Cardiology Coding Alert

Modifier 51 exemptions to common catheterization and electrophysiological codes mean that your bottom line could be affected -- in a big, bad way.

Red flag: "You should note this in case you start receiving denials on things that were previously paid; it could be the code needs modifier 51," says Staci Dougherty, CPC, certified procedure coder at the Internal Medicine Billing ...quot; Cardiology department of VCUHS/MCVH (Virginia Commonwealth University Health Systems/Medical College of Virginia) in Richmond.

CPT 2008 reassessed codes that AMA has previously designated as modifier 51 (Multiple procedures) exempt. "Modifier 51 exempt" means that you don't need to add this modifier to a code that CPT has not designated as an add-on procedure/service, says Diane Hoffman, CPC, coder/biller for a private practice in Madison, Wis. These are typically codes that do not involve significant pre- or postoperative work.

However, the CPT 2008 revision to modifier 51 exempt status to cath and electrophysiology procedures means that you'll be applying modifier 51 more often.

What happens: When you apply modifier 51 to claims specifying separate procedures on the same patient on the same session, you trigger multiple-procedure payment reductions. Your payer will reimburse the highest-ranked procedure at 100 percent and any additional procedures at 50 percent. When procedures are "modifier 51 exempt," they are not subject to this multiple-procedure payment-reduction rule.

No longer will you see the modifier 51 exempt symbol (X) beside the following cath codes in your book: 93505, 93508, 93510, 93511, 93514, 93524, 93526-93533, 93541-93543. Therefore, you will need to use modifier 51 when your cardiologist performs any of these services and suffer the multiple-procedure reduction hit.

Example: The withdrawal of the modifier 51 exemption status means that 93510-26 (Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous; professional component) will now require a modifier when your cardiologist performs this service with other procedures (such as 92980, Transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel). In that case, your claim should look like this:

• 92980

• 93510-26-51.

What this means to you: Your payer will pay the highest-ranked procedure at 100 percent and any additional procedures at 50 percent, Hoffman says. In other words, your payer will pay the full $869 for 92980 but will reduce the fee for 93510-26-51 to only $129.

This shouldn't be a terrible surprise, because CMS has reduced 93510's reimbursement by 50 percent for many years, says Jim Collins, CPC-CARDIO, ACS-CA, CHCC, president of The Cardiology Coalition in Saratoga Springs, N.Y. "Now the modifier 51 status is in harmony with this policy."

Keep in mind: You'll arrive at these amounts (and others included in this article) using the conversion factor (CF) of 37.8975. This was the 2005 rate Congress froze for 2007. Many suspect that Congress will freeze the CF rate for 2008 as well.

All of the heart cath injection codes remain modifier 51 exempt except for codes:

• 93541 -- Injection procedure during cardiac catheterization; for pulmonary angiography

• 93542 -- ... for selective right ventricular or right atrial angiography

• 93543 -- ... for selective left ventricular or left atrial angiography.

These codes will need a modifier when your cardiologist performs this service along with another service during the same session.

Example: Your cardiologist performs an injection service for a left ventriculargram (93543) as well as a stent placement (such as 92980) or even at the same time as a regular diagnostic heart cath (93510). In both cases, you should expect the fee for the injection code (93543) to be only $8.15 rather than its full $16.30 fee.

Source for decreased revenue: This methodology, however, does not make sense. Your cardiologist cannot perform 93543 as a stand-alone procedure. You must report this code in combination with other codes that include left ventricular catheter placement. Therefore, this will be a source for lost reimbursement in 2008.

For over a decade, all of the codes in the Intracardiac Electrophysiologic Procedures/Studies subsection (93600-93662) of CPT (with the exception of add-on codes 93609, 93613, 93621, 93622, 93623, and 93662) were modifier 51 exempt.

In CPT 2008, you won't see the modifier 51 exempt symbol alongside EP study codes 93619, 93620, 93624, 93640, 93641, 93642 and 93660, and ablation procedures 93650, 93651 and 93652. This change eliminates the longstanding exemption status and will result in payment decreases by 50 percent when the same physician performs multiple procedures during the same patient encounter.

Example 1: Your physician performs the professional component of a complete EP study (93620-26, Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording) valued at 17.83 RVUs and an SVT ablation 93651 (Intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination) valued at 24.78 RVUs. Both of these codes are no longer modifier exempt, therefore you will add modifier 51 to the lesser code (93620-26).

So when you report both codes together, Medicare will pay both procedures, the highest valued at 100 percent (93651 at $939) and decrease the second procedure by 50 percent (93620-26 decreased to $338).

Bad news: That's a loss of $338 per occurrence of this code combination in 2008.

Example 2: Your physician performs an ICD implant (33249, Insertion or repositioning of electrode lead[s] for single- or dual-chamber pacing cardioverter-defibrillator and insertion of pulse generator) valued at 25.04 RVUs with a defibrillation threshold (DFT) test (93641, Electrophysiologic evaluation of single- or dual-chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation [induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination] at time of initial implantation or replacement; with testing of single- or dual-chamber pacing cardioverter-defibrillator pulse generator) valued at 9.04 RVUs. The DFT test is no longer modifier 51 exempt, so you will add modifier 51 to the lesser code (93641-26-51).

However, this use of modifier 51 doesn't make sense, Collins says. You'll never report 93641 as a stand-alone procedure. You must report this code along with another procedure, such as the ICD implant. "There is no logic in applying the modifier procedure reduction to this code."

Bottom line: When you report this code combination, Medicare will pay both procedures, the highest valued at 100 percent (33249 at $949) and decrease the second procedure by 50 percent (93641-26-51 decreased to $171).

Bad news: That's a loss of $171 per occurrence of this code combination in 2008.

For info more, see Web site http://www.hrsonline.org/Policy/CodingReimbursement/reimbursement/physician/wr-modifier51.cfm. You'll discover how and why this change took affect, as well as the Heart Rhythm Society's and American College of Cardiology's stance on this issue.