Oncology & Hematology Coding Alert

Also, consider new 2020 E/M codes bundled into the regular office E/M codes.

If you’re applying the new nerve block anesthesia codes 64451 (Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) and 64454 (…genicular nerve branches, including imaging guidance, when performed) to your professional-fee claims and receiving denials, then the National Correct Coding Initiative (NCCI) edits for professional-fee/physician fee schedule services could be to blame. The latest round applies a bunch of edits to these codes, among others, which means you may find your claim in limbo if you don’t adhere to these changes.

We’ve broken down all the confusing edits, so you’ll have the full picture.

Key: You’ll see modifier indicators of “1” and “0” mentioned below. A modifier indicator of “1” means you can apply a modifier (such as, 59, Distinct procedural service) to bypass the edit if your physician’s documentation supports the modifier applied. However, no modifier will bypass an edit with an indicator of “0.”

Remember: “Modifier 59 and other CCI-associated modifiers should not be used to bypass a CCI edit unless the proper criteria for use of the modifier are met,” says Mary I. Falbo, MBA, CPC, president and CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “Documentation in the medical record must satisfy the criteria required by any CCI-associated modifier that is used,” she adds.

New Nerve Block Codes Mean Tons of New Edits

The Current Procedural Terminology (CPT^®) book added new nerve block anesthesia codes 64451 (Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) and 64454 (… genicular nerve branches, including imaging guidance, when performed), which means the latest round of NCCI edits zeroed in on these codes.

“You won’t be able to report 64451 or 64454 with a lot of procedures, surgeries, and many other diagnostic and therapeutic services without a modifier when documentation supports the allowance of the payment for both services”, says Amy C. Pritchett, BSHA, CCS, CPC, CPC-I, CANPC, CPMA, CASCC, CDEO, CRC, CPMP, CMPM, CMRS, CEDC, C-AHI, Senior Consultant at Pinnacle Enterprise Risk Consulting Services LLC in Mobile, Alabama.

Example: Codes 64451 and 64454 cannot be reported with hydration and therapeutic drug administration infusion codes such as 96360 and 96365 as well as other injection service codes such as 96374-+96376. Payers who follow these edits will only reimburse you for the 64451 or the 64454 unless a modifier is supported by the documentation and applied to the infusion and injection administration codes. For instance, you could use a modifier when the infusions are not at the same time.

Example: Under these new edits, when documentation supports a modifier, you would report 64454 and 96360-59 if the infusion was administered prior to or after the procedure for a medically necessary underlying condition.

Apply These Various Other Changes

Mastectomy: Add-on code +19297 (Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure)) can be reported with imaging guidance related codes 76380, +77002, 77012 and 77021. The definition of +19297 explicitly states it includes imaging. However, when the imaging guidance is reported for something other than the performance of +19297 and the code does not include imaging guidance, you now have an edit between these codes. Be sure your oncologist’s documentation supports adding a modifier before applying it to bypass the edit.

Neck and thorax codes: You won’t be able to report the new neck (soft tissue) and thorax codes 21601-21603 along with 00400, 0213T, 0216T, 0228T. That’s because these edits have a modifier indicator of “0.” However, you can report 21601-21603 with 19281, 19283, 19285 and 19287. You’ll need an appropriate modifier with supporting documentation. While the same edits apply for 21601-21603 and the 1928X codes listed above for hospital facility charge reporting, be aware there are different OCE edits between 21601-21603 and 0213T, 0216T and 0228T.

Excision Examples: If your oncologist performs excisions, then you should note the following changes:

• When reporting the excision of the humerus (upper arm) and radial head/neck codes (24150 and 24152) with new codes 0566T (Autologous cellular implant derived from adipose tissue for the treatment of osteoar­thritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral) and +20704 (Manual preparation and insertion of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure)), be aware of NCCI edits between the codes. If documentation supports, a modifier can be applied to bypass these edits. Services performed on the same day but on separate sites would typically be a reason to justify the use of the modifier.
• You can report the excision of the hand and finger codes (26111-26118 and 26250-26262) with new codes 20560 (Needle insertion(s) without injection(s); 1 or 2 muscle(s)) and 20561 (… 3 or more muscles). Don’t forget the modifier if you have the supporting documentation justifying application.
• You can report the excision of the thigh region and knee joint codes (27327-27329, 27337, 27339, 27360, 27364 and 27365) with 0566T and +20704, but don’t forget the modifier when the supporting documen­tation will allow it.
• You can report the excision of the foot and toes codes (28039-28047 and 28171-28175) with 20560-20561. Don’t forget the modifier and supporting documentation.
• You can report the excision of the bladder code (51597) with new code 46948 (Hemorrhoidectomy, internal, by transanal hemorrhoidal dearterial­ization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed). Don’t forget the modifier and supporting documentation.
• You cannot report the excision of the prostate codes (55810-55815, 55821, 55831, 55840, 55842, and 55845) with new code 0582T (Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance). The procedures are performed utilizing two separate methodologies and cannot be reported together. No modifier will unbundle the services.
• Finally, you can report clinical brachytherapy codes (77750-77790) with 0591T-0593T, 99421-99423, and G0442-G0445, so long as you apply a modifier and have supporting documentation.

Finally, Evaluate These New E/M Edits

Evaluation and Management (E/M) codes (99201-99215), and most others, are bundled with the new codes for health and well-being coaching (0591T-0593T). When rendered and reported on the same date, you need a modifier to identify whether supporting documentation allows for payment separately. Keep in mind, the 059XT codes have very specific requirements. Before reporting the service, be sure to understand the type of provider and qualifications of the provider required to report these assessments and follow up session timed codes.

The new health behavior assessment and intervention codes (96158-+96171) are bundled with 0591T and 0593T. These edits carry a modifier indicator of “0,” which means no modifier will bypass the edit. For 0592T, the same is true for 96164-+96171 where no modifier will bypass the edits.