Practice Management Alert

Knowing when you can append a modifier is your key to success

The start of a new year means the potential for denials by the dozen, thanks to new codes and new code bundles. With more than 500,000 changes to the Correct Coding Initiative (CCI) that took effect on Jan. 1, this year is no exception. Take a look at the basics of what you need to know to avoid the denials that incorrectly billing bundled codes can bring.

Medicare carriers and other payers that follow CCI edits will now bundle most of the E/M codes (99201-99215) into the new brachytherapy codes (77785-77787), and no modifier can separate these bundles.

"Most of the other brachytherapy codes include an E/M service according to CCI, so although it would have been nice not to have this new code bundled with E/M, it was expected," says Ali Johns with East Billing in East Hartford, Conn.

In addition, CCI will also bundle the E/M series into several codes from the new hydration series (such as 96360, 96365, and 96372-96374). This means the payer will deny the E/M code when billed with the hydration code. However, you can separate this edit with a modifier -- such as 59 (Distinct procedural service) -- when the physician performs the services as separately identifiable and they are medically necessary (for example, two separate encounters).

Hydration codes under fire: The new edition of CCI bundles codes from CPT's new hydration series into hundreds of other codes besides just E/M codes.

For example: You-ll no longer be able to report 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour) with most of the codes from the anesthesia section (01000-01999), and no modifier can separate these bundles.

Likewise, 96365 also now bundles into most of the remaining surgical and procedural codes from the rest of CPT, including integumentary, musculoskeletal, respiratory, cardiovascular, digestive, radiology, and other systems. In some cases, a modifier can separate the bundles (such as with the urology codes, 50010-53852), whereas in others, no modifier will allow you to collect for 96365 -- for instance, when it's bundled into the radiology oncology codes (77261-77790).

Many of the new code edits have a modifier indicator of "1." This means that you can unbundle these edits with the proper modifier under the appropriate clinical circumstances.

Although you can bypass many of the bundles with modifier 59, you must meet the criteria for doing so, says Debra Pierce, MD, MBA, CPC, founder and managing member of Pierce MD Consulting LLC in Rockbridge, Ohio. CPT 2008 revised the modifier's descriptor, specifying, "Documentation must support:

- different session

- different procedure or surgery

- different site or organ system

- separate incision or excision

- separate lesion

- separate injury (or area of injury in extensive injuries)."

Caution: "CMS has improper use of modifier 59 on its radar screen, and practices are well- advised to exercise due caution in using this modifier," Pierce cautions.

Remember: Although you can bypass many of the bundles using modifier 59, this is the modifier of last resort, experts say.

CPT warns that you should not use modifier 59 "when another already-established modifier is appropriate, unless no more descriptive modifier is available, and so long as it best explains the circumstances," Pierce says.

The success of your Medicare claims will also be affected by CCI alterations that change whether you can append a modifier to separate a code pair.

The good news: Some of the switches will help you by allowing you to break edit bundles using a modifier, such as modifier 59.

Example: In the past, you couldn't use a modifier to separate the edit bundling 95861 (Needle electromyography; 2 extremities with or without related paraspinal areas) into 95810 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist). Now, however, CCI assigns a modifier indicator of "1" to this bundle, which means you can separate it with a modifier. Again, this would be applicable only if the physician performed the two procedures at different encounters (sessions) or different body locations.

The bad news: Most of the modifier changes in version 15.0 work the other way around. You can no longer use a modifier to separate 87 of the bundles that you previously could separate with a modifier.

For instance, you can't separate the edits bundling 90865 (Narcosynthesis for psychiatric diagnostic and therapeutic purposes) into codes from the 90807-90829 series (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility -).

Plus: You-ll also be out of luck if you try to report conscious sedation codes 99143-99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status -) with any of the codes from the 49440-49442 series (tube placement). Medicare payers will deny the conscious sedation charge, and no modifier can separate the bundles.

"With each edition of CCI comes more codes that are forbidden to report with conscious sedation," says Aran Hicks, billing consultant for six practices in Raleigh, N.C.

Want to learn more? There are many other edits. To make sure you know all the applicable bundles for your specialty, review the entire list. To download a free copy of CCI 15.0 go to the CMS Web site at www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp