Q: I work in a hospital-owned outpatient wound care department (HOPD) where physicians perform all of the procedures. I have identified the codes that represent these procedures in the 2008 CPT(R)*Current Procedural Terminologybook. However, our billing department often tells me that I cannot bill some codes together. If CPT codes exist for these procedures, can the codes be billed together?
A: Remember, there is a difference between coding and payment. Coders should follow CPT codes and guidelines that are published in the CPT book and the CPT Assistant.** Billers, on the other hand, must consider the payers' rules, which often differ from the official American Medical Association CPT guidelines.
To ensure over coding, the Centers for Medicare & Medicaid Services (CMS) set up edits that prohibit fragmenting/unbundling of services through the inappropriate reporting of multiple CPT/HCPCS codes, and that may lead to incorrect payment of Medicare Part B claims. The National Correct Coding Initiative (NCCI) edit system is for physicians. The Outpatient Coding Edit (OCE) system is for hospital-owned outpatient departments that are paid by the Ambulatory Payment Classification system. The NCCI and OCE edits are refined on a quarterly basis. However, the OCE refinements are always implemented one quarter after the NCCI edits. These coding edits are pairs of CPT or HCPCS Level II codes that are not separately payable except under certain circumstances. The edits affect Part B services that are billed by the same provider, for the same beneficiary, and on the same date of service.
There are 2 main types of NCCI edits:
Column 1 and column 2 edits are applied to code combinations in which the column 2 code is a component of the column 1 code. The column 1 code generally represents the major procedure or service (ie, the code with the greater work Relative Value Units [RVUs]) when reported with the column 2 code. The column 2 code generally represents the lesser procedure or service (ie, the code with the lower work RVU) when reported with the column 1 code. If 2 codes of a code pair are billed by the same provider for the same beneficiary for the same date of service without an appropriate modifier, only the column 1 code is paid. If clinical circumstances justify appending an appropriate modifier to the column 2 code of a code pair edit, payment of both codes may be allowed.
These edits also contain a "modifier" indicator column on the far right. The modifier column contains a "1," "0," or "9," which indicates whether a modifier can be used to bypass the edit.
* A CPT code with an indicator of "1" means the edit may be bypassed with a modifier, when clinically justified, so that both codes in an edit pair can be paid.
* A CPT code with an indicator of "0" means the edit may never be bypassed by using a modifier; do not report those 2 codes together. In this instance, only the column 1 code is paid.
* A CPT code with an indicator of "9" means the code pair edit has been deleted.
To ascertain if 2 procedures have the potential of being paid, search for both codes in column 1 and column 2 of the coding edit table. Normally, Medicare only pays for the column 1 code of each code pair. The column 2 code is considered "bundled into" the column 1 code. Next, look at the modifier indicator column, which indicates if you can override the bundling edit by using an appropriate modifier. Table 1 shows column 1 and column 2 edits that answer the questions:
* Can the application of an Unna boot be billed on the same day as the application of dermal substitutes relevant to 15340 and 15430?
* Can low frequency, noncontact, nonthermal ultrasound be billed on the same day as a partial-thickness surgical excisional debridement?
Mutually Exclusive Edits are applied to code combinations in which it is considered to be either impossible or improbable for one of the codes to be performed with the other code.
Q: Why do some of the codes listed in column 2 of the coding edits have higher relative values than their counterparts in column 1?
A: This issue has been corrected in CCI version 14.2. Now the higher value codes are in column 1.
Q: How can HOPDs and physicians master these correct coding edits?
A: Here are some tips to help incorporate the coding edits into a wound care practice:
* Identify the top procedures that are performed in the HOPD. Look at the "Mutually Exclusive" list and the "Column 1/Column 2" list to see if those procedures appear.
* Review quarterly updates of the coding edits that apply to you. Please note that the NCCI edits are always one quarter ahead of the OCE edits; thus providers should use the edits that apply to them and always use the current version of the edits.
* Do not change the CPT/HCPCS code to get around the coding edits.
* Avoid using modifiers as a "free pass." Do not attach a modifier to every CPT/HCPCS code just to ensure that the Part B claim is paid.
