Global Periods for Non-Invasive Procedures
Office based procedures (like echocardiograms and pacemaker checks) have a Global Period of “XXX” in the Medicare Fee Schedule. According to the National Correct Coding Initiative Policy Manual, “With most “XXX” procedures, the physician may, however, perform a significant and separately identifiable E&M service on the same day of service which may be reported by appending modifier –25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the “XXX” procedure but cannot include any work inherent in the “XXX” procedure, supervision of others performing the “XXX” procedure, or time for interpreting the result of the “XXX” procedure. Appending modifier –25 to a significant, separately identifiable E&M service when performed on the same date of service as an “XXX” procedure is correct coding.”
Thanks to this clarification, payment for office visits performed on the same day as office-based diagnostic testing should be facilitated by appending the 25 modifier to the office visit code. While some private payers will only compensate the office visit if it is reported with a different diagnosis code than is used for the diagnostic test, Medicare Administrative Contractors should not require distinct diagnosis codes. If it is identified as a problem for your practice it may be beneficial to direct your Medicare Administrative Contractor’s attention to the Policy Manual and to your state’s timely claim payment policy. Whole-hearted efforts to appeal inappropriate denials through the mandated appeal process most commonly result in payment.However, using a different diagnosis for each service will reduce the incidence of denial.
Device Checks & Global Periods
Pacemaker and defibrillator checks performed in the 90-Day Global Period of the implant are separately payable whenever they are medically necessary. The Medicare National Coverage Determinations Manual confirmed (several years ago) that it is routine to perform two pacemaker checks in the first six months after device implant. More recently, the October 2, 2012 edition of the Journal of the American College of Cardiology (excerpted below) established that, at a minimum, patients should have their devices checked within 72 hours of implant and 2 - 12 weeks postoperatively.
If the 72-hour check is performed in the office, at the time of the incisional site check, the physician will receive about $26 more than if it was performed while the patient was still in the hospital. In order to receive this additional $26, the service must be performed in the office and it must be performed by a practice employee rather than a device company representative. When a device check is performed in a hospital or by a device company representative the practice cannot claim reimbursement for the technical portion of the service. To carve this portion of the device check off of the claim we must attach the professional component modifier (26) to the device check code.
The second device interrogation would ideally be performed at a follow-up visit during the second half of the 90-day global period that applies to the device surgery. The data from the device interrogation will provide the physician with data that helps guide patient management. Since the patient’s heart may have reverse remodeled or the leads may have migrated since implant, it is medically necessary to check the device. Based on the results of the device check and the office visit, it will frequently be beneficial to optimize the device settings and medications at this point. As long as the services are medically necessary, adequately documented, and properly reported they should be paid. Just keep in mind that the 24 and 25 modifier should be attached to the office visit code. As mentioned in my invasive procedure global period post, the 24 modifier distinguishes the visit as separate from routine post-op recovery services. As mentioned above, the 25 establishes it as separate from the routine face-to-face time associated with the typical device check.