Elston Presentation

Coding Update
Dirk M. Elston, MD Geisinger Medical Center Danville, PA
AAD representative to the CPT Editorial Panel Advisory Committee CoChair AMA Skin Cancer Performance Measure Workgroup Chair AAD P4P Workgroup No conflict of interest
Coding Changes for 2008
Destruction Modifiers Mohs Lab self-referral
Destruction codes
17000 series: premalignant only 17110: Up to 14 benign lesions 17111: 15 or more benign lesions (stand alone)
Destruction codes
17000-59 if used with either
17110: Up to 14 benign lesions 17111: 15 or more benign lesions (stand alone)
Destruction codes
17110/17111-59 if used with 17004
Premalignant
AK Leukoplakia lesion found in the mouth would most likely be appropriately reported with CPT code 40820. However, if the lesion is on the lip, 17000 could be reported. One would need to check their Carrier's policy on the destruction of premalignant lesions to determine whether codes 702.8 or 528.6 are covered. If not a covered diagnosis, one would need to have the patient sign an ABN.
Destruction codes
Plantar warts: Even though they may evolve to verrucous CA 17110: Up to 14 benign lesions 17111: 15 or more benign lesions (stand alone)
17110
Destruction (eg laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of benign lesions other than skin tags or cutaneous vascular proliferative lesions
Modifiers
Language has changed to eliminate the word physician in the explanatory text
Mohs Codes
Complex or ill-defined tumors Single physician is both surgeon and pathologist
Do not report 88305 separately
Repair still reported separately 51 exemption lost Jan 2008
Mohs Codes
Biopsy on same day because no prior histologic confirmation
Must determine subsequent procedure Report 11100/11101, 88331 59 to override CCI edit
Mohs Codes 2007

17304-17310 deleted 17311-17315
Includes first routine stain Additonal special stains or immunostains use 88311 (decalcification), 88314 (special stain), 88342 (immunostain per antibody, not per slide), add -59
Mohs Codes
17311: Head/neck/hands/feet/genitalia, first stage up to 5 blocks 17312: Add-on code Head/neck/hands/feet/genitalia, additional stage up to 5 blocks 17313: Trunk/arms/legs, first stage up to 5 blocks 17314: Add-on code Trunk/arms/legs, additional stage up to 5 blocks
Mohs Codes
17315: Each block after first 5
Used for any body site
88314: Additional non-routine special stain (in additon to toluidine blue or H&E)
Add -59 to override CCI edit
Lab Self-referral
Anti-mark-up restrictions for purchased technical or professional component
When purchased or performed outside the billing physicians office Bill the lesser of
Suppliers net charge Physicians actual charge Amount if supplier had billed directly
Derm Coding Consult Winter 2007
PQRI
Dermatology and other specialty measures not included by CMS Can still report other codes to qualify for incentive pay
PQRI
Electronic Health Record
G8447 reported for all patients 18 and older CCHIT certified HER or capable of generating medication list, problem list and entering lab tests as searchable data elements
PQRI
e-Prescribing
GH448 all patients 18 and older G8446 some handwritten or phoned in because required by law, patient request or system down System capable of generating med list, receiving data from drug plans, conducting safety checks, cost comparison, alternatives, tiered formulary, patient eligibility and authorization reqirements
15731: 2007
Forehead flap with preservation of vascular pedicle; (e.g., axial pattern flap, paramedian forehead flap). Complex myocutaneous with admission for airway management now separate family of codes
Excision of Excessive Skin

15830 (includes lipectomy): Used with panniculectomy to prevent intertrigo after weight loss 15832: Thigh 15847: Add on code to report abdominoplasty (umbilical transposition, fascial plication) used in conjunction with 15830
Skin Grafts/Substitutes
15100-15431: Grafts/substitutes 15150 series: Autologous tissue cultured epidermal grafts 15170 series: Acellular dermal replacement 15999: Excision pressure sore 15002 series: To close ulcer or donor site (burn or wound preparation/contracture release requiring graft)
15002: Trunk/arms/legs first 100 sq cm 15003: Add on code: Trunk/arms/legs each additional 100 sq cm 15004: Face/genitalia/hands/feet first 100 sq cm 15005: Add on code: Face/genitalia/hands/feet each additional 100 sq cm
15002 series: Report separately with code for graft or replacement
For excision to create recipient site for dressing or material not listed in 15040-15431, use 15002-15005 only Not used for stasis ulcer debridement
Key Issues
Inappropriate bundling of services
E&M Procedural
Future of Destruction and Mohs codes Pay for Performance
Excision and Repair Codes

