Description
Reviewers shall complete a complex medical review to determine if endomyocardial biopsy and right heart catheterization were performed as two distinct services. The review shall identify claims where modifier 59 or XU have been inappropriately appended when Endomyocardial Biopsies and Right Heart Catheterizations are billed together. Billed services that are not supported by medical record documentation will result in an overpayment.
Affected Code(s)
93505, 93451
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Medicare Claims Processing Manual, Chapter 23- Fee Scheduled Administration and Coding Requirements, §20.9.1.1(B)- Instructions for Codes with Modifiers- Modifiers 59 or -X{EPSU}
9. NCCI Manuals, Chapter 1- General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare
10. NCCI Manuals, Chapter 11- Medicine & E/M CPT Codes 90000-99999 for National Correct Coding Initiative Policy Manual for Medicare
11. CPT Manual