STS/AATS CODING. NEWSLETTER Recent Information on CPT and ICD-9 CM Codes for Cardiothoracic Surgeons

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1 N E W S STS/AATS CODING L E T T E R Vol. 13 No. 1, Spring , The Society of Thoracic Surgeons, Chicago, IL TEE s; Maze; 0,10, XXX Global Periods; Medicare Usage for Assistants-at- Surgery and Co-Surgeons; Coding Workshops INSIDE Reporting Intra-op TEEs... 1 Maze Procedure... 2 Services with 0,10, XXX global. 2 STS Coding Workshops... 2 Q&A. 2 Reporting Assistants-at-Surgery with CT Codes... 5 Reporting Co-Surgeons with CT Codes... 6 The STS/AATS Coding Newsletter is published under the auspices of the STS/AATS Workforce on Nomenclature and Coding -Keith Naunheim, M.D., Chair STS/AATS Workforce on Nomenclature and Coding Julie R. Painter, Editor th Street, Suite 1000 Denver, CO Telephone: (720) Fax: (720) juliepainter@grandsuites.com NEWSLETTER Recent Information on CPT and ICD-9 CM Codes for Cardiothoracic Surgeons R EPORTING I NTRA- OPERATIVE T RANSESOPHAGEAL E CHOCARDIOGRAMS (TEE) It is becoming more common for cardiothoracic surgeons to perform transesophageal echocardiography (TEE) during a cardiac procedure, often to evaluate valve function and/or anatomy. Some confusion exists whether cardiothoracic surgeons should bill this service or include it in the cardiothoracic surgery global package. The STS/AATS Workforce on Nomenclature and Coding has been requested to review and make a recommendation regarding the suitability of cardiothoracic surgeons reporting an intra-operative TEE. The Workforce reviewed this issue at the STS Annual meeting in January 2004 and recommends the following for reporting this service: It is appropriate for the cardiothoracic surgeon to report the professional component of this service, which includes the supervision, interpretation and report for an intra-operative TEE as long as the following criteria are met: 1) The cardiothoracic surgeon must perform the professional component (interpretation and report) of the TEE; 2) The cardiothoracic surgeon must fully document his/her findings regarding his/her interpretation of the TEE; Text such as intra-operative TEE performed is not sufficient to support separately reporting the service; 3) The cardiothoracic surgeon should report his/her portion of the service with modifier 26 to indicate that he/she performed the professional component of the service (the hospital owns the equipment and will always account for the technical component of the service); 4) The cardiothoracic surgeon should coordinate with the hospital and all other physicians involved to verify that no other physician (i.e. anesthesiologist, cardiologist, etc.) has billed or will bill for the professional component of the service either that day or at a later date (such as a cardiologist reading and interpreting the TEE after the surgery); 5) The cardiothoracic surgeon should include an appropriate indication in the operative report supporting medical necessity for the TEE. If all of these criteria are met, the cardiothoracic surgeon should report the interpretation and report for the TEE using code Echocardiography, transesophageal, real time with image documentation (2D) (with or without M- mode recording); image acquisition, interpretation and report only. Code Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only should be used with the congenital cardiac procedures.

