Cardiology Coding Alert

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Pennsylvania's Independence BCBS New Modifier 25 Policy Cuts Payments

How will this policy impact your cardiology reimbursement?

Is Pennsylvania's Independence Blue Cross Blue Shield a payer for your cardiology practice? If so, don't miss their most recent modifier 25 policy, which states that you will now be facing a 50 percent reduction to claims appended with modifier 25.

Practices Billing This Payer Will See Modifier 25 Pay Slashed by Half

Here's the scoop: Effective as of August 1, Independence will reimburse claims appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) "at 50 percent of the applicable fee schedule amount" in the following circumstances, the payer said in a May 1 notification:

  • When the E/M service is submitted on the same date of service, by the same professional provider or other qualified healthcare provider, as a minor procedure. Note that a minor procedure has a zero-day or 10-day post-operative period.
  • When a problem-focused E/M service is submitted on the same date of service, by the same professional provider or other qualified healthcare provider, with a preventive E/M.

In addition, Independence's notification indicates that when you're using modifier 25, "documentation for the additional E/M must be entered in a separate section of the medical record in order to validate the separate and distinct nature of the E/M service." Therefore, it appears that this payer will no longer allow you to document both the E/M and the procedure in the same sentence or paragraph of the note.

Pay Cuts Could Be Major

Seeing your pay fall by 50 percent for E/M services with modifier 25 appended could be a drastic change for practices.

Example: The cardiologist sees an inpatient for acute claudication/ischemia of the foot and recommends peripheral vascular angiography with possible intervention. The same day, the cardiologist performs angiography and mechanical thrombectomy of the patient's popliteal artery.

You should report the following codes:

  • An E/M codes like 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...)
  • Append modifier 25 to the E/M code to show that the service was significant and separate from the procedures performed the same day
  • A diagnostic angiography code, such as 75716 (Angiography, extremity, bilateral, radiological supervision and interpretation)
  • Modifier 26 (Professional component) appended to the angiography code (75716) to indicate that you're coding only the angiography's professional component; this is the only service the cardiologist performed that has separate professional and technical components
  • Popliteal artery thrombectomy code 37184 (Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection[s]; initial vessel)
  • A catheter placement code, such as 36247 (Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family).

You would normally collect about $105 for the 99233 service, based on the 2017 Medicare Physician Fee Schedule values. However, under the new Independence Blue Cross rules, that number will fall to just $52.50. Say you report 99233-25 twice a day at your practice - you've now just lost $525 a week or close to $27,300 annually from Independence Blue Cross Blue Shield.

"This policy is absurd," says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO,  AAPC Fellow and vice president at Stark Coding & Consulting LLC in Shrewsbury, New Jersey. Although the policy is not a broad CMS directive, it could begin to infiltrate other payers if practices affected by it don't act quickly.

"This could really affect the bottom-line of the practice," says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med Group in Pittsburgh. "The patient's health and convenience are always considered by the providers, but once they start losing money when performing both services on the same day, they will have no other choice but to schedule the patient at a later date for the procedure."

Consider this advice: If you have contracts with Independence Blue Cross Blue Shield, consider approaching your state medical society to see if this policy represents such a radical reinterpretation of contract terms that is not a legally allowable unilateral amendment without the payer getting permission from the state's department of insurance or other regulatory body. Some states have such regulations.

What this could do, according to Hauptman, is burden the patient with a return to the office.

"The physician wants to provide the best healthcare possible to his patients. However, cutting the reimbursement for these surgeries by 50 percent may not cover the expenses to perform them at that time," Hauptman says. "The E/M service that was performed in order to make certain the procedure is the best course of treatment should stand on its own merit when the procedure is performed. Applying the modifier 25 to that visit should clearly illustrate that the both services were performed in their entirety and should be paid accordingly."