Pathology/Lab Coding Alert

Don't report similar tests for one specimen

When you bypass National Correct Coding Initiative (NCCI) edits in 2005, be sure you only use modifier -59 (Distinct procedural service) when you have clear documentation that you're not "unbundling" procedures but are providing distinctly separate services.

The HHS Office of Inspector General (OIG) 2005 Work Plan contains an initiative allowing CMS to detect and correct improper billing for claims that include the modifier with code pairs listed in NCCI.

Note: To view the OIG's Work Plan online, visit http://oig.hhs.gov/publications/workplan.html#1.

Make Sure Services Are Separate

When your lab performs tests for the same patient on the same day that might provide similar diagnostic information, you have to watch out for NCCI edits. NCCI has two lists of code pairs: mutually exclusive codes, which represent two services that a physician would not normally perform for the same patient on the same day; and column 1/column 2 codes, which generally represent a comprehensive code (column 1) that includes the lesser, component code (column 2).

Because these bundled tests provide similar diagnostic information, when the lab performs two of the tests on the same specimen to arrive at a diagnosis, you can't report both procedures. "You can only report two codes of an edit pair together if the lab performed two separate services, typically on two different specimens," says Laurie Castillo, CPC, CPC-H, CCS-P, owner of Castillo Consulting in Manassas, Va. Then you can override the edit pair by listing the column 2 code with modifier -59. CPT indicates that modifier -59 may represent a "different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury."

Example: A physician orders a serum cytomegalo-virus (CMV), which the lab processes using DNA direct probe technique, and on the same day orders a CMV test on a bronchoalveolar lavage (BAL) specimen that the lab processes using direct fluorescence antibody (DFA) technique.

Although NCCI lists 87495 (Infectious agent detection by nucleic acid [DNA or RNA]; cytomegalo-virus, direct probe technique) and 87271 (Infectious agent antigen detection by immunofluorescent technique; cytomegalovirus, direct fluorescent antibody [DFA]) as mutually exclusive, you can override the edit pair because the procedures involve two separate specimens. You should report 87495 and 87271-59 for these services

Obey Modifier Column Instructions

Before you even think about using a modifier to override an edit pair, you have to check NCCI's "modifier indicator" for that code pair. A modifier indicator of "1" means that you can use a modifier with the code pair when appropriate, and "0" means that you are not allowed to use a modifier with the code pair under any circumstances.

Hidden Trap: If you erroneously report two mutually exclusive codes together, Medicare will pay for the column 1 code, which, according to NCCI instruction, "generally represents the procedure or service with the lower work RVU [relative value unit]."

"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 lab service," Castillo says.

Document Separate Services for Modifier Use

Physicians should be aware that when they append modifier -59, they are indicating that they have documentation on file to support using it, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. "You should always be prepared to submit additional documentation demonstrating that your procedures were separate and distinct from one another." If your documentation can't prove the separate nature of the bundled services, don't append modifier -59, she adds.

Payers Are Watching

Some insurers have grown so suspicious of modifier -59 misuse that several payers, such as the North Dakota Medicaid program, handle modifier -59 claims by hand. If the computer detects modifier -59 on a claim, someone will manually process the claim before Medicaid will reimburse the practice. Coupled with the OIG's increased scrutiny, this attention from other payers should give you ample motivation to review your modifier -59 coding practices.