Coding Strategy

A revised GA and new GX hope to clarify some of Medicare’s non-coverage policies.

At least one aspect of dealing with Advance Beneficiary Notice of Non-Coverage (ABN) forms is about to get a little simpler, thanks to two modifiers.

CMS is now giving you two HCPCS level 2 modifiers to distinguish between voluntary and required uses of liability codes, according to release CR6563.

Know when you need an ABN with this expert advice:

Background: When your physician provides a service that Medicare does not cover, your practice must provide an ABN to the patient. The patient should then examine and complete the form before your providers administer that service or procedure.

When you have a patient sign an ABN, you also need to append the appropriate modifiers on your claim. ABN modifiers tell the Medicare carrier that you have an ABN on file for services that won’t be covered.

Luckily, modifiers GA (Waiver of liability on file) and GX (Notice of liability issued, voluntary under payer policy) should add more tools to your belt that will help you fend off denials.

Good practice: “It is in the provider’s best interest to discover which procedures need ABNs in their offices, and flag accounts prior to the patient coming in,” says Melinda Brown, CMBS, insurance biller with H. Matt Smith, MD in Kennewick, Wash.

Don’t Waver on Modifier GA Use

CMS redefined modifier GA to be a “waiver of liability statement.” You should only use modifier GA “to report when a required ABN was issued for a service, and should not be reported in association with any other liability-related modifier and should continue to be submitted with covered charges,” CMS says.

Simply put, “the GA indicates that you have a signed ABN on file,” Brown explains.

Unfortunately, using GA does not mean you’ll get automatic reimbursement. According to the CMS guidelines, a GA modifier indicates the possibility that a service may be denied for medical necessity only, and that the physician may bill the patient after the claim is denied.

Example: A patient presents for lesion destruction (freezing) of seborheic keratosis(es). In this case, you would bill 17000 (Destruction [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [eg, actinic keratoses; first lesion) and 17003 (second through 14 lesions, each) times three units of service, for four total lesions with a diagnosis code of 702.19 (Other seborrheic keratosis). You’ll need to obtain an ABN from the patient and then use modifier GA since Medicare may deny 17000 with any diagnosis except 702.0 (actinic keratosis), for medical necessity, says Brown.

Use GX for a Voluntary ABN

When your practice issues a voluntary ABN for a particular service, you’ll instead turn to modifier GX. CMS defines modifier GX as “notice of liability issued, voluntary under payer policy.” You will use modifier GX when you need a denial remittance advice to submit for secondary insurance, when Medicare does not pay as primary, but the secondary insurance does pay with a denial explanation of benefits (EOB).

Old way: Before CMS revised the ABN last year, you would have used a Notice of Exclusion of Medicare Benefits (NEMB) form for these cases. CMS eliminated the NEMB, however, so modifier GX helps you tell the payer you have a voluntary ABN on file.

You might also use the ABN for a never covered service if a patient does not believe the service is not covered and insists that you submit the claim to Medicare. You would have the patient sign the ABN and submit the service to Medicare with a GX modifier so that the patient receives the denial remittance advice.

Watch for: If you append GX on the same line as many liability-related modifiers, including EY (No doctor’s order on file), GA, GL (Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN), and others, Medicare will likely deny your claim.

Example: A patient needs a hearing aid, which Medicare never covers, but the patient has secondary insurance that will pay. The patient signs an ABN. You should submit the claim to Medicare with a GX modifier. Your practice may then submit to the secondary insurance, which will pay for a part of the hearing aid based on the denial from Medicare.

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Understand ‘significant’ and ‘separate’ to earn a gold star.

Knowing when to report modifiers and choosing the best one for each situation can be an easy trip-up for coders. If you find yourself especially befuddled by modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), keep reading for real-world tips that will help you code confidently every time.

Starting point: Remember you can only consider reporting modifier 25 when coding an E/M service. If the procedures you’re reporting don’t fall under E/M services, check whether the encounter qualifies for modifier 59 (Distinct procedural service) instead.

1. Verify That Service Is Significant

As CPT’s Appendix A explains, a significant and separately identifiable service “is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.” Ask yourself two questions when deciding if your case meets the criteria:

• Could the complaint or problem stand alone as a billable service? A single trigger point injection (20552, Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]), for example, qualifies as a stand-alone service you might see in conjunction with an E/M visit.
• Do you have a different diagnosis for the portion of the visit unrelated to the initial service? For example, the patient might be in the office for a planned knee injection, but also complains of shoulder pain during the visit.

Reporting an E/M code with modifier 25 would be appropriate for the services performed and documented concerning the shoulder.

If you can answer “yes” to either question, you’re one step closer to reporting modifier 25.

Example: “My physicians complete a lot of lumbar and cervical injections that have a 0-day global period,” says Mary Baierl, RHIT, CPC, CCA, CMT, a coder with BayCare Clinic, Pain Management and Rehabilitation Medicine in Green Bay, Wis. “When they evaluate the patient in the office, offer an injection, and have time to do the injection that day, we code the injection and include office visit E/M code with modifier 25 as a separately identifiable service.”

2. Check for Additional Work

If the diagnosis remains the same, Quita Edwards, CCS-P, CPC, COSC, CPC-I, owner of CASE Contracting Services in Fort Valley, Ga., says you have a third question to ask: Did your orthopedist perform extra work that went above and beyond the typical pre- or postoperative work associated with the procedure code? Another affirmative answer points you to modifier 25.

Example: A patient comes to your office for a scheduled joint injection. She has received injections to treat knee pain due to osteoarthritis but they don’t provide long-term relief. During the appointment your physician says she needs to begin thinking about surgical intervention. He spends between 30 and 40 minutes discussing the risks and benefits of surgery so the patient can make an informed decision.

Even though the diagnosis you report for the injection and the E/M service will be the same, you can separately report the two services in this case. “The physician spent enough time discussing the surgery to count as significant and separately identifiable from the injection,” Edwards explains. “You can bill an E/M code with modifier 25 based on the amount of time he spent, even though he didn’t evaluate the patient.”

3. Look for Pre-Planning

Modifier 25 is meant for those “oh, by the way” type situations, not procedures that are tied to previous services. Consider these scenarios and whether you think they merit modifier 25, then watch the Medical Coding News for our experts’ recommendations.

Scenario 1: Your orthopedist sees Mrs. Jones in the office and gives her a prescription for pain medication to help her wrist pain. He says that if this doesn’t help, he’ll give her a wrist injection when she returns. Mrs. Jones returns to the office two weeks later for the injection. Your physician completes another evaluation prior to administering the injection.

Scenario 2: Your physician treats Mrs. Adams for a minor shoulder injury. She returns a few days later because her arm was snatched during activity and she’s experiencing significant pain. The physician completes a full evaluation before prescribing treatment.

Scenario 3: Your surgeon completes total hip arthroplasty on Mr. Brown. Six weeks after the surgery, Mr. Brown returns to your office and sees a different physician because of an ankle sprain.

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Check your 2010 consultation coding savvy.

Find out if you’re set to properly code your physician’s consultation services this year by tackling three problems and their solutions.

Check With Your MAC for Guidance

When your physician sees a Medicare inpatient and would have used an inpatient consultation code, this year you should report an initial hospital care code (99221-99223). If the E/M service and documentation do not meet the requirements of an initial inpatient hospital care code, however, your coding will now depend on your Medicare Administrative Contractor’s (MAC) or carrier’s policy.

Problem: The lowest initial hospital care code (99221) requires a detailed history and detailed exam. When your physician’s documentation does not reach this level, there is a question as to what CPT codes you should use.

