Radiology Coding Alert

Medicare won't pay both US and fluoro guidance with new CVC codes - unless you append a modifier

The latest version of the National Correct Coding Initiative (NCCI) may squash your hopes of recouping appropriate reimbursement when you perform the new central venous catheter (CVC) services with other procedures. The NCCI bundles chest x-rays, fluoroscopy and hundreds of other procedures into the new CPT Codes
 
CCI Edits version 10.0 (effective from Jan. 1 through March 31) indicates that you will have to report either fluoroscopic guidance or ultrasound guidance - but not both - with your new venous access codes (36555-36597). The edit does, however, list a "1" indicator, which means you can separate this edit with a modifier (most often modifier -59, Distinct procedural service) when both forms of guidance are medically necessary and separately identifiable from one another.
 
CPT 2004 introduced both +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting [list separately in addition to code for primary procedure]) and +75998 (Fluoroscopic guidance for central venous access device placement, replacement [catheter only or complete], or removal [includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position] [list separately in addition to code for primary procedure]), but Medicare doesn't want you to report them at the same time unless the physician can prove that both services are distinct and medically necessary.

Select One Form of Guidance Only - or Append a Modifier

If there is a reason to use both ultrasound and fluoroscopic guidance, and the radiologist performs both, you can still report both codes, says Gary S. Dorfman, MD, FACR, FSIR. "If only a quick-look ultrasound is done, followed by placement under fluoroscopy, then only fluoroscopy should be billed. However, if a full ultrasound service and a full fluoroscopy service are provided, both should be billed and the -59 modifier should be used. The report should document why both were necessary and that both were performed."
 
Based on the 2004 fee schedule, Medicare carriers will reimburse about $36 for ultrasound code 76937 and $80 for fluoroscopy code 75998.

NCCI Bundles X-Ray Codes Into CVC Codes

The NCCI also bundles chest x-rays (71010-71020), fluoroscopy (76000-76003), and ultrasound guidance (76942) into most of the CVC codes, reminding coders to use the new versions of these codes instead of the outdated ones.
 
"The chest x-rays really have been part of the edit for the CVC procedures all along," says Linda Thornton, CPC, billing supervisor at St. Louis University's SLUCare, a healthcare service provider.
 
If the physician uses the chest x-rays to verify that the line is in the right place, that service is included in the imaging codes. But if the patient has some other medical reason for a chest radiograph, you can separately report the x-ray service, as long as you append modifier
-59 to the x-ray code.

NCCI Includes Venography With Angiography

NCCI 10.0 also includes several venography codes (including 75820 and 75860) with the corresponding angiography codes (such as 75630 and 75650), but this edit simply "makes official" the way most payers were already reimbursing claims, says Jeff Fulkerson, BA, CPC, CMC, certified coder for the department of radiology at The Emory Clinic in Atlanta.

"I do not believe that the new edit will make any difference in how most coders are assigning CPT codes," Fulkerson says. "The imaging of venous structures from an arterial injection of contrast during an arteriogram is not something that we report. I consider it to be a part of the angiogram itself."
 
For a complete list of the new NCCI edits, visit www.cms.hhs.gov/physicians/cciedits/default.asp.