Cardiology Coding Alert

NCCI 11.2 says these procedures are mutually exclusive. This means that you cannot report both 0076T and one of these codes on the same day and expect to receive reimbursement for both procedures. Instead, Medicare will only pay for the lesser-valued of the pair. Because the modifier indicator is a "1," however, you can override this edit using a modifier - if the procedures are distinct from one another.

Example: The four codes listed above actually reference different vessels. A common example in which you may need to separate this edit with a modifier is when the doctor places a stent in a renal artery (37205) and one in the vertebral artery (0076T). These are in separate vessels, so you can use modifier 59 (Distinct procedural service) to separate the procedures

#2: Double-Check Claims With 0078T and 0080T

According to NCCI 11.2, you can no longer report certain cardiology codes together because you are unlikely to perform them during the same session.

In particular, you can't report codes 0078T (Endovascular repair of AAA, pseudoaneurysm or dissection, abdominal aorta involving visceral vessels, using fenestrated modular bifurcated prosthesis) and 0080T (... radiological supervision and interpretation) with the following:  

 * This code is the only edit with a modifier indicator of "1." Every other edit is listed with a "0," meaning you cannot bypass the edit under any circumstances.

Understanding the direct repair edit won't be too difficult. "You're not likely to find cardiologists completing or performing an endovascular repair at the same time of an open direct repair unless, of course, the endovascular procedure was unsuccessful. In that situation, you'd look to codes 34830-34832 instead," says Gary W. Barone, MD, associate professor at the University of Arkansas for Medical Sciences in Little Rock.

As for 34900 (Endovascular graft placement for repair of iliac artery [e.g., aneurysm, pseudo-aneurysm, arteriovenous malformation, trauma]), you've got a trickier situation.

Best bet: "One of the keys is to understand the anatomy involved," says Roseanne R. Wholey, president of Roseanne R. Wholey and Associates in Oakmont, Pa.

There are three iliac arteries - the common, internal (hypogastric), and external - and 34900 does not differentiate which iliac artery the cardiologist repairs, Barone says.

Example: A cardiologist repairs an isolated internal or external iliac artery aneurysm separate from an aortic aneurysm. At the same time, the cardiologist also repairs an aortic aneurysm with an endograft. Although you may be tempted to report both 34900 and 0078T, NCCI 11.2 prevents reimbursement for both. These procedures are mutually exclusive, and no modifier can separate them. You'll therefore receive payment for the lesser-valued code.
 
Note: Code 0078T is among cardiology Category III codes 0075T-0088T that have a "C" status for 2005, according to CMS. A "C" status means that you'll have to appeal to your carrier for pricing information.

#3: Don't Be Duped by Duplex Scan Edits

Duplex scan codes 93975-93979 will become components of the code for supervision and interpretation of the IVC filter placement, 75940 (Percutaneous placement of IVC filter, radiological supervision and interpretation), but you will be able to use a modifier to override those edits.
 
Note: Duplex scan, a noninvasive vascular diagnostic study, implies an ultrasonic scanning procedure display of both two-dimensional structure and motion with time and Doppler ultrasonic signal documentation. The documentation also includes spectrum analysis and/or color flow mapping or imaging, says Cynthia A. Swanson, RN, CPC, senior consultant for Seim, Johnson, Sestak & Quist LLP, in Omaha, Neb.

Originally, CMS wanted to set those duplex scan edits so you couldn't use a modifier with them, but the Society of Interventional Radiology (SIR) convinced the agency to allow a modifier, says Dawn Hopkins, senior manager for reimbursement with SIR. "We were able to present to them that these were just unrelated procedures and they just could be performed together," she says. "You can't just base edits on the idea that I've never seen claims for A plus B, so A and B can never be performed together."

#4: Avoid Coding Needle/Cath Placement Separately

NCCI 11.2 strikes at needle placement (36000, Introduction of needle or intracatheter, vein) and catheter placement codes (36010-36014), turning theminto component codes of heart imaging codes, such as 78492 (Myocardial imaging, positron emission tomograpy [PET], perfusion; multiple studies at rest and/or stress).

These edits fit under the reasoning of (1) standards of medical practice and (2) more extensive procedure. Because the cardiologist can't perform some procedures without inserting a needle or catheter, you shouldn't report them separately from their column 1 counterparts.

Note: If you've got stellar documentation meeting modifier criteria, however, you may append a modifier to separate these edits because they carry a modifier indication of "1."

Example: Your cardiologist should not separately report 93503 (Insertion and placement of flow-directed catheter [e.g., Swan-Ganz] for monitoring purposes) and 36013 (Introduction of catheter, right heart or main pulmonary artery). As of July 1, code 93503 includes 36013. The appearance of these two codes on a claim without a modifier and supporting documentation will result in reimbursement for 93503 only.

#5:  Include Singles in Multiple PET Scan Codes

When your cardiologist performs a multiple-study PET scan (78492, Myocardial imaging, positron emission tomograpy [PET], perfusion; multiple studies at rest and/or stress), then he's also performed a single-study PET scan (78491, ... single study at rest or stress). The multiple study includes the less extensive procedure of the single study.

Red flag: You cannot separate this pair with a modifier because they have a status indicator of "0."

In addition: Both single (78491) and multiple (78492) PET scans now include the venipuncture code 36410 (Venipuncture, age 3 years or older, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes [not to be used for routine venipuncture]). You can separate these edits, as long as you've got solid documentation supporting the use of a modifier.