Option 1: Some MACs/carriers have stated that you should use the subsequent hospital care codes (99231-99233). “Our MAC (Highmark) has actually stated to not use 99499 (Unlisted evaluation and management service) for consultations and to use subsequent care codes,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network. She adds that instructions about whether or not to use 99499 seem to be MAC-by-MAC specific right now.

Option 2: Other MACs, however, have instructed practices to use the Not Otherwise Classified (NOC) code 99499, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

For example, WPS Medicare states on its Web site: “Many providers have questioned the use of a subsequent care code when the provider does not meet the requirements of an initial care code. Wisconsin Physicians Service (WPS) Medicare advises the use of Not Otherwise Classified (NOC) code 99499 as stated in the Internet-Only Manual (IOM).”

“Check with your contractor,” Buechner advises. “Code 99499 is the correct coding choice by CPT rules.” Some payers, such as Highmark, don’t seem to like that coding, however, so you need to know what code(s) your payers want you to use.

Important: Because five levels of inpatient consults are now billed using only three levels of inpatient E/M visits, some practices are seeking crosswalks that refer them from consult codes to E/M codes. But you should not rely on any such guides as the final word. Instead, when the practitioner performs an E/M service, report the code “that most appropriately describes the level of services provided,” notes MLN Matters article MM6740.

Stick With Two Letters for Admitting Physician

Admitting physicians now have a new modifier for their initial inpatient service. As of Jan. 1, if you’re billing for the admitting physician you must append modifier AI (Principal physician of record) to the initial visit code. This will denote the admitting physician who is overseeing the patient’s care, “as distinct from other physicians who may be furnishing specialty care,” according to CMS Transmittal 1875.

Example: A trauma surgeon admits from the emergency room a patient who was involved in a motor vehicle accident and calls in an orthopedic surgeon to perform a consult for multiple fractures in the patient’s leg. The trauma surgeon would report 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) with modifier AI appended. The orthopedic surgeon then bills 99221-99223 with no modifier for his initial examination of the patient whether the visit represents a consultation or a new visit.

Remember: The new modifier is made up of two letters. “Some people are interpreting the new modifier as a one,” Cobuzzi says. “But it’s two letters, A and I,” she reminds coders. Think: A-eye.

Skip 99241-99255 for Medicare, Even as Secondary

Don’t even think about billing a consult to Medicare — even if the claim is to a Medicare secondary payer (MSP).

The challenge: Medicare may have scratched consultations codes off its list of payable services, but many other insurers did not follow suit. This dual system leaves you in a quandary when your physician performs a consultation, and the primary non-Medicare insurer pays for the consultative service, but the secondary payer is Medicare.

The MSP “will not pay for consults,” says Samantha Daily, a medical biller for a practice in Portland, Ore.

Official word: MLN Matters article MM6740 indicates the following: “In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes [99241-99255, Office or other outpatient consultation …]. If the primary payer for the service continues to recognize consultation codes” you should bill for secondary payment from Medicare in one of the following two ways:

• Bill the primary payer using an E/M code (not a consultation code), and then report the amount paid by the primary payer, along with the same E/M code, to the MSP for determination of whether additional payment is due; or
• Bill the primary payer using a consult code, and then report the amount paid by the primary payer, and change the code to the non consult E/M code (that is equal to the consultation code/service documented and paid), to the MSP for determination of whether you are owed additional payment.

Potential snag: In some cases the physician may not know whether a hospitalized patient is on Medicare or another insurance when he documents his consultation and determines code assignment for the billing department. You will need to be able to glean an appropriate E/M code from your physician’s consult documentation if the patient ends up also having Medicare as secondary insurance.

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Remember ligament repair abbreviations to simplify elbow ligament surgeries.

Baseball players are gearing up for the season, which means your orthopedist could see a sudden increase in elbow ligament injuries. If conservative therapies fail to help torn medial (841.1) or lateral (841.0) collateral ligament injuries, your surgeon might opt to perform a ligament repair or reconstruction. Follow our tips to distinguish between procedures, and you’ll hit a coding homerun.

Terms, Diagnosis Can Signal Correct Procedure

Because surgeons don’t always use the words “reconstruction” or “repair” in their operative reports, you might have difficulty choosing between elbow ligament surgery codes:

• 24343 — Repair lateral collateral ligament, elbow, with local tissue
• 24344 — Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft)
• 24345 — Repair medial collateral ligament, elbow, with local tissue
• 24346 — Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft).

Tip: Look for words such as …

“graft” in your surgeon’s documentation to help you distinguish between repair and reconstruction — seeing “graft” means the surgeon performed a reconstruction instead of only repairing local tissue. “Also look for other conditions that make repair impossible and create the need for reconstruction,” says Kathy Nelson, CPC, COSC, an orthopedic coder with Fletcher Allen Health Care in Burlington, Vt. Examples could include when the ligament was retracted and couldn’t be located, the ligament was diseased, or the tissue was friable so a repair most likely wouldn’t hold.

If the physician does not document a graft, he probably performed a repair — but that is much less common, says Bill Mallon, MD, an orthopedic surgeon and medical director of Triangle Orthopaedic Associates in Durham, N.C. Instead, Mallon says physicians usually perform reconstruction with a tendon graft.

Another clue: The patient’s diagnosis also can point you in the right direction. Surgeons can perform reconstruction on an acute tear, but normally use reconstruction for patients with chronic tears. If the surgeon documents a chronic tear (with terms such as “diseased ligament,” “retracted and not retrievable,” or “chronic and friable tissue not conducive to repair”), he probably reconstructed the ligament.

Tip: The lateral collateral complex consists of the radial collateral ligament (which goes to the radius) and the ulnar collateral ligament (which goes from the humerus to the ulna). The ulnar collateral ligament is the true lateral collateral that surgeons repair or reconstruct, and goes from humerus to ulna, just like the medial collateral. That’s why the surgery sometimes is called an ulnar collateral reconstruction.

Know Abbreviations to Select Code

Physicians often document abbreviations instead of the full anatomical ligament name. If your orthopedist documents a torn “RCL” (radial collateral ligament) or  “LCL,” he is referring to a torn lateral collateral ligament. Report RCL or LCL tears with 24343 (for repair) or 24344 (for reconstruction).

Likewise, physicians often refer to the medial collateral ligament as the “MCL,” and the ulnar collateral ligament as “UCL.” You might even see documentation for a “Tommy John” surgery, which is another nickname for UCL reconstruction. Therefore, you would probably assign 24346 if the surgeon documents a chronic tear to the UCL.

Don’t assume: “It might not always be a chronic tear,” Nelson cautions. “A tremendous medial or lateral dislocation could have caused a space or gap or really stretched out the ligament that required more than a repair.” Talk to your surgeon to verify whether he or she went beyond a repair.

Watch out: The surgeon most often performs grafts from the palmaris longus tendon during reconstruction. Reconstruction codes include the graft harvest, so you should not charge a graft harvest separately.

Shoulder surgery coding secrets you need to know.

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Improve your reimbursement chances by applying modifier 58 in this situation.

When your surgeon targets the brain or spine with stereotactic radiosurgery (also called gamma knife surgery) to treat multiple lesions over multiple sessions, you need to know two crucial things: what stereotactic radiosurgery codes to use and how many units to include.

Take this three-question challenge to see whether you’ve got stereotactic radiosurgery intricacies down.

Hint: If you want to pass with flying colors, follow this expert advice: you’ll report “61796 through 61799 depending on simple or complex lesions and add a second code for additional lesion treatment,” says Nancy Chicolte, CPC, senior coding specialist for Johns Hopkins University’s Department of Neurosurgery in Baltimore.

Read 3 Statements, Then Choose True or False

Question 1: True/False — If your neurosurgeon performs stereotactic radiosurgery on five simple lesions, you should report five units of 61796 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 simple cranial lesion).

