Revenue Cycle Insider

Question: One of our cardiologists performed a balloon aortic valvuloplasty (BAV) to temporarily relieve stenosis while the patient was being medically optimized for a transcatheter aortic valve replacement (TAVR) in the near future. The BAV has a 90-day global period, but the provider is seeing the patient in the office during that time to evaluate and counsel for the upcoming TAVR.

Can we bill for these office visits, or are they bundled under the BAV global period? If they’re billable, what modifier should we use?

AAPC Forum Participant

Answer: Great question and it highlights a key point in understanding global surgical package rules and how they apply to staged cardiac interventions.

In this case, the office visits after the BAV are not related to the recovery or routine postoperative care of the BAV procedure (92986 [Percutaneous balloon valvuloplasty; aortic valve], which has a 90-day global period. Instead, they are distinct evaluation and management (E/M) services related to planning and evaluating a separate, staged procedure — the upcoming TAVR.

Because the BAV was a bridge to TAVR, the post-BAV visits are focused on:

• TAVR risk-benefit counseling
• Reviewing diagnostics
• Confirming candidacy and patient readiness
• Discussing procedural logistics

These are not routine post-op care for BAV, so they fall outside the global period for coding purposes.

In this case, you should:

• Report the appropriate E/M service (e.g., 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) or 99214 [Office or other outpatient visit for the evaluation and management of an established patient … 30 minutes …]).

• Append modifier 24 (Unrelated E/M by the same physician or other qualified health care professional during a postoperative period) to the E/M code. This modifier signals that the visit is not part of the global package of the BAV.

Important: If the TAVR is performed within the BAV global period, and it was planned/staged at the time of the BAV or a more extensive procedure as part of the patient’s treatment progression, then you should report the TAVR with modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period). 

Example: Imagine this scenario:

• Date of BAV: June 1
• Follow-up visit (June 21): Provider evaluates patient’s status and counsels for TAVR
• TAVR performed July 15

For the follow-up visit, you should report an office visit with modifier 24, such as 99213-24.

For the TAVR, assuming this was staged and related, you would report 33361 (Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach) with modifier 58.

Always make sure documentation clearly supports:

• That the BAV and TAVR are distinct, planned procedures
• That post-BAV visits are TAVR-focused, not follow-up care for the BAV itself.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor