Posts Tagged ‘modifier 26’

If your practice can’t seem to successfully bill for the professional component lately, there could be a logical explanation. It could be something as simple as an incorrect modifier.

According to First Coast Service Options Inc. (FCSO), an excessive number of claims from providers are being denied because they request payment for the professional component using the wrong modifier with the CPT^® or HCPCS Level II code.

Prevent Delays and/or Denial

When billing for the professional component of a procedure, hospital outpatient departments, ambulatory surgical centers (ASCs), and other practitioners should properly identify the service by adding modifier 26 Professional component to the appropriate CPT^® or HCPCS Level II code — not the new modifier effective July 1,  PC Wrong surgery on patient.

Medicare automatically denies all lines related to an erroneous surgery with dates of service on or after Jan. 15, including claims for related hospitalizations.

Claims Appeal

FCSO advises providers appeal claims billed in error with modifier PC and subsequently denied for wrong surgery. Correcting and resubmitting these claims won’t work. Only an appeal will remove the edit logic that was installed for the beneficiary and date of service of the wrong surgery based on the initial claim.

Accurate coding and claims payment start with dispelling four ovarian cyst removal coding myths, according to an article in Ob-Gyn Coding Alert 2009. It’s all in the approach, says Celia Hernandez, CPC.

Myth #1: Coding by documentation alone

For laparoscopic removal of an ovarian cyst, your code selection should be based on the procedure’s extent. “Always make sure to read your op note carefully,” says Hernanadez, “as sometimes the Ob/Gyn does more than what is noted under the beginning.”

“Coding based on documentation alone can cost you $58,” warns the Ob-Gyn Coding Alert editor.

CPT^® code 58662 Laparoscopy, surgical; with fulgration or excision of lesions of the ovary, pelvic viscera, or peritonial surface by any method is appropriate when no additional tissue is removed. When the cyst is large and difficult to remove, possibly requiring partial removal of the ovary, code 58661 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectony).

Myth #2: Underestimating documentation requirements for common procedures

According to the American College of Obstetricians and Gynecologists (ACOG), the ob-gyn should document the following in the patient’s medical record:

1. Last menstrual period and contraceptive method and one or more of the following:

a) Pelvic examination or ultrasound demonstrating a cystic mass that is 8 cm or larger.
b) Persistence of a cystic mass of 6 cm or larger for two cycles.
c) Presence of a cystic mass that is multilocular (many-celled) or has solid components, as confirmed by ultrasound.

2. Pelvic examination in the operating room or within 24 hours prior to the procedure to confirm persistence or presence of mass.

Myth #3: Treating documented terms “aspiration” and “drainage” differently

These terms mean the same thing when an ob-gyn removes fluids from an ovarian cyst using a suction device. Base your code selection on the method:

58800 Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach
58805 Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); abdominal approach
49322 Laparascopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple)

Myth #4: Guidance is part of the main procedure and should not be reported separately

When the ob-gyn uses ultrasound guidance to place the needle she uses to aspirate the cyst, report 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation or 76998 Ultrasonic guidance, intraoperative if the physician performs the actual aspiration under ultrasound guidance.

Remember to append modifier 26 Professional component to codes for services the physician performs in a hospital.

Contractors will soon process Medicare claims for diagnostic tests subject to the anti-markup payment limitation based on new rules outlined in the 2009 Physician Fee Schedule (PFS).

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