Correct Coding Initiative

CMS Responds to SIR Opposition to Revision to NCCI Guidelines Manual Regarding Multiple Same Session Interventions

(Posted 8/12/08)

On February 22, 2008, SIR joined by the American College of Cardiology (ACC), American College of Radiology (ACR), Society for Cardiovascular Angiography and Interventions (SCAI) and Society for Vascular Surgery (SVS) submitted a letter opposing the recent revision to the National Correct Coding Initiative Policy Manual for Medicare Services (Version 13.3): Chapter 5, example 16, page 12, which erroneously asserts only the "final" procedure is reportable for percutaneous minimally invasive therapeutic when multiple interventions are performed such as atherectomy, PTA and stent.

On August 6, 2008, CMS responded, indicating that they will replace the offending paragraph with a previous version issued in 1996 that reads as follows:

"When percutaneous angioplasty of a vascular lesion is followed at the same session by a percutaneous or open atherectomy, generally due to insufficient improvement in vascular flow with angioplasty alone, only the most comprehensive atherectomy that was performed (generally the open procedure) is reported (see sequential procedure policy, Chapter I, Section M)."

Per CMS, this change will be retroactive to October 1, 2007 with revision made to the online version of the Manual "as early as possible".

SIR Successfully Opposes the Creation of NCCI Edits Limiting Dialysis Maintenance PTA Services

(Posted 2-1-08)

SIR successfully opposed the creation of NCCI (National Correct Coding Initiative) edits that would have prohibiting the reporting of fistula/graft PTA Services (G0392-G0393) with dialysis declot (36870).

• Copy of the letter submitted to CMS by SIR in opposition to the proposed edits
• Copy of response indicating that CMS will not implement these proposed edits

SIR Opposes Recent CCI Edits Involving DX Angiography Codes

SIR, joined by the American College of Cardiology (ACC), American College of Radiology (ACR), Society for Cardiovascular Angiography and Interventions (SCAI,) and the Society for Vascular Surgery (SVS) has submitted request to the Centers for Medicare and Medicaid Services (CMS), requesting deletion of the National Correct Coding Initiative (NCCI) edits involving diagnostic angiography codes in conjunction with therapeutic interventional radiological supervision and interpretation that went into effect on October 1, 2004.

Vascular Coalition Letter to CMS Requesting Deletion of Edits

CMS has provided instruction that "it is appropriate for a provider to bill for both a diagnostic angiogram/venogram RS&I and an interventional therapeutic vascular RS&I when the decision to perform the interventional therapeutic vascular procedure is based on the results of the preceding diagnostic angiogram/venogram. Providers may bill both codes utilizing an NCCI associated modifier".

CMS Letter Regarding Edits (August)

Appeal ALL Inappropriately Denied Claims

SIR has received notice from numerous members that many carriers are inappropriately denying claims impacted by these edits even when the appropriate NCCI modifier "–59" is appended signifying a distinct diagnostic angiography/venography service has been provided. Providers are urged to appeal all inappropriately denied claims.

For information on the Medicare claims appeals process, see HERE.

SIR Successfully Opposes Modifier Edits with Comments to CMS

On June 23, 2006 SIR received a notice from CMS regarding proposed edits involving diagnostic cholangiography and therapeutic biliary services that a modifier use is now supported for separate and distinct diagnostic studies. SIR had previously commented on the edits and Dr. M. Victoria Marx had submitted her medical reports that were required by CMS to successfully oppose the initial proposed edits that would not have allowed modifier use.

"After reviewing the comments and redacted medical records submitted, CMS has decided to retain the currently active edits, but modify the one edit that does not allow use of NCCI-associated modifiers so that it will allow use of NCCI-associated modifiers. CMS will also add the two proposed new edits allowing use of NCCO-associated modifiers with each."

CCI edits Impacting Interventional Radiology Effective Oct. 1, 2004

National Correct Coding Initiative (CCI) edits (effective Friday, October 1, 2004) for diagnostic angiography and venography radiological supervision & interpretation (RS&I) codes reported in conjunction with a RS&I code for a therapeutic intervention require that modifier "-59" be appended to the diagnostic angiography/venography RS&I code to signify that a separate and distinct diagnostic study was provided. Failure to append this modifier as appropriate will result in denied or delayed payment of these claims.

Complete Listing of DX Angiography-Venography/Therapeutic Intervention CCI Edits.

