Widespread Targeted Review Results for Alabama Providers Billing Current Procedural Terminology (CPT) 76000

Part A Medical Review recently completed the 4th quarter widespread targeted prepay review of outpatient hospital billing of CPT 76000 with any of the above additional procedures processed between October 1, 2007, and December 31, 2007. Educational articles regarding this and other uses of fluoroscopy were posted on the What’s New from Cahaba Web page on April 11, 2006, May 1, 2006, November 8, 2006, February 5, 2007, May 2, 2007, July 27, 2007, and October 23, 2007.

The review results are as follows:
Providers Reviewed: 12
Claims Reviewed: 31
Claims Approved: 0
Claims Denied: 31
Charges Reviewed: $10,675
Charges Approved: $0
Charges Denied: $10,675
Error Rate: 100%*

* error rate is based on the charges denied divided by the charges reviewed

The medical review decisions were based on the Correct Coding Initiative (CCI), developed by the Centers for Medicare & Medicaid Services (CMS) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in claims. The purpose of the CCI edits is to ensure the most comprehensive groups of codes are billed rather than the component parts, and to check for mutually exclusive code pairs. According to the National Correct Coding Initiative Policy Manual, if a CPT code descriptor includes the phrase, ‘separate procedure’ (as does CPT 76000); the procedure is subject to CCI edits. CMS does not allow separate reporting of a procedure designated as a ‘separate procedure’ when it is performed at the same patient encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach.

The majority of claim denials reviewed resulted from denial reason 53604—the documentation in the medical record did not support the billing of fluoroscopy as a separate service from the procedure performed on the same patient encounter. In most instances, the fluoroscopy billed was an inherent component of the procedure performed and not separately billable. As instructed in the Medicare Claims Processing Manual, (CMS Pub. 100-04), Ch. 23, §20.9.1.B, if a separate and distinct procedure (in this case fluoroscopy) is performed independent of the other services performed on the same day, then the provider should add modifier -59 to the secondary, additional or lesser service on the claim. The -59 modifier may represent a different session or patient encounter, different procedure or surgery, different anatomical site or organ system, separate incision/excision, or separate injury area.

Additionally, claims were denied because providers did not submit medical record documentation in response to an Additional Development Request (ADR). According to The Medicare Program Integrity Manual, (CMS Pub. 100-08), Ch. 3, § 3.4.1.2, if a coverage or coding determination cannot be made based upon the information on the claim, the Fiscal Intermediary (FI) may solicit additional documentation from the provider by issuing an Additional Documentation Request (ADR) and must notify the provider of the 30-day time period to respond. If the ADR-requested information is not is received within 45 days after the date of the request, then the claim must be denied.

To eliminate 56900 denials, please review the following elements to ensure appropriate and timely record processing:

Access the Fiscal Intermediary Standard System (FISS) to identify claims selected for ADR. Claims selected for ADR can be identified by accessing FISS Inquiry Option 12, and will appear in status location S B6001. Pages 07 and 08 of the claim will contain the date your documentation is due, and the elements of documentation requested.
Print screen the ADR letter and attach the copy to the front of the requested medical documentation
Send requested information to the address on the ADR letter
Do NOT send certified mail or overnight mail
Include ALL requested documentation outlined in the ADR
Submit the above information via regular mail in a timeframe to ensure the FI receives the information by the 45th day after the date of the request.

Refer to the Inquiry Menu section of the Fiscal Intermediary Standard System (FISS) Reference Guide for detailed information on how to access ADRs.

Although this review only included the use of CPT 76000 with CPT 36561 (insertion central venous access with port, age 5 or older), CPT 47563 (Laparoscopic cholecystectomy with cholangiography), CPT 52332 (Cystourethroscopy with insertion indwelling ureteral stent) and CPT 74420 (Urography, retrograde with or without KUB), this is not an all-inclusive list of procedures that include a fluoroscopy component. For additional information regarding the accurate coding and billing of services in adherence with CMS coverage criteria, please review the National Correct Coding Initiative Edits for Hospital Outpatient PPS.

As a result of this targeted review, Part A Medical Review will continue the targeted pre-pay review of all outpatient hospitals (bill type 13X) billing CPT 76000 with CPT 36561, CPT 47563, CPT 52332, and CPT 74420, identified by edit reason code 5123K. Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review.

Page last updated: March 3, 2008