Radiology Coding Alert

Consider these Medicare rules for sequential IR procedures.

Those with a firm grasp on the National Correct Coding Initiative (NCCI) Correspondence Manual are well aware of the broad range of rules coders must consider when coding surgical procedures. One important, occasionally overlooked rule pertains to surgical procedures that Medicare deems "sequential."

A sequential procedure is, simply put, a procedure that follows another separate or related procedure. While the definition is basic enough, understanding when, where, and how to incorporate Medicare's policy regarding sequential procedures isn't as clear-cut as one might think.

Check out this real-world example to fully equip yourself to handle all sequential procedure coding situations.

Focus on End Result with Modifier Eligibility

Example: The physician unsuccessfully attempts a deep bone biopsy of the L4 vertebral body. Following the unsuccessful attempt, the physician performs a successful open biopsy of the same L4 vertebral body.

The procedure codes in consideration are as follows:

• 20225, Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur)  
• 20251, Biopsy, vertebral body, open; lumbar or cervical

Without an extensive knowledge of the NCCI Policy Manual, coders may find themselves incorrectly coding this scenario. If you perform an NCCI edits check on these two procedures, you will see that the NCCI edit states that you may code 20225 (the column 2 code) alongside 20251 with an overriding modifier. However, context is crucial in determining whether or not a modifier is actually allowable.

Consider Medicare's policy on sequential procedures as stated in the NCCI Correspondence Manual:

"If a provider attempts several procedures in direct succession at a patient encounter to accomplish the same end, only the procedure that successfully accomplishes the expected result is reported. Generally, this occurs when a less extensive procedure fails and requires the performance of a more extensive procedure. A failed procedure followed by a more extensive procedure should not be reported separately. Procedures that are often performed in sequence have been identified and the less extensive procedure is not separately reportable with the more extensive procedure."

The key phrase coders should focus in on here is "to accomplish the same end." In the example scenario, the physician clearly performs both biopsies for the same diagnostic reasons, so the sequential procedure policy applies to this situation. However, some coders and physicians may argue that, due to the time and effort put into the first procedure, you should report both codes with modifiers 53 (Discontinued procedure) and 59 (Distinct procedural service) attached to 20225.

While the use of modifier 53 seems to make sense based on the circumstances, the NCCI rules on sequential procedures do not allow these two procedures to be paired together, no matter the extent of the physician's work on the initial bone biopsy. Therefore, you should code this example exclusively as 20251.

Caveat: "However, if the physician performs a technically successful percutaneous needle biopsy on one day, with the resultant final pathology analysis being nondiagnostic, the physician may then proceed with an open biopsy on a subsequent day, states Gregory Przybylski, MD, interim chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. In this case, you would not need to append a modifier to the second procedure due to the initial procedure's global period of zero days.