Coding Strategy

Here’s why you should append modifier 25.

Question: A 47-year-old male reports to the ED complaining of a painful, swollen, and reddening right thumb. The physician performs an expanded problem focused history and examination, which uncovers two splinters. The ED physician cannot grasp the splinters with tweezers, so she uses a scalpel to make two small incisions above the splinters. The physician then uses tweezers to remove both pieces of wood. The notes do not indicate evidence of infection at the extraction site; medical decision making is moderate. Can I code this as a foreign body removal (FBR)?

Kentucky Subscriber

Answer: Since the physician made an incision before removing the splinters, this is an FBR. On the claim, report the following:

• 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the FBR
• 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity …) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99282 to show that the E/M and FBR were separate services
• 915.6 (Superficial injury of finger[s]; superficial foreign body [splinter] without major open wound and without mention of infection) appended to 10120 and 99282 to represent the patient’s injury.

Explanation: The incision, or lack of it, drives code choice in this scenario. If the physician had removed the splinters without making an incision, you would have rolled the removal work into the E/M service and left 10120 off the claim.

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Upcoming policy change will slash your payments by half.

Big changes are on the horizon if you participate with insurance provider Horizon Blue Cross Blue Shield (BCBS) of New Jersey.

In a recent memo, BCBS states that effective May 17, 2010, they will cut reimbursement by half on many modifiers, regardless of the circumstances surrounding their use. Your practice might stand to lose thousands of dollars. Take a look at the policy details.

Beware a New Reimbursement Trend

The February 2010 memo offers a list of modifiers that BCBS states “will be considered nonstandard — that either the full service was not performed or that the service in question was performed in conjunction with another service or procedure.”

If the policy proceeds as planned, the move will create logistical migraines for those submitting to Horizon BCBS in NJ, experts warn. Many industry watchers hope that this policy will not set a deeply troubling precedent across the country.

Expect the Worst for Modifiers 25, 59

Of the modifiers being cut, the effects on modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and modifier 59 (Distinct procedural service) may have the greatest impact for your practice.

Important: The memo states that evaluation and management (E/M) services that are appropriately appended with modifier 25 will pay “at 50 percent of the applicable Horizon BCBSNJ fee schedule amount. This recognizes that the service in question was rendered in conjunction with a separately identifiable E&M service performed on the same day by the same practitioner.”

“In general, it’s becoming tougher every day to get payers to pay with a 25 modifier,” says Karla Westerfield, COPM, business manager at Southeast Wyoming Ear, Nose and Throat Clinic in Cheyenne.

Modifier 59 will also receive the same drastic 50 percent reduction. “I feel that even though the 25 modifier is going to hurt practices, it will not be as much of a ‘hurt’ factor as the situation with the 59 modifier,” says Brian Fornutaro, a billing professional with Medi-corp in Cranford, NJ.

Reasoning: Horizon’s memo states that it is following CMS Correct Coding Institute (CCI) guidelines for appropriate use of the modifiers. CCI edits do not allow a reduction on modifier 25, however. They do allow a modifier 59 reduction as part of the multiple procedure reduction rules.

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Measuring total removal lengths is a no-no … here’s why.

Your ED physician removes a pair of benign lesions from the patient’s left thigh; you add the repair lengths and code based on those numbers. You’ve coded correctly … right?

Wrong: Many coders get tripped up by lesion removal codes, which are governed by different rules than lesion excision codes. Get the real lowdown on coding multiple lesion excisions right here, and you’ll get it right every time.

CPT, Experts Agree: Don’t Add Lengths

When your physician removes multiple lesions, “code for each individual lesion; this is not like laceration repairs, where you combine the length of all of the same body area/complexity wounds,” explains Sharon Richardson, RN, compliance officer at Emergency Groups’ Office in Arcadia, Calif.

“Report separately each benign [or malignant] lesion excised,” reads the CPT 2010 guidelines preceding each lesion excision section: Depending on the nature and location of the lesions, however, you may need to employ modifiers on multiple lesion removals.

Example: A patient presents with one lesion on his forehead and one on his neck. The patient cannot stop scratching them, which is causing bleeding. The ED physician performs an expanded problem focused history and physical exam. During the history portion of the E/M,the patient reports that he has no access to a dermatologist, so the ED physician chooses to excise the lesions.

