Insurers will pay only for services deemed to be medically necessary, based on the patient’s chief complaint or additional conditions that require work-up or focused attention. Services provided out of “convenience” for the patient will not be considered medically necessary if the patient did not have any specific complaints relating to the service. This often happens in specialty practices with subspecialists within the same group practice.
For example, in an ophthalmology practice, the patient comes in to see the general ophthalmologist. Because he has traveled three hours to get to the clinic, he also will see the cataract specialist, the retinal specialist, and the glaucoma specialist. The patient did not have any complaints—rather, the patient had seen these providers in the past and it was felt that he should be “checked on” while he was in the office. In other words, the services were not medically necessary.
If you were to think about it from the payer’s perspective, you would wonder why the general ophthalmologist cannot “check on” all areas of the eye. If a problem is then identified, then medical necessity has been identified and a second visit may be supported. There is immense potential for excessive fraud and abuse in allowing these types of services to be reimbursed at an unlimited capacity.
October 15th, 2014
Coders learn early and are reminded often to avoid unbundling, or separately reporting procedures/services that are meant to be reported together, using a single code. As the introduction of the National Correct Coding Initiative (NCCI) Policy Manual explains, “Procedures should be reported with the most comprehensive CPT® code that describes the services performed.” To make the point clear, the policy manual provides examples of all the ways you shouldn’t unbundle:
A physician should not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services. For example if a physician performs a vaginal hysterectomy on a uterus weighing less than 250 grams with bilateral salpingo-oophorectomy, the physician should report CPT code 58262 (Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)). The physician should not report CPT code 58260 (Vaginal hysterectomy, for uterus 250 g or less;) plus CPT code 58720 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)).
A physician should not fragment a procedure into component parts. For example, if a physician performs an upper gastrointestinal endoscopy with biopsy of the stomach, the physician should report CPT code 43239 (Upper gastrointestinal endoscopy …; with biopsy, …). It is improper to unbundle this procedure and report CPT code 43235 (Upper gastrointestinal endoscopy …; diagnostic, …) plus CPT code 43600 (Biopsy of stomach; …). The latter code is not intended to be utilized with an endoscopic procedure code.
A physician should not unbundle a bilateral procedure code into two unilateral procedure codes. For example if a physician performs bilateral mammography, the physician should report CPT code 77056 (Mammography; bilateral). The physician should not report CPT code 77055 (Mammography; unilateral) with two units of service or 77055LT plus 77055RT.
A physician should not unbundle services that are integral to a more comprehensive procedure. For example, surgical access is integral to a surgical procedure. A physician should not report CPT code 49000 (Exploratory laparotomy,…) when performing an open abdominal procedure such as a total abdominal colectomy (e.g., CPT code 44150).
Atrial septal defect (ASD) is the most commonly recognized congenital cardiac anomaly presenting in adulthood. An ASD is a defect in the interatrial septum that allows pulmonary venous return from the left atrium to pass directly to the right atrium. Depending on the size of the defect symptoms can range from no significant cardiac sequelae to right-sided volume overload, pulmonary arterial hypertension, or atrial arrhythmias.
There are four major types of ASD:
- Ostium secundum ASD results from incomplete adhesion between the flap valve associated with the foramen ovale and the septum secundum after birth. This is the most common type, accounting for 75 percent of all ASD cases.
- Ostium primum ASD are caused by incomplete fusion of septum primum with the endocardial cushion. This is the second most common type, accounting for 15-20 percent of cases.
- Sinus venosus ASD is an abnormal fusion between the embryologic sinus venosus and the atrium. In most cases, the defect lies superior in the atrial septum near the entry of superior vena cava (SVC). This is the third most common type, accounting for 5-10 percent of cases.
- Coronary Sinus ASD is often associated with absence of the coronary sinus and a persistent left SVC that joins the roof of the left atrium, also referred to as an “unroofed coronary sinus.” This is a rare type of ASD and accounts for less than 1 percent cases.
Relevant ICD-10-CM codes for ASD are:
Q21.1 Atrial septal defect – Alternative wording includes: coronary sinus defects, patent or persistent foramen ovale, ostium secundum defect (type II), or sinus venosus defect.
