General Surgery Coding Alert

Question: A patient with atherosclerotic heart disease undergoes a diagnostic cardiac catheterization 93458 (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed). During the same encounter, the cardiologist performs a coronary angiography as part of the catheterization procedure 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed, single major coronary artery and/or its branch(es); 1 lesion involving 1 or more coronary segments). I noticed there’s a National Correct Coding Initiative (NCCI) edit between the reported services: Could I add modifier 59 (Distinct procedural service) to the second procedure (92928) since the physician performed two different procedures? Or maybe modifier XU (Unusual non-overlapping service) because the second service represents additional work?

Alabama Subscriber

Answer: No, your reasoning does not support appending either modifier. The Centers for Medicare & Medicaid Services (CMS) specifically warns that coders should not use modifier 59 or the X{EPSU} modifiers simply because two services have different CPT^® code descriptors.

For an NCCI edit, the documentation must demonstrate that the services meet the requirements for a distinct procedural service. Appropriate circumstances can include a different encounter, different anatomic site or organ system, separate lesion, separate incision or excision, or another circumstance that establishes that the services did not overlap.

If the physician performs both services during the same cardiac catheterization encounter and the coronary angiography represents work already included in the primary procedure, you cannot append modifier 59 or XU merely to force separate payment. The fact that the codes describe different services does not, by itself, establish that the services were distinct. CMS specifically identifies this reasoning as a misuse of modifier 59.

Suppose the physician performs a medically necessary diagnostic procedure during one encounter and later performs a genuinely separate procedure at a different anatomic site. If the applicable NCCI edit permits a modifier and the documentation clearly supports the separate service, modifier 59 or a more specific X modifier may be appropriate.

Beware: A pattern of appending these modifiers to edited code pairs without documentation demonstrating separate and distinct services can attract payer scrutiny and create an audit risk.

Do not use modifier 59 or XU as a payment workaround. When you encounter an NCCI edit, first determine why the edit exists. Then review the documentation to determine whether the physician performed services that meet the modifier’s requirements. If the services overlap or the documentation does not establish a distinct service, leave the modifier off.

NCCI edits and modifier indicators can change by code pair and quarterly update. Always verify the current NCCI edit and its modifier indicator before reporting a modifier.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor