Anonymous NM Subscriber
Answer: The American College of Cardiology Guide to CPT 1999 states that an E/M service will be denied by Medicare and most insurers when reported on the same day as pacemaker evaluation, unless documentation supports separately identifiable services.
For example, an examination of the patient might determine that the pacemaker needs to be re-evaluated. In that scenario, the ACC recommends attaching modifier -57 (decision for surgery) to the appropriate E/M code, which would be billed together with the correct pacemaker monitoring code (see box in next column). Some carriers may prefer to see modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended, so make sure you check with your carrier, and provide the appropriate documentation. Such a situation could also occur if, during the course of the pacemaker examination a medical problem is discovered, or if a pacemaker problem is found during the E/M.
If the examination occurs during the global period of the installation of the pacemaker, which is 90 days from the date it was inserted, an E/M visit cannot be claimed unless the patient presents with a new problem. This could be a totally unrelated issue, which would require another ICD-9 code to indicate medical necessity, or a major complication.
Note: Medicare coverage in these situations may vary from commercial carriers interpretations. Check with your carrier for specific instructions.
In these instances, modifier -24 (unrelated evaluation and management service by the same physician during a post-operative period) should be attached to the appropriate E/M code and the appropriate ICD-9 used to help the carrier determine medical necessity.
If the patient sees the cardiologist for a routine pacemaker checkup, which usually occurs on a set schedule of about 90 days, no E/M service could be charged unless the exam reveals a significant problem.