2 2 SPRING 2004 STS/AATS CODING NEWSLETTER MAZE PROCEDURE Variations in the technique for the Maze procedure have made coding for the Maze confusing. Code Operative incisions and reconstruction of atria for treatment of atrial fibrillation or atrial flutter (eg. Maze procedure) should be used to report all variations on the Maze, including RF, cryosurgical, or microwave ablation, or any other techniques used to accomplish the operative treatment of atrial fibrillation of flutter. REPORTING SERVICES WITH FEWER THAN A 90-DAY GLOBAL PERIOD Most of the cardiothoracic surgery codes have a 90-day global period. For those codes that have fewer than a 90-day global period, it is important to remember that services provided outside of the global period should be reported separately. For codes with a 0 day global period, you should report all services provided the day before and beginning the day after the procedure (as long as you are not in the global of another procedure). For example, when the only procedure performed is a chest tube insertion, code 32020, you should report the E/M service where the decision to perform the procedure is made; if this is performed the day before the procedure, no modifier is needed; if it is performed the day of the procedure, report the E/M service with the -25 modifier (significantly separately identifiable E/M service same day as a procedure). You should also report any services provided beginning the day after the procedure. This may include daily visits at the hospital, a discharge day, or other services provided to the patient. Services may be charged as long as you are not in the global period of another procedure. Cardiothoracic codes with a 0-day global period include the following: 32000, 32002, 32005, 32020, 32201, 32400, 32405, 32420, 32601, 32602, 32603, 32604, 32605, 32606, 33010, 33011, 33210, 33211, 33224, 33226, 33960, 33967, 33968, 33970, and For codes with a 10-day global period, the same concept applies. If you perform the decision for surgery the day before the procedure, the appropriate E/M service should be reported and no modifier is needed; if it is performed the day of the procedure, the E/M should be reported with modifier -25. Postoperative services that are provided after day 10 of the surgery should be reported. Again, this would include any E/M services or procedures provided as long as you are not in the global of another procedure. Cardiothoracic procedures with a 10-day global period include code For codes with an XXX global period, this means that the global concept does not apply and all E/M or other services provided prior to the surgery and after the patient is in recovery the day of the procedure should be reported. No modifier is needed. Again, please pay attention to whether you are in the global period of another procedure. See the Vol. 12, No. 3 Summer 2003 edition of the STS/AATS Coding Newsletter for additional information on reporting services with an XXX global period. Cardiothoracic procedures with an XXX global period include the following: 33975, 33976, and STS CODING WORKSHOPS Save the date! The STS Fall Coding Workshop will be held October 8-9, 2004 in Arlington, Va. at the Crystal City Marriott. Keep checking the STS Web site at for more information. C ODING Q&A Question: Codes and per CCI: They are not bundled but there are insurance companies that state these two codes cannot be billed together. Answer: These two codes are not bundled through the Medicare National Correct Coding Initiative (NCCI) and should be allowed when reported together. Code Ascending aorta graft, with cardiopulmonary bypass, with or without valve suspension; does not account for the work of an aortic valve replacement (33405). When performed together in the same session, code and should both be reported. Private payers often have different, more extensive bundling edits. In this case, you must follow their rules. To make changes to their edits, you must work directly with the payer to remove edits. Question: Modifier order when you have several modifiers (eg 78, 51, or 80, 78, 51). Answer: Medicare does not specify an order for reporting multiple modifiers in the same session. Their systems should be set up to recognize the use of multiple modifiers and apply them correctly. If the payer requires a specific order or method of reporting multiple modifiers, the requirements should have been published in your state Medicare bulletin. Some payers will require the use of the -99 modifier to indicate more than two modifiers reported during a surgical session, if so, this should be the first modifier listed. Private payers will vary as to their (Continued on page 3)

