Radiology Coding Alert

Review 36221’s definition to see why this code isn’t included.

To make the most of April’s Medicare Physician Fee Schedule (MPFS) update, checking the effective date of each change is a must. Discover why this attention to detail will pay off for cervicocerebral angiography codes.

Take Action to Capture 2013 Bilateral 36222-+36228 Payment

Typically you can check the MPFS to help you determine whether a code is considered unilateral or bilateral, says Sylvia Conrad, insurance coordinator with a Jacksonville, Fla., practice. You locate the bilateral indicator in the column labeled “Bilat Surg,” and it indicates whether Medicare provides additional reimbursement when you report the code bilaterally.

But sometimes the bilateral indicator is wrong and needs to be corrected. Case in point: The April MPFS update corrects the bilateral indicator for cervicocerebral angiography codes 36222-+36228. CPT^® defines the codes as unilateral, but the original bilateral indicator, 0, essentially resulted in bilateral services being paid at the same rate as unilateral services. The new indicator, 1, allows for bilateral services to be paid at 150 percent of the unilateral rate to compensate for the extra work required.

Effective date: The correction is retroactive to Jan. 1, 2013, so you should review your practice’s 2013 claims to identify improperly paid bilateral services. Then, you should take steps to ensure you receive the additional bilateral reimbursement from your Medicare contractor. In the April update, CMS states that “Medicare contractors need not search their files to either retract payment for claims already paid or to retroactively pay claims. However, contractors shall adjust claims brought to their attention” (Transmittal 2677, CR 8169, www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2677CP.pdf).

Each MAC may have different appeal/claim correction processes, says Laureen Jandroep, CPC, CPC-I, CMSCS, CHCI, CPPM, of CodingCertification.org. Contact your MAC directly by its specific claim correction/appeal line, keeping in mind that MACs may have rules about the number of claims allowed per call or the types of corrections made by phone. But the MPFS change means MACs should be prepared to make this correction for claims.

Background Begins With New Code Review

To better understand the change, review the code definitions. The codes in question are part of this new range introduced by CPT^® 2013:

·         36221, Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed

·         36222, Selective catheter placement common carotid or innominate artery unilateral any approach with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation includes angiography of the cervicocerebral arch when performed

·         36223, Selective catheter placement common carotid or innominate artery unilateral any approach with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation includes angiography of the extracranial carotid and cervicocerebral arch when performed

·         36224, Selective catheter placement internal carotid artery unilateral with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation includes angiography of the extracranial carotid and cervicocerebral arch when performed

·         36225, Selective catheter placement subclavian or innominate artery unilateral with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation includes angiography of the cervicocerebral arch when performed

·         36226, Selective catheter placement vertebral artery unilateral with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation includes angiography of the cervicocerebral arch when performed

·         +36227, Selective catheter placement external carotid artery unilateral with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)

·         +36228, Selective catheter placement each intracranial branch of the internal carotid or vertebral arteries unilateral with angiography of the selected vessel circulation and all associated radiological supervision and interpretation, e.g., middle cerebral artery posterior inferior cerebellar artery (List separately in addition to code for primary procedure).

Dig Into the Bilateral Indicator Details

If you like going straight to the source for your coding information, then consider how the CPT^® code definitions compare to the CMS bilateral indicator definitions. Once you sift through the technical language, you’ll understand why paying bilateral services at a higher rate than unilateral services makes sense for these codes.

The codes affected by the correction, 36222-+36228, are defined as “unilateral” only. That means each code is designed to represent the work required for a service on just one side of the body.

The original, incorrect bilateral indicator for 36222-+36228 was 0, causing Medicare to underpay bilateral services at the unilateral rate. CMS defines the 0 indicator as “150% payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 [Bilateral procedure] or with modifiers RT [Right side] and LT [Left side], base the payment for the two sides on the lower of: (a) the total actual charge for both sides or (b) 100% of the fee schedule amount for a single code.”

The new indicator is 1, and it means Medicare will pay bilateral services at 150 percent of the unilateral rate. The 1 indicator stands for “150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.”

Did you notice? The first code in the new range, 36221, is not included in the bilateral indicator change. This is because 36221 is defined as “unilateral or bilateral,” meaning the code without modifier 50 or RT/LT is appropriate for imaging on one side or on two sides from nonselective catheter placement.

“Unilateral or bilateral” code 36221 has an indicator of 2, which means “150% payment adjustment does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for both sides on the lower of (a) the total actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code.”

Reconcile CPT® and CMS Rules

Fortunately, the change for 36222-+36228 brings the CMS indicator in line with CPT^® guidelines, which state, “When bilateral carotid and/or vertebral arterial catheterization and imaging is performed, add modifier 50 to codes 36222-36228 if the same procedure is performed on both sides. For example, bilateral extracranial carotid angiography with selective catheterization of each common carotid artery would be reported with 36222 and modifier 50.”

Watch out: If the physician performs procedures on both the left and right sides but the services aren’t identical, CPT^® guidelines indicate you should use modifier 59 (Distinct procedural service) rather than modifier 50: “When different territory(ies) is studied in the same session on both sides of the body, modifiers may be required to report the imaging performed. Use modifier 59 to denote that different carotid and/or vertebral arteries are being studied.”