I wish I had a dollar for every time that I answered a wound care professional who asked if he/she could bill Medicare for 2 services/procedures during the same patient encounter. And, I wish I had $2.00 for every time a sales representative from a wound care product manufacturer/distributor told me that their wound care professional customer asked if they could bill for their product/procedure at the same encounter when another service/procedure was performed.
As all Payment Strategies readers know, I enjoy answering your questions and educating you as often as needed. It worries me, however, when wound care professionals ask sales representatives about reimbursement issues. Wound care sales representatives have expertise about their wound care products and their clinical utilization, but they do not have reimbursement expertise. In fact, reimbursement questions beyond the material that is released by a company's reimbursement director likely cause great angst for sales representatives. Instead, wound care professionals should obtain their reimbursement information from the governmental and private payers who insure their patients, wound care journal columns such as Payment Strategies, wound care webinars, wound care reimbursement consultants, wound care business seminars, manufacturer's wound care reimbursement directors, and reimbursement sessions at local, regional, and national wound care symposia.
Now, let's talk about this "hot topic" of billing for 2 services/procedures during the same patient encounter. Even though I have often written and spoken about Medicare's National Correct Coding Initiative (NCCI) Edits, I suspect that many wound care professionals have not proactively added this reimbursement tool to their "wound care business toolbox." In addition, wound care professionals may not always interpret the NCCI Edits according to the NCCI Edit Manual guidelines. Please take the first corrective steps to this problem by reviewing Table 1 to learn the names of the various NCCI Edit tools, the location of the tools, and the frequency of updates to the tools.
As described in Table 1, the Procedure to Procedure (PTP) NCCI Edits are updated quarterly and can be found in 4 different NCCI Edit tables.
* Two of the NCCI Edit tables are for hospital PTP edits. Note: These tables also pertain to hospital outpatient departments, such as wound care departments.
The last row of the October 1, 2015, NCCI edits in the first hospital PTP table lists CPT(R)* code 39599 in column 1 and CPT(R) code 49570 in column 2.
The first row of the October 1, 2015, NCCI edits in the second hospital PTP tables lists CPT code 40490 in column 1 and CPT code 0213T in column 2.
* Two of the NCCI Edit tables are for practitioner PTP edits. Note: These tables pertain to wound care professionals, such as MDs, DOs, DPMs, NPs, PAs, CNs, and so on.
The last row of the October 1, 2015, NCCI edits in the first practitioner PTP table lists CPT code 39599 in column 1 and CPT code 49570 in column 2.
The first row of the October 1, 2015, NCCI edits in the second practitioner PTP tables lists CPT code 40490 in column 1 and CPT code 00170 in column 2.
Therefore, any time a wound care professional and/or hospital outpatient wound care department wants to know if 2 procedures/services can be billed to Medicare for the same patient encounter, they should log onto the current quarter's NCCI Edit table that pertains to them. They should look to see if the 2 CPT codes are listed together in the NCCI Edit table. If the 2 CPT codes are not listed together in column 1 and column 2 of the NCCI Edit table, the 2 services/procedures may be billed to Medicare as long as a National Coverage Determination and/or Local Coverage Determination does not prevent coverage of the 2 services/procedures during the same encounter. If the 2 CPT codes are listed together in columns 1 and 2 of the NCCI Edit table, the wound care professional must then view the modifier in column 6 of the same edit row as the code pair.
* If modifier "0" appears in column 6, the 2 CPT codes may never be billed together to Medicare during the same patient encounter.
* If modifier "9" appears in column 6, it indicates that an NCCI edit used to exist for the code pair, but the edit is no longer applicable, and the 2 codes may now be billed together to Medicare. If the wound care professional wishes to know the date that the edit was removed, that information can be found in column 5 of the table.
* If modifier "1" appears in column 6, that means the 2 CPT codes may only be billed together to Medicare if they meet the NCCI Edit exception guidelines. Column 4 states the effective date of each NCCI Edit. Column 7 provides the PTP edit rationale for each NCCI edit, for example, standards of medical/surgical practice, CPT Manual or CMS manual coding instructions, mutually exclusive procedures, misuse of column 2 code with column 1 code, and so on. If a wound care professional reports the 2 codes of an NCCI Edit pair for the same beneficiary on the same date of service, the "column 1 code" is eligible for payment, but the "column 2 code" is denied unless it is clinically appropriate to utilize an NCCI-associated modifier. In the latter case, both the "column 1" and "column 2" codes are eligible for payment.
It is very important that NCCI-associated modifiers be used only when appropriate. Most edits involving paired organs or structures (such as eyes, ears, extremities, lungs, kidneys) have modifier indicators of "1" because the 2 codes of the code pair edit may be reported if performed on the contralateral organs or structures. However, most of these code pairs with the indicator of "1" should not be reported with NCCI-associated modifiers when performed on the ipsilateral organ or structure unless there is a specific coding rationale to bypass the edit.
Note: The existence of the NCCI PTP edit indicates that the 2 codes generally cannot be reported together unless the 2 corresponding procedures are performed at 2 separate patient encounters or 2 separate anatomic locations. However, if the 2 corresponding procedures are performed at the same patient encounter and in contiguous structures, NCCI-associated modifiers generally should not be utilized.
Some examples of common "column 1" and "column 2" wound care NCCI edits (such as subcutaneous debridement; application of cellular and or tissue-based products for wounds on trunk, arms, legs; selective debridement; physician supervision of hyperbaric oxygen therapy) are listed in Table 2. Please note that column 2 includes a combination of procedures and evaluation and management (E&M)/clinic visit codes. This is important because wound care professionals may have misperceptions about NCCI Edits that pertain to E&M/clinic visits.
To clear up these misperceptions, let's review some of the NCCI Edits Manual guidelines regarding E&M/Clinic Visits. I have underlined some portions of the guidelines that wound care professionals must understand and implement.
"Since NCCI PTP edits are applied to same-day services by the same provider to the same beneficiary, certain Global Surgery Rules are applicable to NCCI. An E&M service is separately reportable on the same date of service as a procedure with a global period of 000, 010, or 090 under limited circumstances.
If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable. NCCI does not contain edits based on this rule because Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits.
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.
For major and minor surgical procedures, postoperative E&M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package as are E&M services related to complications of the surgery. Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed unless related to a complication of surgery may be reported separately on the same day as a surgical procedure with modifier 24 (Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period).
Treatment of complications of primary surgical procedures is separately reportable with some limitations. The global surgical package for an operative procedure includes all intraoperative services that are normally a usual and necessary part of the procedure. In addition, the global surgical package includes all medical and surgical services required of the surgeon during the postoperative period of the surgery to treat complications that do not require return to the operating room. Thus, treatment of a complication of a primary surgical procedure is not separately reportable (1) if it represents usual and necessary care in the operating room during the procedure or (2) if it occurs postoperatively and does not require return to the operating room.
Modifiers may be appended to HCPCS/CPT(R) codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to an HCPCS/CPT(R) code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use. If the Medicare program imposes restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI PTP edit if the Medicare restrictions are fulfilled. Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include:
* Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
* Global surgery modifiers: 24, 25, 57, 58, 78, 79
* Other modifiers: 27, 59, 91, XE, XS, XP, XU
Now let's review the NCCI Edits Manual guidelines for the 2 most misused modifiers: 25 and 59. Wound care professionals should read these guidelines thoroughly.
Modifier 25: The CPT Manual defines modifier 25 as a "significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service." Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s).
Modifier 25 may be appended to E&M services reported with minor surgical procedures (global period of 000 or 010 days) or procedures not covered by global surgery rules (global indicator of XXX). Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work. Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient.
Modifier 59: Modifier 59 is an important NCCI-associated modifier that is often used incorrectly. For the NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are "separate and distinct." Modifier 59 should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes. The CPT(R) Manual defines modifier 59 as follows:
Modifier 59: "Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25."
One of the common misuses of modifier 59 is related to the portion of the definition of modifier 59 allowing its use to describe "different procedure or surgery." The code descriptors of the two codes of a code pair edit usually represent different procedures or surgeries. The edit indicates that the two procedures/surgeries cannot be reported together if performed at the same anatomic site and same patient encounter. The provider cannot use modifier 59 for such an edit based on the two codes being different procedures/surgeries. However, if the two procedures/surgeries are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifier 59 may be appended to indicate that they are different procedures/surgeries on that date of service.
Use of modifier 59 to indicate different procedures/surgeries does not require a different diagnosis for each HCPCS/CPT coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.
From an NCCI perspective, the definition of different anatomic sites includes different organs, different anatomic regions, or different lesions in the same organ. It does not include treatment of contiguous structures of the same organ, eg, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site.
CPT codes representing services denied based on NCCI PTP edits may not be billed to Medicare beneficiaries. Since these denials are based on incorrect coding rather than medical necessity, the wound care professional cannot utilize an "Advanced Beneficiary Notice" form to seek payment from a Medicare beneficiary. Furthermore, since the denials are based on incorrect coding rather than a legislated Medicare benefit exclusion, the wound care professional cannot seek payment from the beneficiary with or without a "Notice of Exclusions from Medicare Benefits" form.
SUMMARY
I hope this article has motivated wound care professionals to include the NCCI Edit tools into their "wound care business toolkit." Rather than hearing the answers regarding procedure-to-procedure coding and billing from this author or from sales representatives, the quotes from the NCCI Edit Manual guidelines should clarify that (1) billing for an E&M and procedure on the same day should be an infrequent occurrence and that (2) many wound care procedures are included in column 2 of the NCCI Edits.
*CPT is a registered trademark of the American Medical Association.