Coding Strategy

Anesthesia, patient well-being can clue you in to the best modifier choice.

When your urologist ends a procedure early, you know you need to append a modifier to the procedure code, but the challenge is deciding between modifier 52 or 53. Learn the very specific criteria for reporting each modifier to ensure successful coding every time.

Turn to 52 for ‘Physician Discretion’

You should use modifier 52 when your urologist, while performing a service or procedure, chooses to partially reduce or eliminate a portion of the code’s requirements.“Under certain circumstances a service or procedure is reduced at the physician’s discretion and this decision can be made prior to or during the procedure,” explains Daniel J. Rogers, practice manager for Gulf South Urology in Biloxi, Miss.

You should use modifier 52 when services your urologist performs are less than those described by the code. For instance, you can use modifier 52 when the urologist performs a service/procedure unilaterally when code specifies “bilateral.” In such a case, you must be certain that there is no designated CPT code to describe the lesser procedure.

Example: Your urologist performs a retropubic radical prostatectomy with nerve sparing and a unilateral pelvic node dissection. Report 55845-52 (Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy …) for the procedure.

Because the code descriptor for 55845 specifies bilateral, and the urologist performed only a unilateral node dissection, you should append modifier 52. You do not have to indicate the side, but that information should be in your urologist’s documentation if the payer requests the documentation.

Tip: Let the payer reduce the fee for the procedure when you use modifier 52. Do not apply the fee reduction on the claim. If you do, the payer may still reduce your reimbursement because of the modifier, and you may then receive a double fee reduction.

Tackle Extenuating Circumstances With 53

You will use modifier 53 when your urologist ends a procedure due to a threat to the patient’s well being or other extenuating circumstances, says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn. For example, if the equipment your urologist is using fails, and he has to discontinue the procedure before completion, append modifier 53 to the procedure code. Note: Equipment failure qualifies as an extenuating circumstance.

Documentation clue: Look at your urologist’s documentation to see if the patient underwent anesthesia. You can only use modifier 53 after anesthesia administration and/or a surgical prep took place, and the procedure was actually started, Gross cautions. CPT “specifically states that the procedure was started but discontinued due to extenuating circumstances. This implies that the patient has been fully prepped and anesthetized for surgery,” Rogers confirms.

Example: Your urologist performs a transurethral resection of the prostate (TURP) but must terminate the procedure before finishing because the patient’s blood pressure drops significantly for an extended period of time. You should report code 52601-53 (Transurethral electrosurgical resection of prostate , including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) for the TURP procedure. Just as with modifier 52, you should let the payer reduce the fee on services to which you attach modifier 53. Otherwise, you risk additional payment reductions.

Bottom line: “When reading the operative report of a discontinued service, simply look at the reason for the discontinuance,” Rogers says. “Was it an extenuating circumstance — in which case it would be it would modifier 53? Was it physician discretion? Then it would be modifier 52.”

Facility difference: If you are coding only for facility payment, such as for an ambulatory surgical center (ASC), use modifiers 73 (Discontinued outpatient procedure prior to anesthesia administration) or 74 (Discontinued outpatient procedure after anesthesia administration) instead of 52 and 53, says Nancy Giffin, MA, CPC, CUC, billing manager for five physicians at the Swedish Urology Group in Seattle.

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Knowing how to use add-on codes can net you up to $258 in additional reimbursement.

CPT is full of “add-on” codes, additions to minor and major surgical procedures as well as to E/M services. Fortunately for urology there are not many “add-on codes,” but that makes it essential for you to know the special rules that apply to these codes when you do have to use them. If you learn just a few main guidelines, you can gain the best possible reimbursement for your urologist’s procedures including all add-on codes.

Look for the ‘+’ Symbol

There’s an easy way to tell if a CPT code is designated as an add-on code…

Just look for a plus sign (+) symbol to the left of the code in your CPT manual. Another hint is that in their code descriptors all add-on codes contain a variation of the phrase “List separately in addition to code for primary procedure.”

