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Outpatient Facility Coding Alert

HOPD Compliance:

Don't Use Modifier 59 to Unbundle 93505 and 93454

CMS wants you to avoid the problems outlined in the OIG report.

Does your hospital outpatient department submit claims for patient encounters that include both outpatient right heart catheterizations (RHCs) and heart biopsies? If so, CMS wants you to know that it's not okay to use modifier 59 (Distinct procedural service) to override NCCI edits that bundle the two procedures together unless you have supporting documentation.

In March 2017, the HHS Office of Inspector General released a report called Hospitals Nationwide Generally Did Not Comply with Medicare Requirements for Billing Outpatient Right Heart Catheterizations with Heart Biopsies. The report describes how the OIG audited a random sample of 100 RHC line items among claims submitted during an audit period spanning 2011 and 2012. The watchdog agency reviewed clinical documentation to discern whether there was medical necessity for heart biopsies being separately reportable from the RHCs in the sample.

"The hospitals incorrectly appended modifier 59 ... representing that the RHCs were separate and distinct procedures from the heart biopsies even though the medical record documentation did not support the use of the modifier," the OIG report says. "As a result, the hospitals received overpayments of $122,031." From the overpayments identified in the sample, the OIG estimates that "hospitals nationwide received overpayments totaling $7,629,229 for the audit period."

A September 7, 2017, MLN Matters article alerts hospitals to the OIG's report (along with another report about inpatient claims). CMS "encourages hospital billing and coding personnel to review the OIG reports and take steps to avoid the problems identified in those reports," the article notes.

"By appending modifier 59 to the HCPCS code to claims for RHCs and heart biopsies, some hospitals represented that the RHCs were separate and distinct from the heart biopsies; however, the payment for a heart biopsy is generally intended to cover an RHC when the RHC is performed during the same encounter," the MLN Matters article notes.

What this means: When you bill CPT® 93505 (Endomyocardial biopsy) to report a procedure that takes a tissue sample to look for signs that the body is rejecting a recent heart transplant, CPT® 93454 (Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation) is included with the 93505 procedure unless clinical documentation shows that modifier 59 is appropriate.

Note: Recovery Audit Contractors Cotiviti, Performant, and HMS are also auditing for this topic, according to their audit issues pages.

Resources: To read the OIG's report, To read the MLN matters article, go to: