E/M Coding Alert - 2017 Issue 10
HOPD Compliance: Don't Use Modifier 59 to Unbundle 93505 and 93454
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Article Overview
This article reviews Medicare compliance guidance for hospital outpatient department claims that involve right heart catheterizations and heart biopsies. It discusses an OIG audit finding, follow-up CMS MLN Matters guidance, and the role of documentation when claims are affected by NCCI bundling edits. The article is aimed at hospital billing and coding staff, compliance professionals, and others responsible for outpatient cardiac procedure claims.
Why This Topic Matters
Hospitals submitting outpatient cardiac procedure claims need to understand how Medicare compliance reviews, audit findings, and documentation support affect billing accuracy and claim editing. The article helps readers identify the policy issue, the organizations involved, and the broader compliance context.
What You Will Learn
- The compliance issue raised by Medicare audit activity for outpatient cardiac procedure claims
- How OIG and CMS guidance relate to hospital outpatient billing practices
- Why documentation is central when claims are reviewed for bundling and edit concerns
- Which organizations and audit programs are monitoring this topic
Who Should Read This
- Hospital outpatient billing staff
- Medical coders
- Compliance officers
- Revenue cycle professionals
- Cardiology practice administrators
Codes Discussed
Modifiers Discussed
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