In May of 2003, CMS submitted notice to SIR regarding their intent to enact CCI edits for diagnostic angiography and venography RS&I codes reported in conjunction with a RS&I code for a therapeutic intervention. CMS cited concerns that unnecessary repeat diagnostic angiography/venography was being reported when the "lesion is previously diagnosed and only the definitive procedure is performed" as the impetus for these edits. CMS also asserted that providers were inappropriately reporting RS&I services already captured by the RS&I code for the therapeutic intervention using diagnostic angiography/venography RS&I codes.

The initial response to CMS expressed concern that these edits were inappropriate. SIR instead asserted that education regarding the appropriate separate reporting of diagnostic angiography/venography RS&I services performed at the same setting as a therapeutic RS&I services was needed. To that end, SIR supported by the ACR and SVS, developed introductory language for CPT detailing those services represented by the therapeutic RS&I codes. It is anticipated that this new introductory instruction will appear in the 2005 edition.

SIR has consistently educated its members that diagnostic angiography/venography codes should NOT be used to report services already captured through the reporting of a therapeutic transcatheter RS&I code, including:

• contrast injections, angiography/venography and fluoroscopic guidance,
• vessel measurement,
• roadmapping, and
• completion angiography/venography (except in those circumstances when code 75898 is applicable)

CMS was informed that conversely there are many legitimate reasons for a patient to have a full and complete diagnostic angiogram/venogram on the same day as a therapeutic vascular intervention. Interventional radiology services, which are less invasive than surgical procedures, enable the quick transition from a diagnostic procedure to a therapeutic procedure, commonly allowing for same day diagnosis and treatment. A full and complete diagnostic arteriogram/venogram commonly precedes many therapeutic arterial/venous interventions and when this occurs these services are separately reportable. Some scenarios supporting the separate reporting of a diagnostic arteriogram/venogram in addition to a therapeutic intervention RS&I code are as follows:

• An angiogram or venogram may establish a diagnosis from a non-invasive imaging study, particularly important if the patient is going to undergo a therapeutic intervention.
• The treatment plan may be affected by the results of the pre-procedure angiogram or venogram. Based on the results, a patient who was a previous candidate for percutaneous therapy may now require surgical bypass or more extensive interventions such as stenting and/or thrombolytic therapy.
• The results may identify other vessels requiring treatment.
• The prior angiogram or venogram may be sufficiently old or the patient's condition may be rapidly changing, thus requiring a more current study.

Despite the anticipated addition of introductory language to CPT, CMS has provided notice that CCI edits--for diagnostic angiography/venography RS&I codes reported by the same provider, for the same patient, on the same date of service as a therapeutic interventional RS&I code--are in effect as of October 1, 2004. CMS has indicated that use of modifier "-59", distinct procedural service is indicted when a diagnostic angiogram/venogram RS&I "precedes the definitive interventional procedure RS&I."

Coding of Ultrasound Guidance for Needle Localization

A new code is now available to report ultrasound guidance for vascular access. There are clearly identified documentation requirements that are detailed within the descriptor of the code.

76937, Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency , concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting

A CCI edit did become effective on January 1, 2004 for code pair involving the new US guidance code 76937 and the new fluoro guidance for CVA Device procedures, 75998. Per AdminaStar Federal, the CMS contractor overseeing the Correct Coding Initiative (CCI) edits, the -59 modifier can be appended to code 76937, when reported in conjunction with code 75998, signifying the "legitimate" use of "both kinds of guidance". SIR's opposition to this burdensome edit was well received and we have received notice from CMS that this edits has been deleted effective on April 1, 2004.

Correct Coding Initiative (NCCI) Edits are now available to providers via the Medicare website. There are two sets of edits, Correct Coding Edits (formerly titled Comprehensive/Component Edits) and Mutually Exclusive Correct Coding Edits. The listing of edits are available as Excel files contained in ZIP files which can be downloaded. Both sets of edits are broken down to correspond with the sections of CPT®.

The Centers for Medicare and Medicaid have responded to SIR’s letter of opposition to National Correct Coding Initiative (NCCI) edits for AAA/IA endo repair codes reported in conjunction with renal PTA/stent placement . CMS has agreed to delete the edits involving code 75966 (renal PTA) effective January 1, 2004. However, providers will need to append the 59 modifier during the time that the edits are in effect (October 1, 2003-December 31, 2003). The edits involving code 75960 (stent placement) reported in conjunction with AAA/IA endo repair codes will remain unchanged. SIR is in the process of sending another letter opposing these edits, as CPT instruction also states 75960 is reportable outside the AAA/IA treatment zone.