3 3 SPRING 2004 STS/AATS CODING NEWSLETTER (Continued from page 2) specifications regarding the reporting of multiple modifiers in one session. Regardless of the payer, please check reimbursements to ensure that payments for the modifiers were applied properly [.i.e., the bilateral adjustment (payment at 150%) should be applied before the multiple procedure adjustment)]. Question: Assistant Surgeon for code A lot of Medicare plans do not allow this but all documentation we have says you can bill assist for this code. Answer: Per the 2004 National Physician Fee Schedule Relative Value File, code has an assistant at surgery indicator of 2 which means that Payment restrictions for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid. The Medicare Carriers should recognize this and allow payment for an assistant at surgery for this procedure. If you are being denied, you should verify the reason for the denial and the coding and appeal if appropriate. Private payers may vary regarding their coverage and coding requirements for assistants at surgery for code Question: Modifier 53- Discontinued service for cardiac procedures AVR and CABG- Is anyone else experiencing this problem? Answer: For Medicare, Modifier - 53 is used only with the colonoscopy code, 45738, for which a specific value has been assigned. Any other codes billed with modifier -53 are subject to carrier medical review and priced by individual consideration. Therefore, if you report -53 on an AVR or CABG procedure, your carrier may not recognize or may deny upon review of the claim. Coverage is at the discretion of the individual carrier. Many private payers do recognize modifier -53 for failed procedures outside of the colonoscopy, but this coverage and the criteria will vary by the individual carriers. Question: If within 90 days of surgery and patient is re-admitted, can we charge for H&P? Answer: For Medicare, if the H&P for the re-admission is related to the original procedure or due to a complication of the original procedure, you cannot charge as it is considered part of the global period. If H&P for the re-admission is unrelated to the original procedure, then you may report the appropriate level and category of evaluation and management service with the -24 modifier and a different diagnosis than for the original procedure. Private payers may vary on their definition of the global surgical package. For those that follow the Medicare global definition, you should not charge as indicated above. If they follow the CPT definition of typical follow-up care, as long as the reason for the H&P falls outside of these criteria, then you may report the service without a modifier. Question: If within 90 days of surgery and patient is re-admitted can we charge for diagnostic procedure i.e. bronchoscopy? Answer: Again, for Medicare you may only charge for the bronchoscopy under two circumstances. If the reason for the bronchoscopy is considered related to, or for a complication of the original procedure and does not require a return to the OR, there is no charge because it is considered part of the global surgical package. If the bronchoscopy requires a return to the OR, you should report it with the -78 modifier (return to OR for related procedure during post-op period). If the reason for the bronchoscopy is considered unrelated to the original procedure, you may charge for the bronchoscopy and append modifier -79 (unrelated procedure or service during the global period). You must have a different diagnosis from the original procedure and documentation in the patient s medical record supporting that the service is unrelated to the original procedure. Again, private payers will vary regarding coverage and payment for this procedure depending on their definition of the global surgical package. Question: If within 90 days of surgery can we bill for the re-scheduled office visit code? Answer: For Medicare, if the office visit is part of the follow-up with the patient for the original procedure, there is no charge regardless of the circumstances. All follow-up care that is related to or considered a complication of the original procedure is considered part of the global surgical package. Again, private payers may vary on coverage and criteria for this situation. Question: Can we bill for an office visit if patient has an unrelated problem and can we arrange consultation (i.e., urinary retention)? Answer: For Medicare, as long as the reason for the office visit is unrelated to the original procedure or surgery you may report it. However, you should use the -24 modifier and a different diagnosis for evaluation and management services, and the -79 modifier and a different diagnosis for procedures. If necessary, consultations or other tests/services can be provided to treat the unrelated problem. (Continued on page 4)

4 4 SPRING 2004 STS/AATS CODING NEWSLETTER (Continued from page 3) As with the other situations, private payers may vary on their coverage and coding criteria for unrelated services. Question: Please discuss: When is it appropriate to bill central lines when placed by the surgeon prior to or immediately after the surgery? Answer: The placement of central lines by the surgeon in the preoperative, intra-operative, or postoperative period is considered part of the global surgical package bundle and should not be reported separately by the surgeon. If the placement of the lines in the postoperative period is considered unrelated to the original procedure, then you should report the appropriate code with a -79 modifier and different diagnosis than the original procedure. Question: Patient had two previous aortic valve replacements through a mediastinotomy; can we charge a re-do code for another re-do via thoracotomy? Answer: Yes. As long as the original procedure performed was a CABG or valve procedure, and the re-do procedure is a CABG or valve, you may report reoperation, coronary artery bypass procedure or valve procedure, more than one month after original operation (list separately in addition to code for primary procedure). [Use in conjunction with codes ; , ] The code is not specific to the approach used to accomplish the procedure. Question: Can I bill out lymph node sampling when a lobectomy or wedge resection is performed for lung cancer or nodules? Answer: Yes. You should report code Thoracic lymphadenectomy, regional, including mediastinal and peritracheal nodes (list separately in addition to code for primary procedure) for lymph node sampling when performed in conjunction with a lobectomy or wedge resection. These codes are not bundled and should be recognized by most payers as a primary procedure for code However, some payers have developed a list of primary procedures for this code (as well as other add-on codes).so if you are experiencing denials, check with your payer for additional edits they may have implemented. Question: Blue Shield has denied claims when a decortication is billed at the same time a lobectomy or wedge resection- Nat 1 Correct Coding Guidelines says we can bill these Any ideas? Answer: The decortication codes, Decortication, pulmonary (separate procedure); total and Decortication, pulmonary (separate procedure); partial both include the terminology separate procedure. Per CPT definition and that of many payers, the separate procedure terminology indicates that the procedure is commonly carried out as an integral component of a total service or procedure, and should not be reimbursed in addition to the main procedure. It will generally be denied when reported in addition to other procedures/services listed within the same family or organ system of codes. If the decortication is performed as a distinct procedure, or if it is considered unrelated to the other procedures/services provided in the same session, you should report the decortication code with the -59 modifier. Also, please make sure that there is documentation in the patient s record that supports the use of the -59 modifier. Payers may or may not recognize the -59 modifier when used in this capacity. The material presented herein is, to the best of our knowledge, accurate and factual to date. The information and suggestions are provided as guidelines for coding and reimbursement and should not be construed as organizational policy. The STS/AATS disclaim any responsibility for the consequences of actions taken, based on the information presented in this newsletter. CODING HOTLINE ASSISTANCE AVAILABLE FOR MEMBERS The STS Coding Hotline is available to assist STS/AATS members and their staff with coding questions. You may ask questions via phone at , Fax at , or them to: juliepainter@grandsuites.com, or via mail. Please limit operative notes to one per month per physician. All requests must include the physician s name, STS or AATS membership number, and a phone number. All answers will be provided via a return phone call. STS/AATS Coding Newsletter Please send subscription-related questions to: The Society of Thoracic Surgeons Coding Department 633 N. Saint Clair St., Suite 2320 Chicago, IL Phone: (312) FAX: (312) Web site:

