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General Surgery Coding Alert

CCI:

Important Changes Clarify Modifiers, Endoscopic Billing

Published on Tue Jan 01, 2002

General surgeons and their coders will want to pay close attention to Correct Coding Manual Version 7.3 (CCM 7.3), the latest version of the manual that compiles all changes to the Correct Coding Initiative (CCI), as it contains significant revisions to long-standing coding conventions. "A lot of this is just plain common sense coding, but now it has been put in writing, which will be really helpful with carriers and surgeons," says Elaine Elliott, CPC, a coding and reimbursement specialist in Jensen Beach, Fla.

Modifiers

Modifier -22. CCI now states: "When an unusual or extensive service is provided, it is more appropriate to utilize the -22 modifier than to report a separate code that does not accurately describe the procedure performed." The guidelines note that routine use of the modifier is inappropriate, because this modifier is meant for unusual circumstances only. Chapter One/Section C9 of the CCI now instructs surgeons to use modifier -22 (unusual procedural services) if a laparoscopic procedure is converted to open. Medicare has long held that when this happens, only the open procedure may be billed. The new wording should make it easier to file modifier -22 claims in such situations.
 
Modifier -25. Chapter One of CCI revives a short-lived policy laid out in CCM 6.3 (October 2000) that required appending modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to "significant, separately identifiable" E/M services performed on the same day as a diagnostic test.  The policy shift that came with CCM 6.3 prompted thousands of new edits, all of which were suspended in January 2001 due to confusion among carriers and physicians dealing with the new edits.
 
Although CCM 7.3 does not reintroduce the edits, it restates the policy in Chapter One/Sections D and H2 of CCI: "Many of these XXX procedures are performed by physicians and have inherent pre-procedure, intra-procedure and post-procedure work usually performed each time the procedure is completed. This work should never be reported with a separate E/M code With most XXX procedures, the physician may, however, perform a significant and separately identifiable E/M service on the same day of service which may be reported by appending the -25 modifier to the E/M code."
 
Many practices, says Elliott, reported an E/M service performed at the same time as a diagnostic test only if it was significant and separately identifiable. For these practices, the only change will be to remember to append modifier -25. Other practices never stopped appending modifier -25, even after the original edits were suspended, Elliott adds.
 
Note: Check upcoming editions of local Part B bulletins for more information on how local carriers are implementing the new policy directions.
 
Modifier -58. CMS now wants surgeons to append modifier -58 (staged or related procedure or service by the same physician during the postoperative period), rather than modifier -59 (distinct procedural service), to a diagnostic procedure followed by a surgical one. Chapter Six/Section B4 of CCI states that "in the case where the endoscopic procedure upon which the decision to perform a more extensive (open) procedure is made, the endoscopic procedure may be separately reported. The -58 modifier may be used to indicate that the diagnostic endoscopy and the more extensive, open procedure are staged, or planned services." Chapter One/Section H3 of CCI notes that "from the National Correct Coding Initiative perspective, this action would result in the allowance and reporting of both services as separate and distinct," as long as "scout endoscopy" was not performed.
 
Note: CCI points out that scout endoscopy "represents a part of the assessment of the surgical field to establish anatomical landmarks, extent of disease, etc."
 
Modifier -59. Chapter One of CCI notes that "when certain services are reported together, there may be a perception of 'unbundling,' when, in fact, the services were performed under circumstances which did not involve this practice at all The -59 modifier indicates that the procedure represents a distinct service from others reported on the same day of service. This may represent a different session, different surgery, different site, different lesion, different injury or area of injury (in extensive injuries)."
 
Note: If another modifier describes a situation more specifically, it should be used in place of modifier -59.
 
Situations that required modifier -59 to be appended to one or more codes now may require either modifier -58 (when a diagnostic endoscopy, for example, precedes a surgical procedure) or modifier -78 (return to the operating room for a related procedure during the postoperative period) (when a second endoscopy is performed on the same day, for example, to control bleeding).
 
Modifier -78. The introduction to Chapter Six/Section B8 of CCI reads: "When bleeding results from an endoscopic or surgical service, the control of bleeding at the time of the service is included in the endoscopic procedure. Separate procedure codes for control of bleeding are not to be coded. If it is necessary to repeat the endoscopy at a later time during the same day to control bleeding, a procedure code for endoscopic control of bleeding may be reported with the -78 modifier, indicating that this service represents a return to the endoscopy suite or operating room for a related procedure during the postoperative period."
 
Use of modifier -78 in such situations is new, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill. "In the past, they used to tell us to use modifier -59, when appropriate, because the -78 modifier was supposed to apply to procedures with global days, and endoscopic procedures, such as colonoscopies, typically have 0 global days," Mueller says.
 
Inclusion of the words "endoscopy suite" is significant, she adds, because the descriptor for modifier -78 specifically states "return to the operating room," and until now most carriers and coding specialists have taken that to mean only the operating room.
 
Note: The procedure to treat the complication should not be billed if it is performed during the same operative session. Medicare global surgery guidelines indicate that any complication treated during the operative session is included in the primary procedure performed during that session.

Fluoroscopy

Fluoroscopy can be used to guide the placement of central venous lines and other catheter placements.
 
Many of these procedures are reported using codes that are not linked to a specific radiology code; as a result, many surgeons report 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy) for the radiologic supervision and interpretation to guide the procedure.
 
Chapter One of CCI ends this practice, stating that "general fluoroscopic services necessary to accomplish routine central vascular access or endoscopy cannot be separately reported unless a specific CPT code has been defined for that purpose."
 
In other words, only specific radiology codes that CPT links to specific catheter placements may be billed. Surgeons may still bill for fluoroscopy only when a specific fluoroscopy code is linked to the procedure performed.

Endoscopic Procedures

Chapter Six/Section B1 of CCI notes for the first time that "when a diagnostic endoscopy is followed by a surgical endoscopy, the diagnostic endoscopy is considered part of the surgical endoscopy and is not to be separately reported."
 
An endoscopic service performed "to establish the location of a lesion, confirm the presence of a lesion, establish anatomic landmarks, or define the extent of a lesion" should also not be separately reported, "as it is a medically necessary part of the overall surgical service."
 
The distinction between two types of bronchoscopies is also important, Elliott says. "Some surgeons perform one before lung surgery, just to 'double check,' but if a diagnostic bronchoscopy already was performed, they shouldn't expect to get paid for that 'check' one."
 
CCM 7.3 also instructs surgeons to follow multiple endoscopy rules when reporting multiple GI endoscopies.
 
Chapter Six/Section B1 of CCI states: "If different therapeutic [endoscopic] services are performed and are not adequately described by a comprehensive CPT code, the appropriate codes can be designated in accordance with the multiple GI endoscopy rules previously established by CMS."

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