Cardiology Coding Alert

Remember: Take care not to mix up modifiers 58 and 78.

Understanding CPT^® modifiers is a vital part of coding correctly because if you append an inappropriate modifier to a procedure, your claim will be denied. Although modifiers can be tricky, you don't have to be confused.

Take a look at the following tips to help you understand when you should report three common modifiers you may see over the course of your cardiology coding career.

Tip #1: Append Modifier 52 When Reduction of Services Occurs by Choice, not Necessity

Modifier 52 (Reduced services) normally applies when the physician plans or expects a reduction in services as represented by the CPT^® code. This reduction of services must occur by choice (by either the physician or patient) rather than necessity, which would fall under the requirements for modifier 53 (Discontinued procedure), instead.

In other words, when you report modifier 52, you are telling your payer that the physician completed the procedure, but not the full procedure as indicated by the code descriptor.

Example: To detect abnormal heart rates and rhythms, the cardiologist attaches a Holter monitor to the patient for 10 hours of continuous recording. The cardiologist performs all of the components of the service including the connection, the scanning analysis and report, and the review and interpretation.

Coding solution: For this procedure, you would report 93224 (External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional). You would also append modifier 52 to the service since the cardiologist only performed 10 hours of continuous recording, per the documentation. According to CPT^® guidelines, for less than 12 hours of continuous recording, you should use modifier 52.

Tip #2: Choose Modifier 53 if Patient's Wellbeing Threatened

Unlike modifier 52, where the reduction of service occurs by choice, modifier 53 (Discontinued procedure) indicates that discontinuing the procedure or diagnostic test was necessary to protect the patient's health.

"Due to extenuating circumstances or those that threaten the wellbeing of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued," according to Appendix A in the CPT^® manual. "This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure."

Example: The cardiologist attempted to upgrade an already-implanted cardiac venous system to a biventricular device by adding a left ventricular lead. During the procedure, the patient started experiencing respiratory distress. The cardiologist chose to terminate the procedure to protect the patient's health.

Coding solution: You would report 33224 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator)) and append modifier 53 to indicate that the procedure was discontinued because of health reasons.

Always submit documentation:  Submitting modifier 53 alone does not provide the payer with enough information to know how to correctly reimburse the provider. So, make sure you submit the supporting documentation for appending modifier 53. The documentation must state that the physician actually started the procedure, why it was medically necessary for him to discontinue the procedure, and what percentage of the procedure he did perform.

Tip #3: Look to Modifier 58 for Staged Procedures

Don't forget that modifier 58 applies to planned procedures, not unplanned procedures.

"Modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) should be used to indicate that a staged or related procedure by the same physician is performed during the post-op period," says Catherine A. Brink, BS, CMM, CPC, CMSCS, president of HealthCare Resource Management Inc. in Spring Lake, New Jersey.

Modifier 58 indicates that a procedure was planned prospectively at the time of the original surgical procedure, or "staged," Brink adds.

"A new global surgical period begins with the use of modifier 58 on the staged or related surgical procedure," Brink explains. "Medicare requires a return to the OR for the staged or related surgical procedure."

Caution: Don't mix up modifier 58 with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).

Modifier 78 defined: Unlike modifier 58, modifier 78 applies to an "unplanned" related surgical procedure by the same physician during the post op period, according to Brink.

Use modifier 78 "when the patient returns to the OR (operating room) during the global period of another procedure for a complication or other unanticipated problem" related to the initial surgery, adds Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Don't miss: That return to the OR/procedure room would be with the same surgeon, or a surgeon within the same practice and specialty, if you're using modifier 78. This modifier shows the payer that, although the patient is in his postoperative period, the physician had to perform an additional surgery.