Cardiology Coding Alert

The Health Care Financing Administration (HCFA) will not eliminate the global period for pacemaker and implantable cardioverter-defibrillator (ICD) procedures as originally announced in its July 17 proposed rule (see HCFA Proposes Elimination of Pacemaker Global Surgery Periods on page 61 of the August 2000 Cardiology Coding Alert). Under HCFAs final rule, published in the Nov. 1, 2000, Federal Register, these procedures will keep their 90-day global periods, at least for now. The final rule also included several changes to reimbursement and coverage policies, notably affecting pacemaker studies, critical care guidelines and observation guidelines.

CPT 2001, also released in November, includes two new cardiology codes as well as new wording in the critical care section that confirms changes previously announced by HCFA.

The top changes in CPT 2001 and the final rule and their significance for cardiology practices and coders are outlined below.

New CPT Codes

Trans-esophageal Echocardiography Monitoring. Code 93318 (echocardiography, transesophageal [TEE] for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing [continuous] assessment of [dynamically changing] cardiac pumping function and to therapeutic measures on an immediate time basis) should be billed when TEE is used to monitor the patient during surgery.

During the repair of a leaky mitral valve performed in the hospital, for example, a TEE probe may be positioned after the endotracheal tube is placed, says Sandy Fuller, CPC, a practice coder with Abilene Cardiology Consultants, a 13-physician practice in Abilene, Texas. At several points during the session the cardiologist may be called in to guide the imaging and to interpret the TEE study. The probe would remain in place while the procedure takes place. In such cases, the cardiologist should bill 93318 with modifier -26 to indicate that he or she performed the professional component of the procedure.

The probe monitor may also be used during bypass or transplant surgery to acquire specific images at particular times or may be placed and used by the anesthesiologist to guide his or her management of the patient during surgery.

HCFA has not yet established a fee schedule for this service: Different carriers (both Medicare and private) may have widely varying coverage and reimbursement policies for this service. Before billing the service, coders should contact their carrier and make sure theyve read the operative report and can determine exactly what the cardiologist did.

Pacemaker Study Echo. Code 93662 (intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and inter-pretation [list separately in addition to code for primary procedure]) has been assigned 4.13 relative value units (RVUs) when billed with modifier -26 (professional component) or 8.19 RVUs if done in an office setting, and should be used when the electrophysiologist performs intracardiac echocardiography (ICE) while performing one of the following four primary procedures:

93621 comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters; with left atrial recordings from coronary sinus or left atrium, with or without pacing, with induction or attempted induction of arrhythmia;

93622 ... with left ventricular recordings, with or without pacing, with induction or attempted induction of arrhythmia;

93651 intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination, and;

93652 ... for treatment of ventricular tachycardia.

ICE was originally developed to locate and ablate the sinus node without damaging the hearts secondary pacer function. Subsequently it began to be used for other purposes (i.e., to help pinpoint the triscuspid annulus, so that the slow pathway can be localized and ablated). The procedure is performed by inserting into the heart a specialized catheter that provides high-quality images.

HCFAs Final Rule

Global Periods for Insertion, Removal and Replacement of Pacemakers and ICDs. In its July 17 proposed rule, HCFA planned to change the global period for certain CPT codes involving the insertion, removal and replacement of pacemakers and implantable cardioverter- defibrillators (ICDs) from 90 days to 0 days and simultaneously to reduce substantially work and practice expense RVUs for these same services. The final rule, however, states, As a result of comments received on the proposed rule, we are not adopting the proposed policy. The global period will remain at 90 days, and we will not implement the proposed reductions to the work and practice expense RVUs.

The changes would have affected the 19 pacemaker and event recorder-related CPT codes and would have permitted separate payment for any care furnished during the postoperative period by the physician who performed the pacemaker or cardioverter-defibrillator procedure.

Organizations such as the North American Society of Pacing and Electrophysiology (NASPE) had urged HCFA to withdraw the proposal, noting that the proposed reduction in reimbursement for these services was inappropriate. Most of the work in these procedures is intraservice (i.e., not much pre- or postservice work is required) and electrophysiologists generally do not see their patients postoperatively or render postoperative care for related conditions.

HCFA said it was deferring its proposal and noted that the proposed policy had been intended to facilitate separate payment for the evaluation and management services unrelated to the surgical service. Our concern was that the 90-day global period was precluding separate payment for the evaluation and management services.

In light of the objections, HCFA decided, The issue of the global period and appropriate relative value units for these services will need further review. Until a further review HCFA will continue with current pricing and a 90-day global period for these services.

Surgical Risk Factor for Electrophysicological Study. Malpractice RVUs for intracardiac electrophysicological (EP) procedure codes 93600-93612, 93618-93641 and 93650-93652 have been increased in response to NASPEs contention that these EP codes have the same relative risks as cardiac catheterization codes and should be assigned a similar surgical risk factor.

The increase triples and sometimes quadruples the procedures malpractice RVUs, says Amy Melnick, manager of government relations for NASPE in Washington, D.C. She notes that malpractice RVUs for 93609 (mapping of tachycardia) were increased from 0.14 to 0.66. Its a recognition that this work is complex. This is not evaluation and management; these are invasive procedures.

