Cardiology Coding Alert

Two modifiers allow cardiologists to bill successfully for separate procedures performed during an extended global period, such as those for pacemaker and internal cardioverter-defibrillator (ICD) implants and replacement. This coding can be tricky for cardiologists because they do not perform as many procedures with 90-day global periods as other specialties involving surgery. These are modifier -78 (Return to the operating room for a related procedure during the postoperative period) and modifier -79 (Unrelated procedure or service by the same physician during the postoperative period). Sometimes, modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) may be more appropriate. Using Modifier -78 This modifier, which is known as the "complications" modifier even though this word does not appear in the CPT descriptor, is used when a related problem, such as an infection, becomes so severe that the patient has to be returned to the operating room.

Modifier -78 was introduced because global surgery guidelines in the Medicare Carriers Manual (MCM) state that complications are included in the original procedure's global package. The only exception, according to the MCM, is when the patient must be returned to the operating room (OR). Scenario 1: An ICD is implanted ( 33240, Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator; 33249, Insertion or repositioning of electrode lead[s] for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator), but within 10 days the implantation site becomes infected. The patient is returned to the OR, where the cardiologist performs incision and drainage (I&D) of the site and reimplants the ICD.

In this case, the I&D (10180, Incision and drainage, complex, postoperative wound infection) is billed with modifier -78 appended to indicate that the procedure required a return to the operating room because 33240 has a 90-day global period. (The infection occurred at the site of the generator implantation. No complication was reported for the lead implantation, which is a more complex procedure.)

Although modifier -78 will likely be used more often for complications of procedures with 90-day global periods, even services with zero global days may, in some cases, generate related services that need modifier -78 to obtain proper payment. Note: CPT Codes 2002 included a new definition of a surgical package that does not include complications. And some private payers do not consider treatment of complications as a related service. Scenario 2: The cardiologist performs a left heart catheterization (93510, Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous) that does not appear to indicate the need for an intervention. The patient is taken from the cath lab [...]