Q21.2 Atrioventricular septal defect – Alternative wording includes: common atrioventricular canal, endocardial cushion defect, and ostium primum ASD (type I).
I23.1 Atrial septal defect as current complication following acute myocardial infarction – Use when a patient develops an ASD as a complication following an acute myocardial infarction (AMI). This condition is not congenital and appears only as a result of the acute MI.
I51.0 Cardiac septal defect, acquired – If a patient develops an ASD that is not congenital and not related to an AMI, report I51.0.
Q21.9 Congenital malformation of cardiac septum, unspecified
Documentation must state the exact type of defect the patient has (e.g., type I, type II), and if the condition is congenital or acquired. The contributing factors will indicate the presence of the condition in the setting of an AMI.
CHIEF COMPLIANT: Excessive sweating and bluish coloring around the patient’s mouth during feeding.
A 4-month-old female patient with Down syndrome presents to the cardiac team after it was noted that she had a systolic and diastolic heart murmur; the second heart sound is split. The liver edge is palpable 4 cm below the right costal margin. The patient’s mother reports that she has noticed the patient has been sweaty, and during feedings she sometimes has a blue cast around her mouth and has been eating less than what she had been eating previously. An ECG was performed that indicates a superiorly oriented QRS frontal plane axis and counterclockwise depolarization pattern and right ventricular hypertrophy.
ASSESSMENT: Atrioventricular canal defect
ICD-10-CM coding: Q21.2, Q90.9 Down syndrome, unspecified
Modifier 91 Repeat clinical diagnostic laboratory test is used to report the same lab test when performed on the same patient, on the same day, to obtain subsequent test results.
Modifier 91 causes a lot of confusion when differentiating its use from that of modifier 59 Distinct procedural service. When reporting lab procedures, modifier 59 is used when the same lab procedure is done, but different specimens are obtained, or the cultures are obtained from different sites.
The June 2002 CPT® Assistant provides the following example showing the correct application of modifier 59:
For example, if multiple bacterial blood cultures are tested, including isolation and presumptive identification of isolates, then code 87040, Culture, bacterial; blood, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate), should be used to identify each culture procedure performed. Modifier -59 should be appended to the additional procedures performed to identify each additional culture performed as a distinct service.
A contrasting example shows correct application of modifier 91:
A 65-year-old male patient with diabetic ketoacidosis had multiple blood tests performed to check the potassium level following subsequent potassium replacement and low-dose insulin therapy. After the initial potassium value, three subsequent blood tests were ordered and performed on the same date following the administration of potassium to correct the patient’s hypokalemic state.
Coding for this scenario is:
84132 Potassium; serum, plasma or whole blood
Per CPT® guidelines, you should not append modifier 91 for lab tests:
- That are repeated to confirm the initial results;
- That are repeated due to malfunctions of either the testing equipment or the specimen; or
- When another appropriate one-time code is all that is needed to report the service.
If the test is repeated to confirm the initial results or because of a malfunction of the equipment, the service cannot be coded and modifier 91 would not apply.
If multiple tests are run but a single code describes the test, you should report only one code and modifier 91 would not apply. For example, 82951 Glucose; tolerance test (GTT), 3 specimens (includes glucose) includes three specimens; therefore, if three specimens were obtained during the encounter, you’d report only 82951.
Robotic surgery is covered by routine and customary laparoscopic CPT® and ICD-9-CM coding practices, existing medical policies for advanced laparoscopic surgery, and current payer contract rates. The primary surgical procedure remains laparoscopic: You should not report unlisted procedure codes or modifier 22 Increased procedural services for robotic assistance (except perhaps, for instance, there is no existing laparoscopic code to describe a procedure).
Although any insurance covering minimally invasive surgery (including Medicare) generally covers robotic surgery, no additional payment is made when a robotic surgical technique is used.
For instance, if the surgeon performs radical, nerve sparing prostatectomy with robot assist, the appropriate code is 55866 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed.
If your payer accepts HCPCS Level II S codes, you may report S2900 Surgical techniques requiring use of robotic surgical system (List separately in addition to code for primary procedure) in addition to the primary procedure code to identify the procedure as robotic-assisted. Note that S codes are not payable under Medicare, and likely won’t result in additional payment from any insurer.