Cardiology Coding Alert

Deciding to assign a "wrong surgery" modifier is serious business, so arm yourself with the facts so you and your practice can make an informed decision. These three steps will get you on your way.

Medicare will not cover surgical or other procedures when the physician performs one of the following:

• A procedure on the wrong body part

• A procedure on the wrong patient

• The wrong procedure.

Impact: If you bill and receive reimbursement for procedures that meet any of the above conditions, you could face a recoupment request in the future. "If the doctor made a mistake, the patient should not have to pay for it, nor should the insurance company," explains Christine M. Bitner, CPC, CPC-I, chart abstraction specialist at HCA Physician Services in Brentwood, Tenn.

Watch for: Medicare also won't cover services related to the error. For example, "all services provided in the operating room when an error occurs are considered related and therefore not covered," states Transmittal 1819. But "related services do not include performance of the correct procedure," the transmittal states.

2. Connect Modifiers to Matching Mistakes

If you submit a claim with codes 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. Choose from the following:

• PA -- Surgical or other invasive procedure on wrong body part

• PB -- Surgical or other invasive procedure on wrong patient

• PC -- Wrong surgery or other invasive procedure on patient.

"Unfortunately, the introduction of these new modifiers has caused much confusion, and they are often being submitted incorrectly," says Sandra Jongebreur, CPC-GENSG,CPC, CPC-H, PCS, FCS, coder for Raafat Abdel-Misih, MD, in Wilmington, Del.

PC vs. 26: In particular, beware of confusing wrong surgery modifier PC with the modifier for the professional component of a procedure: 26 (Professional component). The source of confusion is easy to see. "People often think of the professional and technical components as PC and TC," explains Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions in New Jersey. The modifier for the "technical component" is TC, so many coders accidentally append PC (instead of 26) for the professional component.

The problem is so widespread that CMS issued MLN Matters article 6718 (www.cms.hhs.gov/MLNMattersArticles/downloads/MM6718.pdf) warning providers about the issue and announcing that contractors will review all claim lines with modifier PA, PB, or PC. If the contractor determines the provider used one of the modifiers incorrectly, the contractor will return the claim as unprocessable and ask for submission of a new claim.

Red flag: Modifiers PA, PB, and PC ensure you won't be paid and may increase malpractice risk. Be sure the cardiologist is involved in the decision to report them -- you don't want to make the mistake of applying these modifiers in error.

Know more: You can read the NCDs at www.cms.hhs.gov/Transmittals/downloads/R102NCD.pdf and the update to claims processing instructions at www.cms.hhs.gov/Transmittals/downloads/R1819CP.pdf.

You'll find a related MLN Matters article at www.cms.hhs.gov/MLNMattersArticles/downloads/MM6405.pdf.

Stay tuned: Look to the next issue of Cardiology Coding Alert for additional information on how CMS defines surgery on the wrong body part.