The physician performs a pair of simple benign lesion excisions: a 1.3 cm lesion from the patient’s face and a 1.8 cm lesion from the patient’s neck. The physician then writes a five-day antibiotic prescription and a 10-day prescription for Tylenol #3.

On this claim, Richardson recommends reporting the following codes:

• 11422 (Excision, benign lesion including margins,except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm) forthe neck lesion removal
• 11442 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm) for the facial lesion removal
• modifier 59 (Distinct procedural service) appended to 11442 to indicate the separate nature of the removals — if the insurer requires it**
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity …) for the E/M service
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and lesionremovals were separate services

**Alternate scenario: If the patient in the above example had both lesions removed from his face, you could report 11442 and 11442-59 for the repairs.

You Won’t Always Need Modifier 59

If the lesions are in different anatomic areas – or if the lesions differ in pathology – the payer might want you to code the removals separately without any modifiers. Other payer peculiarities might include wanting  o see modifier 51 (Multiple procedures) on multiple lesion removal claims.

Best bet: Check with the carrier before coding multiple lesion removals, as there can be some coding differences among insurers for these services.

@ General Surgery Coding Alert

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Measuring total removal lengths is a no-no … here’s why.

Your ED physician removes a pair of benign lesions from the patient’s left thigh; you add the repair lengths and code based on those numbers. You’ve coded correctly … right?

Wrong: Many coders get tripped up by lesion removal codes, which are governed by different rules than lesion excision codes. Get the real lowdown on coding multiple lesion excisions right here, and you’ll get it right every time.

CPT, Experts Agree: Don’t Add Lengths

When your physician removes multiple lesions, “code for each individual lesion; this is not like laceration repairs, where you combine the length of all of the same body area/complexity wounds,” explains Sharon Richardson, RN, compliance officer at Emergency Groups’ Office in Arcadia, Calif.

“Report separately each benign [or malignant] lesion excised,” reads the CPT 2010 guidelines preceding each lesion excision section: Depending on the nature and location of the lesions, however, you may need to employ modifiers on multiple lesion removals.

Example: A patient presents with one lesion on his forehead and one on his neck. The patient cannot stop scratching them, which is causing bleeding. The ED physician performs an expanded problem focused history and physical exam. During the history portion of the E/M,the patient reports that he has no access to a dermatologist, so the ED physician chooses to excise the lesions.

The physician performs a pair of simple benign lesion excisions: a 1.3 cm lesion from the patient’s face and a 1.8 cm lesion from the patient’s neck. The physician then writes a five-day antibiotic prescription and a 10-day prescription for Tylenol #3.

On this claim, Richardson recommends reporting the following codes:

• 11422 (Excision, benign lesion including margins,except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm) forthe neck lesion removal
• 11442 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm) for the facial lesion removal
• modifier 59 (Distinct procedural service) appended to 11442 to indicate the separate nature of the removals — if the insurer requires it**
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity …) for the E/M service
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and lesionremovals were separate services

**Alternate scenario: If the patient in the above example had both lesions removed from his face, you could report 11442 and 11442-59 for the repairs.

You Won’t Always Need Modifier 59

If the lesions are in different anatomic areas – or if the lesions differ in pathology – the payer might want you to code the removals separately without any modifiers. Other payer peculiarities might include wanting  o see modifier 51 (Multiple procedures) on multiple lesion removal claims.

Best bet: Check with the carrier before coding multiple lesion removals, as there can be some coding differences among insurers for these services.

@ General Surgery Coding Alert

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Attach your procedure notes and the OIG’s report to pack extra punch.

Even if you follow all of CMS’s rules in reporting modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), your Medicare payer may sometimes still choose to deny your claim.

If you feel you deserve the pay for the EM service you performed, you should appeal the denial. Alice Kater, CPC, PCS, coder with Urology Associates of South Bend in Indiana, offers the following sample appeal letter (below) as an example of how she has challenged her payer to collect rightful reimbursement.

What you should know: To improve her odds of success, Kater submits her physician’s documentation with the appeal letter, as well as a copy of a 2005 letter from Mark B. McClellan, MD, PhD, former HHS administrator, to Inspector General Daniel R. Levinson that was a response to the 2005 OIG report “Use of Modifier 25.”

In addition, Kater includes the first three pages of the OIG report, which outlines the appropriate way to report modifier 25. You can download McClellan’s letter, as well as the OIG report, at http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf.

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