“You will also find a listing of the CPT code range in which that add-on code may be used in addition with,” says Nicole Martin, CPC, owner of Innovative Coding Analysis in Coplay, Penn. That listing follows the add-on code descriptor in the CPT manual.

Example: For urology a typical add-on code listing appears as follows:

• +57267 — Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure).

Pointer: CPT designates some E/M services as add-on codes as well. For instance, you may report prolonged services — such as +99354 (Prolonged physician service in the office or other outpatient setting …) — in addition to other primary E/M services such as an outpatient visit.

Tip: Remember you can find a complete list of add-on codes in Appendix D of your CPT manual.

Always List “Add-Ons” With a Primary Procedure

As noted above, you should never report an add-on code without also listing a “primary” procedure code.

Here’s why: The add-on code describes additional intra-service work associated with specific primary procedures the physician performs during the same operative session or patient encounter. “Add-on codes do not get reported alone as they are an integral part of the primary procedure in which CPT and the AMA feels should be reimbursed in addition to the primary procedure,” Martin explains.

“In most cases, add-on codes represent the ‘above and beyond’ that a provider might do along with the usual services,” says Denae M. Merrill, CPC, CEMC, HCC coding specialist for The Coding Source and owner of Merrill Medical Management.

Example: Your urologist would never use an operating microscope (+69990, Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) in the absence of a surgical procedure that required microscopic visualization of a particular anatomic location. Because you would only bill +69990 in addition to another procedure, CPT lists this code as an add-on.

In most cases, the primary code(s) for a given add-on code immediately precede the add-on code in the CPT listings. For example, consider the following CPT code sequence:

• 51728 — Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure), any technique
• 51729 — … with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique
• +51797 — Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure).

In this case, the add-on code (+51797) follows the primary procedure codes (51728 and 51729) to which it is related, even though the code is not in numerical order in the CPT manual. Plus, CPT instructs, “Use 51797 in conjunction with codes 51728, 51729.”

Caveat: CPT doesn’t always list add-on codes directly after all of the primary procedure codes. In most cases when the add-on code and primary code(s) are not listed together, CPT will provide instructions on which code(s) should accompany the add-on code. For example, CPT states that you should report +57267 with 45560, 57240-57265, 57285. CPT only lists +57267 after 57265, however.

Skip Modifier 51 With Add-on Codes

You should never append modifier 51 (Multiple procedures) to a designated add-on code, Merrill says. Modifier 51 designates a procedure or service that can be performed independently but, in the cited case, is performed at the same time as another procedure.

CPT stresses this point by stating, “All add-on codes found in the CPT book are exempt from the multiple procedure concept.”

Reason: “Add-on codes have been given a separately reimbursable value that has already had the applicable discount for multiple procedure at the time the relative value unit (RVU) was assigned,” Martin says.

Check your payments: Always check your explanation of benefits (EOB) carefully for claims with add-on codes to be sure the payer reimburses you the entire fee schedule rate for the billed procedures or services. For example, if you report +57267 for a mesh insertion procedure, you should receive the full $258 fee for that code (7.16 relative value units [RVUs], based on the 2010 Medicare Physician Fee Schedule, and the conversion factor [CF] of 36.0846).

“Add-on codes should never be reduced for multiple procedure discounts,” Martin warns. “They should always be paid at 100 percent of the contract amount unless you have entered into an insurance contract agreeing to otherwise, such as hospital/facility insurance contracts.”

If you find a payer reducing the fees for your add-on codes, be sure to appeal the claims. Cite the definition of add-on codes as additional procedures exempt from modifier 51 rules.

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Focus on form and drug to pinpoint the correct asthma supply code.

Are you clear on how to report asthma procedures and inhalers? Follow this advice, and you’ll breathe easy when it comes to asthma related claims.

Propellant-Driven Inhaler Falls Under 94664

If there’s confusion in your office over whether to use 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler, or IPPB device) to report education/training with the Advair diskus, look no further for your answer.

