Cardiology Coding Alert

Although surgical specialists deal with 10- or 90-day global periods routinely, most cardiology procedures, including left heart caths, PTCAs and stents, have zero global days.

However, one important group of procedures pacemaker and internal cardioverter-defibrillator (ICD) services, such as implantation, removal or replacement of generators or leads has 90-day global periods.

Their global periods complicate billing for procedures and services performed postoperatively, such as pacer checks and unrelated E/M services.

"This can be difficult for cardiologists because these are the only procedures they regularly perform with 90-day globals, and they aren't used to the surgical-package concept. Normally, they can bill for services performed on separate days," says Sandy Fuller, CPC, a cardiology coding and reimbursement specialist in Abilene, Texas.

According to Medicare guidelines first published in 1984 (see sidebar on page 43 for more on global period billing guidelines) but still in effect, two payments for pacer checks are covered in the first six months after implantation. These pacer checks may be reported separately because they are not considered part of a routine implantation and are not related to the wound.

"The 90-day global period applies to the incision and the surgery that inserted the pacemaker. If the cardiologist has to treat a hemorrhage or an infection related to the surgery, it's included and shouldn't be billed to Medicare. The removal of staples or sutures also should not be reported separately," says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. "But pacer checks are not related to the surgery and, as long as the cardiologist sticks to the guidelines, they may be reported separately."

Mechanical problems, too, may be reported separately, Callaway adds. "If the cardiologist believes there may be a mechanical problem with the pacemaker, then checking the device should be billed," she says. "The cardiologist is not responsible for the defective pacemaker, and repairing it is not part of the insertion's global period."

If the pacer check is due to mechanical failure, ICD-9 code 996.01 (Mechanical complication due to cardiac pacemaker [electrode]) should be associated with the appropriate pacer check code (see note below).

Procedures such as pacer checks performed during the global period of an insertion must be reported with modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to indicate they are not included in the pacer insertion's global period.

Note: When a pacer check is performed in the office, two codes should be used: 93731 (Electronic analysis of dual-chamber pacemaker system [includes 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]; without reprogramming) and 93734 (Single-chamber system, without reprogramming). If reprogramming is required, use 93732 (Dual chamber, with reprogramming) or 93735 (Single chamber, with reprogramming). CPT also provides two codes for telephonic analysis: 93733 (Telephonic analysis, dual-chamber system) and 93736 (Single chamber system).

Patients with pacemakers or ICDs are likely to have other cardiac problems that have little or nothing to do with why the pacemaker/ICD was installed. Visits during the global period for unrelated problems may be reported but require that modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) be appended to the E/M code.

Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is distinguished from modifier -24 by the date of the E/M service. When the physician provides a separate service (usually linked to a separate diagnosis) on the same day as a minor procedure, such as an intervention or left heart cath (which have zero global days), modifier -25 should be appended. If the E/M is provided during the postoperative global period, modifier -24 is appropriate.

Modifier -57 (Decision for surgery) is for E/M services performed the day of or the day before a major (90-day global) surgery that resulted in the decision to operate. The E/M service that led to the decision to perform major surgery must be appended with modifier -57 if the E/M service is provided either the day of or the day before surgery.

Scenario 1: Modifier -25. A patient with CAD has a left heart cath. A few hours after the procedure, the patient develops an arrhythmia, which the cardiologist treats with medication. The left heart cath is reported using 93510, which has zero global days. Although routine pre- and postprocedural evaluation on the same day as the procedure are included in the cath, the arrhythmia is a separate condition, which means the cardiologist may be able to report the visit separately even though it occurred in the global period of the heart cath, as long as the cardiologist lists the appropriate arrhythmia diagnosis and documents well, and modifier -25 is appended to the appropriate E/M code.

Scenario 2: Modifier -57. The patient has an arrhythmia. The cardiologist evaluates the patient and schedules a dual-chamber pacer implantation for the next day. Because the pacemaker insert has a 90-day global, a visit on the day before surgery is normally included in the procedure's surgical package. However, because the decision for surgery was made during the visit, it should be paid separately as long as modifier -57 is appended to the E/M visit code.

Scenario 3: Modifier -24. Ten days after the implantation of the pacemaker, the patient, who also has coronary artery disease, returns to the cardiologist's office complaining of chest pain. The cardiologist does not detect any arrhythmia and orders more diagnostic tests to determine the cause of the pain. In this case, the visit is for an unrelated problem. Modifier -24 should be appended to indicate that although the visit occurred during the global period of the pacer implant, it is unrelated. Coronary artery disease should be the diagnosis for the E/M visit.

Note: In most cases, services that meet CPT and Medicare criteria for critical care are not included in surgical packages and may be reported separately.