Cardiology Coding Alert

The Health Care Finance Administration (HCFA) has proposed to remove the global period for all CPT codes involving the insertion, removal and replacement of pacemakers or cardioverter-defibrillators, simultaneously reducing the value of the procedures.

If adopted, the removal of global periods would mean that cardiology practices could bill for any follow-up care after these devices are implanted, either by the electrophysiologist who implanted the device or by a cardiologist who is following the patient for other heart conditions.

Other changes proposed by HCFA include significant revisions to clinical care and observation codes.

The pacemaker changes would dramatically affect cardiology practices because pacemaker insertions are among the few procedures cardiologists perform that have a global period. The proposed reduction in relative value units (RVUs) is already under fire from the North American Society of Pacing and Electrophysiology, which says that being able to bill for post-implantation visits does not make up for the diminished value of the pacemaker service.

Cardiologists Can Charge for Visits After Pacer Implants

Now there is a 90-day global period in the physician fee schedule for all CPT codes involving the insertion, removal and replacement of pacemakers or cardioverter- defibrillators.

According to HCFA, during these global surgical periods no separate payment may be made for any evaluation and management (E/M) service furnished by the surgeon, unless the visit is:

1) unrelated to the diagnosis for which the surgical procedure was performed;
2) for treating the underlying condition; or
3) an added course of treatment that is not part of normal recovery from surgery.

In such situations, the surgeon must append modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) to the E/M service provided. In addition, HCFA notes, services billed with a -24 modifier must be sufficiently documented and attest that the E/M service provided, although performed during the postoperative period, was for a reason unrelated to the original procedure.

The proposal also notes that patients with pacemakers or cardioverter-defibrillators have clinically serious cardiac conditions that often require significant post-operative care. In such cases, it is difficult to separate care during the postoperative period for the related cardiac problem(s) from the postoperative care for the pacemaker or cardioverter-defibrillator procedure.

Today, HCFA says, the physician performing the pacemaker or cardioverter defibrillator procedure is typically the same physician who is expected to furnish care for the patients related cardiac disease. But because of the global package, one cardiologist often provides post-operative care both for the pacer and any related medical problems but can only be paid for the original insertion.

Patients undergoing pacemaker and cardioverter- defibrillator procedures [commonly] require significant care for related cardiac disease during the postoperative period, HCFA states. Because this care overlaps substantially with the care furnished for the pacemaker ... and may be coded with the same ICD-9 code, using modifier -24 is inadequate, adds HCFA.

To remedy the situation, HCFA proposes to change the global period for CPT codes 33206, 33207, 33208, 33212, 33213, 33214, 33216, 33217, 33218, 33220, 33233, 33234, 33235, 33240, 33241, 33244, 33249, 33282 and 33284 from 90 days to 0 days. This would permit separate payment for any care furnished during the postoperative period by the physician who performed the pacemaker or cardioverter-defibrillator procedure.

Cardiology Practices as a Whole May Benefit

If the proposals are adopted, cardiology practices might benefit greatly, though electrophysiologists operating on their own would be hurt, says Susan Callaway-Stradley, CPC, CCS-P, a coding and reimbursement specialist in North Augusta, S.C.

This proposal would put more reimbursement in the hands of the physician who actually sees the patient after the pacer implant, Callaway-Stradley says. Currently, if the patient had a pacer or ICD implanted by an electrophysiologist and sees another cardiologist in the same practice during the pacer implants global period, it is hard to get paid because both physicians operated under the same tax identification number.

The patient may not see the electrophysiologist after the implant, but if there are other cardiac issues the patients regular cardiologist may be able to bill for all of his or her visits, which benefits the practice as a whole.