Health Information Management

Q/A: Billing CT and CTA

APCs Insider, October 5, 2012

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Q: Our ED physicians order both computed tomography (CT) and CT angiography (CTA) exams to insure that the blood vessels and soft tissue are examined. When we report the codes for both exams, we hit an edit that requires a modifier in order to report both exams. We have been using modifier -59 (distinct procedural service) to bypass the edit, but recently one of our internal auditors is questioning this. Is there any documentation to support using modifier -59 in this instance?

 
A: Modifier -59 should be used only as a last resort and only after each situation has been reviewed. Modifier -59 should never be an “automatic” addition to a code. This modifier identifies a service that is “separate and distinct” from another service or performed at a separate encounter. For modifier- 59 to be applicable in the instance you describe, the services must be separate and distinct and the provider must clearly document medical necessity.
 
Facilities report technical services based on the resources use and CMS has questioned the applicability of reporting two complete studies when performed on the same body area at the same session. While the CTA provides more information regarding the blood vessels, the question becomes whether faciltie should report an entire separate study when they performed a CT of the same body area. The National Correct Coding (NCCI) manual, Chapter 9, notes:
 
Computed tomography (CT) and computed tomographic angiography (CTA) procedures for the same anatomic location maybe reported together in limited circumstances. If a single technical study is performed which is utilized to generate imagesfor separate CT and CTA reports, only one procedure, either the CT or CTA, for the anatomic region may be reported. Both a CT and CTA may be reported for the same anatomic region if they are performed at separate patient encounters or if two separate and distinct technical studies, one for the CT and one for the CTA, are performed at the same patient encounter. The medical necessity for the latter situation is uncommon.
 
The provider may document medical necessity for studying both the soft tissue and the blood vessels. However, the question is – does the documentation support the medical necessity for reporting the HCPCS codes for two separate and distinct complete technical studies? This involves more than just having two separate reports by the radiologist as this doesn’t support the need for two complete technical studies.
 
The NCCI narrative notes that it would be a rare occurrence that the medical necessity would support reporting two distinct studies when they are performed at the same time. If the combined study requires additional resources to image the blood vessels, the cost of the additional resources (slices, contrast, etc.) can be added to the cost/charge of the base procedure.
 
For example, a line item for the combination study could be added to the chargemaster. The description could be “CT with CTA” of the body area and the cost for the additional slices/cuts can be added to the base charge. This allows compliant reporting of the procedure and the additional cost of the combination procedure.
 
Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.



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