CPT 2001 specifically states that repair by intermediate or complex closure should be reported separately
11400 11446 11600-11646
Complex bundled by some carriers Always document indication, depth and extent
Excision and Repair Codes

CPT 2003: Excision includes the margins (benign and malignant) Narrowest margin required to remove the tumor in its entirety Tumor plus standard margin
Excision and Repair

Measurement of lesion and the most narrow margin is made prior to excision Malignant tumor excisions continue to be worth more because of the greater risk, pre and post-service work involved
Flap Closure
CPT 2004: Defect includes primary and secondary defects Square cm area of primary plus secondary defect if single repair, separate if distinct repairs Includes zone of undermining
Adjacent Tissue Transfer

Bundles the excision Do not code separately for the excision Slow Mohs doesnt exist in CPT
If the surgeon does not also read the path, it is NOT Mohs Excision of malignant, bundled in ATT
Skin Biopsy
CPT 2004: Distinct procedure unrelated to other services provided the same day Precludes inappropriate bundling by payers
Skin Biopsy
Excision of a BCC, specimen sent to lab
Do not code biopsy separately
Excision of a BCC on cheek, biopsy of lesion on nose, both specimens sent to lab
Code biopsy separately
Mohs
CPT 2003: Appropriate to code for preoperative biopsy on the same date as Mohs if the biopsy interpretation determines the subsequent treatment Code skin biopsy 11100 and frozen section pathology 88331 with -59 DO NOT report the biopsy if it is done but only sent to the lab prior to Mohs
Lab
CPT 2001: KOH (87220) redefined as Tissue examination of skin, hair or nails for fungi or ectoparasites Frozen section (88331) clarified as first block, single specimen
Laser
CPT 2003: Inflammatory skin disease (psoriasis) 96920-96922 based on square cm
Multiple Surgeries
Primary procedure: 100% Second through 5th: 50% (represents intraservice work only) Reductions to 25% for 3rd + procedure does not represent intraservice work appropriately Add-on codes exempt
Multiple Surgeries
Refers to number of procedures, not number of lesions 4 BCCs, 3 complex repairs = 7 procedures (2 not paid) If you cannot cover your practice expenses, reasonable to delay some procedures
What Has Not Changed?

CPT defines procedures RUC determines value Physician Survey Data Practice Expense
What Has Not Changed?

Physicians are responsible for
selecting diagnosis and procedure codes Should be selected with the highest degree of specificity
Document Clearly
All components of E&M Location and size of lesions, what was done, why it was done (valid indication for procedure) Submit only medically necessary services
Ultimate Goal of Coding

Accurate capture of the work actually provided for medically necessary conditions Fair reimbursement for those services
Coding Basics
Evaluation and Management Codes Procedure Codes
Evaluation and Management History Physical Exam Medical Decision Making

All 3 for a New patient or Consult

2 of 3 for an Established patient
V codes
V10.82 Personal history of melanoma V10.83 Personal history of other skin CA V16.8 Family Hx CA V19.4 Family hx skin condition V58.41 Planned postop wound closure V58.69 Longterm use of high risk medication
New patient
Patient has not received any professional services within the last three (3) years from the physician or a physician of the same specialty who belongs to the same practice group.
Established Patient
Patient has received professional services within the last three years from the physician or another physician from the same specialty who belongs to the same practice.
Consultation
Seen at the request of another physician or provider for evaluation and management (documented) E&M documented Documentation of communication back to the referring physician Regardless of whether new or established Documented in referring MD record
CHIEF COMPLAINT (CC)

Must be stated May be included in HPI
CC, ROS, PMFSH

CC, ROS and PMFSH may be listed as separate elements, or may be included in the HPI My advice: List separately
HISTORY OF PRESENT ILLNESS

location quality severity duration timing context modifying factors associated signs and symptoms
HISTORY OF PRESENT ILLNESS

Some carriers do not allow negatives Some allow only the physician to document HPI
Template
CC: HPI:
Location: Duration: Timing: Associated signs and symptoms: Severity: Modifying factors:
ROS: PMH: FH: SH:
REVIEW OF SYSTEMS (ROS)

Constitutional symptoms (e.g., fever, weight loss) Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic
REVIEW OF SYSTEMS (ROS)

One should relate to Skin
PAST, FAMILY AND/OR SOCIAL HISTORY (PFSH)

Complete two or all three of the PFSH history areas, depending on the category of the E/M service. At least two of the three: outpatient services, established patient Each of the three: outpatient services, new patient; consultations
Established Patient
ROS or PFSH does not have to be rerecorded as long as the physician indicates that he reviewed and updated the information
Established Patient
ROS or PFSH does not have to be re-recorded as long as the physician indicates that he reviewed and updated the information ** To indicate this, the physician may describe a new ROS or PFSH, note there are no changes from previous ROS and PFSH and note the date and location of the previous ROS/PFSH referred to in the present note.
Established Patient
ROS or PFSH does not have to be rerecorded as long as the physician indicates that he reviewed and updated the information **(EMR template - @ROS, @PMH, @FH, @SH)
New, Consult or Established

If the PFSH and/or ROS was recorded by ancillary staff (including residents) or a form was completed by the patient, the physician must document that he reviewed, confirmed and/or supplemented the information.
CMS and Medicaid May 2007

Only the physician or non-physician practitioner can perform the HPI and chief complaint (CC) Shall not be relegated to ancillary staff Noridian Applies to the states of: AK, AZ, CO, HI, IA, MT, ND, NV, OR, SD, UT, WA & WY. Effective May 21, 2007.
New, Consult or Established

If the physician is unable to obtain a history from the patient, family or other source, the documentation should describe the patient's condition and other circumstances that precludes obtaining a history.
History (4 categories)
Problem Focused -- requires documentation of a chief complaint, and brief history of patient's present illness or problem Expanded Problem Focused -- includes chief complaint, brief history of present illness and a problem pertinent review
Problem Focused CC, HPI (N1 99201, C1 99241, E2 99212) Expanded Problem Focused -CC, HPI, 1 ROS (N2, C2, E3)
Problem Focused CC, HPI (N1, C1, E2) Expanded Problem Focused -CC, HPI, 1 ROS (N2, C2, E3)
Detailed -- chief complaint, extended history of present illness, problem pertinent system review (which includes a limited examination of additional systems) and pertinent past, family, and/or social history which directly relate to the patient's problem Comprehensive -- chief complaint, extended HPI, review of systems related directly to patient's problem, a review of additional body systems and complete past, family and social history
Detailed -- CC, 4HPI, 2ROS, 1 PFSH (N3, C3, E4) Comprehensive -- CC, 4HPI, full ROS, 1 each PFSH (N4, C4)
Detailed -- CC, 4HPI, 2ROS, 1 PFSH (N3, C3, E4) Comprehensive -- CC, 4HPI, full ROS, 1 each PFSH (N4, C4)
HPI
4 HPI or 1 HPI + the status of at least three chronic or inactive conditions
ROS
Complete (full) ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems. At least 1 specifically stated For the remaining systems, a notation indicating all other systems are negative is permissible.
Inpatient vs Outpatient
Consultation elements similar (IP vs OP) except when coding by time New pt. elements differ (IP vs OP)
For in-patients: New and Established elements are the same Neither matches outpatient elements
My Recommendation
95 for almost everything 97 for detailed exam (N3 99203, C3 99243, E4 99214)
12 bullets
Alert, oriented, pleasant 47 year old in no apparent distress Eyelids Lips Digits and nails 6 skin sites
Examination
Body areas : Head, including the face Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity Hematologic/lymphatic/immunologic
Examination
Organ systems : Constitutional (e.g., vital signs, general appearance) Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic
Examination -95 (4 categories)

Problem Focused -- a limited examination of the affected body area or organ system. Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ systems.

Problem Focused Skin Expanded Problem Focused Skin + one other system (2 7)

Problem Focused Skin Expanded Problem Focused Skin + Alert and oriented and in no apparent distress

Problem Focused Skin Expanded Problem Focused Skin + General + Neuro + Psych

Detailed -- an extended examination of affected body area(s) and other related systems. Comprehensive -- a general multi-system examination or a complete examination of a single organ system.

Detailed Skin + 2 7 other systems (4X4 method or clinical inference)
Under the 1995 guidelines both the expanded problem focused examination and the detailed examination provide for the examination of up to 7 systems or 7 body areas.

Detailed Skin + 2 7 other systems (4X4 method or clinical inference) 4X4: 4 elements examined in 4 body areas or 4 organ systems satisfies a detailed examination Less than such can be a detailed exam based on the reviewers clinical judgment
5X3, 3X5, 2X6

Comprehensive -- 8 or more systems or a complete examination of a single organ system.
97 guidelines required complete skin exam plus one bullet in every unshaded box
1995 DOCUMENTATION GUIDELINES (EXAMINATION)

Problem Focused -- a limited examination of the affected body area Expanded Problem Focused -- a limited examination of the affected body area Detailed -- an extended examination of the affected body area(s) Comprehensive -- a general multi-system examination or complete examination of a single organ system.
97 Guidelines
Problem Focused Examination-should include performance and documentation of one to five elements identified by a bullet () in one or more organ system(s) or body area(s). Expanded Problem Focused Examinationshould include performance and documentation of at least six elements identified by a bullet () in one or more organ system(s) or body area(s).
Detailed Examination--should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet () is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet () in two or more organ systems or body areas. Comprehensive Examination--should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet () should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.
SINGLE ORGAN SYSTEM EXAMINATIONS

Problem Focused Examination--should include performance and documentation of one to five elements identified by a bullet (), whether in a box with a shaded or unshaded border. Expanded Problem Focused Examination-should include performance and documentation of at least six elements identified by a bullet (), whether in a box with a shaded or unshaded border.
SINGLE ORGAN SYSTEM EXAMINATIONS

Detailed Examination--at least twelve elements identified by a bullet (), whether in box with a shaded or unshaded border. Comprehensive Examination--should include performance of all elements identified by a bullet (), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected.
My Recommendation
95 for almost everything Check with your local carriers regarding criteria for detailed exam (N3, C3, E4) N3, C3, E4
Highmark Medicare: 4 elements in 4 organ systems. Clinical inference overrides the 4 x 4 tool. Reviewers utilize either the 95 or the 97 guidelines. The method chosen must be the one that is most beneficial to the physician.
My Recommendation
95 for almost everything 97 for detailed exam (N3, C3, E4)
12 bullets
Alert, oriented, pleasant 47 year old in no apparent distress Eyelids Lips Digits and nails 6 skin sites
Physical Exam
1. Abnormal or unexpected findings should be described. 2. A notation of "negative" or "normal" is sufficient for unaffected areas or organs. 3. If a specific element of the examination has been deferred (i.e., a pelvic or rectal examination), the reasons for the deferral should be documented.
E3 1 HPI, 1 ROS Alert and oriented + Skin
N3
IPN3
N3 4 HPI, 1PFSH, 2 ROS 12 bullets Low IPN3
N3 4 HPI, 1PFSH, 2 ROS 12 bullets Low IPN3 4 HPI, 3PFSH, full ROS Full skin exam High
Established Patient
History Physical Exam Medical Decision Making Only need 2 of 3
N3
IPN3
Medical Decision Making
Medical Decision Making (4 categories)

Straightforward -- involves a minimal number of diagnoses or treatment options, minimal amount of data to be reviewed and a minimal risk of morbidity or mortality (M&M). Low Complexity -- involves a limited number of diagnoses, limited amount of data to be reviewed and a low risk of M&M.
Medical Decision Making (4 categories)

