Reader Questions: Check LMRPs When Billing Follow-Up Chest X-Rays

Contact FI for Post-PICC X-Ray Coverage

Question: When we report 36555 and 71010 together, we hit an edit that disallows this. If the physician performs a follow-up x-ray to check the placement of a catheter, should we append modifier -59, or is that service part of the procedure?

Illinois Subscriber

Answer: Your best bet is to check with your fiscal intermediary (FI) about local medical review policies (LMRP) regarding chest x-rays.

First Coast, for example, has an LMRP that specifically states that you can bill a chest x-ray for final placement verification separately from the catheter insertion.

Trailblazer, however, has no such LMRP. Other FIs state that if the patient shows no symptoms of complications post-insertion, the follow-up x-ray is included in the procedure.

Logically, if the combination of 36555 (Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age) and 71010 (Radiologic examination, chest; single view, frontal) hits an edit, the likelihood is that the x-ray is included as part of the primary procedure. Because National Correct Coding Initiative (NCCI) edits bundle these procedures together, you should probably evaluate each case individually to decide whether appending modifier -59 (Distinct procedural service) (and therefore bypassing this edit) is appropriate.

Determine why the physician performed the x-ray. At some facilities, if she just wanted to check the catheter placement, then the x-ray is probably meant to be included in the original catheter insertion. Other facilities, however, do not usually perform the follow-up x-ray, so modifier -59 may be more appropriate.

If the physician completes the x-ray because the patient has signs and symptoms not routinely associated with the catheter insertion (that require diagnosis and treatment), you should append modifier -59. Even if the physician customarily performs checkup x-rays for catheter placement, the reason for this patient's x-ray is unrelated to the original procedure, so the x-ray qualifies as "distinct."

Appeal for OCE 62

Question: What is the difference between outpatient code edit 28 (Not recognized by Medicare) and OCE edit 62 (Not recognized by OPPS)? I thought the edit number was related to the APC Status Indicator, but that correspondence isn't very consistent. Edit 28 flags status B and E (among others), and the same goes for edit 62. Why?

Alaska Subscriber

Answer: The main difference between OCE 28  and OCE 62 is that 28 generates a "line-item rejection" while 62 allows the claim to be "returned to provider" (RTP). With line-item rejections, the fiscal intermediary (FI) can process the claim for payment with the exception of those line items that it denies. You can't correct these rejected line items, but you can appeal them. An RTP denial, on the other hand, means that the FI has returned the entire claim for correction and resubmission.




Find Method for Ablation Answers

Question: The physician performed endometrial ablation on a patient after performing cervical dilation on her four hours earlier in the same day. How should we report this procedure, and are we allowed to report the dilation separately?
 
Michigan Subscriber

Answer: The ablation code depends on the physician's method.

If the physician used a hysteroscope to accomplish the ablation, you should report it with these steps:

report 58563 (Hysteroscopy, surgical; with endometrial ablation [e.g., endometrial resection, electrosurgical ablation, thermoablation]) for the ablation.

append modifier -59 (Distinct procedural service) to 59200 (Insertion of cervical dilator [e.g., laminaria, prostaglandin] [separate procedure]). The modifier tells the fiscal intermediary (FI) that the dilation is a distinctly different procedure from the ablation.

If the doctor used the thermal balloon procedure to accomplish the ablation, you should code it this way:
report 58353 (Endometrial ablation, thermal, without hysteroscopic guidance) for the ablation.
append modifier -59 to 59200.

Remember: If the physician performed the dilation at the same time as the ablation, you cannot report the dilation separately. But some physicians may dilate the patient earlier in the day, then perform the ablation later.

- Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP,  president of SLG Inc., a consulting firm in Raleigh, N.C.