Ob-Gyn Coding Alert

Refresh your modifier 59 tactics to make claims indisputable

Thankfully, you-re not as loaded down by the National Correct Coding Initiative (NCCI) version 12.1 as you were by 12.0, but you-re still responsible for learning six new bundles affecting ob-gyn practices--and sooner rather than later. These edits took effect April 1.

Count 76828 and 76820-76821 as Mutually Exclusive

NCCI classifies the first set of edits as -mutually exclusive.- You-ll find that 76828 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study) is a component of 76820 (Doppler velocimetry, fetal; umbilical artery) and 76821 (... middle cerebral artery).

Keep in mind: When codes are mutually exclusive, you should not bill them together, due to conflicting CPT definitions or -the medical impossibility/improbability that the procedures could be performed at the same session,- NCCI states. Although these codes are technically not bundled, you should not typically report them on a single claim. When you report codes identified as mutually exclusive for a single surgical session, usually the carrier will recognize and reimburse only the lesser-valued procedure.

Good news: You can separate 76828 from 76820-76821 with a modifier (such as modifier 59, Distinct procedural service) if you meet the modifier's documentation requirements. Payers would then pay 76828 as the primary procedure and 76820 or 76281 as the secondary procedure, even though these two codes have higher relative value units (RVUs).

Best bet: When preparing to use modifier 59, -look for documentation regarding the different site or organ system that will indicate this is a separate and distinct service,- says Donna Kroening, CPC, reimbursement manager for the ob-gyn department at the Medical College of Wisconsin in Milwaukee. -It also helps if you have separate diagnoses for each procedure.-

For instance, your ob-gyn performs a fetal Doppler echocardiography (76828) to detect fetal cardiac disease. The mother has diabetes, so the fetus is at higher risk. This would be the reason for doing the echo (648.03, Diabetes mellitus, antepartum condition or complication). Or the ob-gyn might perform the fetal Doppler echocardiography because the fetus has an abnormal heart rate (659.73, Abnormality in fetal heart rate or rhythm; antepartum condition or complication). 

On the other hand, your ob-gyn may also perform an umbilical artery velocimetry (76820) when the fetus has intrauterine growth retardation (656.53, Poor fetal growth; antepartum condition or complication). Or your ob-gyn might perform a middle cerebral artery velocimetry (76821) to detect fetal anemia (655.83, Other known or suspected fetal abnormality, not elsewhere classified; antepartum condition or complication).

If your ob-gyn performs more than one of these procedures on the same day, you can support modifier 59 and prove they were separate and distinct using your diagnosis codes.

Don't Drop the Ball on This NME Doppler Edit

In addition, among the new ob-gyn-related non-mutually exclusive edits are those affecting 3-D rendering codes (76376-76377). NCCI bundles these two codes into 76821 (Doppler velocimetry, fetal; middle cerebral artery). 

Rationale: The reason given is the -misuse of  column 2 code with column 1 code,- according to NCCI. Your ob-gyn cannot do a 3-D rendering of this type of Doppler scan. In other words, 3-D is useful in obtaining a dimension of a body part, not looking at arteries or veins.

Because this edit has a modifier indicator of -1,- you can bypass it with a modifier (such as 59) as long as you meet the requirements--but don't forget to make your claim indisputable. -We encourage providers to clearly indicate the additional procedures billed so that if questioned, their documentation is very cut-and-dried,- says Lisa Nelson, CPC, coding and compliance specialist at Reedsburg Physician's Group in Wisconsin.

Don't get discouraged if your first pass isn't successful. -Keeping your physician educated regarding the documentation required for 59 helps your chances on an appeal,- Kroening says.

NCCI Follows CPT's Moderate-Sedation Symbol

So far, no Medicare carriers have decided to pay for the new moderate sedation codes (99143-99149). That hasn't stopped NCCI 12.1 from applying new edits to 99143-99149 just in case.

Look out for the edit that bundles 99143-99144 into 58823 (Drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous [e.g., ovarian, pericolic]). This is the only code in the gyn section that carries the -bullet within a circle- symbol: 8. This symbol means that moderate sedation is an inherent part of the procedure and not reported separately. For that reason, NCCI has added this edit to match what the CPT manual specifies.