In the February 1999 issue of CCA (page 13), we urged readers to check their HPSA status to find out if they were eligible for a 10 percent incentive bonus for services provided in a healthcare shortage area.
But we did not remind you to get your Medicare carrier to clarify whether you are in a geographic HPSA or a population HPSA, points out Ron Nelson, president, HSA Consulting Group in Freemont, MI, and advisor to the American Academy of Physician Assistants.
While the differences between these two classifications are too detailed to explain here, the important point for coders is that a population HPSA is not eligible for a bonus payment, he explains. However, Medicare may inadvertently pay if you add the QU or QB modifier. But eventually they will discover their mistake and then practices will have to pay back the overpayment.
Nelson knows of several of these situations. So the precise question our readers need to ask the Medicare carrier is: Do we provide service in a geographic HPSA?
Dealing with Dump Codes
Steve Hunt, business office supervisor for the Portland (OR) Cardiovascular Institute, called to discuss the dump code insert mailed separately from the January 1999 issue of CCA. (The list was compiled from the AMA CPT manual, which flags dump codesunspecified codeswith yellow caution signs.)
What advice should we be giving to our physicians about these dump codes? he asks. Should they not be using them?
Dump codes are not the same as linking codes (codes that support medical necessity), yet they may cause claims to be rejected because they are non-specific or ill defined. Use them as a last resort after youve checked all other options; dont just default to them out of habit.
For example, 401.9 (unspecified essential hypertension) is a dump code that cardiologists may be tempted to use much too often. But you can use your superbill to reduce that tendency by listing the specified diagnostic codes first, 401.0 (malignant) and 401.1 (benign) and then listing 401.9 (unspecified). Hopefully, the physician will select one of the more specific ones because he or she sees it first. When you change the superbill, be sure to follow up with a memo to the physicians reminding them not to use a dump code by default.
Correction Regarding Modifier -59
In the November 1998 issue of CCA (page 12), we reported incorrectly that, in some circumstances, when an EKG and a stress test are performed on the same day, you should attach modifier -59 to the stress test to be reimbursed for both procedures. (Modifier -59, which first appeared in the 1997 edition of CPT, is used to identify procedures and/or services not normally reported together, but under certain circumstances are separately billable. It applies to codes that are bundled under the Correct Coding Initiative [CCI]).
Felecia Bernstein, CPC, formerly of Shore Heart Group in Neptune, NJ, said that modifier -59 should be attached to the EKG (93000), not the cardiac stress test (93015).
The purpose of modifier -59 is to tell payers that, because of extenuating circumstances, the EKG was completely separate from the stress test, she explains. So you need to modify the EKG, not the procedure that normally includes it.
Under CCI, the EKG would be considered part of the cardiac stress test and, as such, would not be separately reportable. But suppose an EKG in the morning showed abnormalities that led to a stress test later that day. Then you should attach a modifier -59 to the EKG to get paid for both.
Bernstein uses this analogy to teach her coders how to properly use modifier -59. Suppose a breakfast includes toast, but you order an extra side of toast. The waitress writes up the side order with a -59 modifier, so the cashier will know that the toast was not part of the meal and should be paid for separately, she says.
This same rule of thumb applies if the cardiologist does an EKG, followed later by a Holter monitor, event recorder or pacemaker check, she adds. You would add a modifier -59 to the EKG to show there were extenuating circumstances which caused the other procedure to be performed at a later time that day, she says.
The American College of Cardiology adds this tip: Dont confuse modifier -59 with modifier -51, (multiple procedures performed by the same physician at the same session on the same day). Modifier -51 is considered a payment modifier, because it directly affects the reimbursement of a procedure. (Medicare says the first procedure listed will be reimbursed at 100 percent, the second through fifth procedures are payable at 50 percent. If you list procedures beyond that, you must submit a report and the carrier will determine payment.)
Thats why, when the physician performs multiple procedures at one session, you should list the one of higher value first and append the -51 modifier to the ones of lesser value.
But modifier -59 is not a payment modifierappending it doesnt directly affect the fee; rather, it tells the carrier that one of the two codes, which are usually bundled, should be paid in this instance.