Hospitals Nationwide Generally Did Not Comply With Medicare Requirements for Billing Outpatient Right Heart Catheterizations With Heart Biopsies 

The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote correct coding by providers and to prevent Medicare payments for improperly coded services. The NCCI edits include procedure-to-procedure edits that define pairs of HCPCS/Current Procedural Terminology codes (code pairs) that generally should not be reported together for the same beneficiary on the same date of service. One function of the procedure-to-procedure edits is to prevent payments for codes that report overlapping services except in those instances where the services are "separate and distinct" (e.g., different session or patient encounter). Typically, an NCCI edit would prevent the payment for a right heart catheterization (RHC) when billed on the same claim as a heart biopsy. However, under certain circumstances, a hospital may bill and get paid for both services in an NCCI code pair by including a modifier on the claim. If a hospital included modifier -59, it would bypass the NCCI edit and receive payment for both procedures as though they were performed separately. A hospital should not append modifier -59 to the HCPCS code representing an RHC when it is performed with a heart biopsy unless the procedures are separate and distinct.