Code 94664s descriptor specifies demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device. Part of teaching the proper technique in using an inhaler (either propellant-driven [Advair Diskus] or dry powder) is to demonstrate and evaluate. In this respect, the code would seem appropriate to use for demonstration and evaluation, say sources with the Joint Council of Allergy, Asthma & Immunology.

The drawback: Not all payers will reimburse 94664. If practices abuse 94664, probably fewer payers will pay. To support reporting 94664, documentation should include an indication of medical necessity.

Clear Up Inhaler Code Confusion

Patients sometimes need multiple nebulizer treatments in the office to control acute asthma. If you’ve wondered whether to bill 94640 and J7613 multiple times, one time, or one time with modifiers for additional treatments, follow this advice and youll breathe easier.

Submit 94640 for Each Treatment

When a patient receives multiple aerosol treatments on the same date, you should use 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device]) for the first treatment.

Subsequent treatments will require modifier 76 (Repeat procedure by same physician), CPT says. Therefore, you would code three nebulizer treatments as:

• 94640 — First treatment
• 94640-76 x 2 — Two subsequent treatments.

A dose of coding: For the inhalation solution, report three units of J7613 (Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg). Because J7613 represents one unit dose, you should report per nebulizer treatment or, in our example, J7613 x 3.

E/M Might Also Be Acceptable

If the allergist meets the criteria, you should report the appropriate-level E/M code (such as 99214, Office or other outpatient visit for the evaluation and management of an established patient …).

If the physician performs and documents a significant, separate E/M from the treatment (94640), append the E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Time is a factor: If the asthma treatment lasted at least an hour, you’d code it with 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour). Report code 94640 for intermittent or one-time treatments.

Clue In to 5th Digit for Asthma Diagnosis

When you submit an asthma diagnosis, don’t forget that ICD-9 requires you to use a fifth-digit sub-classification with asthma codes (493.xx, Asthma). If you submit four digits for an asthma diagnosis, payers will probably reject the ICD-9 code as incomplete.

Correct method: Assign the fourth digit based on the asthma category:

• 493.0x, Extrinsic asthma
• 493.1x, Intrinsic asthma
• 493.2x, Chronic obstructive asthma
• 493.8x, Other forms of asthma
• 493.9x, Asthma, unspecified.

Then, identify the asthmas current state with the appropriate fifth digit:

• 0, unspecified
• 1, with status asthmaticus
• 2, with (acute) exacerbation.

For patients who do not have status asthmaticus or acute exacerbation, use a fifth digit of 0. Code 493.x0 is appropriate when the patients asthma is controlled. A final digit of 1 indicates that the patient has status asthmaticus, which is a medical emergency and is usually treated in the emergency department. You should assign a 2 when something has caused the condition to flare up.

Why it matters: Without this level of specificity, the payer may deny your claim for lack of medical necessity.

Example: An extrinsic asthma patient has an acute exacerbation that requires a nebulizer treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device]). In this case, you should link 94640 to 493.02. Reporting a 2 as the fifth digit helps the payer understand why the patient needs the treatment. Without the final digit (or a fifth-digit of 0), the payer may assume that the patients asthma is under control, making the coded treatment unnecessary.

Reinstate Old J Codes to Get Claims Paid

If you flagged J7611-J7614 as invalid for CMS, you can green light the codes with a valid as of April 1, 2008, notation.

The spring-quarter updates to HCPCS 2008 deleted albuterol/levalbuterol codes J7602 (Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 1 mg [albuterol] or per 0.5 mg [levalbuterol]) and J7603 (& unit dose …). HCPCS reinstated:

• J7611 — Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 1 mg
• J7612 — Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 0.5 mg
• J7613 — Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 1 mg
• J7614 — Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 0.5 mg.

The CMS fee schedule Web site recognizes J7611-J7614 and not J7602-J7603.

