c.1 New Correct Coding Combinations
The Health Care Financing Administration (HCFA) awarded a contract to AdminaStar Federal to define correct coding practices. The coding practices are the basis of national Medicare policy for payment of claims using the American Medical Association (AMA) Physician's Current Procedural Terminology Fourth Edition (CPT-4) system.
The New Correct Coding Initiative replaces the current Rebundling Phase III information in Appendix C of the Medicare Part B Reference Manual for 1996 dates of service. Please retain and reference your current copy of Appendix C for all services prior to 1996 dates of service.
c.2 Policy Development Process
AdminaStar Federal developed correct coding combinations based upon review of CPT code descriptors, CPT coding instructions, review of existing local and national coding edits and review of Medicare billing history.
A comprehensive narrative policy (the correct coding policy) was developed which outlines general and specific guidelines for the appropriate use of CPT coding for physician claims.
The narrative policy which contained 94,000 coding combinations was distributed in December, 1994 to physician specialty societies through the AMA. It was also distributed to other national specialty societies which represent physicians and non-physicians who may be impacted by this policy. In addition, this draft policy was also shared with the Medicare Carriers Medical Directors.
After reviewing and incorporating the combined comments, and receiving HCFA's approval, AdminaStar Federal developed a "code matrix", or collection of correct coding combinations. The coding combinations were sent directly to the standard system maintainers to be incorporated into the Medicare carriers' claims processing systems. This matrix, based on the correct coding policy, will automatically identify inappropriate CPT code combinations and will properly determine payment. Existing national Medicare payment policies are not changed by the correct coding policy.
c.3 Coding Combinations
There are two types of code combinations:
Example: When billing for comprehensive code 19162 (mastectomy, partial with axillary (lymphadenectomy) and component code 19160 (mastectomy partial), in the CPT definition procedure code 19160 is a component code for the comprehensive code 19162. Therefore, if both procedures codes 19162 and 19160 were reported, the services would be combined into comprehensive procedure code 19162.
Column I Code
Column II Code
Example: A physician performing an upper lid blepharoplasty for correction of ptosis may submit a claim using CPT code 15822. At the same session, a reduction of overcorrect of ptosis (CPT code 67909) would not be performed on the same eye. Accordingly, CPT codes 15822 and 67909 are mutually exclusive of each other.
c.4 Column I and Column II Codes
Column I (comprehensive code) identifies the code that should be allowed when billed with the incorrect code in Column II (component code). Column II lists the incorrect code(s) that are denied (component code).
c.5 Types of Correct Coding Combinations
The following policy considerations were used when the correct coding combinations were created:
CPT Procedure Code Definition: The CPT procedure code definition, or descriptor, is based upon the procedure being consistent with current medical practice. In order to submit a CPT code to Medicare, the provider must have performed all of the services included in the code descriptor. Otherwise, the provider must submit a less comprehensive code. Providers must not submit codes describing components of a comprehensive code in addition to the comprehensive code. Components are services necessary to accomplish the more comprehensive procedure/service. In the rare instances where the national Medicare policy differs from instructive language in the CPT descriptor, providers should follow the national Medicare policy.
The codes that are rebundled due to this policy are those where the component (Column II code) is included in the CPT descriptor for the comprehensive (Column I) procedure code.
Example: When billing for procedure code 19162 (mastectomy, partial with axillary lymphadenectomy) and component code 19160 (mastectomy partial), in the CPT definition procedure code 19160 is a component code for the comprehensive code 19162. Therefore, if both procedure codes 19162 and 19160 were reported, the services would be combined into the comprehensive procedure code 19162.
Column I Code
Column II Code
Mutually Exclusive Code Pairs: These codes represent services or procedures that, based on either the CPT definition or standard medical practice, would not or could not reasonably be performed at the same session by the same provider on the same patient. Mutually exclusive procedures are those procedures that cannot be reasonably performed during the same session. To clarify further, AdminaStar has determined that codes which are mutually exclusive of one another are so based on either the CPT definition of the codes or the medical impossibility/improbability that the procedure could be performed together.
Example: When a blepharoplasty (code 15822) is performed as part of repairing an entropoin (code 67916), simultaneously billing CPT code 15822 is inappropriate for the procedure performed on that eye.
Codes representing these services or procedures cannot be submitted together, except when designated as a separate and distinct procedure by use of the 59 modifier (refer to Section c.7).
Separate Procedures: Although certain CPT codes are identified as "separate procedures", HCFA has determined that these codes may be occasionally provided as part of a more comprehensive procedure and at those times these codes with a designation of a "separate procedure" should be submitted with their related and more comprehensive codes.
The narrative for many CPT codes includes a statement that the procedure represents a "separate procedure". This indicates that the procedure, while possible to perform separately, is generally included in more comprehensive procedure and should not be billed separately.
Example: For comprehensive code 19125 and component code 19100, the needle core biopsy of the breast represented by code 19100 is classified as a "separate procedure". When the service represented by code 19100 is performed with an excision of a breast lesion (code 19125) it is not performed alone or independent of the related and more comprehensive service described by code 19125; therefore code 19100 cannot be reported separately and will be combined as comprehensive code 19125.
Most Extensive Procedures: When CPT descriptors designate several procedures of increasing complexity, only the code describing the most extensive procedure actually performed should be submitted.
If CPT definition indicates that a series of procedures are simply more extensive and complex versions of the same service, the less extensive procedure will be combined into the more extensive comprehensive code.
Example: If the course of obtaining a bone biopsy (code 20240), a muscle biopsy is obtained through the same incision (code 20200), then the most extensive procedure represented by code 20240 is reported. Therefore, code 20200 is combined with comprehensive 20240.
With/ Without Services: Certain CPT descriptors designate that procedures performed "with" or "without" other services. Submit only the code describing the service actually performed.
Many services in the CPT manual include descriptions that a service exists with or without another related service.
Procedure codes for fractures state "treatment of fracture, with manipulations." In such instances, the service without manipulation would be combined into the services with manipulation if both were reported on the same date of service.
Example: For comprehensive code 70460 and component code 70450, the only difference in the code descriptions is the fact that code 70450 does not include contrast material and code 70460 does include it. Reporting both codes together is a contradiction in the actual performance of the services at the same session; therefore, procedure code 70450 (without) is combined with comprehensive code 70460 (with).
Sex Designation: Certain CPT code descriptors identify procedures requiring a designation for male or female. Submit only the appropriate one of these designations for an individual patient.
Example: Procedure code 52270 describes a cystourethroscopy with an internal urethrotomy for a female and code 52275 describes the identical procedure but only for a male. These two procedures cannot be reported for the same session, same provider, and the same beneficiary. Therefore, only the appropriate one should be submitted.
Standards of Medical Practice: Medicare considers all of the services necessary to accomplish a given procedure to be included in the description of that procedure as defined by CPT. Ancillary services necessary to accomplish the procedure are considered included, although independent CPT codes may exist for these ancillary services. Medicare considers billing for these independent CPT codes unbundling, which is prohibited.
All services necessary to achieve the end result of a completed procedure are included in the description of the completed service. Related services may have independent CPT codes, but these independent codes should not be billed in conjunction with the completed procedure.
Such generic services that would be combined with a surgical procedure include cleansing and preparing skin, surgical closure, wound, irrigation, etc.
Example: In the course of a tonsillectomy (procedure code 42821), bleeding may be expected, and the control of bleeding intraoperatively represents part of the procedure. It is inappropriate to bill separately for control of oropharyngeal hemorrhage (code 42961) which occurs during the same operative session. Therefore, the independent code 42961 is combined into the comprehensive code 42821.
Anesthesia Performed During Medical/Surgical Procedures: The Medicare Physician's Fee Schedule precludes payment of a separate fee for anesthesia when provided by the same physician performing the medical/surgical procedure. Therefore, do not submit CPT codes describing anesthesia services or services necessary to provide anesthesia with primary procedure/service codes.
Example: When a local anesthetic injection is performed as a part of an inguinal hernia repair (code 49505), the local anesthetic procedure (code 64425) performed by the surgeon is included in the surgical procedure and is not reported separately. Therefore, code 64425 is bundled into code 49505.
Laboratory Panels: When CPT describes laboratory services performed as a "panel" or grouping, submit the appropriate code describing the panel or grouping. Do not submit codes for individual laboratory tests when a code for a grouping or "panel" exists for the services performed.
