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 and admitted to observation. A few hours later, the patient has a myocardial infarction that requires immediate intervention, and the cardiologist performs an angioplasty in the left anterior descending artery.

In this case, the angioplasty (92982, Percutaneous transluminal coronary balloon angioplasty; single vessel) must be appended with modifier -78 to indicate that the procedure required a return to the cath lab.

Note: For this modifier, the cath lab is considered the same as the operating room.

Procedures with zero global days actually have a 24-hour global period, and any procedure performed on the same day is subject to the same global surgery guidelines as procedures with 10- or 90-day global periods.

Had the percutaneous transluminal coronary balloon (PTCA) been performed during the same session, you would not be required to use a modifier.

Note: Some carriers may reduce reimbursement for procedures with modifier -78 appended because they may perceive the second procedure as part of the first. Medicare pays only the intraoperative rate for procedures appended with modifier -78.

Coding With Modifier -79

Modifier -79 is used for procedures performed during the postoperative period that are unrelated to the original procedure. When this occurs during a 90-day global period (following an ICD or pacer implant, for example), an E/M service during which the cardiologist diagnosed the unrelated problem will likely be reported with modifier -24 (Unrelated E/M service by the same physician during a postoperative period) appended.

"To justify the second procedure, carriers are likely to want to see an E/M service with modifier -24 appended," says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. "This is not an infrequent occurrence with heart patients, who often have more than one cardiac problem that can flare up at any time."

Like modifier -78, modifier -79 may also be used when a service is performed on the same day as another procedure that has a zero-day global period.

Scenario 3: A patient presents with chest pain. The cardiologist wants to rule out ischemia, so he or she performs a left heart catheterization (LHC). After the patient leaves the cath lab, he develops a tachyarrhythmia and experiences syncope. An electrophysiologist from the same practice (with the same tax ID number) performs an electrophysiologic (EP) study.

In this case, modifier -79 should be appended to 93620 (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 induction or attempted induction of arrhythmia) to indicate that the EP study is unrelated to the earlier LHC. The LHC's diagnosis is chest pain, but a different diagnosis (tachyarrythmia and syncope) should be used for the EP study and the E/M service.

Reporting Modifier -58

Modifier -58 is appended to a procedure to indicate "that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure," CPT says.

Modifier -58 is used when the cardiologist knows another procedure will be or may be performed, says Sueanne Bicknell, RRA, CPC, CCS-P, a cardiology coding and reimbursement specialist in Dallas.

Confusing modifiers -58 and -78 can be easy because both are used for "related" procedures, Bicknell says. But whereas modifier -78 is used only for complications that require a trip to the OR, modifier -58 is used when the initial surgery went as planned and the physician decides to perform the second procedure based on the patient's condition, she says.

Scenario 4: A patient with an infected pacemaker pocket is admitted to the hospital. The generator is removed (33233, Removal of permanent pacemaker pulse generator), but because of the infection, a new generator cannot be implanted. The cardiologist plans to install it once the infection is treated. Subsequently, the infection clears, and a new dual-chamber generator is placed (33213, Insertion or replacement of pacemaker pulse generator only; dual chamber). Modifier -58 is appended to 33213 to indicate the procedure was planned when the first generator was removed, Bicknell says.