Moderate Complexity -- multiple number of diagnosis or treatment options, moderate amount of data to be reviewed and a moderate risk of M&M. Extensive -- extensive number of diagnosis and treatment options, extensive amount of data to be reviewed and a high risk of M&M.
Established diagnosis
Document status of each problem The record should reflect: a) improved, well controlled, resolving or resolved or b) inadequately controlled, worsening, or stable
D. Tabulation of Medical Decision Making Elements
A. Diagnoses/Management Options
Minimal Limited (2) (< 1) Minimal Limited (< 1) (2)
Multiple (3)
Extensive (> 4)
B. Amount/Complexity of Data
Moderate Extensive (3) (> 4)
C. Highest Risk (from any category)
Minimal Low SF Low
Moderate High Moderate High
Circle the intensities of the three components. If two or three circles appear in one column, look at the bottom of that column for the type of decision making. Otherwise, if there is only one circled element (intensity per column), pick the middle column of the three columns containing one circled element.
Multiple (3)
Extensive (> 4)
Minimal Low SF Low
B. Amount/Complexity of Data Reviewed

Points
Categories of Data Reviewed Order and/or review clinical lab tests Order and/or review tests from radiology Order and/or review tests from medicine/allergy Discussion of test results with performing provider Independent review of image, tracing or specimen Decision to obtain old records/discuss case w/ another provider
1 1 1 1 2 1
Multiple (3)
Extensive (> 4)
Minimal Low SF Low
Number of Diagnoses or Treatment Options
Categories of Problem
Number
Points
Self-limited or minor problem - stable, improved max=2 1 or worsening Established problem to examining provider 1 stable, improved Established problem to examining provider 2 worsening max=1 3 New problem to examining provider - no additional work up planned New problem to examining provider - additional 4 work up planned Total:
Number
Points
Number
Points
Number
Points
Minimal Limited (2) (< 1) Minimal/L Limited ow (< 1) (2)
Multiple (3)
Extensive (> 4)
Minimal Low SF Low
Number
Points
Multiple (3)
Extensive (> 4)
Minimal Low SF Low
Number
Points
Self-limited or minor problem - stable, improved max=2 1 or worsening 1 Established problem to examining provider stable, improved Established problem to examining provider 2 worsening max=1 3 New problem to examining provider - no additional work up planned New problem to examining provider - additional 4 work up planned Total:
Number
Points
Self-limited or minor problem - stable, improved max=2 1 or worsening Established problem to examining provider 1 stable, improved 2 Established problem to examining provider worsening max=1 3 New problem to examining provider - no additional work up planned New problem to examining provider - additional 4 work up planned Total:
Multiple (3)
Extensive (> 4)
Minimal Low SF Low
2 stable problems or 1 worsening problem

1. The highest level of risk in any one category determines the overall risk; 2. Determine the number of diagnosis/activities or management options; 3. Determine the amount and/or complexity of data to be reviewed 4. Determine the risk of complications and/or morbidity or mortality.
Multiple (3)
Extensive (> 4)
Minimal Low SF Low
1 New problem
Established Patient (2 of 3 required)

History Physical Examination Medical Decision Making Time (minutes) 5 10 15 - - - - - - - - - - Provider Not Required - - - - - - - - - Problem Focused EPF Detailed Comprehensive Problem Focused EPF Detailed Comprehensive Straight Forward Low Complexity
Code
99211
99212
99213
99214
Moderate Complexity 25 High Complexity 40
99215
New Patient or Consultation (requires 3 of 3 elements)

Exam Medical Decision Making E/M Office or Other E/M Outpatient Outpatient Visit Consult
History
Minutes PF EPF Detailed SF SF Low 10 20 30 45 60
Level 99201 99202 99203 99204 99205
Minutes Level 15 30 40 60 80 99241 99242 99243 99244 99245
PF
EPF
Detailed
Comprehensive Comprehensive Moderate
Comprehensive Comprehensive High
Multiple (3)
Extensive (> 4)
Minimal Low SF Low
1 Worsening problem, or 2 Stable problems
Established Patient (2 of 3 required)

History Physical Examination Medical Decision Making Time (minutes) 5 10 15 - - - - - - - - - - Provider Not Required - - - - - - - - - Problem Focused EPF Detailed Comprehensive Problem Focused EPF Detailed Comprehensive Straight Forward Low Complexity
Code
99211
99212
99213
99214
Moderate Complexity 25 High Complexity 40
99215

