Gastroenterology Coding Alert

Plus: Know when to use modifiers 24 and 57

Whenever two codes hit a coding bundle with edit indicator “1,” as per Correct Coding Initiative (CCI) edits, you have the option of using a modifier such as 59 to override the edit – as modifier 59 is the modifier of last choice, you’ll need to be aware of other modifiers that can be used to unbundle two codes.

CMS has recently added a few more options to the list of applicable modifiers, with the introduction of four more modifiers that Medicare contactors will now accept to bypass CCI edits.

Background: When a CCI coding combination is listed as either a mutually exclusive or comprehensive/component edit, the general rule is that both codes cannot be reported separately. However, two CCI indicators are commonly used to indicate when you can, in fact, report the procedures together under circumstances.

An indicator of “0” indicates that it is never acceptable to bill these procedures together, and an indicator of “1” indicates that these codes are considered bundled but can be billed separately under certain circumstances, such as a separate site, separate incision, or separate injury.

Most coders who are trying to separate CCI edits will use either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for edits involving E/M codes, or modifier 59 (Distinct procedural service) for bundles that involve two procedures.

However, coding experts have long maintained that modifier 59 should be the modifier “of last resort,” making many coders reluctant to use it extensively.

Help Is Here

CMS Transmittal 1136, released on Nov. 1, announces that you’ll be able to use the following modifiers to override a CCI edit with a modifier of “1” effective Jan. 1, 2013:

·         LM (Left main coronary artery)

·         RI (Ramus intermedius)

·         24 (Unrelated evaluation and management service by the same physician during a postoperative period)

·         57 (Decision for surgery)

Whereas modifiers LM and RI will mainly meant for use by heart surgeons, the other two modifiers are quite familiar to most other coders. Both modifiers 24 and 57 can be appended to E/M codes when the E/M service is either unrelated to a surgery (modifier 24) or results in the decision to perform the bundled procedure (modifier 57).

Example: Your gastroenterologist performs a hemorrhoid banding procedure on a patient with recurrent bleeding. You report this procedure with CPT^® code 46221 (Hemorrhoidectomy, internal, by rubber band ligation[s]). The patient returns to the office one week later with complaints of upper abdominal pain, nausea, and fever.  An E&M service for the office visit one week after the hemorrhoid banding might be denied because the surgical global period for code 46221 is 10 days.  Because the office visit is unrelated to the surgical procedure you should append modifier 24 to the subsequent office visit service.

Here are some more examples for modifier 24 and modifier 57 shared by Suzan Hauptman, CPC, CEMC, CEDC, Manager of Physician Compliance and Auditing at West Penn Allegheny Health Systems, Pittsburg, PA:

“If a patient has a procedure that carries a 90 day global period (such as a cholecystectomy) and then comes into the office for something unrelated. Perhaps the patient now has a hemorrhoid, the visit to treat/plan for the hemorrhoid would be billable with the hemorrhoid diagnosis and the -24 modifier appended to the E/M service. Any level of E/M that is documented appropriately is billable in this type of scenario.”

“Patient presents to the office with abdominal pain. It is determined that the patient needs to be taken to the OR for a bowel obstruction, the visit at which this was determined is billable if documented appropriately at any level of service/type if the -57 modifier is appended. The physician cannot bill the service at a high level just because the outcome is surgery; the documentation still has to be medically appropriate and based on the documentation guidelines.”

Resource: To read the complete Transmittal, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1136OTN.pdf.