Cardiology Coding Alert

Although surgical specialists deal with 10- or 90-day global periods routinely, most cardiology procedures, including left heart caths, PTCAs and stents, have zero global days. However, one important group of procedures pacemaker and internal cardioverter-defibrillator (ICD) services, such as implantation, removal or replacement of generators or leads has 90-day global periods.

Their global periods complicate billing for procedures and services performed postoperatively, such as pacer checks and unrelated E/M services.

"This can be difficult for cardiologists because these are the only procedures they regularly perform with 90-day globals, and they aren't used to the surgical-package concept. Normally, they can bill for services performed on separate days," says Sandy Fuller, CPC, a cardiology coding and reimbursement specialist in Abilene, Texas. Pacer Checks,Mechanical Problems Not Included According to Medicare guidelines first published in 1984 (see sidebar on page 43 for more on global period billing guidelines) but still in effect, two payments for pacer checks are covered in the first six months after implantation. These pacer checks may be reported separately because they are not considered part of a routine implantation and are not related to the wound.

"The 90-day global period applies to the incision and the surgery that inserted the pacemaker. If the cardiologist has to treat a hemorrhage or an infection related to the surgery, it's included and shouldn't be billed to Medicare. The removal of staples or sutures also should not be reported separately," says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. "But pacer checks are not related to the surgery and, as long as the cardiologist sticks to the guidelines, they may be reported separately."

Mechanical problems, too, may be reported separately, Callaway adds. "If the cardiologist believes there may be a mechanical problem with the pacemaker, then checking the device should be billed," she says. "The cardiologist is not responsible for the defective pacemaker, and repairing it is not part of the insertion's global period."

If the pacer check is due to mechanical failure, ICD-9 code 996.01 (Mechanical complication due to cardiac pacemaker [electrode]) should be associated with the appropriate pacer check code (see note below). Procedures such as pacer checks performed during the global period of an insertion must be reported with modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to indicate they are not included in the pacer insertion's global period.

Note: When a pacer check is performed in the office, two codes should be used: 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 [...]