Cardiology Coding Alert

Notice how 93745's descriptor includes the phrase "establishing baseline electronic ECG." Fragmenting the ECG component part and coding that service separately is inappropriate, says Cynthia A. Swanson, RN, CPC, a cardiology coding specialist at Seim, Johnson, Sestak & Quist LLP in Omaha, Neb.

Example: A patient presents with sign/symptoms warranting an evaluation that includes an ECG. Based on the findings of the ECG, the cardiologist decides that the patient is at increased risk of sudden cardiac death and/or ventricular fibrillation. As a bridge to the patient receiving an implanted defibrillator, the cardiologist sets up a wearable defibrillator (93745). In this case, the ECG was truly diagnostic and not a part of the wearable defibrillator setup. Result: You would report both services and apply  modifier 59 (Distinct procedural service) to the ECG code.

Red flag: Make sure your cardiologist's documentation meets one of two criteria to justify reporting modifier 59: (1) The physician performs services he does not normally provide together on the same day, but the services are necessary under the circumstances and (2) the procedure codes fit into any of five situations: different sessions or encounters, different sites/organ systems, separate incisions/excisions, separate lesions, or separate injuries.

Count 93745 as a Component of 93743/93744

You won't get anywhere, however, if you try to append a bundle-breaking modifier to 93745 and report it alongside 93743 (Electronic analysis of pacing cardioverter-defibrillator [includes interrogation, evaluation of pulse generator status, evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response]; dual chamber, without reprogramming) or 93744 (...dual chamber, with reprogramming). Scratch out those two code combinations from your coding options.
 
The work involved with 93745 is now a component of the services represented by 93743 and 93744. This edit carries a modifier indicator of "0," which means you cannot bypass this bundle with a modifier, says Cindy Parman, CPC, CPC-H, RCC, president-elect of the AAPC National Advisory Board and co-founder of Coding Strategies Inc., in Powder Springs, Ga.

Example: If a patient has a faulty defibrillator that needs to be replaced, the cardiologist may reprogram the device to not inappropriately shock the patient (93744) as well as set up a wearable defibrillator (93745) to protect the patient until the cardiologist can implant a new defibrillator. You still cannot report these as separate procedures. The "0" modifier indicator prevents this as a possibility. You would, therefore, report 93744 only.

Apply 59 to Temporary Pacemaker Insertion Edits

When you report the insertion of a temporary single- or dual-chamber pacemaker, you'll use the following codes: 

The National Correct Coding Initiative (NCCI) makes each of these two codes components of 18 other pacemaker/lead codes as of July 1:

These edits have a modifier indicator of "1," which means you can possibly separate the bundle with a modifier and supporting documentation - but that should be a last resort. "When a code combination lists indicator 1, it means that if the documentation supports a separately identifiable service ... then it is appropriate to apply modifier 59." But if the physician performs both services in the same session and one service "is integral to the other," you absolutely should not use modifier 59, Parman says

Example: A patient presents with bilateral bundle branch block, necessitating the urgent placement of a temporary pacemaker (33210). Later in the day, the cardiologist is able to implant a biventricular pacemaker, which you would report using: