Part B Insider (Multispecialty) Coding Alert

Published on Thu Sep 15, 2005 PDF

Muster extra documentation to pass carrier scrutiny on catheterization

Effective Oct. 3, the bilateral status for a series of selective catheter codes has changes. Read on to learn how to get a full 150-percent reimbursement for multiple units of CPT 36215 under the new rule.

The Centers for Medicare & Medicaid Services changed the bilateral status for thoracic/brachiocephalic codes 36215-36217 from "1" to "0" (See PBI, Vol. 6, No. 31). That means you can't use the 50 or LT/RT modifiers with these codes, but you can use the 59 modifier for separately identifiable services.

Correction: The earlier PBI story incorrectly stated that you'll only receive payment for one unit of 36215-36217 after Oct. 3. In fact, you can bill for multiple instances of these codes using the 59 modifier, or the frequency unit data field, says the Society for Interventional Radiology.

Example: If your physician performed a selective catheterization of both the innominate and the left common carotid vessels, in the past you would have reported 36215-LT, 36215-RT. After Oct. 3, you should either report 36215 x 2, or 36215, 36215-59. You'll receive 150 percent of the reimbursement for 36215.

But if you use the LT/RT or 50 modifiers, then you'll only receive payment for one unit of 36215.

Note: This change will be more of a problem for radiologists than for cardiologists, because radiologists catheterize further up in the brain, according to Laguna Beach, CA-based consultant Terry Fletcher.

"We're going to have trouble with carriers understanding the changes," worries Dawn Hoy, AR manager with Advanced Cardiac Specialists in Phoenix, AZ. She's waiting to see if her carrier will deny claims with the 59 modifier, because of questions as to whether each service is separately identifiable. With the LT/RT modifiers, "it was perfectly clear they were different families."

Smart idea: You may have to gather more documentation to support multiple units of these codes for a while, in case the carrier decides to deny or downgrade your claims.

SIR and the American College of Radiology wrote to CMS to ask it to delay the bilateral status change for 36215-36217, or to change the bilateral status to "3" instead of "0". With a status of "0," carriers may downgrade two units of 36215 from 150 percent to 100 percent of the reimbursement if coders inadvertently use the LT/RT or 50 modifiers, worries Dawn Hopkins, the SIR's senior management of reimbursement.

CMS officials told SIR that you should try using the frequency limits field instead of the 59 modifier, because there's no limit to the frequency rate at which you can report these codes, Hopkins reports. But either way, CMS officials claim you should receive the 150 percent you're entitled to.