Radiology Coding Alert

Know when the rules call for ditching modifiers and fusing two codes into one.

Last month, you were briefed on situations that do and do not condone the use of modifiers 76 (Repeat Procedure or service by Same Physician or other qualified health care professional) and 77 (Repeat Procedure by Another Physician or other qualified health care professional). While solving these scenarios is not necessarily clear-cut, coders must only apply duplicate procedure modifiers when the procedure codes are identical.

While, on the surface, that sounds like an obvious point, there are numerous confounding scenarios in which the exams in question differ by one tiny detail. In these cases, how a coder defines a duplicate exam becomes vital in deciding how to code the procedures in question. As you will see, in some cases you should even opt to combine procedural codes into a single, more comprehensive code.

Check out these tips and real-world examples to better understand when and where to apply this lesser-known set of rules.

Identify True Duplicate Procedures

You always want to prepare yourself to handle any and all confounding coding situations, no matter how infrequently they might present themselves. There is one scenario, in particular, that coders notoriously struggle with - and for good reason. As you learned last month, identifying duplicates and applying the appropriate modifier is easy when you know what you're doing.

For instance, consider the example of the same physician performing a computed tomography (CT) scan of the head without contrast at two separate times of the day. You know to apply modifier 76 to the second 70450 (Computed tomography, head or brain; without contrast material) in order to receive reimbursement for both procedures.

But, what if one of those CT scans is with contrast, and the other without? Most coders' first inclination is to code it the same way as the previous example. It makes sense, on the surface. It's still a CT scan of the head, so whether the physician applies contrast should not change the fact that it's a duplicate procedure, right? Wrong. Duplicate procedures must share the same, exact CPT^® code in order for a coder to identify them as such.

Combine with and without Contrast Procedures on the Same Day

Now that you have a firm understanding of what procedure combinations do and do not classify as duplicates, you've got to know how to handle the situation presented above. Consider this hypothetical scenario:

A patient presents for a scheduled CT scan of the head/brain with contrast at 2:50 PM. Later that evening, the patient is ambulated to the hospital following a fall. Thesame provider performs a CT scan of the head without contrast.

With this situation in place, a coder has two different options, with only one of them being right. They could:

1. Code 70450 and 70460 (Computed tomography, head or brain; with contrast material[s]) with modifier 76 or 59 (Distinct procedural service) attached to 70460 (since it was subsequently performed).
2. Combine 70450 and 70460 into 70470 (Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections).

Many coders have heard about combining procedural codes in theory, but never actually implemented the technique in their practice. On one hand, Medicare does not appear to offer any definitive guidelines on the topic of combination coding. On the other hand, the American Hospital Association (AHA) does instruct coders on how to handle the specific situation of when the physician performs a with contrast and without contrast procedure on the same day. Consider these instructions from AHA's 2016 Coding Clinic:

• "The CCI edits bundle 'without contrast" exams into 'with contrast' exams when both are performed on the same day. The edit is modifier status '0,' meaning that it cannot be overridden with a modifier. Therefore, even if the exams were performed at separate encounters (for example, one in the morning and one in the evening), only one exam (without and with contrast) should be billed."

"The NCCI edit in place for 70450 and 70460 prevents separate payment and you cannot bypass this edit with a modifier," relays Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. With these rules in place forbidding the use of an overriding modifier, it becomes clear that the second option is the only correct method of coding this example.

Check Order for Procedures on Separate Days

In this issue of the 2016 Coding Clinic, the AHA also instructs coders on what to do if the provider performs these two procedures a day apart. AHA states:

• "If the referring physician ordered a single exam, bill for only a 'with and without' contrast exam even if for some reason the two portions of the exam were performed on separate days. If a CT was ordered as with and without contrast and was performed at two separate times or even on separatedays, the correct code assignment would be for one study."

"In other words, you've got to make sure to check the order form before making a final coding determination on these two procedures," says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. If the order form is for a single with and without contrast exam, you should code accordingly. If the order form lists the exams separately, and the provider performs them on separate days, you may code each exam separately.

However, if the order form lists the exams separately, and the provider performs the procedures on the same day, you should combine the procedural codes into one with and without contrast code.