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Cardiology Coding Alert

CCI:

Long-Standing Coding Policies, Modifier -25 Changed

Published on Sat Dec 01, 2001

Correct Coding Manual/Version 7.3 (CCM 7.3), the latest version of the manual that compiles all changes to the Correct Coding Initiative (CCI), was released Oct. 1. Although CCM 7.3 includes few edits specific to cardiology, significant revisions to long-standing coding policies are worth the attention of all physicians. Changes to Chapter One of the CCI, for example, include:
 
Reintroducing the requirement that modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) be appended to any E/M service provided on the same day as a diagnostic test.
 
Elaborating on the use of modifiers "designated specifically for use with the correct coding and mutually exclusive code pairs."
 
Bundling "general fluoroscopic services" with placement of central access devices, such as catheters, unless a specific CPT code has been defined for this service.

Chapter One of the CCI, titled "General Correct Coding Policies," has not been revised for years, which makes the changes even more important, says Kathleen Mueller, RN, CPC, CCS-P, a coding and reimbursement specialist in Lenzburg, Ill. Many of the changes, Mueller notes, reflect existing coding conventions and principles that CMS is putting in writing in the CCI Edits for the first time. For example, the following principles provide the rationale for including individual services with a more comprehensive procedure:
 
1. The service represents the standard of care in accomplishing the overall procedure.
 
2. The service is necessary to successfully accomplish the comprehensive procedure; failure to perform the service may compromise the success of the procedure.
 
3. The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure planned.

CCM 7.3 uses cardiology-specific situations to drive home the point. For instance, "procurement of a rhythm strip in conjunction with an electrocardiogram (ECG) would not be separately reported if it was procured by the same physician performing the interpretation, since it is an integral component of the interpretation." Similarly, obtaining an ECG as part of a cardiac stress test should not be separately reported "if procured as a routine serial ECG typically performed before, during or after a cardiac stress test."

Modifier -25

The change to the CCI that is likely to have the greatest impact involves wording in Chapter One reminiscent of the controversial policy of bundling E/M services with diagnostic tests. The policy was first introduced in CCM 6.3 (October 2000) and suspended several months later, following outcries from the American College of Cardiology and others that the more than 56,000 edits that this policy generated were confusing to local Part B carriers.
 
Note: E/M services and diagnostic tests could be billed separately before this policy was introduced, because diagnostic tests are not covered by global surgery rules and are listed in the fee schedule as having XXX global days.
 
Although CCM 7.3 does not reintroduce the edits per se, the policy itself has been restated in Chapter One of the CCI: "Many of these 'XXX' procedures are performed by physicians and have inherent pre-procedure, intra-procedure and post-procedure work usually performed each time the procedure is completed. This work should never be reported with a separate E/M code 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 the -25 modifier to the E/M code."
 
The same policy reiterates that, as with any E/M service performed on the same day as another procedure or service, the E/M service "may be related to the same diagnosis necessitating performance of the XXX procedure." But, it concludes, it "cannot include any work inherent in the 'XXX' procedure, supervision of others performing the 'XXX' procedure, or time for interpreting the results of the 'XXX' procedure."
 
"We are hoping that it won't be implemented by our carriers," says Rebecca Sanzone, CPC, billing manager with Mid-Atlantic Cardiovascular Associates, a 54-physician practice in Baltimore. "But if they do implement it, we've dealt with it before and we'll do it. Any office, if they're doing an echo or a holter or even a stress test, should have the documentation to show why the E/M is separate and significant and warrants a separate E/M claim with modifier -25. They shouldn't be putting modifier -25 on just to try to get paid for something the cardiologist didn't do."

Modifier -59

Apart from the new information regarding modifier  -25, E/M services and diagnostic tests, Chapter One of the CCI also discusses modifiers -58 (staged or related procedure or service by the same physician during the postoperative period) and -59 (distinct procedural service). These two modifiers are used to bypass edits in specific situations.
 
Although the section on modifier -58 mainly reiterates the full description of the modifier in the CPT manual, Mueller says, Chapter One of the CCI provides new insight into modifier -59. A scenario involving the placement of a pulmonary artery catheter for hemodynamic monitoring via the subclavian vein is included in the chapter, noting that this procedure would be coded 93503 (insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes) and that removal of the catheter and insertion of a central venous catheter through the femoral vein later that same day would be coded 36010 (introduction of catheter, superior or inferior vena cava). Chapter One of the CCI states: "Because the pulmonary artery (PA) catheter requires passage through the vena cava, it may appear that the service for the PA catheter was being unbundled if both services were reported on the same day. Accordingly, the central venous catheter code should be reported with the -59 modifier indicating that this catheter was placed in a different site as a different service on the same day."

Fluoroscopy

Fluoroscopy is often used to guide the placement of cardiac, coronary and noncoronary catheters. The codes for some of these catheter placements also refer to specific fluoroscopy codes in the radiology section (70000 series) of the CPT manual, or, in the case of cardiac catheterizations, a specialized coding system has been established that includes catheter placement, injection of dye, and supervision and interpretation.
 
Other catheter placements do not refer to a specific radiology code, even though fluoroscopic guidance is required. As a result, "generic" fluoroscopy code 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) is often used to bill for the radiologic service.
 
Chapter One of the CCI ends this practice, stating that "general fluoroscopic services necessary to accomplish routine central vascular access or endoscopy cannot be separately reported unless a specific CPT code has been defined for that purpose." In other words, only specific radiology codes that CPT links to specific catheter placements may be billed.
 
"Some practices have been billing for fluoroscopy with every Swan-Ganz and every CV line even though fluoroscopy for guidance purposes is included in these procedures. As a result, 76000 has been overutilized by physicians," Sanzone says. She notes that when fluoroscopy is used during pacemaker insertion, it may be reported separately because there is a specific code for the service (71090, insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation).
 
Physicians and coders alike should review Chapter One of the CCI, Mueller says. "It always was a good idea to read the introduction whenever a new CCI was published to brush up on coding conventions and principles," she says. "But now, with so many additions and changes, reading Chapter One and the chapter introductions in 7.3 is a must."

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