5 5 SPRING 2004 STS/AATS CODING NEWSLETTER ASSISTANTS-AT-SURGERY MODIFIER USAGE WITH CARDIOTHROACIC CODES In the 2004 National Physician Fee Schedule Relative Value File, each CPT code has an assistant-at-surgery (modifiers 80, -81, -82, or AS as appropriate) designation that falls into one of three categories: 1) Assistant-atsurgery is allowed; 2) Assistant-at-surgery is allowed, with documentation supporting medical necessity; and 3) Assistant-at-Surgery is NOT allowed. The designation for the most commonly reported Cardiothoracic codes from the following ranges , , 35600, , and are listed below. Assistant-at-Surgery Allowed

6 6 SPRING 2004 STS/AATS CODING NEWSLETTER Assistant-at-Surgery Allowed, Documentation Supporting Medical Necessity Required Assistant-at-surgery NOT Allowed CO-SURGEONS MODIFIER USAGE WITH CARDIOTHROACIC CODES In the 2004 National Physician Fee Schedule Relative Value File, each CPT code has a co-surgeons (modifier 62) designation that falls into one of three categories: 1) Co-surgeons allowed; 2) Co-surgeons allowed, with documentation supporting medical necessity; and 3) Co-surgeons NOT allowed. The designation for the most commonly reported cardiothoracic codes from the following ranges , , 35600, , and are listed below. The co-surgeons modifier (-62) should only be used to report a single CPT code that requires two surgeons of different specialties to complete the procedure. For example, for procedures where the cardiothoracic surgeon provides the spinal exposure for a spinal procedure, both the spinal surgeon and the cardiothoracic surgeon should report the appropriate spinal surgery procedures (other then the instrumentation and grafting codes) with the -62 modifier (the modifier may be appended to several codes if appropriate), and each surgeon should dictate his/her portion of the procedure. The -62 modifier would not be appropriate in a situation where one cardiothoracic surgeon performs a mitral valve replacement and another cardiothoracic or vascular surgeon performs a carotid endarterectomy, these are distinct procedures and each surgeon should report the service that he/she performed. Co-Surgeons allowed Co-Surgeons NOT Allowed

7 Co-Surgeons Allowed, Documentation Supporting Medical Necessity Required SAVE THE DATE: FALL CODING WORKSHOP, OCTOBER 8-9, 2004 ARLINGTON, VA

8 The Society of Thoracic Surgeons 633 N. Saint Clair Street Suite 2320 Chicago, IL N E W S STS/AATS CODING L E T T E R NEWSLETTER PRESORTED STANDARD U.S. POSTAGE PAID BERWYN, IL PERMIT NO. 73