Cardiology Coding Alert

 96 percent of the time, CMS call centers won't be of any help

When appending modifiers -22 and -57 to cardiology procedures or visits, you shouldn't rely on "what someone told me" - even responses from CMS call centers.
 
A study by the Government Accountability Office (GAO) reports that 96 percent of the answers provided by CMS call centers - including answers to cardiology coders' questions - are inaccurate, only partially correct, or totally incomplete.
 
See how the GAO's "correct and complete" answers to two of four cardiology-specific questions stack up to the advice of our cardiology coding experts. (See next month's edition of Cardiology Coding Alert for the other two questions.)

Combat Denials With Documentation for Modifier -22

Question: Do carriers pay for second surgical procedures performed by the same physician on the same day but during different operative sessions?
 
What the GAO counted as the correct and complete response: "If the physician believes that extenuating circumstances exist for performing multiple surgeries on the same day and that these surgeries would be paid at the full amount, he or she may bill for the surgeries with modifier -22. After reviewing the operative report, the carrier may determine that the standard adjustment rules do not apply and pay 'by report.' "

What's left out: In order for carriers to see the report, you will have to file your claim in hard-copy format and attach the operative report and a cover letter explaining why you used modifier -22 (Unusual procedural services).
 
Without documentation, carriers will deny claims with the reasoning that they require additional information before they can adjudicate the claim, says Jim Collins, ACS-CA, CHCC, CPC, president of Compliant MD Inc. in Matthews, N.C.
 
The operative report should clearly identify additional diagnoses, pre-existing conditions or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure.
 
Every operative note should have a separate section - such as a "Special Circumstances" section - in which the physician must indicate when a procedure is significantly more difficult than anticipated.
  
Keep in mind: There's a good chance that the person employed by the insurance carrier to review your claim is not a medical professional. So you have to translate what went on in the operating room into quantifiable terms.
 
CPT guidelines indicate that "when the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier -22 to the usual procedure code." And convincing the carrier that a procedure was "greater than that usually required" is crucial for claims with modifier -22, because when approved, these claims will yield additional reimbursement - in many cases an additional 20 to 25 percent more than their standard payment.

Separately Identifiable E/M? Don't Count Out Modifier -57

Question: Will Medicare reimburse both a visit and a procedure reported by the same physician for the same patient on the same day?
 
What the GAO counted as the correct and complete response: "Medicare will not pay separately for a visit on the same day as a minor surgery or endoscopic procedure unless other significant separately identifiable services are performed in addition to the procedure. The payment amount for the procedure covers such pre- and postservice work as record keeping, counseling, and prescribing recovery therapy.
 
"However, if other significant evaluation and management services are performed on the same day, the physician may bill for the visit with modifier -25. In determining the level of visit to bill with the modifier, physicians should consider only the content and time associated with the separate evaluation and management service, not the content or time of the procedure.
 
"Visits that are related to a major surgery are not paid for separately if reported by the same physician on the same day as the surgery. However, the initial evaluation or consultation by the surgeon will be paid for separately even if reported on the same day."

What's left out: When the E/M is unrelated to the procedure, make sure you list different diagnosis codes with each service code. While most call centers won't tell you this pointer, "It is a tried-and-true approach," Collins says.
 
A cardiologist may decide to perform a minor surgical procedure and perform this procedure on the same day. In these situations, you can report an E/M code separately and receive separate reimbursement, as long as you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). 
 
If a cardiologist performs a major surgery, you can report the E/M service by the surgeon separately for the same day - as long as it is a separately identifiable service, says Sandra Banes, RHIA, coding specialist at Dupage Medical Group in Winfield, Ill.
 
However, in this circumstance, you will have to append modifier -57 (Decision for surgery), not modifier -25.

Lesson Learned - Get Carrier Responses Tape Recorded or in Writing

By reading the full report, you'll discover some surprising aspects about the survey itself - and not only the results.
 
For example, the GAO audited CMS contractors under generally accepted auditing standards, but CMS played an active roll in narrowing down a set of 18 frequently asked questions to the four questions used in the study.
 
"Wouldn't it be nice if CMS let providers narrow down the questions they were asked in an audit situation?" Collins asks.
 
Also, CMS debated each of the answers received in the audit and had a say in which were considered accurate, inaccurate, and incomplete.
 
Even though the GAO survey results reflected unfavorably on CMS, the process erred on the side of conservatism, rather than by the book.
 
What this means for you: If you call your carrier with a question, you should make sure that you have their response either in written or audio-recorded format. 
 
Based on this survey, if you follow the advice you receive from carriers, it will frequently be incorrect. 
 
However, as Collins says, "If you can definitively prove that you were following the guidance of your carrier, you will be much better off if you had to submit the statement 'Someone at my carrier told me to bill it this way' as your only defense."