Coding Strategy

Overlooking these new Interstim and hemorrhoid destruction bundles could mean denial headaches.

Don’t let CCI version 16.1’s lack of ob-gyn mutually exclusive edits lull you into a false sense of security. Here’s what you need to know to prevent a denial from landing on your desk.

Payers like Noridian Part B will cover the female stress urinary incontinence treatment code 0193T, but before you submit a 0193T claim, you’ll have to check with the Correct Coding Iniative (CCI) version 16.1’s edits. For instance, as of April 1, the work represented by 0193T will include that of cystourethroscopy codes 52000-52001 and 52281.

1. Look For 0193T in Both the Column 1, Column 2 Position

In 2009, CPT added 0193T (Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence) to your possible stress urinary incontinence (SUI) treatment coding options. This code includes the Renessa transurethral collagen radiofrequency denaturation procedure. Ob-gyns typically perform this nonsurgical, minimally invasive alternative for women who have failed other nonsurgical treatments or who aren’t good candidates for surgery.

What happens: The ob-gyn uses controlled heat at low temperatures and targets tissue in the woman’s lower urinary tract. The heat changes the structure of the patient’s natural tissue collagen. This helps the firmness of tissue and improves her continence. Although the ob-gyn may use heat on multiple sites and document multiple cycles, you should report 0193T once to represent all the treatment cycles performed during an encounter.

As of April 1, 0193T will include the work represented by 52000-52001 (Cystourethroscopy …) and 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female).

Reaction: “These edits don’t surprise me at all because 0193T says ‘transurethral’ which implies the use of the scope,” says Jan Rasmussen, CPC, AGS-GI, ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis. For instance, you should always include “inserting the scope (52000) into the major procedure.” As for 55281, “that is a little less obvious,” but CCI “probably bundled that because these services may be part of the approach,” Rasmussen adds.

You should also include 53660-53666 (Dilation of female urethra …) and 90901 (Biofeedback training by any modality). CCI describes these edits as “misuse of column 2 code with column 1 code” (0193T). Remember: Column 1/column 2 edits describe “bundled” procedures. The column 1 code generally represents the comprehensive service, and the column 2 code is the component that is part of the more extensive column 1 procedure, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, consultant with MJH Consulting in Denver.

All of these edits carry a modifier indicator of “1,”meaning you can use a modifier (such as 59, Distinct procedural service) to separate them — but make sure your documentation supports the modifier.

Additionally, as of April 1, you should do the opposite and bundle 0193T into the following services:

• 51845 — Abdomino-vaginal vesical neck suspension,with or without endoscopic control (e.g., Stamey, Raz, modified Pereyra)
• 51990 — Laparoscopy, surgical; urethral suspension for stress incontinence
• 51992 — … sling operation for stress incontinence (e.g., fascia or synthetic)
• 57160 — Fitting and insertion of pessary or otherintravaginal support device
• 57288 — Sling operation for stress incontinence (e.g., fascia or synthetic).

CCI describes these bundles as “misuse of column 2 code” (which is 0193T) “with column 1 code.” Again, all of these edits carry a modifier indicator of “1,” meaning you can use a modifier to separate it — but make sure your documentation supports the modifier, or you’ll face a denial.

2. Take Note of New Fluoroscopy Bundle With Interstim Procedure

If your ob-gyn tests electrodes for the Interstim procedure, you’re probably used to reporting 64561 (Percutaneous implantation of neurostimulator electrodes; sacral nerve [transforaminal placement]).

What you may not be used to is including fluoroscopy codes (76000-76001, Fluoroscopy …; 77002-77003, Fluoroscopic guidance …). CCI 16.1 tacks these codes as column 2 codes with a modifier “1” indicator, which means you’ll have to append  — and justify — a modifier onto the fluoroscopy code to separately report both procedures.

To read more about this change and how it could affect you, subscribe to Ob-Gyn Coding Alert (Editor: Suzanne Leder, BA, MPhil, CPC, COBGC).

