Modifier 58 vs. Modifier 79; Coding from Fourth-Year Residents

BRONCHOSCOPY

Q: With the new 2016 CPT codes, I no longer see the 31620 Diagnostic Bronchoscopy code I used to use with EBUS (Endobronchial Ultrasound). How do I report a bronchoscopy with fine needle aspiration using EBUS now?

A: So, code CPT 31620 - the code that was used along with all diagnostic and therapeutic bronchoscopies when EBUS was performed - has been deleted. One of the three new codes added to the respiratory section, 31654 is the code that you will now use with other diagnostic and therapeutic bronchoscopies, if those codes are on this list (the list appears as a parenthetical note under code 316540): 31622, 31623, 31624, 31625, 31626, 31628, 31629, 31640, 31643, 31645 and 31646.The old combination 31620 and 31629 for Bronch with FNA and EBUS - is now 31629 and 31654.

MODIFIER 58 or MODIFIER 79

Q: A patient with end-stage renal disease (ESRD) is taken to the operating room for creation of arteriovenous (AV) fistula (90-day global) in anticipation of dialysis. (As you are most likely aware, the fistula must mature for a period of time before it may be used).

Unexpectedly, the patient's renal status declined even further and the patient was not able to wait for the AV fistula to mature, so he was taken to surgery only a week later for a dialysis catheter placement.

We are struggling with modifier 58 vs. modifier 79. (I know, it's usually a question of modifier 58 vs. modifier 78) Some coders believe it should be modifier 58 because the reason for the surgery is the same: ESRD with need for dialysis. Some of our coders believe it should be modifier 79 because it is unrelated to the previous surgery, only related to the disease process and the second surgery was even a separate anatomical area.

A: Great question but you may be over-thinking this. You'll likely be asked to submit the documentation to the payer with either of these modifiers - so they will surely have an answer for you - you can count on that.

The purpose of both modifiers 58 and 79 is to underscore either the character of or the distinctness of the second procedure.

Modifier 58 gives three broad conditions that you may need to indicate: a) Staged (planned), b) more extensive, and c) therapy following a surgical procedure. Your scenario fits none of those.

Modifier 79 simply says "unrelated" to the original procedure. And "related" can mean a lot of things. The CCI edits do not link the codes to which you are referring - so there is no bundling. It is unlikely that these would hit an exclusion edit in payer software in the first place.

As to the reason for the surgery being the same - there is truth in that - but they are separate surgeries, unrelated to one another in a surgical sense. Given your scenario, I'd go with modifier 79.

FOURTH-YEAR RESIDENTS

Q: Can licensed fourth-year residents work in urgent care without supervision? Will CMS allow full payment for non-board-certified fourth-year residents for their patient care practice with no supervision? Is it a good or legal practice for an urgent care to hire solely fourth-year residents doing all the patient care?

A: We can't give legal advice. So you may need to share this question with others. From a coding and billing perspective there are some options here:

Residents are licensed medical professionals, MDs. There is a large body of regulatory guidance pertaining to supervision of residents in a teaching setting - very little outside the teaching setting. This is due principally to payments made to attending physicians and the need to make distinctions between which provider did what.

In your scenario, residents can apply for billing privileges and become credentialed to the extent possible with a given payer. There may be payer-specific limitations related to board certification but residents have been "moonlighting" since before there was a Medicare.

If a resident is not supervised by another credentialed physician, direct billing would be the only way to go to facilitate professional billing. If there were another credentialed physician onsite, CMS does allow one physician to bill incident-to another.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is an AAPC-certified instructor and has been active in physician training for more than 25 years.

This article was originally published in the January 2016 issue of Physicians Practice.