Cardiology Coding Alert

After a patient undergoes cardiac surgery, the surgeon often passes the care of the patient over to a cardiologist. Billing for such care can be difficult because it frequently is included in the surgerys global period. But through proper coding and clear communication between physicians, cardiologists can ensure they maximize their reimbursement for the follow-up treatment they provide.

Practice Stance Required

To get paid for treating a cardiac surgery patient, cardiologists need to be proactive. Depending on the circumstances, this could mean:

- Coordinating a transfer of care from the cardiac surgeon

- Billing for a consult with the appropriate documentation

- Demonstrating that the care is concurrent and unrelated directly to the surgery

- Billing for office visits, even though the surgery has a 90-day global period

For cardiologists, these situations can be delicate because some surgeons expect to be reimbursed for the entire surgical procedurea percentage of which will include postoperative care for the duration of the global periodeven though such care has been handed off to the cardiologist, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, SC. She notes that if cardiac surgeons know a cardiologist is going to see the patient after the surgery, they may leave the postoperative care to the cardiologist but still bill for the entire procedure, which includes preoperative, intraoperative and postoperative care.

The problem with that, Callaway-Stradley says, is that the Health Care Financing Administration (HCFA) and third-party payers will not reimburse two physicians for rendering routine postoperative care for the same patient.

Consequently, many state American College of Cardiology (ACC) groups now advise their members not to provide care for a cardiac surgeons patients unless they receive a clear understanding in writing about the co-management of the patient that indicates the cardiologist will be paid part of the procedures global fee.

Further complicating the issue is the nature of the care provided by the cardiologist during the postoperative period. If the cardiologist sees the patient for a problem that is not directly related to the surgery, he or she is free to bill for those services, whether in the hospital or post-discharge, if there is supporting documentation to that effect.

But if the cardiologist is simply providing routine postoperative care, It is important for cardiovascular surgeons and cardiologists to communicate and delineate their respective areas of responsibility, according to the ACC. In other words, a transfer of care from the cardiovascular surgeon to the cardiologist needs to occur. Otherwise, says the ACC, the cardiovascular surgeon expects that the cardiologist will refrain from providing services to patients who have had cardiovascular surgery, unless the surgeon requests a consultation from the cardiologist about a specific problem unrelated to the initial surgery.

Coordinating the Patients Post-Op Care

When taking over management of the patient immediately following surgery, the cardiologist should bill the procedure code with modifier -55 (postoperative management only) attached, unless another, unrelated condition also is being treated (see section on concurrent care below). Cardiologists should note that the claim likely will be denied unless the cardiac surgeon also billed for the procedure with modifier -54 (surgical care only) appended. Therefore, communication between offices is critical, as is documentation that shows when the cardiologist took over the patients treatment.

For example, a cardiac surgeon performs bypass surgery (33535, coronary artery bypass, using arterial graft[s]; three coronary arterial grafts) and then needs to leave town the same day. He transfers care of the patient to the cardiologist, leaving a clear note to that effect in the patients chart. The cardiac surgeon would bill for the procedure using the appropriate CPT code and add modifier -54.

The cardiologist, meanwhile, notes the day postoperative care began and reports his or her services to the carrier using the same CPT code but with modifier -55 attached. The carrier then computes a percentage of the allotted global payment within the 90-day global period.

What this requires, of course, is that the two doctors communicate and agree about who is going to bill for what. Once the physicians come to terms about their respective responsibilities, they bill using the appropriate procedure code and modifier. Therefore, if a carrier reimburses the procedure at $1,000 and designates 15 percent toward postoperative care, the cardiologist who takes over care of the patient after surgery will receive $150, while the cardiovascular surgeon gets $850.

Billing for Consultations

Even without a transfer of care, if the surgeon requests a consult about a specific problem that is unrelated to the initial surgery, the cardiologist can bill for it. For example, if the patient experienced atrial defibrillation or chest pain and the surgeon requests the cardiologists opinion, the cardiologist would bill the appropriate consultation code (99251-99255, for the first consultation before the patient is discharged). If the cardiologist continues to manage the patient, subsequent hospital codes should be used (99231-99233). Codes 99241-99245 should be billed if the consultation occurs in the cardiologists office after the patient is discharged.

