Cardiology Coding Alert

"Cardiologists need to familiarize themselves with the guidelines on pacemaker checks after a pacer has been installed in a patient. Because the insertion of a pacer is one of the few procedures cardiologists perform that has a 90-day global period, some cardiologists unfamiliar with global package guidelines have been billing for visits when all they do is perform a pacer check, especially if they are performing more checks than Medicare guidelines allow. Others, meanwhile, may inadvertently bill for a pacer check or an office visit, or both, when neither is appropriate. Alternatively, they may not bill the check or the visit even when doing so may be correct.

To correctly code such checks and visits, cardiologists need to understand both global surgery guidelines and the rules governing pacemaker installation and analysis. There are several implantation and replacement codes for pacemakers (3320x, 3321x), depending on whether the device is a single- or dual-chamber pacer, among other things. Typically, after any of these devices is installed, the patient returns within seven to 10 days so the cardiologist can check the function of the pacemaker and the patients condition after the surgery. Normally, such visits are included in the pacemaker insertions global period, but there are several situations in which the cardiologist can bill for the visit, the pacemaker check or both.

Pacemaker Check Guidelines

Medicare allows payment for two pacemaker checks in the first six months after installation of a single-chamber pacemaker, and one check every 12 months after that. For dual-chamber pacers, one check every six months is allowed after the first six months. These guidelines apply after the 90-day global period has ended. So in many cases, the pacer check performed within 10 days after implantation is included in the global package.

For example, if a 68-year-old male patient has a pacemaker inserted and 10 days later returns for a routine follow-up visit and pacer check, neither is billable because both services are part of the pacemaker insertions global package. The removal of staples (or sutures) at that time is not billable, nor is checking the wound or even a minor skin infection caused by the original procedure.

This is tough for cardiologists because its the only procedure they perform that has a 90-day global period, says Sandy Fuller, a coder with Cardiology Consultants, a group practice in Abilene, Texas. They arent used to billing with a surgical package. Normally, everything they do on separate days is billed.

You cant bill for a visit when all you did was a pacer check, Fuller says, adding that checking the pacers programming via an electronic analysis also is part of the global pacemaker insertion package. For documentation purposes, she suggests using code 99024(postoperative follow-up visit, included in global service). Although this code cant be billed, it provides a mechanism to note that a post-op visit took place.

Checking Mechanical Problems Is Billable

If the cardiologist suspects the pacemaker has a mechanical problem, then checking the device can be billed, Fuller says. You are checking the mechanical function of a piece of equipment, not your own work. If the pacemaker is faulty, that is not the cardiologists responsibility. Therefore, checking it is a billable service, she says.

According to guidelines set forth by Palmetto Government Benefits Administrators, the Medicare Part B carrier in South Carolina, Pacemaker monitoring frequency exceeding [the guidelines outlined above] will be reviewed on a prepayment basis. Documentation must support the medical necessity of more frequent monitoring. This would include, but is not limited to: lightheadedness, dizziness, vertigo (780.4), chest pain (786.50), syncope (780.2), atrial fibrillation (427.31), atrial flutter (427.32), unusual confusion (298.9), tachycardia (785.0), PVCs (427.60), lethargy (780.79) or any signs/symptoms of failure of synchronization of atria and ventricles in cases of dual chamber pacemakers.

In other words, mechanical problems with the pacemaker are an exception to these guidelines and should be so noted by providing documentation to the carrier to that effect when the claim is filed. If the documentation is not included, the claim likely will be denied and the documentation will have to be submitted on appeal.

For example, a female patient who had a pacer installed 10 days earlier may visit the cardiologist complaining of little shocks. The cardiologist suspects the pacer is not functioning correctly, possibly due to a lead touching an area it shouldnt. In that situation, the cardiologist can bill for the pacer check. Repair of the pacemaker, if required, will fall under the original implantations global period, but the check does not, Fuller says.

Pacer checks performed in the office or clinic are billed using codes 93731 (electronic analysis of dual-chamber pacemaker system [includes 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]; without reprogramming); 93732 (with reprogramming); 93734 (electronic analysis of single-chamber system [includes 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]; without reprogramming); and 93735 (with reprogramming).

Note: Telephonic analysis of pacemakers (93733, 93736) may be checked only every 30 days. If an in-clinic check occurs during the same 30-day period, only one of the two services can be billed.

Even if the cardiologist suspects a mechanical problem with the pacer, to bill for the pacemaker check, the patients signs or symptoms must be documented to indicate why the cardiologist thought something might be wrong with the pacer because routine pacer checks are included in the pacemaker insertions 90-day global package.

The cardiologist also should include ICD-9 code 996.01 (mechanical complication due to cardiac pacemaker [electrode]) if the pacemaker is defective in any way, says Felecia Bernstein, CPC, EMT, a coding and reimbursement specialist and president of the Monmouth County, N.J., chapter of the American Academy of Professional Coders.

Office Visits in the Global Period

Patients with pacemakers often have other, ongoing cardiac conditions that are separate from the reason the pacer was installed. For example, the patient may have had a myocardial infarction or unstable angina (411.1) or may have hypertension or coronary artery disease, and may return to visit the cardiologist for a reason not directly related to why the pacemaker was implanted.

For example, if a pacemaker patient with hypertension has a regularly scheduled visit with the cardiologist within the 90-day period after the pacer installation, the visit can be billed, but modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) must be attached to the appropriate evaluation and management (E/M) code, Bernstein says.

Although some cardiologists append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in such situations, doing so is inappropriate because the visit did not occur on the same day as the procedure. Modifiers -24 and -25 are distinguished mainly by when the E/M service occurred: If it took place on the same day as the procedure, modifier -25 should be used; if it occurred after a procedure during the global period, you should use modifier -24.

Whether regularly scheduled or not, visits can be billed as long as they are unrelated to the pacemaker implantation, Bernstein says, noting that even if the underlying cause of the symptom is related to the pacemaker, as long as the symptom itself is not and the underlying cause is not known, the visit can be billed. For example, a patient with sick sinus syndrome (SSS, 427.81) who had a pacemaker implanted eight days earlier sees the cardiologist complaining of dizziness (780.4). Even though the underlying cause of the dizziness is SSS, the patients complaintdizzinessis not why the pacemaker was installed, so the visit is billable and should be paid, Bernstein says, adding that once the cardiologist determines that the dizziness is due to the SSS, any subsequent visits are included in the pacemaker implantations global period."