Coding Strategy

Even though Medicare no longer accepts consult codes, you can still apply modifier 57.

Question: In our ob-gyn office, we used to apply modifier 57 to inpatient consult codes. Now that Medicare doesn’t accept consult codes, how should we use this modifier?

Kentucky Subscriber

Answer: The short answer is that you should appendmodifier 57 (Decision for surgery) to the non-consult inpatient E/M code that the documentation supports.

Suppose the ob-gyn performed a 2009 level-three inpatient consult in which the ob-gyn determined the patient required an exploratory laparotomy later that sameday due to severe abdominal distention and pain as well as some uterine bleeding. Adding the modifier to the E/M code will help show payers why you’re reporting an EM in addition to the major surgery performed later that day, 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]).

For 2010, the exact E&M code you choose will depend on the circumstances specific to the visit, such as whether the visit is the first or second ob-gyn visit during the admission. But as an example, suppose you’re coding the ob-gyn’s first visit to an inpatient. Your documentation may support 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity …), which has requirements similar to 99253 (Inpatient consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity).

You should append modifier 57 to the E/M code. If, instead, the ob-gyn is the principal physician — the one overseeing the patient’s care and the one who is admitting the patient — be sure to append modifier AI (Principal physician of record), as well. This would be the case if the ob-gyn admitted the patient for observation for the abdominal pain and bleeding but later made the decision to take her to surgery that same day.

@ Ob-gyn Coding Alert, Editor: Suzanne Leder, BA, M. Phil., CPC, COBGC

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Have your documentation ready for reporting level P4 and higher.

Physical status modifiers, also referred to as P modifiers, PS modifiers, ASAs or ASA P codes, are an important element of your anesthesia coding. If you don’t use them correctly, you could dash your reimbursement opportunities, or risk a payer audit.

Skip P Modifiers With Medicare, But Check Private Payers

If your anesthesiologist works with a number of Medicare patients, you probably haven’t spent much time learning the finer points of anesthesia’s Physical Status Modifiers. Why? Because Medicare does not pay for them.

End of story, right? Not if your practice contracts with private payers. Many private payers will often reimburse for P modifiers if you follow the guidelines.

“Reporting is dependent on the carrier and can be dependent on whether the group negotiated for it in their contract. Most government payers do not allow reporting or payment of PS modifiers,” says Debbie Farmer, CPC, ACS-AN, coder with Auditing for Compliance & Education in Leawood, Kan.

Example: A 2001 Aetna anesthesia policies memo states, “When these modifiers/codes are reported, additional ASA units may be allowed and combined with the base unit value for the anesthesia service performed.” While the trick is in meeting those conditions, you don’t have to shy away from P modifiers if you know the basics.

Use 6 Levels to Define Patient’s Status

The American Society of Anesthesiologists (ASA) developed physical status modifiers to allow coders to distinguish between different levels of complexity of anesthesia service. These levels are based on the patient’s condition, as follows:

• P1 — Normal healthy patient
• P2 — Patient with mild systemic disease
• P3 — Patient with moderate systemic disease which can be a threat to life
• P4 — Patient with severe systemic disease that is a constant threat to life
• P5 — Moribund patient who is not expected to survive with or without the operation
• P6 — Declared brain-dead patient whose organs are being removed for donor purposes.

The ASA does not provide concrete definitions for physical status modifiers because their use is based on clinical decisions the anesthesia provider makes for each patient.

Hint: Most of your anesthesiologist’s services require a P1, P2, or P3 modifier. To use P4 or higher, you need clear documentation in the medical record to support its use. Even if your anesthesiologist classifies a patient as P3, many payers will want more information to support the claim.

How it works: A patient with stable angina would be considered a P3 status. This patient has a systemic disease that could kill him, but he is stable and expected to do well.

A patient with a P4 status has his life constantly threatened by his disease. “ASA 4’s are patients who are not expected to die in the perioperative period, although it wouldn’t be totally unexpected if they do,” says Scott Groudine, MD, professor of anesthesiology at Albany Medical Center in New York. Someone with unstable angina, or in congestive heart failure who needs surgery, would be a 4.

Make Sure You Clarify Dx and Documentation

In its “Revised Hospital Anesthesia Services Interpretive Guidelines,” CMS offers clarification on minimum accepted standards of what should be included in a pre-anesthesia evaluation of a patient, including “notation of anesthesia risk according to established standards of practice (e.g. ASA classification of risk).”

Why it’s important: The preop note should regularly include PS classification, Groudine says. If it doesn’t, your practice may not be complying with CMS rules.

The best way to ensure you’re using the proper PS code is to check, and double-check, your physician’s documentation. In many cases you can find the ASA classification included in the operating room nurse’s notes.

Heads up: “Many times I see that a claim went in without a diagnosis to support the underlying condition for reporting the PS modifier and the carrier will not allow the additional unit,” Farmer says.

Note: You cannot use a PS code with an add-on code such as +01953 (Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area [TBSA] treated during anesthesia and surgery; each additional 9% total body surface area or part thereof).

@ Anesthesia Coding Alert, Joshua Thines

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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.

@ ED Coding Alert

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Did you miss Terri Brame’s Coding for Robust Foreign Body Removal? Click here to order CDs and transcripts.

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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