History
Level 99201 99202 99203 99204 99205
Minutes Level 15 30 40 60 80 99241 99242 99243 99244 99245
PF
EPF
Detailed
1 New problem
1 New problem, 2 worsening, 3 stable, 1 worsening/1 stable
E3 1 HPI, 1 ROS Alert and oriented + Skin 1 worsening, 2 stable
IPN3
E3 1 HPI, 1 ROS Alert and oriented + Skin 1 worsening, 2 stable N3, C3, IP C3 4 HPI, 1PFSH, 2 ROS 12 bullets 1 worsening, 2 stable IPN3
E3 1 HPI, 1 ROS Alert and oriented + Skin 1 worsening, 2 stable N3, C3, IP C3 4 HPI, 1PFSH, 2 ROS 12 bullets 1 worsening, 2 stable IPN3 4 HPI, 3PFSH, full ROS Full skin exam 1 severe worsening + 1 new, 1 worsening, or 2 stable
MDM
If you remember that IP New is different E3, N3, C3, IPC3: 1 Worsening 2 Stable E4, N4, C4, IPC4: 1 New problem 2 Worsening 3 Stable 1 Worsening/1 Stable
Multiple (3)
Extensive (> 4)
Minimal Low SF Low
Number
Points
Self-limited or minor problem - stable, improved max=2 1 or worsening 1 Established problem to examining provider stable, improved Established problem to examining provider 2 worsening max=1 3 New problem to examining provider - no additional work up planned New problem to examining provider - additional 4 work up planned Total:
MDM
If you remember that IP New is different E3, N3, C3, IPC3: 1 Worsening 2 Stable E4, N4, C4, IPC4: 1 New problem 2 Worsening 3 Stable 1 Worsening/1 Stable
Services billed according to time

More than 50% of the encounter is to counseling/coordination of care. For E/M services billed according to time, the teaching physician must be present during the time period for which the claim is made. Time spent by a Resident in the absence of a teaching physician may not be counted.
Services billed according to time

Total length of time of the encounter (faceto-face) should be documented Record should describe the counseling and/or activities to coordinate care.

History
Level 99201 99202 99203 99204 99205
Minutes Level 15 30 40 60 80 99241 99242 99243 99244 99245
PF
EPF
Detailed
SITE SPECIFIC BIOPSY CODES AND 2007 RVU VALUES 2007 CPT 11100 11001 11755 40490 54100 56605 67810 69100 DESCRPTOR RVU Biopsy of skin/subcutaneous tissue mucous membrane, 1 lesion 2.25 ach separate/additional lesion 0.78 Biopsy of nail unit, any method 3.14 Biopsy of lip Biopsy of penis Biopsy of vulva Biopsy of eyelid biopsy of external ear 3.02 4.94 2.26 5.03 2.59
Procedure Codes
Correct Coding Initiative

On January 1, 1996, the Medicare program implemented the "Correct Coding Initiative," employing nearly 83,000 code edits, in an attempt to eliminate unbundling or other inappropriate reporting of CPT codes.
Mutually exclusive codes

Represent services that cannot reasonably be performed in the same session. Comprehensive code will be paid and the component code disallowed.

Mutually exclusive codes
If you excise a lesion and send it to the lab, you cant bill for both excision and biospy
Bundling of procedural and cognitive services

