Awareness : Did You Know? 2017

Did You Know? Weekly Educational Series #6

For the Week of February 13, 2017-Moderate Sedation

A CCI error could delay some moderate sedation payment until after April 1.

Starting in January of this year, there have been about 100,000 new Correct Coding Initiative (CCI) edit additions, including those for moderate sedation, angioplasty, and pain management.

Know When to Bill Separately for Moderate Sedation

One of the biggest changes for CPT® 2017 requires you to bill moderate sedation separately to get paid for the service. In prior years, CPT® and payers bundled the moderate sedation payment into certain specified procedures. In 2017, if a cardiologist performs moderate sedation along with a cardiology procedure, he should bill 99151-+99153 (Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status …), along with the primary cardiology procedure code.

For example, if a cardiologist performs a procedure CPT® code 92920 (Percutaneous transluminal coronary angioplasty; single major coronary artery or branch) for a 72-year-old patient and the cardiologist also provides moderate sedation (99152), you can bill both the angioplasty and the moderate sedation services on the same claim. CCI does not include an edit bundling these two codes together. However, CCI version 23.0, effective Jan. 1, 2017, prevents you from billing moderate sedation services that another provider performs — 99155-+99157 (Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports …) — in conjunction with the cardiologist’s procedure. The cardiologist should not be billing for another provider’s service.

Important news:

The CCI edits tables effective Jan. 1, 2017, included errors for some 99151-+99153 edits. The edits have a modifier indicator of “0,” so you can’t override the edits. Some of the cardiology codes impacted include those for repositioning/relocation of aortic counterpulsation ventricular assist devices (0459T-0461T), the new dialysis circuit codes (36901-36909), and the new angioplasty codes (37246-37249).

In the April 1, 2017, updates these errors will be corrected. If claims are submitted prior to the April 1, the claims will be denied, but you will be able to appeal the denials on or after April 1, 2017. The CCI contractor recommends holding your 99151-+99153 claims until after the correction. You can find the news posted at

Understand When to Override New Angioplasty Edits

2017 CCI edits, for the new transluminal balloon angioplasty codes 37246-+37247 (Transluminal balloon angioplasty [except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit], open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery …), this is getting bundled into many cardiovascular procedure codes like 37220 (Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty) and coronary angioplasty code 92920. The modifier indicator for these edit pairs generally is “1,” meaning you can use a modifier to override the edits when the documentation supports it.

Example: The cardiologist performs coronary angioplasty for a patient with a diagnosis of I25.110 (Atherosclerotic heart disease of native coronary artery with unstable angina pectoris), and the cardiologist clears the stenosis. You bill this coronary angioplasty using CPT code 92920. You must append the appropriate anatomic modifier to identify the artery, if the payer requires it.

The patient also has hypertension (I10, Essential [primary] hypertension), and during the same encounter as the 92920 service, based on the patient’s case, the cardiologist looks to see if renal artery stenosis is the cause of the hypertension. He selects the left renal artery and finds an 80 percent stenosis. It would be billed as a diagnostic service using 36251 (Selective catheter placement [first-order], main renal artery and any accessory renal artery[s] for renal angiography, including arterial puncture and catheter placement[s], fluoroscopy, contrast injection[s], image post-processing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral).

At the same session, the cardiologist performs an angioplasty to remove the renal vessel stenosis. Code the renal angioplasty using 37246.

There isn’t a CCI edit that requires the use of a “distinct services” modifier on 36251 in this specific case, but payers might prefer that you do so when the patient has both the diagnostic and interventional procedures during the same session.  Remember that to be able to code the diagnostic service in addition to the intervention, the 36251 study must be a true complete renal diagnostic study and not part of a planned intervention.

Because CCI does have an edit for 92920 and 37246, append a “distinct services” modifier like XS (Separate structure) or 59 (Distinct procedural service) to 37246, dependent upon what the payer prefers.

It’s not often that you see a coronary interventional procedure (such as 92920) with 37246 so make sure that the documentation supports these services before billing those services for the same encounter with an unbundling modifier.