Pulmonology Coding Alert

Your CPT should jive on both surgeons' op notes, or else bid $4k goodbye.

When you come face-to-face with multi-provider situation, the last thing you would want is to mess up your coding by assigning the wrong modifier(s). Modifiers can be a friend or a foe, depending on how you use them -- or when you use them.

Scenario: A 70-year-old female patient who presents with COPD and coronary artery disease, status post myocardial infarction (CAD s/p MI) has a 28 mm of inner diameter thoracic aortic aneurysm. Imaging studies indicate the aneurysm to be descending. The cardiologist, together with a thoracic surgeon, decides to perform an open operative repair with graft replacement of the diseased segment.

The main key in a multi-provider scenario is to treat each physician's work as a separate activity. However, deciding when to report a case as co-surgery, assistant surgery -- or something else -- has more to it than meets the eye. Find out what with this expert's advice.

Modifier 62, 81, 82 and the Roles They Play

You know that a modifier is at hand in this case, but more importantly you should be able to tell what role each modifier plays in order for your procedure codes to blend well together. Here are the most common modifiers used in multi-provider situations:

• Modifier 62 (Two surgeons). Append this to each surgeon's procedure when the physicians perform distinct, separate portions of the same procedure. Also referred to as co-surgery, modifier 62 applies when the skill of two surgeons (usually of different skills) is required in the management of a specific surgical procedure.
• Choose between modifier 80 (Assistant surgeon), modifier 81 (Minimum assistant surgeon), and modifier 82 (Assistant surgeon [when qualified resident surgeon not available]) when one surgeon assists the other with multiple portions of the case rather than completing his work independently. What to look for? Make sure your physician indicates in his documentation that he's working with an assistant surgeon, what the assistant surgeon did, and why he or she was used during the case.
• Attach modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) when you report a nonphysician practitioner's (NPP's) involvement to Medicare.

Warning: Not all payers recognize modifier AS. You should verify the correct way to report the NPP's service before completing your claim.

Avoid the Modifier 51 Trap

It's easy to fall into the lure of using modifier 51 (Multiple procedures) when you're coding for multiple procedures during the same operative session, but you could end up in the gutters if you're not careful enough.

Why: Modifier 51 tells you that a surgeon was present performing multiple procedures. If a surgeon is not physically present for multiple procedures in a surgical case, it's not appropriate to indicate that he was by using modifier 51.

Two Surgeons Require Two Echo Claims

In the scenario given, both surgeons should bill 33880 (Endovascular repair of descending thoracic aorta [e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption]; involving coverage of left subclavian artery origin, initial endoprosthethesis, plus descending thoracic aortic extension[s], if required, to level of celiac artery origin). Then, you would use 441.2 (Thoracic aneurysm without mention of rupture) with 33880 to describe the condition. Finally, you should append modifier 62 to 33880 to show that two surgeons performed the repair.

Catch: You don't use modifier 62 if the physicians are not reporting the same CPT code. If each doctor can represent his work with a separate CPT code, skip modifier 62. Make sure both surgeons send a claim with the same code and modifier declared or you'd end up throwing away about $4,000 in reimbursements (56.62 RVUs multiplied by 2011 conversion factor of 33.9764; $1,923.74 for each surgeon).