Many procedures include pre and post service work
The general rule in the coding manual, is that the item in column 1 of the mutually exclusive list precludes billing the item in column 2 If they are separate and distinct lesions, add -59 Column 1 is often not the item with the greater RVU value.
Some software now allows the CCI override even if the -59 is placed on the wrong procedure of the pair, as long as one of the two has a -59 For more information go to the AAD website and read Derm Coding Consult June 1997
Modifier 59
Definition: Distinct Procedural Service Modifier 59 is used to clearly designate when distinct, independent and separate multiple procedures are provided. The procedure must not be a component of another procedure.
Different procedures or surgeries Surgery on different sites or organ systems Separate incision/excision Separate lesions
Modifier 79
Distinct Procedural Service during a postoperative period Modifier 79 is used to clearly designate when distinct, independent and separate multiple procedures are provided. The procedure must not be a component of another procedure.
Different procedures or surgeries Surgery on different sites or organ systems Separate incision/excision Separate lesions
Modifier 25
Definition: Significant and Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. Modifier 25 is used to describe separate, distinctly identifiable services from other services or procedures rendered during the same visit. Always attach the modifier to the evaluation and management code.
Modifier 24
Definition: Unrelated Evaluation & Management Service by the same Physician during a PostOperative Period. Separate, unrelated service was performed during the global period of the surgical procedure.
Modifier 24
Treating poison ivy during a post-op global period
Modifiers 24 and 25
When an E/M service is provided and represents a separately identifiable service, it is reasonable for physicians to expect payment, assuming that the physician has documented a separate E/M service in the medical record. It is generally more convenient for the patient and more cost effective if multiple separate services can be provided on the same date rather than requiring multiple return visits.
Modifiers 24 and 25
The CPT definition of modifier -25 states that an E/M service may be prompted by the system or condition for which a separate procedure or service is needed Does not require a separate diagnosis
A skin biopsy code (11100) does not include an E/M service in the physician work, and a separate E/M service submitted with a -25 modifier on the same date should not be bundled with the skin biopsy. A shave removal procedure, e.g. code 11311, does not include an E/M service in the physician work, and a separate E/M service submitted with a -25 modifier on the same date should not be bundled with the shave removal.
The intralesional injection codes (11900 and 11901) do not include an E/M service in their physician work and a separate E/M service submitted with a -25 modifier on the same date should not be bundled with the intralesional injection. A destruction procedure, e.g. code 17000, or an acne surgery, e.g. code 10040, are not components of an E/M service, and if an unrelated E/M service indicated by a -25 modifier is provided on the same date as the other service, the separate E/M service should also be paid on the initial claim with the other services.
Modifier 50
Definition: Bilateral Procedure
Modifier 51
Definition: Multiple Procedures After the first eligible procedure is reimbursed at 100% of our usual and customary allowance, the remaining procedures are reimbursed at 50% up to five procedures. No documentation is required. After the fifth procedure, the procedures will be considered by report and documentation is then required.
Modifier 52
Definition: Reduced Services. This modifier can be used in two different ways: To report when services were not completed in its entirety.
Modifier 57
Definition: Decision for Surgery 90 day global procedures
Mutually exclusive lists:

These would usually be bundled services if performed on the same lesion. When performed on separate and distinct lesions, add -59 to override the CCI edit. 1. Biopsy with any other skin procedure 2. Nail biopsy with skin biopsy 3. Incision and excision on the same day
Biospy and procedure on the same lesion

Biopsy service is appropriately bundled with excision or destruction and should not be reported separately unless it was done on a separate and distinct lesion or was a frozen biopsy interpreted prior to the procedure that leads to the decision to do a more comprehensive procedure.
Examples:
1. Frozen biopsy done on a papule. Based on the biopsy, Mohs surgery, full thickness excision or destruction is done during the same office visit. Code both the biopsy and the subsequent procedure. Add -59 to the biopsy to override CCI edit. 2. You biopsy and curette a lesion suspected to be BCC. You hold for path before billing, but the biopsy did not determine the subsequent procedure. You should only code the destruction (either malignant or benign) after receiving the path report.
Examples:
a. You I&D a cyst on the chest and excise a BCC on the face - code both and add 59 to the excision or you will only be paid for the I&D b. You I&D a cyst to decompress it, then excise it -- code only the definitive procedure (the excision)
Excision and destruction of a malignant lesion on the same day

a. You destroy a bcc on the back, and excise one on the face - code both and add the -59. b. You curette a BCC to define the margins, then excise it - code only the definitive procedure (the excision).
Injection with most procedures

a. You inject an inflamed cyst on the back and excise a BCC on the face - code both and add -59 to the injection b. You inject anesthetic into a BCC then excise it: Code only the excision. The excision code already includes (bundles) all pre and post op work, including injection of anesthetic.
Destruction and Paring

Destruction malignant or 17004 combined with paring of a distinct lesion.
Add -59 to the destruction code
Skin tags
Skin tags combined with any shave, excision or destruction code .
Add -59 to the shave, excision or destruction code.
Multiple Surgery Rule

Bases payment on the lesser of the actual charge or 100 percent of the fee schedule amount for the primary procedure and 50 percent for the second through fifth procedures.
Multiple Surgery Rule

