Coding and modifiers for started or completed procedures when inserting a drug eluting coronary stent

Q.

I always thought that for an outpatient facility billing Medicare that if we attempted to insert a drug eluting coronary stent, but could not, that it would be better to report the Level II HCPCS code C9600-74 as that would help the hospital cover the expense of the coronary drug-eluting stent itself. Per CMS information, the 74-modifier still provides 100% reimbursement on that code. As such, would we not also report the angioplasty in that case? Has that guidance changed?

A.

The question is whether the stent placement was started or not. If not, code for what was done and finished (angioplasty). If started, you can code the stent code with 74 modifier and not the angioplasty.

The problem is – what is “started”? Coding Clinic for HCPCS has published two questions about angioplasty where the provider could not get a wire or catheter past the lesion. In one case, they said that since the angioplasty was started, it would be coded with a -74 modifier, in the other case, they said that since the wire/catheter couldn’t get past the lesion the angioplasty had not been started, and so could not be coded, only the diagnostic angiogram performed would be coded. See Coding Clinic for HCPCS, Volume 7, number 1, 2007, and Volume 8, Number 2, 2008. 

What Medicare said when these modifiers were introduced was: 

a. When one or more planned procedures are completed, report the completed procedures. Any other procedure(s) that were planned, and not started, are not reported. ​

b. When none of the planned procedures are started and no anesthesia is administered, the first planned procedure is reported with modifier 73. In this instance, the patient must have been prepared and taken to the procedure room.

c. If anesthesia has been administered or the first procedure has been started (e.g., scope inserted, intubation started, the incision made, etc.) modifier 74 should be reported with the first procedure. The other procedures are not reported.

d. If the first procedure is terminated prior to the administration of anesthesia and before the patient is taken into the procedure room, the procedure should not be reported.

e. If the first procedure is completed and a second procedure is started but not completed, the second procedure is reported with modifier 74 and the first procedure is reported with no modifier.