When components of a lab panel or multichannel test are performed, the individual components should not be billed. The lab panel procedure that includes all tests performed should be billed.
Example: For comprehensive code 80061 and the component codes 82465, 83718, 84478, by definition of this particular panel test, the lipid panel (code 80061) includes the total serum cholesterol (code 82465), the lipidprotein, direct measurement, high density cholesterol (code 83718) and the triglycerides (code 84478). Therefore, all three of these individual tests are combined into the comprehensive code panel test. Each of the component tests are not reported separately when the complete panel is performed.
Sequential Procedures: There are several different instances addressed regarding sequential procedures:
Example: If a bone biopsy is performed at the same site, and an initial attempt by tocar or needle is made (designated by code 20225) and followed by an open procedure (as described by CPT code 20250) at the same session, both CPT codes should not be billed. The procedures have been performed sequentially, and the more extensive biopsy procedure, in this case as described by 20250, should be reported.
Misuse of Column 2 Code with Column 1 Code: CPT codes have been written as precisely as possible to not only describe a specific service or procedure but to also avoid describing similar services or procedures which are already defined by other CPT codes. When a CPT code is reported, the physician or non-physician provider must have performed all of the services noted in the descriptor unless the descriptor states otherwise. (Frequently, a CPT descriptor will identify certain services that may or may not be included, usually stating `with or without' a service.) A CPT code should not be reported out of the context for which it was intended. Either intentionally or unintentionally, a provider may report a service or procedure using a CPT code that may be construed to describe the service/procedure but, in no way, was the code intended to be used in this fashion. When a column 2 code (component) CPT code is reported as services associated with services described by a column 1 (comprehensive) CPT code, reporting the former code represents a misuse of this code and should not be separately allowed.
c.6 Modifier 59 Replaces the GB Modifier
Effective with services rendered on or after January 1, 1997, the GB modifier has been replaced with modifier 59. Modifier 59 should be used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. The secondary, additional, or lesser procedure(s) or service (s) may be identified by adding the 59 modifier.
Note: For services rendered prior to January 1, 1997, continue to use the GB modifier.
The patient's medical record must reflect that the modifier is being used appropriately to describe separate services.
The 59 modifier should not be used with the following ranges of procedure codes:
77419-77430 - Weekly radiation therapy management codes
99201-99499 - Evaluation and management services
a. The 59 modifier vs HCPCS Modifiers
If the concepts behind the following modifiers apply to the service being rendered, it is not necessary to report the 59 modifier. The following is a list of HCPCS modifiers:
24 - Unrelated evaluation and management service by the same physician during the postoperative period.
25 - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of another service.
58 - Staged or related procedure or service by the same physician during the postoperative period.
E1 - Upper left, eyelid
E2 - Lower left, eyelid
E3 - Upper right, eyelid
E4 - Lower right, eyelid
FA - Left hand, thumb
F1 - Left hand, second digit
F2 - Left hand, third digit
F3 - Left hand, fourth digit
F4 - Left hand, fifth digit
F5 - Right hand, thumb
F6 - Right hand, second digit
F7 - Right hand, third digit
F8 - Right hand, fourth digit
F9 - Right hand, fifth digit
LT - Left side
QR - Repeat laboratory tests performed on the same day.
RT - Right side
TA - Left foot, great toe
T1 - Left foot, second digit
T2 - Left foot, third digit
T3 - Left foot, fourth digit
T4 - Left foot, fifth digit
T5 - Right foot, great toe
T6 - Right foot, second digit
T7 - Right foot, third digit
T8 - Right foot, forth digit
T9 - Right foot, great toe
When certain Column I or Column II codes are appropriate and paid separately, such as for services provided to different anatomic sites, providers should utilize the appropriate HCPCS modifier (E1-E4, FA, F1-F9, TA, T1-T9, LT, RT). The 59 modifier should only be used if no other modifier is appropriate.
