Coding Strategy

Don’t let ‘wrong surgery’ modifier mistakes stall your reimbursement.

You use modifier TC for the technical component of a test. So logically, you should use modifier PC for the professional component, right? Wrong. But many coders are making that mistake and causing their practices unnecessary denial hassles. Here’s what you need to know.

Get ‘Wrong Surgery’ Modifiers Right

When practitioners perform erroneous surgeries, CMS requires the hospital outpatient department, ambulatory surgical center (ASC), physician, or other entity to append one of the following three modifiers to codes for services related to the erroneous procedure effective Jan. 15, 2009:

• PA — Surgical or other invasive procedure on wrong body part
• PB — Surgical or other invasive procedure on wrong patient
• PC — Wrong surgery or other invasive procedure on patient.

“Unfortunately, the introduction of these new modifiers has caused much confusion and they are often being submitted incorrectly,” says Sandra Jongebreur, CGSC,CPC, CPC-H, PCS, FCS, coder for Raafat Abdel-Misih, MD, in Wilmington, Del.

Pause Before Appending PC

In particular, beware of confusing wrong surgery modifier PC with the modifier for the professional component of a procedure: 26 (Professional component). For example, if you want to report that the radiologist performed the professional component of 75966 (Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation), be sure you append modifier 26 and not modifier PC. If you append modifier PC, the payer will review the claim to see if the service was related to angioplasty performed on a patient in error and therefore not payable.

The source of confusion for these modifiers is easy to see. “People often think of the professional and technical components as PC and TC,” explains Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions in New Jersey. The modifier for the “technical component” is TC, so many coders accidentally append PC (instead of 26) forthe professional component.

The problem is so widespread, that CMS issued MLN Matters article 6718 (www.cms.hhs.gov/MLNMattersArticles/downloads/MM6718.pdf) warning providers about the issue and announcing that contractors will review all claim lines with modifier PA, PB, or PC.

If the contractor determines the provider used one of the modifiers incorrectly, the contractor will return the claim as unprocessable and ask for submission of a new claim.

Resource: To read CMS’s transmittal on the use of these modifiers, visit www.cms.hhs.gov/transmittals/downloads/R1867CP.pdf.

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Here are the requirements the exam must meet, according to Medicare.

If your PET claim meets certain requirements, you don’t need to append modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study), according to MLN Matters article MM6753.

Effective for dates of service on or after Nov. 10, 2009, Medicare has an updated national coverage determination (NCD) for cervical cancer FDG PET imaging. Medicare has ended the coverage with evidence development (CED) requirements for initial staging of initial treatment.

Medicare will cover one FDG PET for cervical cancer. That one exam must meet specific requirements:

• The exam must be for staging (not initial diagnosis).
• The patient must have biopsy proven cervical cancer.
• The treating physician must need the study to determine the tumor’s location, extent, or both for one of the following therapeutic purposes related to initial treatment strategy:
• To determine whether the beneficiary is a candidate for an invasive diagnostic or therapeutic procedure
• To determine the optimal anatomic location for an invasive procedure
• To determine the tumor’s anatomic extent when the recommended anti-tumor treatment depends on that information.

Codes: Your claim must include all of the following for reimbursement:

• An appropriate CPT code from 78608 (Brain imaging, positron emission tomography [PET]; metabolic evaluation), 78811-78813 (Positron emission tomography [PET] imaging …), or 78814-78816 (Positron emission tomography (PET) with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization imaging …)
• Modifier PI (PET Tumor initial treatment strategy)
• A cervical cancer diagnosis code (such as 180.x, Malignant neoplasm of cervix uteri).

Action step: The effective date of this policy is Nov. 10, 2009, but the implementation date is Jan. 4, 2010. Carriers won’t search their files for PET cervical cancer claims for Nov. 10 to Jan. 3 dates of service, but they will adjust those claims that you bring to their attention.

Resources: To learn more, check out Transmittal 110, Change Request 6753.

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Want to become an oncology coding expert? Attend this ENCORE presentation of the 2010 Oncology Coding Update, presented by Brenda Chidester.

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