General Surgery Coding Alert

Append -76 for repeats, but not for multiple select catheterizations

Not all multiple procedures require the same modifier, and knowing the difference can mean fewer hassles later on.
 
Providers frequently append modifier -59 (Distinct procedural service) when modifier -76 (Repeat procedure by same physician) is the better choice, says Deborah Churchill, RTT, with Churchill Consulting in Killingworth, Conn. In a nutshell, modifier -59 is for a different procedure on the same patient, but modifier -76 describes the same procedure repeated on the same patient (usually on the same day). Therefore, if the surgeon performs the same procedure twice for some reason, you should use -76 instead of -59.

Rely on -59 as a Last Resort

Because -59 is the "modifier of last resort," you should never use it if another modifier will tell the story, according to CPT guidelines.
 
Coders like modifier -59 because it allows them to unbundle services quickly and easily. But you must remember: If you append a modifier, you're telling the payer you have documentation to back up the claim.
 
Example: The patient undergoes EGD with control of GI bleeding in the morning (43255, Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method). Later that same day, the patient develops bleeding again. This requires that the surgeon repeat the earlier procedure.
 
In this case, you should append modifier -76 to 43255 to describe the repeat procedure on the same day as the initial procedure.
 
If the second endoscopy occurred several days after the initial endoscopy (but still within the global period), you should append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) rather than -76.
 
"In most cases, modifier -76 is used to describe a repeat procedure later on the same date," says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb. "Use modifier -79 to indicate the procedure was performed again later in the global period."
 
Be Careful Choosing -76 for Catheterizations

You shouldn't use modifier -76 if a bilateral modifier will represent the situation more accurately. For example, Part B carrier Cigna warned in its (still-current) December 2000 bulletin that providers often use modifier -76  incorrectly when billing for select catherizations of brachiocephalic vessels.
 
Usually, providers will select more than one vessel for study during a session. You'd normally report 36215 (Selective catheter placement, arterial system; each first- order thoracic or braciocephalic branch, within a vascular family) for a first-order vessel, 36216 (...initial second-order thoracic or braciocephalic branch, within a vascular family) for a second-order, and 36217 for a third- order or higher vessel, says Jim Collins, ACS-CA, CHCC, CPC, president of Compliant MD Inc. in Matthews, N.C. If the surgeon catheterizes more than one second- or third-order vessel per family, you'd use add-on code +36218 (...additional second-order, third-order and beyond, thoracic or braciocephalic branch, within a vascular family [list separately in addition to code for initial second- or third-order vessel as appropriate]) for each of these, Cigna states.
 
There are three families within a normal brachiocephalic branch, which means the surgeon may need to bill for multiple first-, second- or third-order vessels.
 
Take note: In this case, you should use modifiers -RT (Right side), -LT (Left side) and -59. But you should not use modifier -76 in this case, Cigna states. Rather, you should report modifier -RT for a right carotid artery or branch, -LT for a left carotid artery or branch, and -59 for selection of a vertebral artery or arteries.
 
Only in the unlikely event that a specific vessel needs a select catheterization more than once on the same day should you append modifier -76 to the appropriate select catheterization code.