Examples of the 59 Modifier
1) If a patient requires placement of a flow directed pulmonary artery (PA) catheter for hemodynamic monitoring via the subclavian vein, it would be appropriate to submit the CPT code 93503 (insertion and placement of flow directed catheter, e.g., the Swan-Ganz for monitoring purposes) for the service. If, later in the day, the catheter must be removed and a central venous catheter is inserted through the femoral vein, the appropriate code for this service would be CPT code 36010 (introduction of catheter, superior or inferior vena cava).
Because the PA catheter requires passage through the vena cava, it may appear that the service for the PA catheter was being "unbundled" if both services were billed on the same day. Accordingly, the central venous catheter code should be billed with the 59 modifier (36010-59) indicating that this catheter was placed in a different site, as a different service, on the same day.
2) As most fractures are caused by trama, other injuries may be associated with the fractures, many of which require debridement involving skin, subcutaneous tissue, muscle and/or bone. If the debridement is necessary strictly due to the fracture (e.g., open fractures), the CPT codes describing debridement are not separately payable. On the other hand, if debridement is necessary to associated trauma, the codes describing debridement are separately payable. This situation should be reflected in the medical record, and the CPT code should be submitted with the 59 modifier.
3) When a recurrent hernia requires repair, the appropriate recurrent hernia repair code is billed. A code for incisional hernia repair should not be billed in addition to the recurrent hernia repair unless a medically necessary incisional hernia repair is performed at a different site. In this case, the 59 modifier should be reported with the incisional hernia repair code.
c.7 Questions and Answers:
Q: Does the 59 modifier replace the 24, 25 modifiers?
A: The 59 modifier is an entirely new modifier. The 24 and 25 modifiers are both global surgery modifiers and apply solely to the E/M visit performed on the day of or during the global surgery period. Therefore, the 59 modifier should not be used in this situation.
Q: Do we need the 59 and 79, E1-E4, F1-F9, FA, TA, T1-T9, LT, and RT?
A: Previously, if global surgery services were performed in addition to the body site identified by the appropriate modifier, the 79 modifier must be used. This will clarify that the service was unrelated to the original surgery.
The E1-E4, F1-F9, FA, TA, or T1-T9, RT, LT, modifiers are to be used to identify the body site for the reported services. The 59 modifier would not be used in this situation.
Q: What is meant by "different session or patient encounter"?
A: The 59 modifier is used to indicate that a different site, different lesion, different session (or patient encounter) during the same day occurred, and the services should not be rebundled. The 59 modifier was created to allow two specific, separate and unique sessions with patient on the same date of service to be paid.
Q: What is meant by "different procedure or surgery". Do you need the 59 or 51 modifier on multiple surgery claims?
A: The phrase "different procedure or surgery" refers to instances where rebundled services were performed, but the original intent was not to perform both services. Due to extenuating circumstances, separate additional services were required, and since they were not intended to be originally performed, separate payment should be allowed.
Therefore, if the 59 modifier applies to a service, separate payment will be allowed. The 59 modifier does not replace the need to report the 51 modifier and both should be appended to the service if applicable.
Q: What does "mutually exclusive" coding mean?
A: "Mutually exclusive" procedures are those procedures that cannot be reasonably performed during the same session. AdminaStar Federal has determined that codes which are mutually exclusive of one another are based on either the CPT definition of the codes or the medical impossibility/improbability that the procedure could be performed together.
Q: What is an example of a mutually exclusive procedure?
A: An esophageal lesion may be excised either through a thoracic or cervical approach but not both. Accordingly, code 43100 is not reported with code 43101, describing different approaches to accomplish the same procedure.
Q: Is the 59 modifier needed for all codes or just the codes that fall under the new correct coding combinations?
A: If the requirements for use of the 59 are met, the 59 should be applied to services that are subject to denial for rebundling edits in the new correct coding package. The 59 is valid only for 1997 dates of service.
Q: If two surgeries are done today and these surgeries fall within the post-operative period of a previous surgery, do you need to report both the 79 and 59 modifier?
A: The 79 modifier must be reported if the services are unrelated to the original surgery for which the post-operative period exists. If the 79 is not reported, the services will be considered related to this surgery and be denied as routine post-operative care.
The 59 modifier should be applied only if the requirements for its use are met. Failure to use the 59 can result in the component service combining to a comprehensive procedure.
Q: If two distinct services are performed on the same day, which code should the 59 modifier be used on?
