Pulmonology Coding Alert

Question: Our practice frequently reports procedure codes 31500, 93503 and 36620 with critical care code 99291. We bill these codes as 99291 with modifier -25, 31500, 93503 with modifier -59, and 36620 with modifier -51. 

Medicare denied our last bill, stating that we should not append modifier -51 to code 36620. I know now that this is true, but I do not fully understand what this means and how to get the procedure paid. Would you please explain this exemption and how I should bill all of these codes?

North Dakota Subscriber

Answer: The appropriate way to report the services provided above is 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) with modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes), 31500 (Intubation, endotracheal, emergency procedure) and 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous).   

In accordance with CPT standards, critical care services include certain procedures if the physician performs those specific procedures on the same day.

Note: CPT and the National Correct Coding Initiative (NCCI) bundle the following services into critical care services: interpretation of cardiac output measurements (93561-93562); CXR (71010, 71015, 71020); pulse oximetry (94760-94762); blood gases, and information data stored in computers (i.e., ECGs, blood pressures, hematologic data [99090]); gastric intubation (43752, 91105); temporary transcutaneous pacing (92953); ventilatory  management (94656, 94657, 94660, 94662); and vascular access procedures (36000, 36410, 36415, 36540, 36600). 

If you have procedures that you did not previously identify when reporting the same-day procedures, you may report them separately. Make sure that the time you credit toward the critical care service does not include the time the physician spent performing the separately reportable procedures.

Don't forget: If you submit claims for multiple services, you should append the most appropriate modifier to explain the circumstances to the payer. For example, if one physician performs multiple procedures during the same session, you should append modifier -51 (Multiple procedures). 

Warning: CPT identifies several codes as exempt from modifier -51. This means that if you append modifier -51 to these "exempt" services, you may face a denial from your insurer.