Ob-Gyn Coding Alert

Using a modifier to separate mutually exclusive edits should be the rare exception, not the rule

You will discover a mixed bag of ob-gyn coding changes in version 10.2 of the National Correct Coding Initiative (NCCI). The following new edits, effective July 1, describe new bundles affecting your DEXA scan claims -- and a new deletion that could potentially help you.

Insurers will no longer bundle 57820 (Dilation and curettage of cervical stump) into 58152 (Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]; with colpo-urethrocystopexy [e.g., Marshall-Marchetti-Krantz, Burch]) as they did in the past. "Code 57820 was removed from the list of codes bundled into code 58152 because this code combination is unlikely during the same surgical session," says Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Fredericksburg, Va.

Look for two new mutually exclusive edits when your gynecologist performs a CT bone density study of the peripheral skeleton (76071, Computed tomography, bone mineral density study, one or more sites; appendicular skeleton [peripheral] [e.g., radius, wrist, heel]) with a DEXAscan (76076, Dual energy x-ray absorptiometry [DEXA], bone density study, one or more sites; appendicular skeleton [peripheral] [e.g., radius, wrist, heel]) or bone density ultrasound (76977, Ultrasound bone density measurement and interpretation, peripheral site[s], any method).

According to Medicare, mutually exclusive code combinations "represent procedures or services that could not reasonably be performed at the same session by the same provider on the same beneficiary." Therefore, carriers only pay for the lower-valued of the two procedures.

Remember: If the NCCI bundles procedures as "mutually exclusive" (ME), modifier -59 (Distinct procedural service) may apply. But, if you use modifier -59 to separate ME edits, Medicare will reimburse the lower-valued procedure in full but will reduce the higher-valued procedure by 50 percent. Therefore, most coding experts recommend that in the rare cases that you perform two procedures together that NCCI denotes as mutually exclusive, you should normally report the higher-valued code only.

Tip: If you don't want to get stuck with the lower payment rate by default, you should ensure that you accurately report only one code for a given service, says Laurie Castillo, MA, CPC, CPC-H, CCS-P, president of Castillo Consulting in Manassas, Va.

If you report 76076 or 76977 with 76071 (with no modifiers appended), you will collect about $40 for the lower-valued code, 76977. You will, however, lose about $135, the amount that Medicare allots for 76071. But if you bill only 76071, you will collect the full $135 that Medicare allots for this service. If the ob-gyn performs both scans (76071 and 76076) on the same date and cannot prove that modifier -59 is warranted, these codes remain bundled. You should bill for the higher-value code, the CTscan, 76071.