Cardiology Coding Alert

Question: Our physician is asked to perform a cath and/or PTCA on an inpatient. He goes to the hospital and does a consultation then does the cath and/or PTCA on the same day. Medicare is requiring a modifier -57. There was no decision for surgery at the time of the consult, however, because it was understood that the patient was to have the surgery. Modifier -25 implies the consult was done with a different diagnosis, which usually is not the case. How should this be coded so that we can get paid for the consult?

Anonymous Maryland Subscriber

Answer: If the physician was in fact asked to perform a cath and/or PTCA on an inpatient, and it was understood that the patient was to have the surgery, no consult should be billed because transfer of care of the patient already has occurred. The cardiologist can code the appropriate level initial inpatient visit (9923x), however, with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached because the cardiologist still needs to assess whether the catheter and/or PTCA is the appropriate intervention.

Most Medicare carriers now expect evaluation and management (E/M) procedures to be appended with modifier -57 (decision for surgery) only when the procedure that was performed has a 90-day global period.

Finally, modifier -25 should not require a second diagnosis. There has been some confusion about this issue in the past, but Medicare has clarified the issue. Some carriers reportedly still deny claims without a second diagnosis, however, and an appeal may be necessary to ultimately be reimbursed. As long as the visit was significant and separately identifiableand making a decision for surgery qualifies on both countsmodifier
-25 may be appended to the consult that occurs on the same day as surgery.