* Determine the appropriate instances when modifiers should be used. Append the appropriate modifier to the column 2 code. The column 2 code requires additional documentation to explain the circumstances why both services should be paid.
* On the encounter form, include a list of appropriate modifiers for the providers to select.
* Educate clinical and clerical staff about the correct coding edits and the appropriate documentation required to support the various modifiers that pertain to the combination procedures.
* Do not assume that the billing software is perfect. Do not let billing software assign correct coding modifiers; the documentation in the medical record must support the use of modifiers. Because not all coding edits are flagged in all billing software, billers should consult the appropriate coding edit Web site. The NCCI edit system for physicians can be found at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage. The OCE edit system for HOPDs can be found at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEHOPPS/list.asp#TopOfPage.
* Review explanation of benefits to identify code combinations that are being denied.
Q: What is a modifier and when is a modifier needed?
A: Modifiers are 2-digit numeric and/or alphanumeric designations that explain to the payer that the code has been altered by some specific circumstances but has not changed in its definition or code. The main alterations are:
* To add more information regarding the anatomical site of the procedure:Example: -RT and -LT for different levels of surgical excisional debridement to the right and left feet.
* To eliminate the appearance of duplicate billing and to prevent claim rejections:Example: -58 for staged applications of dermal substitutes by the same physician during the postoperative period.
* To eliminate the appearance of unbundling:Example: -59 for a distinct procedural service if the physician applies a dermal substitute represented by 15340 or 15430 on the foot and performs a surgical excisional debridement on the abdomen.
Before appending modifiers to a code, providers must be sure that the medical record documentation supports the need for a modifier. Some modifiers impact reimbursement while others are informational and simply help get the claim paid without costly delays. Caution: Just because a modifier exists, does not mean that you can add it to a code. Additionally, just because a modifier exists, does not mean that the Medicare contractor or the commercial payer that processes your claims recognizes and accepts the available modifiers. Be sure to verify which modifiers are recognized by the payers of your claims.
Here are a few tips for using modifiers correctly:
* Research and review the modifiers that are appropriate for the procedures and services that you perform/provide
* Identify the place of service where the work will be performed; some modifiers are often different for physician services and for hospital outpatient services
* Research the specific payer's guidelines regarding use of the appropriate modifiers
* Document thoroughly in the medical record
* Add appropriate modifiers to the procedure and service codes on claim forms
* Audit claims before they are submitted with modifiers.
Q: Our HOPD is staffed at all times by physicians. On the patient's first visit, the physician takes a complete history, performs an appropriate physical examination, orders appropriate diagnostic tests, makes medical decisions, and often performs a surgical excisional debridement. On subsequent visits, the physician assesses the wound and usually performs some procedure such as sharp selective maintenance debridement, application of an Unna boot, application of a dermal (substitute), etc. For these subsequent visits, the physician insists upon billing an Evaluation and Management (E/M) visit with a modifier -25 and the appropriate procedure code. Is this an appropriate use of modifier -25?
A: On the initial visit, it is appropriate to report a separate E/M code with a modifier -25 plus appropriate surgical excisional debridement code because the history, physical, and medical decision making resulted in the decision to perform the surgical excisional debridement. That is not the case for the subsequent visits. Assessment of the wound is an integral part of all wound care service codes. Therefore, neither the physician nor the HOPD can separately report the assessments using an E/M code with a modifier, unless the patient presented with a separately identifiable new problem.
Here is an easy way to remember this concept: For physicians, modifier -25 represents a significant, separately identifiable E/M service by the same physician on the same day of a procedure or other service beyond the usual preoperative and postoperative care associated with the procedure that was performed. For HOPDs, modifier -25 is appropriate only if a significant, separately identifiable E/M facility service is performed on the same day as a procedure that has a status indicator of "S" (significant procedure, not discounted when multiple) or "T" (significant procedure, multiple procedure, multiple reduction applies).
Caution: (1) Do not use modifier -25 if a procedure was not performed on that day. (2) The diagnosis associated with the E/M service does not need to be different from that for which the procedure was provided. However, the medical record should contain documentation that an important notable distinct problem was managed. (3) Do not append modifier -25 to the procedure codes; only append modifier -25 to the E/M codes.