Codes designated in CPT as AddOn codes are already valued as secondary procedures and are exempt from the multiple surgery rule. Mohs
Mohs
Mohs surgery has 0 global days The repair has 10 90 global days (midnight prior for 90 day)
Justification for Intermediate Closure

Never simply a single deep suture to upcode procedure
Justification for Intermediate Closure

Dead space Tension Muscle pull Wound direction Risk of hematoma or spread scar
Medically Unlikely Edits

Began as anatomic edits
Cant transplant 2 hearts
Now based on statistics

How many shaves or destructions are likely
CMS software uses the edits, but they are not made public
Fraud
Medicare fraud is legally defined as follows: Knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses, representation, or promises, any of the money or property owned by or under the custody of any health care benefit program.
Fraud
Individuals who commit Medicare fraud intentionally obtain, or attempt to obtain, money or property owned by Medicare through false or fraudulent pretenses.
Fraud
A simple mistake is not fraud
Fraud
Medicare may consider a health care provider fraudulent if the provider identifies inappropriate actions or behaviors against the Medicare program but fails to remedy them. Medicare expects all health care providers who participate in the program to furnish and report services in accordance with the established regulations and policies.
Fraud
Health care providers should correct any billing or reporting errors that they identify. If the errors result in overpayments, the health care provider is required to return the overpaid amounts to Medicare.
Fraud
Health care providers should correct any billing or reporting errors that they identify. If the errors result in overpayments, the health care provider is required to return the overpaid amounts to Medicare. I recommend prospective audits

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Coding Update

Dirk M. Elston, MD Geisinger Medical Center Danville, PA

Coding Changes for 2008

Destruction Modifiers Mohs Lab self-referral

Repair still reported separately 51 exemption lost Jan 2008

Mohs Codes 2007

Derm Coding Consult Winter 2007

Excision of Excessive Skin

Future of Destruction and Mohs codes Pay for Performance

Excision and Repair Codes

Excision and Repair Codes

Excision and Repair

Adjacent Tissue Transfer

What Has Not Changed?

What Has Not Changed?

Ultimate Goal of Coding

Evaluation and Management History Physical Exam Medical Decision Making

Evaluation and Management History Physical Exam Medical Decision Making

Evaluation and Management History Physical Exam Medical Decision Making

CHIEF COMPLAINT (CC)

CC, ROS, PMFSH

HISTORY OF PRESENT ILLNESS

HISTORY OF PRESENT ILLNESS

ROS: PMH: FH: SH:

REVIEW OF SYSTEMS (ROS)

REVIEW OF SYSTEMS (ROS)

PAST, FAMILY AND/OR SOCIAL HISTORY (PFSH)

New, Consult or Established

CMS and Medicaid May 2007

New, Consult or Established

Examination -95 (4 categories)

Examination -95 (4 categories)

Examination -95 (4 categories)

Examination -95 (4 categories)

Examination -95 (4 categories)

Examination -95 (4 categories)

Examination -95 (4 categories)

Examination -95 (4 categories)

1995 DOCUMENTATION GUIDELINES (EXAMINATION)

SINGLE ORGAN SYSTEM EXAMINATIONS

SINGLE ORGAN SYSTEM EXAMINATIONS

E3 1 HPI, 1 ROS Alert and oriented + Skin

E3 1 HPI, 1 ROS Alert and oriented + Skin

N3 4 HPI, 1PFSH, 2 ROS 12 bullets Low IPN3

E3 1 HPI, 1 ROS Alert and oriented + Skin

E3 1 HPI, 1 ROS Alert and oriented + Skin

Medical Decision Making

Medical Decision Making (4 categories)

Medical Decision Making (4 categories)

Medical Decision Making

D. Tabulation of Medical Decision Making Elements

Minimal Limited (2) (< 1) Minimal Limited (< 1) (2)

Moderate Extensive (3) (> 4)

C. Highest Risk (from any category)

Minimal Low SF Low

Moderate High Moderate High

Medical Decision Making

D. Tabulation of Medical Decision Making Elements

Minimal Limited (2) (< 1) Minimal Limited (< 1) (2)

Moderate Extensive (3) (> 4)