Cardiology Coding Alert

After performing surgery with a 90-day global period, cardiac surgeons sometimes pass the postoperative management of the patient to a cardiologist. In such cases, coordination with the surgical practice is essential because these arrangements, which are often informal and sometimes involuntary, can result in the cardiologist's performing follow-up care for free.

When a surgeon transfers the postoperative care of a patient to a cardiologist and documents the transfer, the cardiologist can obtain the postoperative share of the procedure fee by appending modifier -55 (Postoperative management only) if the transfer is documented in the patient's chart. The surgeon, meanwhile, indicates that postoperative care was transferred by appending modifier -54 (Surgical care only) to the same procedure code.

If the surgeon does not append a modifier, obtaining payment becomes more difficult, notes Nikki Vendegna, CPC, a cardiology coding and reimbursement specialist in Overland Park, Kan. To deal successfully with such situations, cardiology coders need to do two things, Vendegna says.

"First, they need to find out if the care provided by the cardiologist is related to the surgery. Routine follow-up care is included in the global period and is accounted for in the value of the procedure. Then, if the cardiologist is asked to provide routine follow-up care to a patient after cardiac surgery, the cardiologist bills for these services by appending modifier -55 to the procedure code reported by the surgeon," she says.

The cardiologist can bill this code (with modifier -55) only once to cover any and all routine visits during the postoperative period, Vendegna adds.

To properly use modifier -55, the surgeon must also indicate that he or she performed only intraoperative care, Vendegna notes. You can indicate this by appending modifier -54 to the same code.

"This is where coordination between offices becomes important. Many carriers will reimburse both doctors correctly only if both append the appropriate modifier to the same procedure code," Vendegna says. "But if the surgeon doesn't append -54, the cardiologist's claim with modifier -55 probably will be denied."

The coder must document the transfer of care from the surgeon to the cardiologist including the date and time of the transfer in the patient's chart to support the claim, she says.

Coordinating between offices may require delicacy and diplomacy, because some surgeons bill and expect payment for the whole operation, including any postoperative services, even though care of the patient has been transferred to the cardiologist.

Because Medicare and third-party payers will not pay two physicians for routine postoperative care of the same patient, the American College of Cardiology advises members to obtain a written agreement about fees before providing such care. The agreement should specify that the cardiologist will receive the post-op component of the fee (usually about 9 to 11 percent of the total) while the surgeon will bill for the intraoperative portion (usually about 80 percent) as well as the pre-op evaluation (also 9 to 11 percent).

For example, a triple bypass (33535) has a total value of 56.26 relative value units (RVUs) in the Medicare fee schedule. Both the preoperative component (performed by the surgeon) and the postoperative component are valued at 9 percent of the procedure. The remaining 82 percent is the intraoperative portion claimed by the surgeon. In total, the surgeon will be paid 91 percent of the 56.26 RVUs, and the cardiologist will be paid 9 percent for the postoperative care.

If the cardiac surgeon performs bypass surgery and is then summoned away by a family emergency and care of the patient is transferred to a cardiologist, the cardiologist's coders should contact their colleagues at the surgeon's office to make sure the transfer to the cardiologist was noted by the surgeon in the patient's medical record, and to ensure the surgeon appended modifier -54 to the procedure code.

Note: Medicare indicates the number of global days in a procedure or service in field "N" of the National Physician Fee Schedule Relative Value Guide. !