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Sometimes CCI compliance requires looking beyond the edit pairs.

Correct Coding Initiative (CCI) edits don’t bundle SPECT (78803) and planar (78070) parathyroid imaging codes, but coding experts often tell you not to code the two together for SPECT and planar parathyroid imaging on the same date.

Add some method to this madness by looking at the information offered by two coding resources, the Society of Nuclear Medicine (SNM) and the NCCI Policy Manual for Medicare Services (CCI Manual).

1. SNM Singles Out 78803

SNM’s online Practice Management Coding Corner features a Q&A that recommends reporting 78070 (Parathyroid imaging) for planar imaging alone, but 78803 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; tomographic) for parathyroid SPECT imaging with or without planar, says Jackie Miller, RHIA, CCS-P, CPC, vice president of product development for Coding Metrix Inc. in Powder Springs, Ga.

Support: “Choose the single code that describes the protocol and procedure performed,” states the Q&A, located at http://interactive.snm.org/index.cfm?PageID=2442&RPID=1995. SNM “would NOT recommend coding both CPT codes,” the article notes.

2. CCI Makes the Case for SPECT Code

Although there is notyou won’t find any a specific edit bundling 78070 and 78803, CCI does address the SPECT/planar issue in the CCI Manual, says Miller.

CCI Manual, Chapter 9, Section E.2, explains that you may not report a SPECT study and planar study of the same limited area because “Single photon emission computed tomography (SPECT) studies represent an enhanced methodology over standard planar nuclear imaging. When a limited anatomic area is studied, there is no additional information procured by obtaining both planar and SPECT studies.”

Bonus tip: The manual indicates you may report both planar and SPECT codes only when the size of the scanned area makes both sets necessary, such as with whole body bone scans with SPECT studies, says nuclear medicine coding expert Denise Merlino, MBA, CNMT, FSNMTS, CPC, president of Merlino Healthcare Consulting in Magnolia, Mass. Also keep an eye out for vascular flow studies. If the radiologist performs planar vascular flow studies alongside SPECT studies, you should report the vascular flow combined code, not the flow, planar, and SPECT studies independently, Merlino says.

@ Radiology Coding Alert. Editor: Deborah Dorton, JD, MA, CPC

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Modifier 59 sometimes will rescue your reimbursement.

Just when you’re finally getting a handle on all the 2010 coding changes, here comes round two of the Correct Coding Initiative (CCI) edits. Version 16.1, which took effect April 1, will tie your hands when coding many common urology procedures, including prostate biopsies and urethral dilations.

Heads up: CCI 16.1 includes 2,054 new active pairs and 1,947 modifier changes, says Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions Inc. in Clearwater, Fla.

“For urology, there will be 78 edit pair additions and two edit pair deletions,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.To ensure you get paid appropriately for your urologist’s services this quarter, here’s the rundown of the most important changes.

Say Goodbye to Biopsy with Several Prostate Procedures

You can no longer report prostate biopsy codes 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) or 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance) with 52630 (Transurethral resection; residual or re-growth of obstructive prostate tissue including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]). Your payer will reimburse you for 52630 but deny the biopsy codes, and you cannot use a modifier to separate these new edits.

“I have a major issue with the bundling of 55700 and 52630,” laments Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. Kater says her urologists perform a good number of prostate biopsies transrectally and 55700 is what she uses because the descriptor says “any approach.” When you are performing two separate procedures utilizing two different approaches, how can they be bundled?”

Silver lining: CCI also bundles 55705 (Biopsy, prostate; incisional, any approach) into 52630, but the edit carries a “1” modifier indicator. Therefore, you can break that bundle if clinical circumstances warrant separate reporting.

Additionally: As of April 1, transurethral resection of the prostate (TURP) code 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) and laser prostatectomy codes (52647-52649) are mutually exclusive with saturation biopsy of the prostate under anesthesia (55706).

