Coding for pericardial drainage procedures and noninvasive estimated coronary fractional flow reserve techniques with imaging

Q.

One of our coding software programs does not include modifier 26 for Category lll CPT^® code 0504T and Category l CPT codes 33016–33019, but another one states modifier 26 is necessary when billing the physician component of these codes. Which is correct? 

A.

Category lll CPT code 0504T is, by definition, a professional component only code, and does not need modifier 26. Other codes in the series exist that represent global (0501T), and technical (0502T, 0503T) portions of the study. 

In the Medicare Physician Fee Schedule (MPFS), Category lll code 504T has a PC/TC indicator of 2 –  Professional component only codes: This indicator identifies standalone codes that describe the physician work portion of selected diagnostic tests for which there is an associated code that describes the technical component of the diagnostic test only and another associated code that describes the global test.

CPT codes 33016–33019 are surgical codes, so they do not break into PC (-26) and TC components. 

These codes have a PC/TC indicator of 0 0-Physician service codes: This indicator identifies codes that describe physician services.

That’s a bit confusing because in reality, both the hospital and the physician can bill these codes because the hospital is paid under a different payment system other than the MPFS. The hospital will bill on the UB-04 (or electronic equivalent), and that tells payors that they are billing for the technical part of these CPT codes (room, supplies, non-physician staff, etc.), while the physician bills on the 1500 claim form (or electronic equivalent), and that tells payors it is physician (i.e., “professional”) billing. However, an IDTF or imaging center that is paid under the MPFS can’t bill these codes because there is no TC under the MPFS.

The codes and full descriptions are as follows:

33016 Pericardiocentesis, including imaging guidance, when performed

33017 Pericardial drainage with insertion of indwelling catheter, percutaneous, including fluoroscopy and/or ultrasound guidance, when performed; 6 years and older without congenital cardiac anomaly

33018 Pericardial drainage with insertion of indwelling catheter, percutaneous, including fluoroscopy and/or ultrasound guidance, when performed; birth through 5 years of age or any age with cardiac anomaly

33019 Pericardial drainage with insertion of indwelling catheter, percutaneous, including CT guidance

0501T Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report

0502T Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission

0503T Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model

0504T Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report