Wiki Please help- Mitral valve repair converted to Mitral valve replacement (33430 & 33425)

[malery_03]

Hi all,
How would you code a MEDI-CAL claim for a Mitral valve repair that was converted to a Mitral valve replacement? I just wanted to know which of the two would be primary and the correct modifiers to append. Thank you!

33430-AG, 22
33425-51,52,59

OR

33425-AG,52
33430-22,51,59

 

[cpc2007]

Hi! If the repair was attempted and the mitral valve replacement was then performed during the same surgery, I would actually report only the successful procedure (the replacement). In that case, I would agree with 33430.AG for Medi-Cal coding (if you have documentation of significant increased complexity, you can add modifier 22, but cannot tell from the question that the modifier 22 would be appropriate).

The reason I would not add the 33425 is that there is an NCCI edit between 33430 and 33425 with 33425 bundling as a mutually exclusive procedure. Mutually exclusive procedures "cannot reasonably be performed at the same anatomic site or during the same encounter" (per the NCCI Policy Manual, Chapter 1, section P). Since the repair and the replacement were both at the same anatomic site (the mitral valve) and presumably during the same encounter (given the modifiers suggested), the 33425 cannot be unbundled. The edit between 33430 and 33425 allows for the modifier to bypass the edit in rare circumstance (e.g., a repair was attempted at one encounter and the valve was replaced at a separate encounter later that day). Medi-Cal does follow NCCI guidelines per their website: https://files.medi-cal.ca.gov/pubsdoco/ncci/ncci.asp. For that reason, I would again code only the 33430.AG here, and would consider adding modifier 22 if the full details of the operative report support that additional modifier.

I hope that helps

Kim
www.codingmastery.com