Coding Challenge / modifier 25 / modifier 50 / modifier 51 / modifier 57 / modifier 59

No Correct Coding Initiative Bundle? Find Modifier Details in MPFS.

Question: Sometimes I cannot find my two-code pair in the CCI edits. How do I know which code would be considered a column 1 code and which would be considered a column 2 code, so that I could put my modifier on the correct code?

Answer: If the codes are not listed, the codes are not bundled per the Correct Coding Initiative (CCI). You would not need a CCI modifier, such as 25 (Significant, separately identifiable evaluation and management service by the same physician on  the same day of the procedure or other service), 57 (Decision for surgery), or 59 (Distinct procedural service), to override the edit when appropriate.

A private payer could have a black box edit. You would need to check with a rep for a recommendation.

Watch out: Just because a code does not have a bundle in CCI does not mean a modifier is out of the picture. While you won’t need a CCI modifier to override the edit, you might need apayment modifier.

You can find Medicare’s other allowed modifiers for any given CPT code in the Medicare Physician Fee Schedule (MPFS). Columns Y-AC indicate if modifier 51 (Multiple procedure), 50 (Bilateral procedure), etc. apply.

To determine which code receives modifier 51, you need to know the code’s relative value units, which are also listed in the MPFS. Private payers may not adjust claim items in descending order as Medicare’s Outpatient Code Editor software does. If you append modifier 51 to a higher valued item, the private payer may apply the adjustment based on your coding, costing you payment. You should instead list the items in descending relative value order from highest to lowest. Append modifier 51 to the lower priced procedure as necessary. The insurer will then apply the typical 50 percent,...

Comments Off on No Correct Coding Initiative Bundle? Find Modifier Details in MPFS.
November 23, 2010
modifier 59 / modifier 76 / Provider News

96110 Modifier Requirements Change Again

BC/BS UHC, tell coder to halt 96110-59 denials with 96110-79.

If you’re ready to bill 96110 and 96110-59, think again.

One office was billing 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) with modifier 59 (Distinct procedural service). BlueCross/BlueShield (BC/BS), UnitedHealthcare (UHC), and other insurers were denying the 96110-59s. “I called BC/BS on 8-19-2010 and was told that we should be using a 76 (Repeat procedure or service by the same physician) modifier instead,” reports Bonnie Palmer, with Lawrenceville Pediatrics in Georgia. “I also called UHC and was told the same thing.”

96110 x 2 or 96110-59 Is Technically Correct

Modifier 59 rather than 76 more appropriately describes two distinct 96110s. When you’re reporting two 96110s, you’re doing so to represent two different tests, not a repeat second test as modifier 76 represents. That being said, the American Academy of Pediatrics prefers that you report multiple 96110s using units rather than any modifier.

Two 96110s indicate that the second developmental test is a separate test. Staff administered — or the parent completed — two different tests, such as the Ages and Stages Questionnaire (ASQ) and the Modified Checklist for Autism in Toddlers (MCHAT) — and that the physician interpreted and documented the tests’ interpretation.

Before Using Repeat Method, Obtain Proof

Modifier 76 instead indicates that the second test was repeated. The modifier appropriately describes cases in which staff has to readminister the same test and the physician has to reinterpret the results.

In practice, the old adage is best to follow: Get the policy in writing. If you obtain a modifier directive from an insurer to use modifier 76 for multiple 96110s – either from the payer’s Web site or an email confirmation, save the documentation – and then adhere...

Comments Off on 96110 Modifier Requirements Change Again
October 11, 2010
Hot Coding Topics / modifier 59 / NCCI

NCCI Edits: Watch Out For These Endoscopy Bundles

Code 31575 includes 92511 and 31231 except under these conditions.

Singling out the correct endoscopy code when your otolaryngologist examines multiple areas in the sinuses and throat isn’t always easy, but in most cases it’s imperative to settle on one, according to National Correct Coding Initiative (CCI) edits. You can adhere to these edits and avoid payback requests if you stick to these guidelines.

3 Rules Guide the Way

Rule #1: Never report 92511 (Nasopharyngoscopy with endoscope[separate procedure]) and 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) together, says Stephen R. Levinson, MD, otolaryngologist and coding consultant based in Easton, Conn. Code 92511 is a component of Column 1 code 31231. The bundle has a modifier indicator of “0” — thus, no modifier can break this bundle.

Rule #2: Code 92511 is a component of Column 1 code 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) but a modifier is allowed in order to differentiate between the services provided (that is, you may append modifier 59 [Distinct procedural services] if there are separate and identifiable services with separate medical indications). Report 92511 in conjunction with 31575 for the same encounter, says Levinson, only if the following conditions are met:

  • there are separate medical indications for examining each area (for instance, 784.49 for hoarseness with 31575 in an adult patient with a hyperactive gag reflex and 381.4 for a unilateral or bilateral middle ear effusion with 92511, which would be a rare occurrence), and
  • the ENT uses a different scope for each, separate procedure because there is a documented reason that the fiberoptic scope did not provide adequate visualization of the nasopharynx. “This would be highly unlikely,” emphasizes Levinson.

Rule #3: Code 31231 is a component of Column 1 code 31575 but a modifier is allowed in order...

Comments Off on NCCI Edits: Watch Out For These Endoscopy Bundles
June 1, 2010
CCI / modifier 59 / Provider News

Make Sure You’re Applying Massive Prostate Biopsy, Urethral Dilation Bundlings

Modifier 59 sometimes will rescue your reimbursement.

Just when you’re finally getting a handle on all the 2010 coding changes, here comes round two of the Correct Coding Initiative (CCI) edits. Version 16.1, which took effect April 1, will tie your hands when coding many common urology procedures, including prostate biopsies and urethral dilations.

