Cardiology Coding Alert

Question: If our physician performs two interventions in different branches of the same vessel on the same day, will we get paid for both if we attach modifier -59 to the second procedure?

Arkansas Subscriber

Answer: Billing for two interventions in the same coronary blood vessel, which includes any branch associated with that vessel, is inappropriate, says Terry Fletcher, BS, CPC, CCS-P, a cardiology coding and reimbursement consultant in Dana Point, Calif. Although using modifier -59 (distinct procedural service) to override the edit of the two procedures may result in payment, receiving payment is not the same as correct coding. Modifier -59 use is being watched closely by Medicare carriers, and incorrect use could result in a very costly audit.

The rules governing two interventions in the same vessel or any of its branches are straightforward. According to the American College of Cardiologys (ACC) Guide to CPT Coding, Only one intervention can be coded for each major artery (defined as the right coronary artery [RCA], left anterior descending coronary artery [LAD] and left circumflex coronary artery [LCX] arteries) per session, no matter how many blockages are treated in that artery or its branches during that session. If two or more blockages in the same major coronary artery are treated (i.e., angioplasty, stent or atherectomy), they are collectively coded as one service.

For example, if a percutaneous transluminal coronary angioplasty (PTCA) is performed in one branch of the LAD and a stent is placed in another, only the stent (92980, transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel) should be billed. The ACC goes on to explain that the relative value units (RVUs) assigned to coronary interventions take into account the fact that some interventions involve multiple lesions in multiple branches.

Cardiologists should be cautious about using modifier -59 and should make sure they understand its intent before they use it. There are a lot of coders and coding consultants who tell you to use this modifier because it will get paid, but the short-term gain could result in long-term pain, Fletcher says.

Because modifier -59 automatically overrides CCI edits, it has been red-flagged by HCFA, and overusing it could result in an audit, Fletcher warns.

Modifier -59 should also not be used if another modifier more appropriately explains what transpired during the operative session. According to CPT 2000 guidelines, When another already established modifier is appropriate, it should be used rather than modifier -59. Only if no more descriptive modifier is available, and the use of modifier -59 best explains the circumstances, should modifier -59 be used.

When multiple lesions in multiple branches of the same vessel are involved, the ACC recommends that modifier -22 (unusual procedural services) be attached to the appropriate intervention code and documentation be included when the claim is filed. Most carriers, however, will not increase payment unless three or more lesions in different branches of the same vessel are documented, and even in such cases there is no guarantee of increased reimbursement.

Meanwhile, modifiers -LC (left circumflex, coronary artery), -LD (left anterior descending coronary artery) and -RC (right coronary artery) should be used instead of modifier -59 when the cardiologist performs PTCAs in two separate coronary vessels. For example, one PTCA performed in the LCX and another in the LAD should be coded as follows: 92982-LC, 92984-LD.

Modifier -59 should not be used because the -LC and -LD modifiers better describe why the procedures are distinct.

Note: Some private carriers may not recognize the
-LC, -LD and -RC modifiers. For these carriers, modifier -59 should also be appended to the second procedure.