Switch Back to Drug-Specific Codes

You may recall that CMS once replaced J7611-J7614 with Q4093 (Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 1 mg [albuterol] or per 0.5 mg [levalbuterol]) and Q4094 (& unit dose …)

Both Q4093 and Q4094 were deleted effective Jan. 1, 2008, however. HCPCS introduced new albuterol-levalbuterol combination codes J7602-J7603 to take the place of those deleted Q codes for 2008.
Medicare decided it was better to use the four codes that separated albuterol from levalbuterol, rather than the combined drug codes J7602-J7603.

Focus on 2 J7611-J7614 Factors

You can get the correct noncompounded solution supply code if you zoom in on two items:

• Form- concentrated (J7611, J7612) or unit dose (J7613, J7614).
• Drug- albuterol (J7611, J7613) or levalbuterol (J7612, J7614).

Reading 44373’s code descriptor is key to getting your G Tube claim right.

Question: The gastroenterologist goes to the hospital to treat a patient that had recently been admitted because his gastrojejunostomy tube had migrated to his stomach. After performing a problem focused interval history and exam, the gastroenterologist decides to perform an EGD to reposition the tube. I cannot find a code for repositioning a G tube; how should I code this scenario?

Answer: Judging by your encounter description, the patient’s percutaneous jejunostomy tube (J tube) slipped and became a percutaneous gastrostomy tube (G tube). On the claim, report the following:

• 44373 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneousgastrostomy tube to a percutaneous jejunostomy tube) for the EGD;
• 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 …) for the E/M;
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99231 to show that the E/M and tube fix were separate services; and
• 536.42 (Disorders of function of stomach; gastrostomy complications; mechanical complication of gastrostomy) appended to 44373 and 99231 to represent the patient’s condition.

Explanation: The descriptor for 44373 might be a bit misleading, but it mentions only “tube conversion.” The tube does not necessarily have to be new.

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Initial vs. additional access matters in 2010.

Love them or hate them, the trend toward guidance-inclusive codes doesn’t seem to be slowing.

Case in point: CPT 2010 ousts 36145 (Introduction of needle or intracatheter; arteriovenous shunt created for dialysis [cannula, fistula, or graft]) and 75790 (Angiography, arteriovenous shunt [e.g., dialysis patient], radiological supervision and interpretation) and instead instructs you to consider the following new surgical codes — which include imaging:

• 36147 — Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)

• +36148 — … additional access for therapeutic intervention (List separately in addition to code for primary procedure).

Proper use: If the initial evaluation (36147) prompts a therapeutic intervention requiring a second shunt catheterization, then report +36148 together with 36147, state CPT guidelines.

Remember that for add-on codes, such as +36148, the services “are always performed in addition to the primary service or procedure and must never be reported as a stand-alone code,” says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver.

Fortunately, the 36147 descriptor is clear, and coding catheter placement with a diagnostic angiography should continue to be straightforward, says Kim French, CIRCC, director of interventional coding and reimbursement for a large physician group in Syracuse, N.Y. CPT’s wording for +36148 also shouldn’t lead to confusion, says French.

Avoid Misguided Guidance Coding

In 2009, you could report 36145 and 75790 together for catheter placement and diagnostic angiography. But CPT 2010 deletes 75790, and reporting 36147 covers both services.

These changes raise the question of when to use all new AV shunt angiography code 75791 (Angiography, arteriovenous shunt [e.g., dialysis patient fistula/graft], complete evaluation of dialysis access, including fluoroscopy, image documentation and report [includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior  vena cava], radiological supervision and interpretation).

Solution: Notes with 75791 tell you to use it only if the physician performs the radiological evaluation through an already existing shunt access or an access that isn’t a direct shunt puncture. If the service requires catheter introduction, choose from 36140 (Introduction of needle or intracatheter …), 36215-36217 (Selective catheter placement, arterial system …), and 36245-36247 (Selective catheter placement, arterial system …).

And to head off any confusion, notes instruct you not to report 75791 along with 36147/+36148.

© Cardiology Coding Alert. To read about how you’ll code for MPIs and CTAs in 2010, download your 2 FREE sample issues here.

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