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Question: When billing a diagnostic laparo-scopy with lysis of adhesions (58660) along with a laparoscopy with aspiration of a cyst (49322), should the second procedure have a modifier -51 or a modifier -59?
Answer: The most extensive procedure is always listed first on the claim form. In this case, the laparoscopic lysis of adhesions (58660, laparoscopy, surgical; with lysis of adhesions [salpingolysis, ovariolysis] [separate procedure]) is the higher-valued code so it will be listed first with modifier -59 (distinct procedural service) to let the payer know that it was distinct from the aspiration as it is listed in CPT as a "separate procedure." Code 49322 (laparoscopy, surgical; with aspiration of cavity or cyst [e.g., ovarian cyst] [single or multiple]) will be listed second with modifier -51 (multiple procedures).
If the values of these two procedures had been reversed so that the second code listed was the "separate procedure" code that required the -59 to get paid, you would list both modifiers on the second code, but list -59 first. Modifier -59 tells the insurance payer that you should be reimbursed for the service, and -51 indicates how much.
Question: How do I code a claim when a patient comes in for a blood test and/or injection? How can we appeal if it is denied due to being a part of the office visit?
Answer: Many payers believe evaluation and management (E/M) codes include what they term "incidental" procedures that do not require much physician time or work. This may include things like an injection or collection of a blood sample for testing. However, CPT states specifically that these services can be reported separately because the purpose of the E/M code is to report only E/M services, not other procedures or services identified by another code (see page 2 of CPT 2001, professional edition).
Unless the payer has specifically excluded an injection or blood draw from being reimbursed at the same time as an E/M service as part of its policy manual, you may code either one in addition. You may, however, have to add modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service to indicate that it was separate from the other services provided that day.
If the only reason for the visit was the blood draw or injection and no E/M service was provided or documented, code for the blood draw or injection.
Question: Is there a code for operative vaginal delivery with forceps and vacuum? My hospital has been billing for a global standard vaginal delivery fee, regardless of the delivery mode. However, they bill a higher rate for vaginal birth after cesarean (VBAC) - 59610-59614. Is there a way to notify the insurance carriers of an increased risk and increased liability for these procedures and therefore obtain better reimbursement compared to vaginal delivery?
Charles Deborah, MD
Mason City, Iowa
Answer: The definition of maternity services in CPT 2001 (page 201 of the professional edition) states that vaginal delivery includes episiotomy and forceps (if used). The American College of Obstetricians and Gynecologists in its coding manual Components of Correct Procedural Coding has indicated that vacuum extraction is also included as part of the service and should not be coded separately. VBAC has its own specific CPT code because the service requires more intense physician work routinely.
If a physician believes that the use of forceps or vacuum extraction for a particular patient was much more work than is usually the case and this additional work has been documented, you have the option of billing the insurance company for the global service using modifier -22 for unusual procedural services. You would of course need to send in the documentation with the claim.
New Versus Established Patient
Question: A nurse midwife is joining our practice, a professional corporation. Some of her patients will likely follow her here. Would these patients be new patients or established patients at our office?
Answer: If the nurse midwife bills for the patient care, the patient would be established to the practice because a physician (or other qualified care-giver) of the same specialty has seen her within the last three years. CPT language does not directly address the nurse midwife in its current definition, but the implication is that the qualified care-giver would also meet this definition. It is less clear whether this same interpretation would apply if the nurse midwife was not directly billing for the services, but rather if the services were billed under the physician provider number following "incident to" rules. Check with your payer before billing if you are unsure.
Question: Can I bill 57415 when removing laminaria in the operating room that had been inserted the day before a second-trimester pregnancy termination?
Answer: Code 57415 (removal of impacted vaginal foreign body [separate procedure] under anesthesia) would not be appropriate in this circumstance. It would be highly unlikely that a payer would accept the premise that a laminaria placed the day before the pregnancy termination was an "impacted vaginal foreign body." Simply bill the surgery (probably 59855 for induced abortion) and consider removal of the laminaria part of the exam and prep work involved in the procedure.
- Source for answers to "Coding Q & A" is Melanie Witt, RN, CPC, MA, an independent coding educator based in Fredericksburg, Va.