General Surgery Coding Alert

Shore up diagnostic test, modifier -59 claims in 2004

What could be more frustrating than coding a magnetic resonance imaging (MRI) or other diagnostic test perfectly, only to have your claim denied? That's what could happen if a physician who is excluded from the Medicare program ordered the diagnostic test in the first place. But you can prevent this problem by ensuring that all your surgeons are properly credentialed.
 
If your surgery practice owns its own testing equipment, the U.S. Office of Inspector General (OIG), as outlined in its 2004 Work Plan, will be checking to be sure that the physicians ordering tests are not excluded from Federal healthcare programs. To avoid denied claims, you should check the OIG's database of excluded physicians to be sure that none of your ordering physicians are listed. You can either download the entire database, or search it using physician names or business names, at http://oig.hhs.gov/fraud/exclusions.html.

Apply Modifier -59 With Caution

The OIG also intends to "determine whether claims were paid appropriately when modifiers were used to bypass National Correct Coding Initiative (NCCI) edits." Although several modifiers - including -78 (Return to the operating room for a related procedure during the postoperative period) and -79 (Unrelated procedure or service by the same physician during the postoperative period) - can separate bundled NCCI edits, surgeons usually use modifier -59 (Distinct procedural service) to report two separate (but usually bundled) services provided on the same day, says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues, in Fountain Valley, Calif.
 
For example, a surgeon treats a child with multiple leg wounds who has fallen from a playground swing. She performs intermediate repair and closure for several wounds on the child's right leg, totaling 12 cm, and performs two simple repairs on the left leg, totaling 8 cm. You would report the intermediate repairs with 12034 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 7.6 cm to 12.5 cm), and the simple repairs as 12004 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 7.6 cm to 12.5 cm).
 
Because the descriptor for wound care codes specifies only general anatomic locations (for example, "trunk and/or extremities"), payers cannot easily discern that the intermediate and simple repairs occurred at different sites. As a result, many payers will bundle the simple repair to the intermediate repair of the same anatomic location, says Cynthia Thompson, CPC, senior coding consultant with Gates, Moore & Company, an Atlanta-based medical management consulting firm. Appending modifier -59 to 12004 specifies that the simple repairs occurred at a different site and, therefore, are distinct procedures deserving separate reimbursement.
 
As a second example, the surgeon must repair a hernia at a separate site during gall bladder repair (for example, 47740, Cholecystoenterostomy; Roux-en-Y). To indicate the separate anatomic site and override the NCCI edit bundling associated hernia repairs to the gallbladder surgery, append modifier -59 to 49560 (Repair initial incisional or ventral hernia; reducible).
 
"Physicians should be aware that when they append modifier -59, they are representing the fact that they have documentation on file that supports using it," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. "Therefore, you should always be prepared to submit additional documentation that demonstrates that your procedures were separate and distinct from one another." If your documentation won't prove the separate nature of the bundled services, don't append modifier -59, Jandroep says.

Be Alert to Other Focus Areas

The 2004 Work Plan focuses on several other important areas for surgeons and coders. These include proper coding for consultations (see General Surgery Coding Alert, September and October/November 2003) and other E/M services, as well as application of modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and care plan oversight codes (99374-99380, G0181-G0182).
 
And, as in past years, incident-to billing (that is, services billed by nonphysician practitioners incident-to the physician's services) remains an OIG special area of investigation. The OIG Work Plan includes information about all of its investigative focus areas for 2004. You can access the full 90-page document by visiting the agency's Web site at http://oig.hhs.gov. Search for "2004 Work Plan."