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Answer: Modifier -59 (distinct procedural service) automatically overrides national Correct Coding Initiative (CCI) edits. Therefore, it is a powerful tool that should be used only when a normally bundled procedure is distinct and separate (for example, performed at a different time or at a different site in the body).
Code 93620 (comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters; with induction or attempted induction of arrhythmia [this code is to be used when 93618 is combined with 93619]) describes an EP study. Typically, this procedure helps to determine if the patient requires an ICD.
Code 93641 (electrophysiologic evaluation of single or dual chamber cardioverter-defibrillator leads including defibrillation threshold evaluation [induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination] at time of initial implantation or replacement; with testing of single or dual chamber cardioverter-defibrillator pulse generator), typically performed after the implantation of an ICD device (33249, insertion or repositioning of electrode lead[s] for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator), ensures the device is working properly, says Sandy Fuller, CPC, a practice coder with Cardiology Consultants, a nine-physician practice in Abilene, Texas.
The two codes are bundled in the CCI as mutually exclusive. However, the edit has a "1" indicator, which means using modifier -59 is permissible to override the edit under certain circumstances. (If an edit has a "0" indicator, modifier -59 may not be used.) Using modifier -59 is appropriate if the EP study was diagnostic (i.e., it determined that the patient required an ICD). In such cases, the EP study is separately payable, and modifier -59 should be appended to 93620 (even though it has more RVUs than 93641) to override the CCI edit.
In any other situation, the mutually exclusive edit means these two codes should not be billed together because the CCI has determined they would not be performed together (presumably because an EP study would not be necessary for a patient who already has an implanted ICD).
Note: According to the introductory notes in the CCI, when Medicare carriers process the two codes of a mutually exclusive edit together, "the procedure with the lowest work relative value unit will be allowed. Therefore, the code for this procedure has been placed in Column 1." Therefore, modifier -59 should be attached to the higher-valued procedure (i.e., 93620) because it is in the second column and is the procedure that otherwise will be denied.
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