Cardiology Coding Alert

Question: Should we append modifiers Q0 or Q1 on every ICD implant billed? Our MLN bulletin states to use both modifiers when the procedure is investigational clinical research, etc. Should I base modifier use on a diagnosis code? For instance, should I look to 427.1?

California Subscriber

Answer: You should use either modifier Q0 (Investigational clinical service provided in a clinical research study) or Q1 (Routine clinical service provided in a clinical research study that is in an approved clinical research study). Make it simple: For primary prevention ICD implants, you should choose Q0.

Watch out: You should not report 427.1 (Ventricular tachycardia) for primary prevention implants. Remember, nine out of 10 implants are for primary prevention. The real reason is one of the primary prevention indications, not the potential ventricular tachycardia for which the patient is at risk. Reporting this is like reporting myocardial infarction for patients with chest pain, which is reporting a diagnosis that the patient is at risk of developing but one that the physician has not documented.

The facts: HCPCS 2008 introduced modifiers Q0 and Q1. (Note that Q0 is Q "zero.") You should use this new modifier to differentiate between routine and investigational clinical services. Modifier Q0 indicates your cardiologist performed a service in which the provider took part in an investigational study's objective and submitted the data. Medicare can approve, unapprove, or otherwise cover (or not cover) these items or services.

Remember: You'll use modifier Q0 not only for patients meeting the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) coverage criteria but also for Multicenter Automatic Defibrillator Implantation Trial I (MADIT I), MADIT II patients, and class IV heart failure patients qualifying for cardiac resynchronization therapy.

You should use these modifiers to identify investigational and routine clinical services in a Medicare-approved clinical research study, according to CMS Transmittal R1418CP, CR 5805 (www.cms.hhs.gov/transmittals/downloads/R1418CP.pdf).