Wiki 93458-26 billed with 92980-RC & 92973, cath denied!

[FLSJarrel]

I received a denial for cardiology services billed to Medicare (PA Local carrier). I billed

93458-26
92980-RC
92973

Both 92980 & 92973 paid, however the 93458-26 was denied with following reasoning.

B15 This service/procedure requires that a qualifying service/procedure be received & covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

After reviewing other posts, I was wondering if this means I need to add modifier 59 (93458-26-59), however the practice has been paid when both a cath & stent were performed & billed together without a 59 in the past. Although those billings did not include the percutaneous coronary thrombectomy. I did check CCI edits with these 3 codes and there were none listed.
Any thoughts on this?

 

[willnat2]

When we do a stent we have to now put a 26 and a 59 modifer on the cath, so 93458, 2659 and it should get paid. I believe this started in April.

 

[asims2008]

I have been receiving denials for 93458-26 when it is billed with a stent also...I have been adding a -59 modifier on the 93458 along with the 26 and this is why...

Modifier -59 Distinct Procedural Service

Information from AMA

Distinct Procedural Service

Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.



Modifier Indicators:

0 = modifier not appropriate; services represented by code combination not paid separately

1 = modifier allowed; billed services may be justifiable for the code combination

(For comprehensive/component pair, use modifier on column 2 code;
for mutually exclusive pair, use modifier as appropriate)

9 = no longer an active NCCI edit; code combinations are billable; no modifier needed

View list of modifiers in the HCPCS and CPT CodeBook


--------------------------------------------------------------------------------

1 code pair found in Physician Version 17.1 (4/1/2011-6/30/2011)

Active CCI Edits

The following code pairs generally cannot be reported together. Use the Column 1 code.
(If Modifier Indicator=1, there may be occasions where both codes are payable, see NCCI Chapter I Section E .)


short description for column 1 code

Column
1
Column
2
CCI Edit Description
Modifier
Indicator
Effective
Date
Termination
Date

short description for column 2 code

INSERT INTRACORONARY STENT

92980
93458
Misuse of column two code with column one code
1
4/1/2011
-

L HRT ARTERY/VENTRICLE ANGIO

 

[FLSJarrel]

Thanks for the information, apparently the program I use for CCI edits is using the older version. I'll need to keep that in mind & now with your help, I have a better handle on accessing CCI edits direct from CMS.