Pulmonology Coding Alert

The new Correct Coding Initiative (CCI) revision contains several code edits that rely on the correct use of modifier -59 to capture appropriate reimbursement, and says retroactive reimbursement may be appropriate in some cases. Modifier -59 (distinct procedural service) must be used correctly to support billing separately and obtaining appropriate reimbursement for unrelated procedures performed on the same patient on the same day.

The Health Care Financing Administration (HCFA) issued an updated CCI, Version 6.1, which became effective April 1, 2000. To make sure you receive the maximum reimbursement allowed for services, its crucial that you understand when and how to use modifiers; the CCI includes several edits that refer to modifier -59.

Procedures performed at different sites appropriately may use modifier -59. The CCI will reflect HCFAs edit that code 31629 (bronchoscopy, with transbronchial needle aspiration biopsy) should be allowed with 31628 (with transbronchial lung biopsy, with or without fluoroscopic guidance) as long as the transbronchial needle aspiration biopsy is performed on a lesion other than the one coded as 31628. In this situation, the 31628 and the 31629 should be billed with modifier -59 attached to the second procedure. (See CCI Edits Affect Pulmonology Coding on page 28.) HCFA will allow you to submit retroactively, dating back to Oct. 1, 1998, for reimbursement for CPT codes 31628-31629 appended with modifier -59. Medical billing consultant Don Self, CCS, BFMA, president of Don Self & Associates, a practice management and billing specialist in Whitehouse, Texas, suggests the simplest way to handle this is to file a new claim for the services.

If the carrier denies the claim as being bundled, advises Self, appeal the claim with a copy of the HCFA memorandum, and you should win without any problem.

Editors note: To obtain a copy of any of HCFAs program memorandums, visit the agencys Web site at http://www.hcfa.gov.

Deborah Anderson, a billing consultant with Salem Pulmonary Associates, a physician billing office in Salem, Ore., says the patient encounters can take place on the same day as long as the documentation shows they were done separately.

For example, she says, Its appropriate to bill for a 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) done the day before or on the same morning of the afternoon 94070 (prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, cold air, methacholine or other chemical agent, with subsequent spirometrics]) is performed.

Modifier -59 lets the insurance company know that a separate procedure from the methacholine testthe spirometry, in this instancewas performed. She stresses that its also critical to document the amount of time spent performing the different procedures, and the reason the additional test was performed. Add modifier -59 to your spirometry because the modifier is definitely contingent on a time factor, Anderson adds.

Medicare does not leave it to physicians to determine which procedures are appropriate for application of the -59 modifier. Medicare provides a comprehensive list, which is updated every three months, to include all procedures that are appropriately submitted as separate services. (A current list is available from HCFAs Web site or may be obtained from most commercial claims software vendors.)

Modifier -59 is for distinct and separate procedural services that are not normally reported together, but may need to be under some circumstances. Use modifier -59 to report circumstances similar to these situations:

A procedure or service is distinct or independent from other services performed on the same day.

A different session or patient encounter needs to be represented.

A different procedure or surgery is performed.

A different site or organ system is involved.

A separate incision is used.

A separate injury has occurred (or a separate area of injury in a case of extensive injuries).

A procedure is performed that is not encountered or performed ordinarily on the same day by the same physician.