Oncology & Hematology Coding Alert

Pay close attention to modifier indicators -- and when modifier 59 is safe to use.

Effective July 1, you have more than 16,000 new edit pairs to comply with, thanks to Correct Coding Initiative (CCI) Version 16.2.

The update brings "the total number of active edit pairs to 653,718," said senior analyst Frank Cohen, MPA, MBB, of MIT Solutions, in a June 17 announcement about the CCI changes. Save yourself some time by homing in on the following edits, which are among the most likely to affect your oncology practice.

1. Keep Imaging/Guidance Off of 77785-77787 Claims

CCI bundled several imaging and guidance codes into 77785-77787 (Remote afterloading high dose rate radionuclide brachytherapy ...):

All of these edits have a modifier indicator of 1, which means that you may override the edit with a modifier when appropriate. For example, if on the same date as brachytherapy the patient requires ultrasound imaging guidance (76942) to perform a distinct non-brachytherapy procedure, you may report ultrasonic guidance (76942) and the distinct procedure requiring guidance on the same claim. To indicate to the payer that you are not reporting the guidance in connection with the brachytherapy -- that instead you are reporting the guidance for a different, distinct procedure -- append modifier 59 (Distinct procedural service) to 76942.

Keep in mind: Never use modifier 59 just to get paid for a procedure. "Make sure there is well-documented support for a separate and distinct procedure before adding modifier 59," says Rena Hall, CPC, billing/insurance specialist with a Kansas City, Mo., practice.

In addition, CPT instructions dictate that if a more specific modifier describes the situation, you should not use modifier 59. Because the modifier has the potential to bypass CCI edits, practices use this modifier too often, says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC departments of Surgery and Anesthesiology. Modifier 59 "should be the modifier of last resort and only used when there is no other modifier to compliantly bypass the bundling edit, and the procedure was clearly distinct and different from that of the other procedure," she adds.

2. Beware of This Heparin Coding Hitch

A handful of new edits make sure you aren't reporting heparin supply code J1644 (Injection, heparin sodium, per 1000 units) with the following infusion codes:

These edits have a modifier indicator of 1, so you may override the edit when the heparin is ordered for a medically necessary reason distinct from the chemotherapy infusion or port irrigation. Physicians may order heparin to prevent or treat blood vessel, heart, and pulmonary conditions, such as preventing pulmonary blood clots from forming or growing.

Key point: Reporting J1644 in an attempt to be reimbursed for a heparin lock flush would be incorrect. According to CCI policy manual, chapter 1, section C.1, "After vascular access is achieved, the access must be maintained by a slow infusion (e.g., saline) or injection of heparin or saline into a 'lock.' Since these services are necessary for maintenance of the vascular access, they are not separately reportable with the vascular access CPT codes or procedures requiring vascular access as a standard of medical/surgical practice."

Bonus tip: Another HCPCS code, J1642 (Injection, heparin sodium, [heparin lock flush], per 10 units), specifically refers to heparin lock flush in its definition. But again, you should not report heparin separately when used for a lock flush. In fact, J4 Part B MAC TrailBlazer announced it will no longer pay for heparin code J1642, effective July 14. According to the MAC, practices often bill heparin for flushes following infusions despite Medicare's policy that the flush is included in the infusion and isn't separately billable (www.trailblazerhealth.com/Tools/Notices.aspx?id=13735).

3. No Modifier 59 Allowed for Embolization Edit

All of the edits discussed so far have had a modifier indicator of 1. But there are some additions to CCI 16.2 that have modifier indicator of 0, meaning that you may not unbundle the edit combination under any circumstances. In other words, you can't automatically override every CCI edit with modifier 59 just because documentation supports a separate site, incision, or patient meeting, says Claudia Kernaghan, CPC, coder for Nevada Imaging Centers in Las Vegas.

For instance: Codes 77750 (Infusion or instillation of radioelement solution [includes 3-month follow-up care]) and 77776-77778 (Interstitial radiation source application ...) are not reportable with 37204 (Transcatheter occlusion or embolization [e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method, non-central nervous system, non-head or neck) under any circumstances. The latest round of CCI published these edits with a 0 modifier indicator.

Resource: You can download the CCI edits from www.cms.gov/NationalCorrectCodInitEd.