E&M Codes With Procedures & NCCI Edits Dominated Discussions at SAWC

  Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy of the information. However, HMP Communications and the authors do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received. The responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.   As I write this column, I’m on a flight returning home to Lake Worth, FL, after four unbelievable days of learning and sharing information at the 2013 Symposium on Advanced Wound Care (SAWC) Fall conference, as well as a recent Wound Clinic Business (WCB) seminar in Las Vegas. The WCB event marked the first time it occurred the day prior to SAWC and attendees were very appreciative of the opportunity to maximize these programs back-to-back. In addition to serving as faculty for WCB, I was honored to participate in the wound clinic track for the SAWC meeting. As you might have guessed if you read the session schedule in advance, my assigned topic was “Getting Paid: Reimbursement Pearls.”   Personally, I also had the opportunity to attend most of the high-level SAWC presentations and to have one-on-one discussions with several hundred wound care professionals. Of all the lectures I presented and all the conversations I had over the weekend in general, the most talked about reimbursement issues pertained to evaluation and management (E&M) services with procedures and the National Correct Coding Initiative (NCCI) edits. At first, I could not understand why these would be such “hot topics” for discussion and debate because they aren’t new to the wound care industry. But I had an “ah ha” moment when several wound care professionals and hospital outpatient wound care department (HOPD) program directors declared that they do not like the E&M coding rules and NCCI edits, and that they “keep trying to find ways around them.” In that moment I realized that many practitioners would benefit from a reminder of these coding rules, which, I realize are not popular, but must be complied with because nearly every auditing body is targeting E&M. To begin, consider some comments I’ve heard (paraphrased) that are representative of the confusion that reigns:     • “I want to be paid separately for debridement and multilayer high-compression bandaging on the same wound on the same day, so I report different diagnosis codes for each procedure.”     • “We need to get paid for total contact casting and application of cellular and/or tissue-based products (CTPs [old term skin substitute]) for wounds. How can we get around the NCCI edits?”     • “Our wound clinic bills for a clinic visit at every patient encounter, even when the physician performs procedures, because we always assess the wound.”     • “As a physician, I built my business plan around billing an E&M code at every patient encounter, even when I debride the wounds. I will not make as much money if I stop billing the E&M code.”   If billing clinic visits and E&M codes at each patient encounter represents practice patterns in your wound clinic business, take a moment to understand that the American Medical Association, the Centers for Medicare & Medicaid Services (CMS), the Medicare Administrative Contractors (MACs), the various auditing contractors, and, most recently, the NCCI edits have gone to great extents to educate all qualified healthcare professionals (QHPs) and healthcare facilities about the appropriate use of E&M/clinic-visit codes. The bottom line is that we should not report an E&M service/clinic visit on the same day as another procedure (particularly surgical procedures or within the surgical global period) unless:     1. The patient presents with a significant, separately identifiable problem. NOTE: Ask yourself if the service was completely unrelated to the procedure.     2. The visit is for an unrelated problem during a postoperative period. CAUTION: Medicare considers treatment of a complication that doesn’t require a return to the operating room to be included in the global surgical period.     3. The visit results in the decision for surgery and is not a preoperative visit.   As of July 1, 2013, NCCI edits further clarified coding rules by bundling E&M codes into thousands of surgical and medical procedure codes. The E&M codes that have been bundled are some of the highest volume codes used by wound care professionals and/or HOPDs. When reviewing NCCI edits for common wound care procedures, look for these newly bundled codes in Column 2:     99211-99215     Office/outpatient visit established     99221-99223     Initial hospital care     99231-99233     Subsequent hospital care     99234-99236     Observation/hospital same date     99238-99239     Hospital discharge day     99241-99245     Office consultation     99251-99255     Inpatient consultation     99304-99306     Initial nursing facility care     99307-99310     Nursing facility care subsequent     99315-99316     Nursing facility discharge day     99334-99337     Domicile/rest home visit established patient     99347-99350     Home visit established patient     99374-99375     Home healthcare supervision.   If you’re curious as to which wound care-related procedure codes are in Column 1 of the NCCI edits, the following (along with some of the E&M codes listed above) are the wound care-related services that are impacted by the new NCCI edits:     10060-10180     Incision and drainage     11000-11044     Debridement     11100-11311     Biopsy     11400-11471     Lesion excision, benign     11600-11646     Lesion excision, malignant     11720-11721     Debridement of nails     12001-12021     Repair, simple     12031-12057     Repair, intermediate     13100-13160     Repair, complex     14000-14350     Adjacent tissue transfer     15002-15278     Skin replacement surgery     15570-15776     Flaps and grafts.   The Current Procedural Terminology® manual surgery guidelines are the basis for these new NCCI edit bundles. These guidelines state that the surgical package includes “one related E&M encounter on the date immediately prior to or on the date of procedure (including history and physical).” The new NCCI edits uphold this coding directive and enforce that wound care professionals and facilities should not routinely report an E&M service with a surgical procedure on the same date of service or within the global surgical period. All new NCCI edits have a modifier indicator of “1.” Therefore, wound care professionals and facilities can report the bundled codes together by adding an appropriate modifier to the E&M code in Column 2. However, the medical record must have adequate documentation to support the use of one of these modifiers:     24     Unrelated evaluation and management service by the same physician or other qualified healthcare professional during a postoperative period.     NOTE: E&M service must be for a medical reason unrelated to the original procedure.     25     Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of another service or procedure.     NOTE: The medical record must contain medically necessary history, exam, and medical decision-making.     57     Decision for surgery     NOTE: The medical record should show the same diagnosis code for the E&M service and the major surgery with a 90-day global period.   See Table 1 for a representative sample of wound care-related services and procedures that appear in Column 1 and Column 2 of the NCCI edits. Notice that the NCCI edits bundle many services/procedures for which wound care professionals and HOPDs wish they could receive separate payment (www.cms.gov/medicare/coding/nationalcorrectcodInited/ncci-coding-edits.html).   One last issue to remember regarding use of codes together: Many MACs have restricted coverage of 2 procedure codes on the same visit, even though the NCCI edits do not specify the code pairs as bundled. A good example of this is the use of 15002-15005 surgical preparation or creation of recipient site in conjunction with the 15271-15278 application of CTPs for wounds. To identify such coverage restrictions, QHPs and HOPDs should carefully read the Local Coverage Determinations (LCDs) that pertain to the services, procedures, and products that are part of their business. LCDs can be found on the individual MAC’s website or on the CMS coverage database: www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She may be reached for questions and consultations at 561-964-2470 or kathleendschaum@bellsouth.net.