identify any acquired absence of organs and 2) use additional code to identify the personal history of malignant neoplasm.	Scenario 1: Asymptomatic patient: 99213 (E/M visit); Z85.71, Z51.81 **(attach modifier 25 to E/M) 93350 or 93351; Z85.71, Z51.81 (most likely need modifier 26 for this code) Scenario 2: Patient who has experienced cardiovascular symptoms: 99213 (E/M visit); R06.02 (shortness of breath), Z85.71, Z51.81 ** 93350 or 93351; R06.02, Z85.71, Z51.81
Your patient is a healthy young woman with triple negative breast cancer, and she is being monitored several times during chemotherapy for cardiomyopathy. She has not manifested any non-cancer symptoms.	Code for your E/M visit and any test performed such as an echocardiogram. You have to use the correct sequence of Z codes if the patient is asymptomatic. During chemotherapy, you want to use the ICD-10 diagnosis code of Z51.81 for the echocardiogram as the primary diagnosis. Always code the cancer. Code any cardiovascular symptom that came up during the visit as well as any co-morbidities that you have documented.	Z51.11, Encounter for antineoplastic chemotherapy, should be reported only when patient is receiving the chemotherapy at that encounter.	99213 (E/M visit); Z51.81, C50.111 (attach modifier 25 to E/M) 93306; Z51.81, C50.111 (most likely need a modifier 26 for this code)
* CPT® code 0339T is a Category III CPT code. A Category III code is a tracking code used for emerging technology, services, procedures, and service paradigms. We use these codes when they are available to allow data collection. Category III codes can eventually become Category I CPT codes when FDA approved and we have sufficient literature and clinical evidence to support this new technology. Coding Note: Once a service has a Category III code you cannot use the unlisted codes to bill for this service. ** In the ICD-10 guidelines, there is a “code also” note for Z51.81. This phrase alerts the coder that more than one code may be required to fully describe the condition.

Diagnosis codes to use when you first see your cardio-oncology patients	Z01.818, Encounter for other preprocedural examination, is defined as Encounter for preprocedural examination NOS and Encounter for examinations prior to antineoplastic chemotherapy. Neoplasm Code: Any cardiovascular symptom the patient may be presenting. Code any co-morbidities that you have addressed during your visit.
Diagnosis codes to use when you continue to see your cardio-oncology patients	Z51.81, Encounter for therapeutic drug level monitoring Neoplasm Code: Any cardiovascular symptom the patient may be presenting Code any co-morbidities that you have addressed during your visit
Facts regarding the use of Z codes	Z codes may be used as either a first-listed (principle diagnosis) or secondary code, this varies with the circumstances of the encounter. Z codes are used as an indicator of the reason for an encounter. Categories of Z codes include Status, History (of) (Personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment, but that has the potential for reoccurrence, and therefore may require continued monitoring), Screening, Aftercare, and Follow-up codes to name a few. Personal and family history ICD-10 diagnosis codes are acceptable to report whatever the reason for the visit. A patient's personal health history of an illness that no longer exists is important since this information may alter the type of treatment ordered. The family history diagnosis codes are used when a family member of the patient has had a disease that gives concern that the patient might be at a high risk of contracting the disease. These codes support the need for screening and follow-up exams.

Resources

1. Payment Basics: Physician and Other Health Professional Payment System (Medicare Payment Advisory Commission website): http://medpac.gov/docs/default-source/payment-basics/medpac_payment_basics_17_physician_final9da411adfa9c665e80adff00009edf9c.pdf
2. ICD-10-CM Official Guidelines for Coding and Reporting: https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf
3. 2017 ICD-10-CM and GEMs: https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html

References

1. U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries (The Commonwealth Fund website). October 2015. Available at http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective. Accessed 09/25/2017.
2. Snapshots: Health Care Spending in the United States & Selected OECD Countries (Henry J. Kaiser Family Foundation website). April 12, 2011. Available at http://kff.org/health-costs/issue-brief/snapshots-health-care-spending-in-the-united-states-selected-oecd-countries/. Accessed 09/25/2017.
3. Quality Payment Program website. 2018. Available at https://qpp.cms.gov/. Accessed 09/25/2017.
4. Plana JC, Galderisi M, Barac A, et al. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2014;27:911-39.

Clinical Topics: Cardio-Oncology, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Acute Heart Failure, Echocardiography/Ultrasound, Hypertension

Keywords: Cardiotoxicity, Cardiotoxins, International Classification of Diseases, Echocardiography, Fees and Charges, Centers for Medicare and Medicaid Services, U.S., Comorbidity, Decision Making, Documentation, Fee-for-Service Plans, Gross Domestic Product, Health Care Costs, Health Care Reform, Health Expenditures, Health Services Needs and Demand, Heart Failure, Hypertension, Insurance, Health, Reimbursement, Medicaid, Medical Records, Medicare, Medicare Access and CHIP Reauthorization Act of 2015, Motivation, Nurse Anesthetists, Nurse Clinicians, Nurse Practitioners, Physician Assistants, Registries, Tobacco Use, Ursidae

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