Modifier Coding Alert

Published on Mon Nov 24, 2014 PDF

Appeal denied PCI claims to recoup hundreds of dollars.

Some of your percutaneous coronary artery (PCI) claims may be going unpaid because you’re not attaching an appropriate modifier. 

Get familiar with the five coronary artery modifiers to determine which apply to your clinical scenario, to guarantee more accurate and profitable claims.

Match the Artery to the Modifier

Some Part B Medicare administrative contractors (MACs), such as National Government Services (NGS), have told their providers to review their denied PCI claims looking for missing coronary modifiers and to appeal them with the modifier attached. 

You’ll report coronary therapeutic services and procedures using codes in the 92920-92973 range, and most likely, you’ll need a modifier with those codes. There are five coronary modifiers that correspond to the five major coronary arteries:

• LD — Left anterior descending coronary artery
  
• RC — Right coronary artery
  
• LC — Left circumflex coronary artery
  
• LM — Left main coronary artery
  
• RI — Ramus intermedius coronary artery.
  

You may need to include one of these modifiers to identify which vessel was involved in the PCI procedure. Have a conversation with your payers to see if they require a coronary modifier.

Example: Your physician places a stent in the right coronary artery. He then performs an atherectomy of a different lesion in the right coronary artery and balloon angioplasty of the right coronary artery.

Code it: You’ll code 92933 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch), which covers all three procedures. Attach modifier RC to 92933 to identify the vessel as the right coronary artery.

Money talks: Your failure to include the modifier could result in a denial and a loss of $697.47 for the PCI service (92933 relative value units of 19.47 times the national unadjusted 2014 conversion factor 35.8228 = $697.47).