Pulmonology Coding Alert

Unbundlingbilling separately for two or more procedures that CPT 2000 combines in one comprehensive code-is a major compliance problem. But many physicians dont understand this concept, which can lead to claim denials. By reviewing the basic ideas behind bundling, such as mutually exclusive, component and comprehensive codes, physicians can avoid such problems.

By far the largest source of bundling combinations, or edits, is Medicares national Correct Coding Initiative (CCI), which has developed coding policies and more than 120,000 edits for reimbursement compliance to better control improper coding.

Although the CCI has been in place since Jan. 1, 1996, many physicians still do not understand its impact on how they bill procedures. This has serious compliance consequences because Medicare auditors may construe separate billing for bundled procedures as fraud.

Component and Comprehensive Codes

Approximately 11,000, or just less than 10 percent, of the CCIs 120,000 edits are categorized as mutually exclusiveeach code covers one procedure that may not be billed at the same time as others in the group. The other 90 percent may be categorized roughly as bundlescomprehensive codes that include more than one component. Physicians may not bill the component codes if they also bill the code for the comprehensive procedure.

Effective April 1, 2000, CCI, Version 6.1, was implemented to reflect correct coding edits made by the Health Care Financing Administration (HCFA). This version of the CCI contains the following edits:

The comprehensive/component edit of CPT code 94621 (pulmonary stress testing; complex [including measurements of CO2 production, O2 uptake, and electrocardiographic recordings]), which includes 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) and 94200 (maximum breathing capacity, maximal voluntary ventilation).

HCFA explains this edit by saying that complex pulmonary stress testing (94621) includes spirometry (94010) and maximum breathing capacity (94200) as a standard of medical and surgical practice. The agency states that complex pulmonary stress testing (94621) is a more extensive procedure than simple pulmonary stress testing (94620). The CPT description for 94620 specifically indicates pre- and post-spirometry as an integral part of the procedure code. Maximum breathing capacity (94200) also has been identified in previous CCI versions as a standard of medical and surgical practice for simple pulmonary stress testing (94620).

Editors note: If either of the two component procedures described in these code-pair edits is performed separately from the comprehensive procedure (i.e., at separate sessions or patient encounters) both the comprehensive and component codes may be reported by appending modifier -59(distinct procedural service)to the component code.

A correction for CPT codes 31628 and 31629. This change will be retroactive to Oct. 1, 1998. (In 1998, use of these codes frequently resulted in carriers denials, which were based on black box edits.)

Codes 31628 (bronchoscopy, [rigid or flexible] with transbronchial lung biopsy, with or without fluoroscopic guidance) and 31629 (bronchoscopy, [rigid or flexible] with transbronchial needle aspiration biopsy) are bundled with bronchoscopy codes 31622-31656.

Walter ODonohue, MD, is chairperson of the CPT Committee of the American College of Chest Physicians and a representative to the American Medical Association (AMA) CPT Advisory committee for the American College of Chest Physicians. He says that, in the past, HCFA reimbursed both of these codes for the same patient on the same day. HCFA would pay on 31628 to the extent of the allowable charge with additional reimbursement calculated as the allowable amount for 31629 minus the allowable amount for 31622, which was the base diagnostic flexible bronchoscopy.

Editors note: With the release of CCI, Version 6.1, HCFA agrees that 31629 should be allowed with 31628 as long as the transbronchial needle aspiration biopsy is performed on a lesion other than the one coded as 31628. To report this accurately, use modifier -59 with this code pair.

HCFA has decided to add the comprehensive/ component edit of 94621 (pulmonary stress testing; complex [including measurements of CO2 production, O2 uptake, and electrocardiographic recordings]) and 93015 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report).

Since Jan. 1, 1996, 93015 has been bundled into pulmonary stress testing, both simple and complex, as previously described by code 94620 (pulmonary stress testing, simple or complex). The addition of CPT code 94621 to last years CPT manual, says HCFA, indicates it is appropriate that 93015 also be bundled into 94621.
Editors note: Both these codes may be reported together, if appropriate, by using modifier -59 on the component code if the two procedures are performed at separate sessions or patient encounters.

HCFA now will allow the use of modifier -59 with the code pair edit of 31623 (bronchoscopy, [rigid or flexible]; with brushing or unprotected brushings) and 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]).

Editors note: HCFA agrees that the 76000 procedure should not be payable separately when performed during procedure 31623 unless certain circumstances exist; if these two procedures are performed at separate sessions or patient encounters on the same date of service, HCFA will permit the use of modifier -59.

HCFA added the comprehensive/component edit of evaluation and management (E/M) codes (99201-99205, 99211-99215, 99243-99245, 99273 and 99284) and immunization administration codes (90471 and 90472).

Editors note: According to HCFA, these edits are consistent with the payment policy that permits payment of codes 90471 or 90472 only when no other physician service is provided. Do not attempt to change these codes by using a modifier.

Judiciously Use Modifiers That Override Bundles

Most CCI edits may be overriden by modifiers to indicate that distinct or independent procedures were performed, and that billing with two codes that normally would be bundled is in fact appropriate because of special circumstances. Modifier -59 was created as a response to the CCI edits, and overrides most, but not all, bundling combinations. The CCI uses indicators to show which codes appropriately may use modifier -59 if documentation exists to support the claim that the procedure was distinct (which usually means it was performed on a separate site or at a different time during the same day).

Medicare also has developed its own HCPCS modifiers to indicate procedures were performed on different sites on the body. These include -LT (left side [used to identify procedures performed on the left side of the body]), -RT (right side), -E1 through -E4 (eyelids), -FA to -F9 (fingers and thumbs), -TA through -T9 (toes), -LC (left circumflex, coronary artery), -LD (left anterior descending coronary artery), and -RC (right coronary artery).

Coding combinations when modifier -59 is inappropriate include those in the first category of CCI edits or those that are mutually exclusive. If the codes can be modified, they will have an indicator (1) beside them in the CCI. If they cant, indicator (0) is shown.

Physicians may bill all the edits in the comprehensive/component category and its subcategories using modifier -59 when appropriate. They should keep in mind that using modifier -59 may send up a red flag for audit, however, so it should be used carefully and discriminately after ensuring that the appropriate documentation exists to back up the claim.

According to Susan Callaway-Stradley, CPC, CCS-P, independent coding consultant, N. Augusta, S.C., This is the biggest problem with this modifier. If it is on the claim and unbundling is allowed, the claim will be paid. Many offices have been told in the past by the carrier, we will pay the claim if the -59 modifier is attached with no additional warning that it must be for an appropriate reason. As a result, claims have been paid that would not be supported by documentation in the event of an audit.
Practices must understand that just because the claim got paid does not mean the claim was filed correctly. They must understand the appropriate extenuating circumstances allowing the use of modifier -59.

For complaints about CCI edits, contact the provider relations staff of your local Medicare carrier. To order a copy of the CCI, contact the National Technical Information Service (NTIS) at 1-800-553-6847. The cost of an annual subscription is $260 for hard copy or CD-ROM versions.

Although the Correct Coding Initiative is important, it is not the only group of coding edits that Medicare uses. The Health Care Financing Administration (HCFA) instituted many edits before the CCI was established in 1996 and still enforces these. In addition, HCFA purchased a series of edits from HBO&C, which the agency refers to as commercial or proprietary edits and the rest of the coding world knows as black box edits because they are not published anywhere due to their proprietary nature.

Finally, physicians should remember that commercial carriers are not bound by and do not necessary follow the CCI, though they may use it selectively.