The 52601/55706 and 52648/55706 bundles have a modifier indicator of “0” so you can never bill those codes together. On the other hand, the 52647/55706 and 52649/55706 bundles both have a modifier indicator of “1,” which means you can report the codes together underspecific clinical circumstances using a modifier such as modifier 59 (Distinct procedural service), Ferragamo says.

You will also find prostate biopsy listed as a column 2 code (55706), forming mutually exclusive edits with the following column 1 codes:

• Transurethral destruction of prostate tissue (53850-53852)
• Prostatectomy (55801-55845, 55866)
• Cryosurgical ablation of the prostate (55873).

The modifier indicator for all of these above edits is “1.” You can break the bundles when clinical circumstances warrant.

Beware Multiple Urethral Dilation Edits

CCI 16.1 hits urethral dilation coding hard. To find out what edits you need to apply to your urology practice pronto, subscribe to the Urology Coding Alert.

Editor: Leesa A. Isreal, CPC, CUC, CMBS

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These edits took effect April 1, so start observing them yesterday.

The latest version of the Correct Coding Initiative (CCI) has an edit that family practice coders should note – especially if the practice treats newborn patients.

Get to know the new CCI 16.1 edit and get ready to observe it with this expert breakdown. Check Column 1 on These Hospital E/Ms According to CCI 16.1, these codes are in column 1 of the mutually exclusive edits:

• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity …)
• 99232 (… an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity …)
• 99233 (… a detailed interval history; a detailed examination; medical decision making of high complexity …).

Column 2 of these edits includes these codes:

• 99460 (Initial hospital or birthing center care, per day,for evaluation and management of normal newborn infant)
• 99461 (Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center)
• 99462 (Subsequent hospital care, per day. for evaluation and management of normal newborn).

Translation: An FP may not report both normal newborn care and subsequent hospital care for a newborn on the same date of service. If the FP performs normal newborn services (99460-99462) on the same date that the newborn later becomes ill and receives subsequent hospital care (99231-99233), you should only report a code from the 99231-99233 code set, explains Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

The services are mutually exclusive because the newborn care codes (99460-99463) are for “normal” newborns (i.e., newborns without medical problems); whereas the subsequent hospital care codes (99231-99233) are for problem-oriented services, Moore says.

Since both sets of services are designated as “per day,”coders must choose between them for a given patient on a given date. “Consistent with the mutually exclusive nature of these services, CCI does not permit a modifier to override the edits,” Moore continues.

Bottom line: Never report 99460-99262 and 99231-99233 for the same patient on the same date of service.

@ Family Practice Coding Alert. Editor: Chris Boucher, CPC

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If you’ve been holding study claims, the time to send them in is here.

Correct Coding Initiative (CCI) version 16.1 has the news you’ve been waiting for.

The latest version, effective April 1, deletes 142 edit pairs, Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions Inc. in Clearwater, Fla., reported in a March 22 announcement.

Most importantly: As expected, CCI deleted the edits mistakenly added Jan. 1 that blocked payment for recording, pacing, and electrophysiology (EP) studies performed on the same date of service as an intracardiac catheter ablation procedure (see chart).

Adding potentially delayed EP payments to Medicare’s 2010 fee cuts did not equal good news, as Jennifer Crowell, CPC, CCC, CEMC, lead hospital coordinator for Spokane Cardiology in Washington, pointed out. And the edits had a modifier indicator of “0,” so there was no way to override them to receive payment. (See Cardiology Coding Alert, Vol. 13, No. 1, “Red Alert: Expect EP Study + Ablation Denials Until April 1,” for more information.)

Stake Your Claim for EP Pay

Act now: CCI lists the deletions with a modifier indicator of “9” and shows Jan. 1, 2010, as both the effective and deletion dates, both of which indicate the deletion is retroactive to the effective date. That means if you’ve been holding your claims or have gotten denials because of the erroneous edits, you may now submit the claims for payment.

@ Cardiology Coding Alert, Editor: Deborah Dorton, JD, MA, CPC

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