Coding Strategy

When an EM service occurs during a postop global period for reasons unrelated to the original procedure, use this modifier.

Question: If the cardiologist performs a pacemaker insertion in the hospital and later visits the patient in observation, should I code the observation visit?

Georgia Subscriber

Answer: You should not charge this visit separately. Pacemaker insertion code 33208 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial and ventricular) has a 90-day global period.

For payers applying Medicare rules, that means that payment for the pacemaker insertion service includes the following services (among others) for 90 days following the procedure:

• Services related to complications following surgery, not requiring additional trips to the operating room
• Postoperative visits (follow-up visits) related to recovery from the surgery
• Postsurgical pain management by the surgeon.

FYI: Medicare specifies certain visits that are not included in the global package, meaning you may report them separately:

• Visits unrelated to the diagnosis that prompted the surgical procedure (unless the visits occur due to complications)
• Treatment for the underlying condition or an added course of treatment which is not part of normal surgery recovery
• Diagnostic tests and procedures
• Clearly distinct surgical procedures which are not re-operations or treatment for complications
• Treatment for complications which requires a return trip to the operating room.

When an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code.

Source: You can find the definition of the global surgical package in Medicare Claims Processing Manual, Chapter 12, Section 40.1.A.

@ Cardiology Coding Alert. Editor: Deborah Dorton, JD, MA, CPC

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Test your 2010 consultation coding understanding with these questions and answers.

Consultation coding has every practice on edge this year. Ensure that you’ve got a handle on this complicated coding and billing situation by taking this three-question quiz and then checking your answers against the experts’.

Question 1: When a visit with a Medicare inpatient that would normally have been coded as a consultation does not meet the requirements of an initial inpatient hospital care code, what should you report?

Question 2: What modifier do admitting physicians need to use in 2010 when they report an initial hospital care code (99221-99223)?

Question 3: When Medicare is the patient’s secondary insurance and his primary insurance accepts the consultation codes, should you use a consultation code for the Medicare Secondary Payer (MSP) as well?

Answer 1: 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, CPCP, 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.

Answer 2: Stick With 2 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 (www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf).

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.

Answer 3: 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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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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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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