Radiology Coding Alert

Coders supporting interventional radiologists may help their physicians avoid forfeiting a lot of reimbursement by gaining a comprehensive understanding of how global surgical packages work. Although some interventional services carry no global period, to code properly, coders must recognize the role modifiers play when used correctly with interventional codes that carry a 10- or 90-day global surgical period.

Many physicians and coders mistakenly believe they cant bill for any procedure during the global period, even if it is totally unrelated to the original interventional service or caused by extraordinary circumstances, says Gary Burns, MBA, RHIA, principal of Medical Asset Management Inc., a national training, contract coding and auditing firm in Atlanta. This simply is not the case. There are occasions when it is appropriate to bill for services provided during the global period and they most likely will be paid if they have been reported with the correct modifier.

Although modifiers are useful for procedures with 10-day global periods, they take on even greater significance when the service in question has a 90-day global period, he notes. Because the longer time period creates more exposure in those services with a 90-day global, there is a greater chance another billable service (either related or unrelated) may be required.

Global Periods Standardize Reimbursement

The global system was established by the Health Care Financing Administration (HCFA) to ensure standardized reimbursement for the same services across all jurisdictions, Burns explains. CPT guideline s note that global periods include the procedure and services directly related to them (e.g., sedation), as well as normal, uncomplicated follow-up care.

The Medicare Physician Fee Schedule Data Base provides the periods of time that apply to each interventional procedure, which regulate codes with entries of 000, 010, 090, YYY and XXX. Codes carrying 000 or 010 (zero- or 10-day global periods) most often are minor procedures or endoscopies. Codes with a 090 (or 90-day period) are major procedures, while codes with a YYY are carrier-priced codes for which the payer determines the global period. XXX-designated codes do not fall within the global period policy.

Note: Although it would seem that 000 and XXX global periods are the same both appear to have no days that would preclude billing other services there is a subtle difference. Procedures that carry a zero-day global period include a global period such that certain services provided on the same date of service will not be covered. This concept is covered in discussions of bundled services and fragmentation, as opposed to global periods. Only services with a global period of XXX are truly free of global period issues.

Because interventional radiological services are by their nature less invasive than other surgical procedures, they usually carry an XXX-, zero- or 10-day global period. There are exceptions to this rule, however, Burns points out. A number of biliary procedures have a 90-day global period, he continues. It is important to recognize these codes and learn how to append modifiers that allow radiologists to receive reimbursement when additional services are appropriately performed during this time frame. Of course, these same modifiers can also be used when appropriate during 10-day global periods.

The most common interventional codes that carry a 90-day global period are:

G0159 percutaneous thrombectomy and/or
revision, arteriovenous fistula, autogenous
or nonautogenous dialysis graft

37620 interruption, partial or complete, of inferior
vena cava by suture, ligation, plication, clip,
extravascular, intravascular (umbrella device)

47510 introduction of percutaneous transhepatic catheter for biliary drainage

47511 introduction of percutaneous transhepatic
stent for internal and external biliary drainage

47530 revision and/or reinsertion of transhepatic
tube

47630 biliary duct stone extraction, percutaneous
via T-tube tract, basket, or snare (e.g., Burhenne technique)

Note: A complete list of procedural codes and their related global surgical packages may be found in the Medicare Physician Fee Schedule, published in the Federal Register 2000.

Modifiers to Use for 10- and 90-day Global Periods

The three modifiers that interventional radiology coders will assign to procedures that may occur during a 10- or 90-day global period are:

-58 staged or related procedure or service by the same physician during the postoperative period,

-78 return to the operating room for a related
procedure during the postoperative period, and

-79 unrelated procedure or service by the same
physician during the postoperative period.

Routine follow-up care would not be billed with these modifiers, for instance, because it would be considered part of the original procedure, says Charlene Finchum, CPC, coding specialist supervisor for the department of radiological sciences at the University of Oklahoma Health Sciences Center in Oklahoma City. In addition, these modifiers are never appended to radiology supervision and interpretation (RS&I) or other radiology service codes.

