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Cardiology Coding Alert

Q & A Session

Published on Sat Apr 23, 2005

Question:  Yes, I was wondering if the bell curves that were mentioned that CMS does for each specialty, are they available on their website or somewhere we can get those to compare our practice to those?

Answer:  They are, they do not show it as a bell curve and I cannot even think of the site right now, but I could try to get it for you and relay it to you, or you could call Medicare.  They do have each code and each specialty listed for every single CPT code.  So if you take the numbers, they will say like 99201:33,000, 99202:50,000.  You can take those numbers and transform it yourself and make your own bell curves.  In other words, you will make your bell curve according to their stats and then all you have to do is take your production report, the production analysis for the end of the year - it would be better for the whole year - and provider B (your doctor) and log how many he did 99201, 99202, 99203, 99204, 99205 and put that on a bell curve and then just compare them and you will see exactly how your physician compares to the norms.

Comments:  Okay, thank you very much.

Question:  Hi, I have a question, we understand the concept of when you would utilize modifier 25 with your E/M level in addition to a surgical procedure that is performed.  My question is, I understand according to CMS rules when you would apply the modifier 25 versus the modifier 57 having to do with the minor and the major surgical procedures. However, we have had some information saying that of course CPT does not recognize minor and major surgical procedures, so would there be any information out there to designate if it is not a Medicare or Medicaid patient,  whether we should be appending the modifier 25 or the modifier 57, just for decision for surgery when there are no other problems or diagnoses?

Answer:  Right, the difference is you use modifier 57 when the surgical procedure has a 90-day global.  So it is mostly your surgical procedures that would be in the hospital and of course you know what that is too.  If your decision was made for surgery the same or next day - so you had somebody come in, they were in really bad shape, you admitted them and you did surgery today or tomorrow.  You would use modifier 57.

Question:  Right and I understand that and according to CMS rules, they recognize the minor and the major with 0-10 days for minor and 90-day global follow-up for major.

Answer:  Right.

Question:  But we have received some information that according to CPT guidelines, that CPT does not recognize the minor and the major on the procedures, so that is where we got into a little bit of a conflict between whether we should use the CMS guidelines, even for non-Medicare or Medicaid patents?

Answer:  I think that you should.  I have never seen any practice that did not and CMS everyone is gravitating toward CMS.  No matter what CMS does even with the fees.  You have seen the physician fees globally, nationwide have gone down, down and down.

Everyone is gravitating and copying what CMS does.  Same with the managed care plans now coming into audit and recoup overpayments.  I would go with the CMS because basically what I have always heard and I have never seen deviation from it, is that you will use your modifier 25 for a procedure basically in the office that is usually a 10-day period and modifier 57 when it is a 90-day global.

Question:  Would you comment on your feelings about the OIG's interest in contractual joint ventures? The OIG has come up with an advisory opinion last year and before that there was a special advisory bulletin.  Do you see this as a big issue or ...?

Answer:  You mean contracts between physicians and physicians for releasing space or other types of ...



Question:  Same types of things, sometimes it is typically laboratory but might also be radiology and sometimes it is called a pod laboratory or a condominium laboratory.

Answer:  Yes, I hope you do not think that I am trying to dodge the question.  I am really not.  I actually try to steer clear of that, I always have my clients check with their healthcare attorney because, I do think it is something to be very leery of.  I do think they are looking at these things very carefully and there are so many legalities.  I was a paralegal long, long time ago and I just made a decision that I do not advise my clients on that, I refer them to the health care attorneys because it is too complex and unless I feel absolutely confident that I am giving them the right information, I do not like to.  So that is what I have done in that particular area of practice. So I really cannot help you because, although I do think that we should take what they are doing seriously.  I have had a lot of physicians express concern that they have had inquiries, there are inquiries out there, and they are being contacted.

Comments:  Thank you.

Question:  We talked about the national coding bundling issues and the use of modifier 59.  Most of the time it just states that you may apply modifier 59, but how do you know what the exact circumstances are?  It does not seem to be in writing anywhere what their logic is when you can allow it and when you cannot?

Answer:  And as soon as you get it, they change it.

Comments:  True.

Answer:  I would just go by the coding guidelines.  I use coding software because as you know, the edits change every quarter.  There was one quarter not too long ago where they changed 72,000 code pairs.  I am getting off of this a little bit but the point is, how do you keep track of it?  In other words, if you know that code A and code B are bundled and you do them all the time, but you cannot bill for code A.  And then two quarters later they come out and they say, whoops! We had a lot of inquiries and a lot of dissatisfied physicians and they called in and told us this and that.  We have changed our minds and now you can bill code A and code B together.  So, you can go back for that time period and bill for both of them and be paid interest as well.



Question:  And what I am trying to figure out though is when it says that you may apply a modifier 59, how do you know what their true logic is as to when it is appropriate to really add the 59 and not just adding a 59 just because it says you can.  I mean sometimes I know like some of them are simple, like say you are doing a biopsy on an arm and you are doing another biopsy on the leg, that is obviously two separate sites and that is easy. But there are other code combinations that are a lot more complex and it is hard to know when they feel 59 is appropriate versus when they feel it is just bundled.

Answer:  Well, if you look at the definition of modifier 59, it is also a different site, a different session.  I am trying to look it up because I cannot remember right offhand.  I think definition of 59 would be helpful to see if it is applicable.  "Different site or organ system, separate incision, excision, separate lesion, separate injury;" so I do not know, if you look at the definition of modifier 59, if it applies to that particular CPT code that you are talking about or may be there is another one.  I know that you would use modifier 51 if it was appropriate rather than 59.  They always say use 51 if it is appropriate, but I am finding 59 is appropriate a lot of times.

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