Primary Care Coding Alert

If you missed the Correct Coding Initiative (CCI) 15.1's blanket of edits, be prepared to battle for electrocardiogram (ECG) payment. Since April, Medicare has denied ECG code 93000 on three claims that also involved a procedure, reports Sherry Morshedi, RHIT, practice manager for Benny J. Green, MD, PA, in Little Rock, Ark."Medicare advised me to use modifier 59 on the ECG."

Experts walk you through using this tool to correctly unbundle an ECG (93000) or in/out cath (51701) from another procedure's surgical package.

CMS has expanded its global surgical package inclusions. First, CCI 13.3 included catheter codes in most minor and major procedure codes. Then, to close a loophole that may have allowed physicians to report a routine pre-surgery ECG separately from a procedure, CCI 15.1 placed a blanket bundle on most surgery codes, minor and major.

Some of the bundles contain a modifier indicator of 1. Therefore, you can unspool the edits provided the FP performed the ECG or catheter as distinctly separate from the procedure.

Tip: When you break a CCI edit, you must be able to prove that the FP performed the services for separate reasons. "One way to reinforce that the services are distinct is to have separate and unique diagnosis codes," explains Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.

FPs should note the new bundles on the books for ECGs, recommends Moore. CCI 15.1, effective April 1, bundled the following codes into nearly every CPT procedure code:

• 93000 -- Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report

• 93005 -- ... tracing only, without interpretation and report

• 93010 -- ... interpretation and report only.

To break a bundle for an ECG that is unrelated to another procedure, you'll need to use modifier 59 (Distinct procedural service) on the test code. This indicates that the FP performed the ECG for a separate reason, not as a routine pre-surgery test.

Example: An established patient presents to the FP with a suspected broken collarbone and complaints of chest pain after falling from a ladder. The FP takes an appropriate history, performs an appropriate exam, and orders a plain film x-ray to check for collarbone fracture.

The FP then orders an ECG to evaluate the patient's chest pain (ECG and x-ray occur in-office). The x-ray reveals a broken clavicle, on which the FP performs closed treatment without manipulation. The ECG reveals no heart-related problems.

In this example, Moore says you can break the CCI bundle and code the ECG separately. On the claim, report the following:

• the appropriate-level E/M code (such as 99213) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to show that the E/M was separate from the other services

• 810.00 (Fracture of clavicle; closed; unspecified part), 786.59 (Chest pain; other), and E881.0 (Fall from ladder) appended to the E/M to represent the patient's injury and other complaint

• 23500 (Closed treatment of clavicular fracture; without manipulation) for the fracture care

• 810.00 and E881.0 appended to 23500 to represent the patient's injury

• 93000 for the ECG

• 786.59 appended to 93000 to represent the patient's symptoms

• modifier 59 appended to 93000 to show that the ECG was a separate service from the fracture treatment

• 73000 (Radiologic examination; clavicle; complete) for the x-ray

• 810.00 and E881.0 appended to 73000 to represent the patient's injury.

FPs might also be able to break a CCI bundle on the following catheter codes, confirms Michael A.Ferragamo, MD, FACS, physician and professor at State University of New York, Stony Brook:

• 51701 -- Insertion of non-indwelling bladder catheter (e.g., straight catheterization for residual urine)

• 51702 -- Insertion of temporary indwelling bladder catheter; simple (e.g., Foley)

• 51703 -- ... complicated (e.g., altered anatomy, fractured catheter/balloon).

Once again, the cath must be unrelated to the reason for surgery in order to unbundle the service. Plus, you must use modifier 59 on the catheter code to separate it from the other procedure's global surgical package.

Example: The FP performs incision and drainage (I&D) in the office on an established patient's penis abscess. A few hours later that day, the patient returns to the office having trouble urinating. Unsure if this symptom is secondary to the I&D, the FP inserts a non-indwelling cath to check for urine retention.

In this instance, you can break the bundle and code the cath separately. On the claim, report the following:

• 10060 (Incision and drainage of abscess [e.g.,carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia];simple or single) for the I&D

• 607.2 (Other inflammatory disorders of penis) appended to 10060 to represent the abscess

• 51701 for the cath

• modifier 59 appended to 51701 to show that the cath and I&D were distinctly separate services

• 788.20 (Retention of urine, unspecified) appended to 51701 to represent the patient's retention.