A: The 59 modifier would be applied to the service subject to denial (component service) (i.e., the additional, secondary, or lesser procedure).
c.8 Additional Information
The Health Care Financing Administration has reprocessed a sample of 1993 Medicare claims against the new package of edits. The examples on the following page are some of the edits that occurred most frequently in this sample:
CPT Code for
CPT Code for
|90780- IV Infusion||36000 -
Needle or Intra Catheter
|The comprehensive code describe services involving infusion and because the placement is of peripheral vascular access devices integral to vascular infusions, the CPT code or placement of needle or intra catheter is not billed separately.|
|The codes for pacemaker evaluation and analysis include in their definition, the electrocardiograph recording and interpretation of recordings.|
|71020- Radiological examination, chest, two views.||71010- Radiological examination chest single view.||The frontal view is included in the two view chest x-ray.|
Note: Any questions or concerns regarding the correct coding combinations should be addressed in writing to:
The Correct Coding
PO Box 50469
Indianapolis, IN 46250-0469
c.9 Limiting Charge
Medicare does not make separate payment for procedures that are part of a more comprehensive group of services nor does it make payment for separate services that cannot be performed at the same time. Instead, payment for the Column I procedure includes any separately identified component parts of the procedure. Section 1879 Social Security Act, Limitation of Liability and physician refund protections are not a consideration nor are § 1842 (1), Physician Refund, protections a consideration. The maximum a provider may bill a beneficiary is whatever the limiting charge is for the Column I code. This policy has been in effect since January 1, 1991.
The limiting charge provisions of the law apply to those services which are submitted on unassigned claims and are paid under the physician fee schedule. Procedures excluded are services which are non-covered and statutory exclusion services. Mammography services (which are subject to limiting charge provisions) and restricted coverage are the exception.
Procedure codes listed in the correct coding initiative that are component parts of other procedures or cannot be performed at the same time and are not separately payable, when billed with the principle service. These instances are considered limiting charge violations and will be included on the providers Limiting Charge Exception Report.
Note: For additional information on Limiting Charge, please refer to your Medicare Part B Reference Manual, Chapter 14.
c.10 Where to Request a Correct Coding Manual
To obtain a copy of AdminaStar Federal's correct coding manual, please contact the National Technical Information Service.
|Chapter II||Anesthesia Services||00000-09999|
|Chapter III||Surgery: Integumentary System||10000-19999|
|Chapter IV||Surgery: Musculoskeletal System||20000-29999|
|Chapter V||Surgery: Respiratory,
and Lympathic System
|Chapter VI||Surgery: Digestive System||40000-49999|
|Chapter VII||Surgery: Urinary, Male Genital,
Genital, Maternity Care, and Delivery System
|Chapter VIII||Surgery: Endocrine, Nervous,
Eye and Ocular
Adnexa, Auditory System
|Chapter IX||Surgery: Radiology Service||70000-79999|
|Chapter IX||Surgery: Pathology and Laboratory Services||80000-89999|
|Chapter XI||Medicine, Evaluation and Management Services||90000-99999|
The Correct Coding Initiative
PO Box 50469
Indianapolis, IN 46250-0469
a. Searchable Database System on CD-ROM
The 1998 First Edition is also available as an easy-to-use searchable CD-ROM. The CD-ROM allows customers to easily search for just the codes they need and then either view them on the screen or print them out. All the codes are searchable: comprehensive, component and exclusive.
If you need access to all of the actual text of the data to load into your own database, you must order the raw data file listed below. You can, however, cut and paste one page at a time between the CD-ROM display screens and a word processing document.
b. National Correct Coding: Data Text File ASCII Data
The 1998 First Edition is also provided as an ASCII text file for users who wish to load the data into their own data base. The file lists all the comprehensive and exclusive CPT codes, a short statement about the reason for exclusion, and starting/ending dates for each code, as appropriate. This product contains text only. Buyers must provide their own search and retrieval software. A copy of the introductory chapters of the manual are provided in a text format.
The datafile is on one 3 1/2 inch DOS diskette, 1.44m high density diskette. File format: ASCII text.
c. For Subscription Service
Call the NTIS Subscription Department at (703) 605-6060 OR 1-800-363-2068