Q: Is it appropriate to use a modifier when debriding multiple wounds with separate incision sites on the same extremity during the same visit?
A: If the physician performs surgical excisional debridement and clearly documents in the procedure report the type and amount of tissue removed during the procedure, and the depth, size, and other characteristics of the wound before and after the debridement, then the appropriate surgical excisional debridement code (11XXX) would be listed. However, the procedures will be subject to the multiple surgery reduction. On the claim form, report the code with the highest RVUs on the first line without a modifier. On subsequent lines of the claim, report the other code(s) with modifier -59 Distinct Procedural Service. Never append modifier -59 to the first procedure and never use it with E/M services or with coding edits with a designation of "0." Do not report modifier -59 to bypass the coding edits when the medical record documentation does not support its use. If the physician performs a sharp selective debridement, rather than a surgical excisional debridement, on those wounds, all the work should be included into 1 code (97597 or 97598, dependent upon the collective size of all the wounds).
Be careful when you use modifier -59. This modifier should only be used when the physician performed separate, distinct, and independent procedures (other than E/M services) that are not normally reported together but are appropriate under the circumstances. Use it when there is no other anatomical modifier available to show that the procedure in question was a separate service from other services performed on the same day. Most coders call modifier -59, the "modifier of last resort," which should only be used if a more descriptive modifier is not available, when the documentation fully supports the rationale for the patient encounter, and modifier -59 best explains the circumstances. Modifier -59 should only be used when the medical record documentation supports: a different session or patient encounter, a different procedure or surgery, a service at a different, noncontiguous site or organ system; a separate lesion; a separate site of incision or excision; a separate injury; a separate area of surgery in the case of an extensive injury not ordinarily encountered or performed on the same day by the same individual; a medically necessary evaluation or procedure.
Caution: Do not append modifier -59 to an E/M service. The government has reported that modifier -59 is used inappropriately 40% of the time. (Note: CMS provides guidance regarding modifier -59 on its Web site: MLM Matters article SE0715.)
Q: What should we do if our claims for procedures performed in January were not submitted until May? The correct coding edits for January 1 through March 31 did not include the code pairs that we performed. However, the correct coding edits for April 1 through June 30 did include the code pairs that we performed.
A: The correct coding edits are based on the date of service. Therefore, the new edits would not apply in the above scenario because the procedures were performed during the calendar quarter when the edits did not exist.
Q: Almost all of the applications of dermal substitutes have 90-day global periods assigned by CMS. Some of these products must be applied on a weekly basis. Should modifier -58 be used for the subsequent applications?
A: Modifier -58 is used to designate a staged or related procedure or service by the same physician during the postoperative period. Its use indicates to the payers that the performance of a procedure or service during the postoperative period was: planned or anticipated (staged), more extensive than the original procedure, or for therapy following a surgical procedure. Note: A new postoperative period begins when the staged procedure is billed.
The answer to your question is actually not simple. On one hand, CMS has built the payment for all 15430/15431 applications into the payment for the first application. Therefore, it is not appropriate to stage the 15430/15431 procedure by using modifier -58. On the other hand, CMS has not built the payment for all applications into the payment for the first application of the other dermal substitutes. Therefore, providers must declare that they will be staging the procedure in the operative report for the first application and in each subsequent operative report.
The global surgery policy does not apply to services of other physicians who may be providing services during the preoperative or postoperative period unless the physician is a member of the same group and/or same specialty as the operating physician. If a less extensive procedure fails and a more extensive procedure is required, the second procedure should be reported with modifier -58. If the less extensive procedure and the more extensive procedure are performed as staged procedures, the second procedure should be reported with modifier -58. Note: Modifier -58 is not used when reporting treatment of a problem that requires return to the operating room. Instead, consider using modifier -78 Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period or modifier -79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period.Table 2 show examples of modifiers commonly used by wound care providers.
*CPT is a registered trademark of the American Medical Association. [Context Link]
**CPT Assistant is a copyrighted publication of the American Medical Association. [Context Link]