Cardiology Coding Alert

Hint: Check Append E to see which procedures are exempt from modifier 51.

Knowing when to append modifiers to procedure codes can be tricky, but your cardiology claims don’t have to fall under scrutiny. Answer the following questions about commonly-appended modifiers you can append to CPT^® codes to make sure your claims stay in tip-top shape.

Don’t miss: You can find all of these modifiers in Appendix A of the CPT^® manual.

Follow Handy Rules When Appending Modifier 25

FAQ 1: Can you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to any CPT^® code?

Answer 1: No. You should only apply modifier 25 to evaluation and management (E/M) codes.

You can apply modifier 25 to an E/M service that is separate and significant from another procedure or service at the same encounter, explains Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico. “The note must clearly indicate that the E/M dealt with issues that were not part of the other services,” she continues.

When you use modifier 25, it indicates that “on the day of a procedure, the patient’s condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and postoperative care associated with the [other] procedure or service,” adds Mary I. Falbo,  MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania.

Modifier 25 is one of the most misunderstood modifiers, so if you ever have doubts about whether you are properly using it in the future, make sure you follow these rules:

• Rule 1: You can only append modifier 25 to E/M service codes 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 components ...) through 99499 (Unlisted evaluation and management service).
• Rule 2: You may use modifier 25 only when your provider’s documentation proves that he performed a medically necessary and “significant, separately identifiable” E/M service in addition to the original procedure. Your physician must include a separate History, Examination, and Medical-decision making (HEM) for the E/M service in his documentation.
• Rule 3: The E/M service must occur on the same calendar day as the original procedure for the same patient.
• Rule 4: The procedure following the E/M would be a minor procedure, meaning that it has a zero or 10-day global period.

Report Modifier 26 in This Case

FAQ 2: In a facility, the cardiologist performed cardiac catheterization with coronary injections, left ventriculography, and interpretations of the studies. Which CPT® codes should we report, and do we need to append modifiers?

Answer 2:  You should report 93458 (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed) for this service.

Modifier 26: Because the service took place in a facility, you should append modifier 26 (Professional component) to 93458 to show you’re reporting only the physician’s work and not the technical component.

Reference Appendix E to Append Modifier 51 Correctly

FAQ 3: Can we append modifier 51 to code 93451 (Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed)?

Answer 3: No. CPT^® specifically identifies 93451 as exempt from modifier 51 (Multiple procedures).

Appendix E in the CPT^® manual lists the CPT^® codes that are exempt from the use of Modifier 51. Make sure to pay careful attention to these codes, which are marked with a symbol in the code set.

You should never append modifier 51 to the following:

• Add-on codes, which the CPT^® manual lists in Appendix D and identifies with a + symbol in the code set
• Codes in Appendix E of the CPT^® manual
• Codes that have modifier 50 (Bilateral procedure) appended and therefore already have a fee reduction 
• E/M services
• Physical medicine and rehabilitation services
• Provision of supplies.

Understand Modifier 53 With Coding Scenario

FAQ 4: I’m new to cardiology and was wondering if you could you explain how to appropriately append modifier 53?

Answer 4: You should append modifier 53 (Discontinued procedure) to indicate that discontinuing the procedure was necessary to protect the patient’s health.

“Due to extenuating circumstances or those that threaten the wellbeing of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued,” according to the CPT^® manual. “This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure.”

Take a look at the following coding example to give you an idea about how to correctly append modifier 53.

Coding example: The cardiologist attempted 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch) twice using a balloon catheter on the left descending artery. However, the patient started experiencing hypertensive crisis, so the cardiologist had to discontinue the procedure to protect the patient’s wellbeing. The cardiologist was only able to complete 20 percent of the procedure before he discontinued it.

Coding solution: In this case, you can code according to what the physician attempted before discontinuing the procedure by appending modifier 53. So, you would report 92920-53-LD (Percutaneous transluminal coronary angioplasty; single major coronary artery or branch; Left anterior descending coronary artery) since a “balloon catheter” was inserted into the body.

Always submit documentation: Submitting modifier 53 alone does not provide the payer with enough information to know how to correctly reimburse the provider. So, make sure you submit the supporting documentation for appending modifier 53. The documentation must state that the physician actually started the procedure, why it was medically necessary for him to discontinue the procedure, and what percentage of the procedure he did perform.

Bonus: Always remember to also view CMS HCPCS modifiers X{EPSU} before reporting numeric

modifiers, reminds Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department, and member of AAPC’s Certified Cardiology Coder steering committee.