tci Outpatient Facility Coding Alert - 2017 Issue 10

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...

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