Heads up: CCI 16.1 includes 2,054 new active pairs and 1,947 modifier changes, says Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions Inc. in Clearwater, Fla.

“For urology, there will be 78 edit pair additions and two edit pair deletions,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.To ensure you get paid appropriately for your urologist’s services this quarter, here’s the rundown of the most important changes.

Say Goodbye to Biopsy with Several Prostate Procedures

You can no longer report prostate biopsy codes 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) or 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance) with 52630 (Transurethral resection; residual or re-growth of obstructive prostate tissue including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]). Your payer will reimburse you for 52630 but deny the biopsy codes, and you cannot use a modifier to separate these new edits.

“I have a major issue with the bundling of 55700 and 52630,” laments Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. Kater says her urologists perform a good number of prostate biopsies transrectally and 55700 is what she uses because the descriptor says “any approach.” When you are performing two separate procedures utilizing two different approaches, how can they be bundled?”

Silver lining: CCI also bundles...

Comments Off on Make Sure You’re Applying Massive Prostate Biopsy, Urethral Dilation Bundlings
May 20, 2010
CCI / CPT / Hot Coding Topics / modifier 59 / NCCI

CCI 16.1: Seize the Opportunity to Report 0193T — But Don’t Get Tripped Up By These Edits

Overlooking these new Interstim and hemorrhoid destruction bundles could mean denial headaches.

Payers like Noridian Part B will cover the female stress urinary incontinence treatment code 0193T, but before you submit a 0193T claim, you’ll have to check with the...

Comments Off on CCI 16.1: Seize the Opportunity to Report 0193T — But Don’t Get Tripped Up By These Edits
April 14, 2010
CCI / HCPCS / Hot Coding Topics / Medicare / modifier 59 / NCCI / Oig / Oncology

OIG Hit List: Perfect Your 38220, 38221, and G0364 Usage

Don’t sweat reporting 38220-59 if you meet these Medicare-approved conditions. If your oncologist takes both a bone marrow biopsy and a bone marrow aspiration, whether you’ll see Medicare reimbursement depends on the two guidelines below. But watch out: With OIG scrutiny and a HCPCS twist, these guidelines will put your coding savvy to the test. Append 59 [...] Related articles:

  1. Coding Education: Bone Marrow Harvesting for Autologous TransplantQuestion: Is there a CPT code specific to harvesting bone...
  2. Use This Podiatry Scenario to Perfect Your Emerging Technology ClaimsHint: If you try to use an unlisted code, be...
  3. Multiple Bronchoscopy Coding Crash Course Head off denials & ratchet up reimbursement with these...

Comments Off on OIG Hit List: Perfect Your 38220, 38221, and G0364 Usage
February 21, 2010
CPT / ICD-9 / modifier 22 / modifier 52 / modifier 59 / Modifiers / surgery / Toolkit

8 Simple Steps Organize Your Op Note Coding

This aspect of op note coding is the “horse that pulls the cart.” Stuck on how to tackle this op note or those sitting on your desk? Follow this advice, provided by Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M. and co-presenter of the “Ob-Gyn Op Notes” session at the [...] Related articles:

  1. 3 Steps Take the Guesswork Out of Coding Vaginal Cuff Repairs Find out what colporrhaphy code you’ll use for an...
  2. Write an Appeals Letter That Works In 6 Simple Steps Transform the written word into reimbursement with these tips...
  3. Op Note Coding Clinic: Breast Reconstruction with AlloDermSurgeons now commonly use AlloDerm in a variety of surgeries,...

Comments Off on 8 Simple Steps Organize Your Op Note Coding
February 11, 2010
Hot Coding Topics / modifier 59

What Lab Coders Need to Know About CCI 16.0

Look for transcutaneous hemoglobin limitations, and bundling for those new 2010 culture codes. Think you’re ready to use all those brand new CPT lab codes? Not so fast. You better learn Correct Coding Initiative (CCI) restrictions first, before you start billing Medicare for services using new CPT 2010 codes. CCI released version 16.0, effective Jan. 1, which includes 24,060 [...] Related articles:

  1. CCI 15.3 Update: You Can Resubmit Dozens of Previously-Bundled 22526 ClaimsNewsflash: CCI 15.3 retroactively deletes hundreds of edit pairs, but...
  2. What Interventional Radiology Coders Should Know About CCI 15.1 EXTRA–Radiology Reimbursement WEBINAR: Do you know the difference between...
  3. Can’t Locate an H. Pylori Lab Test Code? 2 Clues Point the Way Solve CLO test culture code dilemma and other mysteries....

Comments Off on What Lab Coders Need to Know About CCI 16.0
January 31, 2010
CCI / Hot Coding Topics / modifier 59 / mutually exclusive

Ob-Gyn CCI 16.0: Hysterectomy Coding

Here’s where you can bypass the edits with modifier 59. The Correct Coding Initiative (CCI) version 16.0 didn’t overlook the hysterectomy, vaginal graft, and colpopexy codes — nor should you. To make sense of the deletions, break these additions into mutually exclusive and non-mutually exclusive. Note: In all these cases — except those involving the anesthetic injection [...] Related articles:

  1. Hysterectomy Coding Simplified: Look at Weight, Removal Severing these ligaments clues you into whether ob-gyn removed...
  2. CCI 15.2 Retracts Neurostimulator Edits from 15.1Look for new edits that affect eye exam codes, anesthesia,...
  3. 3 Steps Take the Guesswork Out of Coding Vaginal Cuff Repairs Find out what colporrhaphy code you’ll use for an...

Comments Off on Ob-Gyn CCI 16.0: Hysterectomy Coding
January 22, 2010