Question 2: True/False — The surgeon uses the gamma knife to target and destroy four spinal lesions. During an initial session, the surgeon treats two of the lesions completely but plans to fractionate treatment for two others. During a later session, the surgeon again treats the remaining two lesions. Because the surgeon treated four separate lesions, you may report 63620 (Stereotactic radiosurgery [particle beam, gamma ray, or linear accelerator]; 1 spinal lesion) x 4.

Question 3: True/False — If any lesion requires multiple isocenters and/or requires more complex targeting, then you can report 61796 and append modifier 22 (Increased procedural services).

Apply This Add-On for Additional Lesions

Answer 1: False.

CPT 2009 established new stereotactic radiosurgery code 61796. It has an add-on code, +61797 (… each additional cranial lesion, simple [List separately in addition to code for primary procedure]), for additional lesions, to a maximum of five total lesions. Remember, “you’ll use these codes for simple lesions,” says Gwen Flaherty, CPC, lead certified coder with 12 years experience at NeuroScience Associates in Boise, Idaho.

In addition, if the neurosurgeon uses a frame-based system, then you should apply another add-on code, +61800 (Application of stereotactic headframe for stereotactic radiosurgery [List separately in addition to code for primary procedure]), says Marianne Schipper, CPC, spine, brain, and endovascular coding specialist at Brown Neurosurgical Associates in Phoenix, Ariz.

In other words: You may not report multiple units of 61796 for multiple treatments on the same lesion, as the code includes the course of treatment, even if performed over several sessions. Instead, you may report one unit of 61797 for each separate lesion the surgeon treats, up to five total lesions.

“Code 61796 describes stereotactic radiosurgery of a single lesion, with one or more isocenters, treated in a single fraction or over several sessions,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

More than five: What if the surgeon treats more than five lesions? AMA instructions state directly that you should not report treatment of more than five lesions. Therefore, even if the surgeon treats more than five lesions per date of service, you should limit yourself to no more than one primary code and four units of the add-on code. In other words, “do not report +61797 more than four times for an entire course of treatment, regardless of the numbers your neurosurgeon treats,” Schipper says.

Number of Sessions Doesn’t Matter

Answer 2: False. The number of sessions the surgeon requires to treat the lesions does not factor into the coding. The codes’ descriptors reflect the work over the course of treatment.

Because the surgeon may choose to treat the same lesion during more than one session over the course of treatment to safely radiate the lesion (called “fractionated treatments”), you should report 63620 only once for the first lesion treated, regardless of how many sessions the surgeon requires to treat the lesion.

Note: You should report any additional spinal lesions your neurosurgeon treats (up to a maximum of five lesions) with the add-on code +63621 (… each additional spinal lesion [List separately in addition to code for primary procedure]).

Examine Your Documentation Before Using Mod 22

Answer 3: False.

“Many lesions require multiple isocenters and/or more complex targeting because of their size or location, Przybylski says. That’s why CPT 2009 introduced two different sets of codes, distinguishing simple from complex. Therefore, you shouldn’t reach for modifier 22 automatically when your neurosurgeon’s documentation describes a complicated surgery.

Example: Suppose a neurosurgeon treats a lesion that:

• is more than 3.5 cm in size,
• consists of a certain pathology including arteriovenous malformation, schwannoma, pituitary adenoma, and pineal and glomus tumors,
• is located in the cavernous sinus, parasellar, or petroclival regions, or
• is proximate to critical structures such as the optic nerve or brainstem.

This meets the definition of a complex lesion, Schipper agrees. Therefore, for this treatment, you should use the complex cranial lesion code 61798 (… 1 complex cranial lesion). If your neurosurgeon treats other complex lesions (up to a maximum of five), you would include +61799.

Tip: Apply modifier 22 only in those truly difficult and unusual circumstances that call for significant additional physician work and/or time that is not accounted for in the complex lesion descriptor.

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