Cardiology Coding Alert

Question: If Medicare automatically adds modifier 51 (Multipe procedures), such as to a heart cath code (93543) when a stent is also placed, do I need to add modifier 51 myself? Also the carrier has been adding mod 51 to 36246 (cath placement) and 35474 (balloon of the SFA). Is this correct?

Florida Subscriber

Answer: Many Medicare carriers and contractors ask that you not report modifier 51 because the carrier or contractor automatically orders the procedures on your claim and reduces payment accordingly. You should ask your specific payer if this is its preference.

To determine if the fee reduction is appropriate for a specific code, you can check Medicares Physician Fee Schedule to see what the codes Multiple Surgery status is.

The codes you mention (93543, 36246, 35474) all have a multiple surgery indicator of 2. This means, Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50% and by report). Base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage.

Resource: Indicator definitions are available through the fee schedule Web site: www.cms.hhs.gov/PhysicianFeeSched/. Click PFS Relative Value Files,choose calendar year 2009/RVU09B, download the .zip file, and then open the file RVUPUF09.

Note that stent code 92980 (Transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel) also has a multiple surgery indicator of 2.

Important: The National Correct Coding Initiative Manual (chapter 11) states that coronary artery interventions (stent, atherectomy, angioplasty) include all of the following:

" Coronary artery catheterization

" Radiopaque dye injections

" Fluoroscopic guidance.

You should report the catheterization and injection codes on the same claim as the stent code only if medically reasonable and necessary diagnostic coronary angiography precedes the percutaneous coronary artery intervention, the manual states.

So, for example, you shouldnt report 93543 (Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography) on the same claim as 92980 unless the 93543 represented a truly diagnostic procedure.