Radiology Coding Alert

Modifiers -59 (distinct procedural service), -76 (repeat procedure by same physician) and -77 (repeat procedure by another physician) have been designed to provide Radiology Practices with a vehicle to report procedures similar to, or exactly the same as, other services performed on the same patient on the same day.

The advantages these codes offer often go unclaimed if coding professionals dont fully understand which to assign under specific circumstances. As a result, coders risk denials and their radiology practices lose the opportunity to recoup fees and costs invested in the service.

Typically, when Medicare or another carrier spots codes that are generally not reported together or that indicate a procedure has been repeated, reimbursement would be disallowed. Assigning one of these three modifiers to the service codes, however, alerts the payer that the sequence of procedures provided was medically necessary and appropriate under the circumstances.

Understanding Subtle Coding Differences

Modifier -59 is assigned only when a distinct procedural service is provided, Charlene Finchum, CPC, coding specialist supervisor for the department of radiological sciences at the University of Oklahoma Health Sciences Center in Oklahoma City, points out. CPT Codes 2000 notes that this code should be reported when a physician needs to indicate that a procedure or service was distinct or independent from other services performed on the same day, and is used when procedures arent normally reported together. Examples include similar procedures performed on two distinct organs or on separate lesions.

While this is closely related to the description for modifier -76, Finchum notes specific differences. Modifier -76 indicates that the same procedure is repeated by the same physician. For instance, maybe three x-rays are taken of the same body part to locate a fracture. This is a repeated service provided by the same doctor, and the -76 modifier would be correctly assigned.

Modifier -77 is very similar to -76, she adds, but is assigned when a repeat procedure is conducted by another physicianperhaps follow-up x-rays are taken when a second radiologist is on duty.

How to Correctly Assign Modifier -59

In my experience, modifier -59 is most often used when work is being conducted in a vascular field, says Jennifer Butler, radiology coding specialist with Arizona Medical Provider Services Inc., in Cottonwood, Ariz., which has provided billing and management services to radiology practices in Arizona for 11 years. Correctly coding services performed on different families and orders of vessels can be extremely complex, and it is important to understand how -59 applies.

One example of the proper use of -59, she says, is during vascular interventional procedures, such as aortagrams conducted to confirm a suspected occlusion of the carotid arteries (433.1, occlusion and stenosis of precerebral arteries, carotid artery). To pinpoint the condition, the radiologist may examine carotid arterial vessels on both the right and left sides.

In this instance a catheter would most likely be introduced into the femoral artery and, if the radiologist chooses to start with the right side, may be advanced to the right internal carotid artery, which is a third-order branch. This would be coded 36217 RT (selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family, right side).

Then, the physician may also examine the left carotid branch by retracting the catheter from the right side and subsequently advancing it into left internal carotid artery, considered a second order branch. This would be coded 36216 LT -59, (selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family, left side; distinct procedural service).

Because the radiologist conducted the second procedure in an entirely different vascular family, explains Anne Masters, a radiology coding specialist who works with Butler, he or she would be allowed to bill this procedure. Its considered a new service, even though it is being conducted on the same patient on the same day.

The correct use of modifier -59 is critical in situations like this, Masters adds, because 36217 is considered a comprehensive code. Correct Coding Initiative (CCI) edits do not allow 36217, 36216 and 36215 to be reported together.

If the radiology coder had simply reported the 36217 and the 36216 together, the claim for 36216 would almost certainly have been disallowed, she points out. Because 36217 includes the work conducted as the interventionalist passes the catheter through the first- and second-order vessels, it would typically not be correct to assign both 36216 and 36217 to the same procedure.

By adding the -59 modifier to the 36216, however, you alert the insurer that the second charge reflects a distinct procedurein this case, catheterization of the left carotid artery, in addition to the right carotid.

How to Correctly Assign Modifiers -76 and -77

Coding experts note that use of modifiers -76 and -77 is easier to understand. In both cases, the code is assigned to a repeated procedure. The difference between the two is that -76 is assigned when the procedure is performed by the same physician, while -77 describes the procedure when performed by a different physician.

Modifier -76 may be assigned if a newborn has suffered from respiratory stress syndrome (769), for instance, says Finchum. It may be medically necessary to perform four or five chest x-rays on the same day to assess how well the infants lungs are functioning.

The first x-ray would be reported using CPT code 71010 (radiologic examination, chest; single view, frontal). Subsequent x-rays read by the same radiologist would be assigned 71010-76. If another radiologist read any of these x-rays, they would be coded 71010-77.

Another example may occur in the emergency department if a trauma patient presents with a broken arm (812.40, fracture of the humerus; lower end, unspecified part). An x-ray may be taken to locate the fracture (73060, radiologic examination; humerus, minimum of two views) and then repeated after the cast had been applied to determine that the bone had been set correctly.

In this instance, the initial x-ray would be coded 73060, while the second would be assigned 73060-76 if the same radiologist read the films or 73060-77 if another radiologist performed this service.

Coding tip: The use of modifier -59 is standard across the country for Medicarebut some third-party payers do not recognize it. In addition, some areas do not allow the use of modifiers -76 and -77. Instead, alternative systems have been implemented. As always, follow the instructions of your local payers when coding the procedures described here.