Pulmonology Coding Alert

You could be losing deserved dollars for given services.

The alleyways of Medicare coding rules are long and winding, and sometimes it’s a challenge to keep a track of all the services for which you can get a rightful reimbursement. Our experts are here to bust three prevailing myths that will help you to rake in deserved payouts:

Myth #1: You Can Never Report Two Codes Included In a CCI Bundle

It’s a common myth that if the Correct Coding Initiative (CCI) prohibits reporting two codes on the same date, that’s the final word. Actually, by clumping all such cases in the same basket, you may be ignoring some legitimate cases where CCI does allow you to use a modifier, such as 59 (Distinct procedural service), to override an edit.

Always keep a sharp eye to catch the CCI edits where you can override code pairs when allowed. These pairs will have a modifier indicator of “1.” However, you should report modifier 59 only when the services are separate, distinct and medically necessary.

For instance, you will find a CCI edit allowing separate reporting for separate pulmonary function testing procedures (e.g., 94060, Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) and simple pulmonary stress testing (94620, Pulmonary stress testing; simple [e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry]) — but only when your physician documents medical necessity and documented need to override the edit. In such cases, you may report 94620, 94060-59, when permitted.

Myth #2: Bilateral Procedures Don’t Require a Modifier 

There is a common misgiving that forgetting to append the appropriate laterality modifier will not hurt much. You can say goodbye to your full reimbursement if you have not appended the correct modifier while coding for bilateral versions of those procedures that are inherently unilateral. 

You may sometimes overlook modifiers while reporting cases of bilateral thoracenteses performed on a patient on the same day. While reporting such bilateral services, you select from modifier 50, 59 or RT/LT, depending on the payer’s preference and recognition of certain modifiers when reporting with 32554. Modifier 50 requires a single line item CPT® code (e.g., 32554-50) with a unit of “1.” The other modifiers require two line items: 32554, 32554-59; or 32554-RT and 32554-LT. When supported with correct documentation, you may receive up to 150 percent of the Medicare allowable rate: 100 percent for the first procedure and 50 percent for the second. 

Note: A bilateral surgery is one that physicians perform on both sides of the body during the same operative session or on the same day (such as 31622, Bronchoscopy, rigid or flexible, including fluoroscopic guidance; diagnostic, with cell washing, when performed [separate procedure]). Remember, you can’t apply this yardstick on all procedure codes that contain the terms “bilateral” or “unilateral or bilateral” in their definitions as they do not yield bilateral pricing (i.e., 150 percent reimbursement). Moreover, only some of the procedures are eligible for bilateral payment. Check the payment policy indicators for each code in the Physician Fee Schedule at www.cms.hhs.gov/PFSlookup/02_PFSSearch.asp.

Myth #3: Once Your Claim Is Rejected, It’s Finished

There is a common perception that if you don’t accept Medicare payers at their word, your practice may be labeled as “troublemaker” or even worse, noncompliant with the False Claims Act’s regulations. Therefore, some coders believe you should accept rejection of your claims, even if you may be right. Sometimes, this may not be such a good idea.

Even if your MAC has denied your claim or requested a refund, go through various resources on the issue before you accept the payer’s judgment. Medico-legal experts say that as a general initial rule, you shouldn’t always give up when faced with “alleged” overpayments. You can always return the money if it is a clear case of overpayment. However, if you are sure that you had submitted the claims properly, then be ready to fight it!

Your best course of action is to appeal any time you feel your payer has erroneously rejected your claim or wrongly requested a refund. Just make sure that the merit of your claim is correctly documented and displayed so that it can stand up to the minutest scrutiny.