For the Week of May 23, 2016

I have a patient who received an implantable cardioverter-defibrillator (ICD) dual-chamber device from company A. During the defibrillation threshold testing (DFT) phase, the device would not convert the patient from ventricular fibrillation, and rescue shocks were performed. The patient returned the following day and a new ICD generator from company B was inserted. This device has a higher joule output that will allow the patient to be converted from the arrhythmia.

Can I assign the following CPT code for an ICD generator change?
33263  Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system

Code 33263 would be the correct code when the existing dual-chamber ICD generator was removed on a separate day from the initial insertion date and inserted and attached to the existing right atrium (RA) and right ventricle (RV) leads. For professional fee billing, assign the following modifier since this is within the global period (90 days).  

Modifier -78  Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period

For hospital billing, the modifier -78 would not be needed as this is construed as a separate date of service and the global period does not apply.

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If a billing provider submits a claim for referred clinical laboratory and imaging services from a provider located outside of the United States will the claim be denied? 

Yes, the claim will deny because the referring provider who is located outside of the United State is ineligible to enroll in Medicare. The Centers for Medicare & Medicaid Services (CMS) remind billing providers that claims denied because they failed the ordering/referring edit do not expose a Medicare beneficiary to liability, and an advance beneficiary notice (ABN) is not appropriate in this situation.

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What is a prodrug?

A prodrug is a forerunner of an active drug. Before becoming an active drug, the prodrug must undergo chemical conversion by metabolic processes (such as being broken down by bacteria in the colon). Sulfasalazine (Azulfidine, Azulfidine EN-Tabs), for example, is a prodrug.

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If we do a solid and liquid gastric emptying study on different days, may we charge 78264 twice (once for each date of service)?

According to CPT Assistant, December 2015, if one is performed and then on a later date it is determined that the other is needed, 78264 would be reported for each exam (78264 x 2). However, this should be rare since in most cases it is known that both will be needed prior to the start of the first study and both should be performed on the same day (dual-phase imaging protocol).

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All of the descriptions for level II codes G0237, G0238, G0239 indicate that the codes are the assigned for therapeutic procedures to improve respiratory function. Aside from paying attention to the specific number of minutes indicated in G0237 and G0238, how should these be assigned?

As its description states, G0237 involves therapeutic procedures specifically targeted at improving the strength and endurance of respiratory muscles (pursed-lip breathing, diaphragmatic breathing, and paced breathing). G0238 involves a variety of activities including teaching patients strategies for performing tasks with less respiratory effort and the performance of activities intended to increase endurance and strength of upper and lower extremities. Both of these codes should be billed for each 15 minutes of direct one-to-one activities or procedures.

G0239 represents group situations where two to four patients are simultaneously receiving services such as those described in G0237 and G0238. It is not a timed code and should be reported only once a day for each patient in the group. Groups are limited to a ratio of not more than one professional to four patients. G0239 should be billed only once per session per discipline.

The above codes include monitoring of the patient prior to, during, and following the specific therapeutic activity. 

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In regard to assigning the mandatory modifier PO on hospital outpatient claims, can the same claim have both a HCPCS with the PO modifier and a HCPCS without the PO modifier? 

As you say, reporting of this two-digit modifier began mandatory beginning on January 1, 2016. It must be reported with every code for outpatient hospital items and services furnished in an off-campus provider-based department (PBD) of a hospital.

In answer to your question, yes, a single hospital outpatient claim (type of bill 13X) could have a HCPCS code with the PO modifier and without the PO modifier such as when a patient is treated at an off-campus provider-based department and the on-campus hospital on the same day.

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