Pulmonology Coding Alert

Question: A pulmonologist provides two hours of critical care with a bronchoscopy, chest tube insertion, and central line placement all in the same day. When billing Medicare, do I need to append the procedures with modifier 51 or 59?

Michigan Subscriber Answer: No. This scenario does not require either modifier 51 (Multiple procedures) or modifier 59 (Distinct procedural service).
 
Reason 1: Medicare carriers do not want modifier 51 on the claim form -- their systems apply the multiple- procedure reduction automatically. Expect a reduction on only the CVP line placement (36556, Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older). The chest tube insertion (32020, Tube thoracostomy with or without water seal [e.g., for abscess, hemothorax, empyema] [separate procedure]) is modifier 51 exempt, according to CPT 2007.
 
Reject 59: Because no National Correct Coding Initiative edits exist on the bronchoscopy (31622-31656), chest tube insertion (32020), and central line placement (36556), modifier 59 is inappropriate. You should reserve modifier 59 for scenarios involving procedures that the NCCI bundles but under the circumstances are separately billable.
 
For instance, the NCCI edits consider 31625 (Bronchoscopy, rigid or flexible, ... with bronchial or endobronchial biopsy[s], single or multiple sites) a component of 31629 (... with transbronchial needle aspiration biopsy[s], trachea, main stem and/or lobar bronchus[i]). So you would not normally report the two bronchoscopy codes together. But when a pulmonologist performs them on different sites of the lungs, you should bill 31629 and also 31625 appended with modifier 59.
 
Watch out: You do need a modifier on the critical care codes. Critical care services do not include the bronchoscopy (31622-31656), chest tube (32020), or central line 36556 (Insertion of non-tunnelled centrally inserted central venous catheter; age 5 years or older), which you should bill separately.
 
But to indicate that the E/M service is significant and separately identifiable from the procedures, you must append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and possibly +99292 (... each additional 30 minutes [list separately in addition to code for primary service]). The pulmonologist should have clearly documented the critical care time separately from the procedure time.  
-- Answers to You Be the Coder and Reader Questions answered/reviewed by Kathy Anderson, CPC, practice consultant for Allergy Partners PA in Asheville, N.C.; Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta; and Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.