HCFA also modified the number of malpractice RVUs for the following EP procedures:

93741 electronic analysis of pacing cardioverterdefibrillator (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); single chamber, without reprogramming;

93742 ... single chamber, with reprogramming;

93743 ... dual chamber, without reprogramming, and;

93744 ... dual chamber, with reprogramming.

But only one procedure 93743 experienced an increase in total RVUs, from 2.13 RVUs to 2.23. The other procedures saw a reduction in their total RVUs (93741, 1.83 in 2001, 1.87 in 2000, down 0.04; 93742, 1.98 in 2001, 2.34 in 2000, down 0.36; 93744, 2.37 in 2001, 2.65 in 2000, down 0.28 RVUs).

Observation and Inpatient Discharge. HCFAs July 17, 2000, proposed rule suggested ending the anomaly whereby certain hospital and inpatient care services performed on a different calendar date but within the same 24-hour period could be separately billed using two E/M codes (see Three More Proposals Will Affect Cardiologists on page 63 of the August 2000 Cardiology Coding Alert).

As a result of comments criticizing the reduction in RVUs for observation and inpatient care codes 99234-99236, HCFA not only left the RVUs unchanged but also did not fully implement the guidelines in the proposed rule: The anomaly whereby two E/M services performed within 24 hours of each other but on different calendar dates remains.

The final rule guidelines published in the Federal Register outlined the following three conditions:

1. Admission and discharge of a patient from observation or the hospital on the same calendar date should be billed using observation or inpatient hospital care codes 99234, 99235 or 99236. To report 99234-99236 for Medicare payment appropriately, the patient must be an inpatient or observation care patient for a minimum of eight hours on the same calendar date.

2. When the patient is admitted to observation status for less than eight hours on the same date, the physician should use initial observation care codes 99218-99220 and should not report a discharge code. For an inpatient admission and discharge less than eight hours later on the same calendar date, 99221-99223 should be used for the admission service. The hospital discharge day management service should not be billed.

3. If patients are admitted for observation care and then discharged on a different calendar date, the physician should use 99218-99220 and CPT observation discharge code 99217. For those patients admitted to inpatient hospital care and discharged on a different calendar date, the physician should use 99221-99223 and CPT hospital discharge day management codes 99238 or 99239.

HCFA also instructs physicians to satisfy the documentation requirements for both admission to and discharge from inpatient or observation care when billing 99234, 99235 or 99236. The time for observation care or treatment status must also be documented.

Critical Care Guidelines

Because of changes in the CPT definition of critical care services, HCFA decreased interim work RVUs for codes 99291 and 99292 in CPT 2000. This year, citing changes that were made to the definition of critical care for 2001, work RVUs for critical care codes have been restored to the 1999 level.

The decision to restore the RVUs was first announced in the July 17 proposed rule in the Federal Register, which also offered an advanced copy of CPTs 2001 critical care guidelines.

The revised CPT introduction to critical care services now states, Critical care and other E/M services may be provided to the same patient on the same date by the same physician. This brings CPTs introduction in harmony with section 15508F of the Medicare Carriers Manual, which states, If there is a hospital or office/outpatient evaluation and management service furnished early in the day and at that time the patient does not require critical care, but the patient requires critical care later in the day, both critical care and the evaluation and management service may be paid.

Note: The earlier E/M service should be reported with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and in most cases should be linked to a different diagnosis code.

The CPT introduction also explicitly rules out using time spent performing a procedure toward critical care time. Previously, only time spent on vaguely defined other activities could not be counted. According to CPT 2001, Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time.

Additionally, the guidelines provide a more accurate clinical definition of critical care, notably continuing the trend away from an earlier guideline that stated critical care services could be claimed only for patients whose condition was unstable. This should make it easier to meet the criteria for claiming critical care services when treating critically ill patients even those who may be ill for a long time.

Note: Services for a patient in a critical care or intensive care unit but who is not critically ill should be reported using other codes, such as 99231-99233 (subsequent hospital care).

Electrical Bioimpedance

Medicare will not allow separate payment for electrical bioimpedance (EB) a noninvasive method of measuring cardiac output when performed while the patient is receiving critical care services. The final rule stressed, however, that EB, if medically necessary, is a covered procedure under Medicare. This service, which should now be billed to Medicare using HCPCS code M0302, has been assigned 1.07 RVUs in the 2001 national Physician Fee Schedule. Previously, M0302 was carrier-priced.

Modifiers -22 and -60

CPT includes a new modifier modifier -60 (altered surgical field). As a result, the description of modifier -22 (unusual procedural services) has changed. According to CPT 2001, modifier -60 should be appended to procedures that involve significantly increased operative complexity and/or time in a significantly altered surgical field resulting from the effects of prior surgery, marked scarring, adhesions, inflammation, or distorted anatomy, irradiation, infection, very low birth weight (i.e., neonates and small infants less than 10 kg) and/or trauma (as documented in the patients medical record).

CPT states modifier -22 should be used for unusual procedural services not involving an altered surgical field. The descriptor for modifier -22 now reads: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier -22 to the usual procedure number. Documentation and reimbursement policies modifier -60 have yet to be issued. Because cardiologists do not typically encounter altered surgical fields, modifier -22 will remain the appropriate modifier in most unusual cases.