The request for the consultation and the medical necessity for it (diagnosis or indications/signs or symptoms) must be documented in the patients medical record, and the cardiologist must provide the requesting physician with a written report of his or her findings.

For example, a surgeon provides routine postoperative care after performing a bypass, but the patient now has ventricular tachycardia. The surgeon consults with a cardiologist, who can bill the appropriate consultation code(s) for his services. If the cardiologist takes over the management of the patients care, he would bill each visit with a subsequent hospital care code (99231-99233).

If the cardiologist sees the patient without a written request or if he helps with routine postoperative management, how-ever, no reimbursement from HCFA will be forthcoming.

Coding for Concurrent Care

The 90-day global period should apply only to routine follow-up after cardiac surgery, but some private payers interpretations of routine follow-up may be considerably broader. Routine follow-up typically means managing the patients recovery from surgerymaking sure the wound heals without infection, for examplebut not for treating any other condition the patient has or may develop.

The cardiologist may be seeing the patient daily for reasons not directly related to the surgery and also may continue caring for the patient after discharge, says Georgeann Edford, RN, MBA, CCS-P, president of Coding Compliance Solutions, a physician reimbursement consulting firm in Birmingham, MI. For instance, the surgery may have repaired cardiac blockages, but the patients underlying tachycardia (785.0) remains after the patient is discharged, and this condition is still managed by the cardiologist. He or she would bill for these services with the appropriate established patient outpatient code (99211-99215).

Occasionally, however, a surgeon may stop seeing the patient after a few visits and leave the follow-up to the cardiologist, who is already following the patient for another unrelated condition. For example, a surgeon may visit a patient once after surgery then ask the cardiologist to continue managing the patient. Unless the cardiologist codes for conditions other than the surgery diagnosis, many carriers will assume the care is covered by the surgerys global period and not reimburse for it. In addition, some payers will include unrelated cardiac conditionsfor example, if the cardiologist sees the patient for atrial defibrillation following surgery for cardiac stenosisin the procedures global period. If a separate diagnosis is included that provides medical necessity for the cardiologists services, however, he or she should be paid, although it may be difficult with some private carriers even after showing such necessity.

Cardiologists Can Bill on Their Own

If the cardiologist is performing all the routine postoperative care without a prior arrangement with the surgeon, he or she should attempt to file a claim in one of two ways, Callaway-Stradley says. Some carriers may prefer the cardiologist to bill the procedure code and modifier
-55, while others may require office visits charged with or without modifier -55.

Because routine postoperative care is included in the surgical procedures global period, the claim may be denied. On appeal, however, the cardiologist should provide documentation that proves he or shenot the surgeonactually performed such care. Although some cardiologists believe they cannot ask for reconsideration of the claim, that is not true as long as they can prove they did the work, Callaway-Stradley says.

After all, she adds, The cardiologist who does the post-op work should be entitled to reimbursement, not the surgeon.

Cardiologists should remember, however, that if there is no prior understanding of co-management of the patient with the surgeons office, no matter what the cardiologist does on appeal, he or she still may not get paid. Therefore, inter-office communication is the key, Callaway-Stradley says.

When No Reimbursement Is Appropriate

There also are situations when it would be inappropriate for the cardiologist to bill during the cardiac surgerys global period. Obviously, if the surgeon performs bypass surgery and provides all the inpatient and outpatient postoperative care for the entire 90-day period, but the cardiologist came to the hospital to greet the patient, he or she could not code for any services performed.

Even if the cardiologist sees the patient during the inpatient postoperative period, takes notes and helps with routine care, unless the cardiovascular surgeon requests a consult, the cardiologist could not code for any services.

Note: When different physicians in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group. When a new physician furnishes the entire postoperative care, however, the group must then bill for the surgical care and the postoperative care as separate line items with the appropriate modifiers (i.e.,
-54 and -55).