Pulmonology Coding Alert

Question: I read in a past issue that I should not append modifier -59 (Distinct procedural service) and modifier -51 (Multiple procedures) to the same CPT code. If that is true, how should I code a bronchoscopy that consists of a transbronchial biopsy, brushing and alveolar lavage of the left lower lobe, with biopsy and brushings of the left upper lobe? Oregon Subscriber Answer: Modifier use can be very troublesome at times. Always keep in mind that there is a difference between "correct coding" according to CPT and coding as accepted by each insurer. The scenario below describes multiple procedures being reported for one date of service. When coding according to CPT, you should code this correctly as the following: 31628 Bronchoscopy (rigid or flexible); with transbronchial lung biopsy, with or without fluoro-scopic guidance 31625-51-59* ... with biopsy 31623-51 ... with brushing or protected brushings 31624-51 ... with bronchial alveolar lavage. *When you list two or more modifiers for one procedure, report modifier -99 (Multiple modifiers) to alert the insurer that more than one modifier applies to this code (for example, 31625-99). Include the actual modifiers used (-51, -59) in the narrative portion of the electronic claim. Some insurers do not require or do not recognize modifier -99. In this case, you can report the modifier that primarily applies to the code (such as -59). Reporting the services as 31628, 31625-59, 31623-59 and 31624-51 is not wrong. Some insurers do not even recognize modifiers -51 or -59 because they will only pay for one procedure code per family, per date of service. In the case listed above, certain insurers will only pay for the highest-valued procedure (31628), indicating that the remainder of the services are integral to the primary procedure. Nonetheless, reporting all of the services as listed above is important to accurately capture all of the physician work involved. This information is useful for different reasons. It may help operationally to allocate staff or equipment or to value the "primary procedure" at a higher rate in future contract negotiations with insurers because the payer considers other procedures (and their inherent extra work) included in the primary one. At any rate, failure to report modifier -51 should not have a negative monetary impact on a claim. The insurer should still pay the claim at the same rate as if you reported modifier -51. Reimbursement for endoscopy procedures follows multiple-endoscopy payment guidelines: 100 percent of the highest-valued procedure plus the difference between the allowable reimbursement for the next-highest-valued procedure and the base endoscopy code. Reimbursement for all other types of procedures (that is, procedures other than endoscopies) is either 100 percent of the allowable reimbursement for the highest-valued procedure, 50 percent [...]