Cardiology Coding Alert

In a perfect world, you'll never need to apply Medicare's rule about properly coding surgery on a wrong body part. But mistakes do happen, so prepare with this explanation of when you should and shouldn't mark a service as "wrong."

Recap: In the last issue, "Bolster Your Modifier PA, PB, and PC Know-How in 3 Steps" explained that if you submit a claim for an erroneous procedure, you must append the appropriate modifier to each line item related to that procedure so Medicare knows not to reimburse them.

Next step: Even if you can keep the modifiers straight, you need to know when to apply them. Determining that the provider performed the wrong surgery (modifier PC) or worked on the wrong patient (modifier PB) may be fairly straightforward, but understanding "wrong body part" involves a little more detective work.

You should consider modifier PA (Surgical or otherinvasive procedure on wrong body part) if the doctor performed an invasive procedure that doesn't match the anatomic location the patient agreed to in writing.

The national coverage determination (NCD) for surgery on the wrong body part spells out this rule: "A surgicalor other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for that patient including surgery on the right body part, but on the wrong location on the body; for example, left versus right (appendages and/or organs), or at the wrong level (spine)" (www.cms.hhs.gov/Transmittals/downloads/R102NCD.pdf).

Example: An elderly patient with severe right leg pain signed an informed consent form for an angiogram and angioplasty of the right leg. Because of the patient's condition, the doctor planned an incision on the same side as the blockage. The team accidentally positioned her for left leg access. The physician punctured the left leg, threaded the catheter, and performed an angiogram in the left leg. A team member noticed the error, and the physician terminated the procedure.

What to do: If you must file a claim for such an encounter, remember that Medicare considers the left leg services noncovered because the patient agreed to surgery on the right leg. So you would append modifier PA to all services associated with the erroneous procedure, such as a catheter placement code (for example, 36140, Introduction of needle or intracatheter; extremity artery; or a code from 36245-36247, Selective catheter placement ...) and angiography code (75710-26, Angiography, extremity, unilateral, radiological supervision and interpretation; Professional component).

So, in short, you can't bill for "an error or any other services related to the erroneous procedure," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, manager of compliance education for the University of Washington Physicians Compliance Program.

"But you can bill for doing it again on the right body part," Bucknam points out. The NCD states that "Related services do not include performance of the correct procedure."

Watch for exception: If the physician decides to do a procedure on a different body part during the course of surgery because of an emergency or a condition discovered during surgery, you may be able to code for this second surgical procedure.

The NCD supports this position by stating "emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under this decision. Also, the event is not intended to capture changes in the plan upon surgical entry into the patient due to the discovery of pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; or the discovery of an unusual physical configuration (e.g., adhesions, spine level/extra vertebrae)."

Rationale: Doing an additional procedure and doing an incorrect procedure are two completely different things, explains Christine M. Bitner, CPC, CPC-I, chart abstraction specialist at HCA Physician Services in Brentwood, Tenn. An additional procedure would have documentation supporting medical necessity, unlike an "incorrect" procedure. The physician's note should reflect the reason for doing the additional procedure(s), says Bitner. "You should also have a diagnosis to support it," she says.