Modifier -58 is defined as a staged or related procedure or service by the same physician during the postoperative period, and may be reported when more extensive work is performed on the same medical condition. This is the modifier you would add to a code for an additional service that was planned prospectively, Finchum points out.

Note: Although less common, interventionalists may have cause to use modifiers -76 (repeat procedure by same physician) or -77 (repeat procedure by another physician) in some instances, as well. Burns notes, for example, that modifier -76 would be used if the original procedure did not produce the results expected and was performed a second time by the same doctor. Modifier -77 would be used, on the other hand, if the physician providing follow-up care was not the same physician as the one who performed the original procedure.

Coders should be aware that there is a significant difference in how modifiers -78 and -79 are paid, Burns adds. Carriers may discount reimbursement on a related service (appended with modifier -78) but will not discount an unrelated service provided within the global period (modifier -79). Similarly, payers generally do not decrease reimbursement levels for staged or related procedures (modifier -58).

The following three examples demonstrate how modifiers -58, -78 and -79 can be used, allowing interventional radiology coders to bill for services they previously may have thought were covered by the original procedure code.

Example 1: Modifier -58

The interventionalist introduces a percutaneous transhepatic stent, and a catheter is planted in the biliary system and duodenum for drainage. Coding for the procedure may include 47511 (90-day global surgical period) accompanied by 75982 (percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and intervention).

At the time of this procedure, the physician knows that the patient will need to return for a cholangiogram, stone extraction and tube change. The cholangiogram injection would be coded 47505 (injection procedure for cholangiography through an existing catheter [e.g., percutaneous transhepatic or T-tube]) and 47525 (change of percutaneous biliary drainage catheter) with 75984 (change of percutaneous tube or drainage catheter with contrast monitoring [e.g., gastrointestinal system, genitourinary system, abscess], radiological supervision and interpretation). The stone extraction would be coded with 47630 and 74327 (postoperative biliary duct stone removal, percutaneous via T-tube tract, basket, or snare [e.g., Burhenne technique], radiological supervision and interpretation]). Code 74305 (cholangiography and/or pancreatography; postoperative, radiological supervision and interpretation) would be reported for the cholangiogram. Three of the codes describing the second, planned procedure would carry the -58 modifier (i.e., 47505-58, 47630-58, and 47525-58) because this represents the second stage of the service. Modifiers are not appended to RS&I codes or any other radiology services.

Example 2: Modifier -78

The interventional radiologist places a percutaneous transhepatic stent for an external biliary drainage, 47510 (introduction of percutaneous transhepatic catheter for biliary drainage) with 75982 in a patient with biliary obstruction (576.2). During the night following the procedure, however, the patient has severe abdominal pain in the right upper quadrant (789.01). A diagnostic ultrasound is conducted (76705, echography, abdominal, B-scan and/or real time with image documentation; limited [e.g., single organ, quadrant, follow-up]), which indicates that the stent is causing a partial obstruction. The patient is returned to the interventional suite where the stent is exchanged for a catheter to accommodate the drainage of the previously excluded bile ducts both internally and externally. The second procedure would be coded 47511-78, with 75984 to indicate that the new procedure was related to the original service.

Example 3: Modifier -79

The interventionalist places an IVC filter into the patients inferior vena cava due to deep venous thrombosis (453.8). This procedure, which has a 90-day global surgical period, would be coded with 37620 and 75940 (percutaneous placement of IVC filter, radiological supervision and interpretation).

A month postoperatively, however, the patient suffers kidney failure (586) and requires a tunneled catheter for dialysis. When this catheter is placed, coders would bill 36533-79 (insertion of implantable venous access device, with or without subcutaneous reservoir; unrelated procedure or service by the same physician during the postoperative period) because the second procedure was in no way related to the filter placement, and both procedures were performed by the same interventional physician.