Part B Insider (Multispecialty) Coding Alert

Published on Sun Nov 26, 2006 PDF

Hint:  You can't have a diagnostic cath twice at different facilities

When one patient receives the same service at two different facilities, you may have to step carefully to obtain your rightful reimbursement.

The problem: Greenwich Hospital in Greenwich, CT sometimes has to send patients to its affiliate, Yale New Haven Medical Center, for cardiology interventions, writes Carl DeRosa with Cardiovascular Services of Greenwich.

That’s because Greenwich Hospital’s Certificate of Need (CON) license with the state doesn’t allow it to perform some cardiac interventions in-house, he explains.

So Greenwich Hospital performs the initial catheterization on the patient, and then sends the patient over to Yale New Haven. But payors often won’t cover the initial catheterization when the patient receives two catheterizations on the same day, DeRosa says. Greenwich Hospital is also having trouble obtaining payment for evaluation and management services on the same date, even with the 25 modifier.

The solution: Most payors “will never pay for a second cath when the problem has been identified with the first cath,” says Jan Rasmussen, president of Professional Coding Solutions in Eau Claire, WI.

The second clinic or hospital shouldn’t be billing for a diagnostic cath, adds Terry Fletcher, coding consultant in Laguna Beach, CA. It should bill the second cath as angiography instead. “The CPT book is clear that if there is a prior diagnostic study and the patient’s condition has not changed, then the doc should only bill for the intervention,” she adds.

You could try appending the 76 or 77 modifier to the second catheterization code, advises Krista Jackson, coding and compliance coordinator with Northeast Cardiology Associates in Bangor, ME. Some payors may also prefer the 59 modifier, she adds.

Moneymaker: If the double catheterization is an occasional circumstance, it may be worth appealing those denials, advises Christopher Felthauser, medical coding instructor for Orion Medical Services in Eugene, OR. If you don’t win those appeals, you should make some arrangement with the second facility for shared payment.

If the physician initially encountered the patient in the hospital, or the patient came into the Emergency Room, then the physician should be able to bill a separate E/M, says Fletcher. A different diagnosis is helpful, she adds. But if the cardiology intervention was scheduled in advance, then the only billable E/M services is the initial consult.

The 25 modifier is the most overused modifier, says Felthauser. “No wonder it’s under investigation so much.” Some payors are denying all 25 modifier claims and making people appeal them, because it’s so frequently abused.