Radiology Coding Alert

Remember to check an edit's modifier indicator before you act.

Correct Coding Initiative (CCI) Version 16.2 is in full effect, as of July 1. But not all news from CCI Version 16.2 is bad news.

In addition to the new edit pairs, CCI also deletes dozens of edit pairs, said Frank Cohen, MPA, MBB, of The Frank Cohen Group, in a June 17 announcement about the CCI changes. Below, see which radiology-related edits have been ousted and what's been added.

These Interventional Combos Made the Deleted Edit List

CCI deleted the edits bundling pulmonary angiography codes 75741 (Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation), 75743 (Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation), and 75746 (Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation) into 75966 (Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation).

Reality: You probably don't see pulmonary arteriograms and renal or visceral artery PTA performed together very often, if at all, so the deletion shouldn't affect your day-to-day coding.

Catch These Modifier Indicator 1 Additions

Of course, there are many added edit pairs, as well. For example, CCI now bundles 75896 (Transcatheter therapy, infusion, any method [e.g., thrombolysis other than coronary], radiological supervision and interpretation) into many codes, including endovascular repair codes 34800-34805, as well as vascular procedure codes 75600-75791 and 75810-75891. These edits have a modifier indicator of 1, which means that you may override the edit with a modifier, such as 59 (Distinct procedural service), when appropriate.

CCI also bundled the following imaging and guidance codes into 77785-77787 (Remote afterloading high dose rate radionuclide brachytherapy ...):

All of these edits also have a modifier indicator of 1, which means that you may override the edit with a modifier when appropriate. For example, if on the same date as brachytherapy the patient requires ultrasound imaging guidance (76942) to perform a distinct non-brachytherapy procedure, you may report ultrasonic guidance (76942) and the distinct procedure requiring guidance on the same claim as the brachytherapy. To indicate to the payer that you are not reporting the guidance in connection with the brachytherapy -- that instead you are reporting the guidance for a different, distinct procedure -- append modifier 59 (Distinct procedural service) to 76942.

Remember that CCI edits only apply to services performed by the same physician on the same date. So if a patient is receiving brachytherapy under a radiation oncologist and your radiologist provides guidance for a separate procedure, you don't need to append modifier 59 on your claim to indicate the guidance is distinct from the brachytherapy.

Mod 59 must: Never use modifier 59 just to get paid for a procedure. "Make sure there is well-documented support for a separate and distinct procedure before adding modifier 59," says Rena Hall, CPC, billing/insurance specialist with a Kansas City, Mo., practice.

In addition, CPT instructions dictate that if a more specific modifier describes the situation, you should not use modifier 59. Because the modifier has the potential to bypass CCI edits, practices use this modifier too often, says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC departments of Surgery and Anesthesiology. Modifier 59 "should be the modifier of last resort and only used when there is no other modifier to compliantly bypass the bundling edit, and the procedure was clearly distinct and different from that of the other procedure," she adds.

Add Cardiac Imaging Edits to the '0' List

Some additions to CCI 16.2 have modifier indicator 0, meaning that you may not unbundle the edit combination under any circumstances. In other words, you can't automatically override every CCI edit with modifier 59 just because documentation supports a separate site, incision, or patient meeting, says Claudia Kernaghan, CPC, coder for Nevada Imaging Centers in Las Vegas.

Case in point: CCI now bundles 78494 (Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing) into 78451-78452 (Myocardial perfusion imaging, tomographic [SPECT] ]including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed]) with a modifier indicator of 0. Keep in mind that the definitions for 78451-78452 include the services 78494 describes.

Want to see all the edits? Download the edits at http://www.cms.gov/NationalCorrectCodInitEd/.