Should You Believe ‘Word-of-Mouth’ or Payers’ Policies?

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When it comes to reimbursement regulations and policies, wound/ulcer management professionals often wish they were different. Therefore, if they receive information from a colleague that is contrary to published regulations and policies, they tend to believe it because that information is more in line with what seems logical to them.

To explain what I mean, I am sharing a recent virtual reimbursement teleconsultation that I did with a hospital-owned outpatient wound/ulcer management provider-based department (PBD) and the physicians who work in the PBD. I am sharing this scenario because this is just one of many consultations I have performed pertaining to this subject. Please read this carefully because it can easily happen to you.

Scenario:

The vice president in charge of the PBD called and asked me to solve a conflict among the coder assigned to the PBD, the physicians’ coders, the PBD director, and the physicians. The topic of the conflict was the application of total contact casts.

   •    Some physicians were scheduling patients to return to the PBD two days in a row: the first day when they either performed surgical or selective debridement of a wound/ulcer, and the next day when they applied a total contact cast to the same anatomic location. The PBD program director did not agree with this practice: She believed the debridement and the application of the total contact cast should be performed at the same encounter. The physicians said their colleagues in other PBDs followed that practice so they could receive payment for both procedures.

   •    Some physicians performed the application of cellular- and/or tissue-based products (CTPs) for skin wounds and the application of total contacts casts during the same PBD encounter. However, the physicians insisted that their coders append modifier 59 (Distinct Procedural Service) to procedure code 29445 (Application of rigid total contact leg cast) when a total contact cast was applied on the same day to the same anatomic location to which a CTP was applied. The physicians’ coders refused to append the 59 modifier to 29445. The physicians are angry because they said they know many physicians who apply the 59 modifier and get paid for both procedures.

   •    Some physicians wanted their coders to code differently when the physician performed surgical debridements and selective debridements before applying total contact casts during the same PBD encounter. When they performed surgical debridements followed by the application of total contact casts, they told their coders not to append modifier 59 to the total contact casts. However, when they performed selective debridements before applying total contact casts, the physicians insisted that their coders append modifier 59 to the total contact cast procedure. The physicians said they read in a blog that Medicare would pay for selective debridements and application of total contact casts during the same encounter. The physicians’ coders keep telling them the rules are the same for surgical and selective debridement. Therefore, the coders would not append modifier 59 when total contact casts were applied after selective debridement was performed.   

Facts to Consider:

•    The National Correct Coding Initiative (NCCI) tools¹ should be the references that physicians, PBDs, and/or coders research when they want to know if 2 procedures performed during the same encounter will be paid by Medicare.

•    The NCCI Policy Manual for Medicare² helps providers to avoid coding and billing
errors, subsequent payment denials, and repayments following audits.

•    NCCI Procedure-to-Procedure (PTP) edits³ define when 2 procedure HCPCS/CPT^®4 codes may not be reported together, except under special circumstances. NCCI PTP edits are based on services provided by the same physician to the same beneficiary on the same date of service. If an edit allows use of NCCI PTP-associated modifiers, the 2 procedure codes may be reported together when the 2 procedures are performed at different anatomic sites or different patient encounters.

•    Chapter 3 of the NCCI Policy Manual states that physicians shall not inconvenience beneficiaries or increase risks to beneficiaries by performing services on different dates of service to avoid NCCI PTP edits.⁵

•    The July 2021 NCCI PTP edit files for hospitals and practitioners show that the following code pairs have PTP edits. Therefore, they can only be reported together during the same encounter if the 2 procedures were performed on separate anatomic sites or at different patient encounters.

Surgical Debridement and Application of Total Contact Cast
11042    29445
11043    29445
11044    29445
11045    29445
11046    29445
11047    29445

Application of CTP and Application of Total Contact Cast
15271    29445
15272    29445
15273    29445
15274    29445
15275    29445
15276    29445
15277    29445
15278    29445
C5271    29445
C5272    29445
C5273    29445
C5274    29445
C5275    29445
C5276    29445
C5277    29445
C5278    29445

Selective Debridement and Application of Total Contact Cast
97597    29445

•    The NCCI Policy Manual also states: “Modifier 59 is an important NCCI PTP associated modifier that is often used incorrectly. For the NCCI, its primary purpose is to indicate that 2 or more procedures are performed at different anatomic sites or different patient encounters. Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass a PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.”

Consultation:

When our teleconsultation began, I advised the program director, physicians, PBDs’ coders, and the physicians’ coders that I was going to teach them about the NCCI tools that they should use as references for these procedure issues, rather than relying on “word-of-mouth.”

First we discussed the NCCI Policy Manual for Medicare, how it is organized in chapters by CPT^® codes, and the type of information provided. In particular I pointed out that the manual clearly states that physicians shall not inconvenience beneficiaries or increase risks to beneficiaries by performing services on different dates of service to avoid NCCI PTP edits. That is why physicians should not perform debridements or application of CTPs on one day and the application of total contact casts the next day. I also congratulated the program director for enforcing that NCCI policy.

Second, we discussed the NCCI PTP edits. I taught the team how to easily filter the hospital and provider files for PTP edits. I also provided them with the link⁶ to the electronic MLN Booklet entitled How to Use the Medicare National Correct Coding Initiative (NCCI) Tools. They were surprised how easy it is to use the NCCI files. Each of the teleconsultation participants filtered both the hospital and provider PTP files.

By the time they finished researching the NCCI PTP files, the entire team knew for certain that the application of total contact casts is bundled into the Medicare payment for surgical debridement, for the application of a CTP, and for selective debridement. Therefore, the physicians’ coders were correct not to attach modifier 59 to 29445 when a total contact cast was applied after a CTP was applied. They were also correct not to attach modifier 59 to 29445 when a total contact cast was applied after a selective debridement was applied.

Most important they learned to use available resources and written articles that are supported by reliable references. The physicians were thankful for the education and announced that they would no longer receive their reimbursement education “by-word-of mouth.”

Summary:

Because this is only one of hundreds of providers who I have educated about the proper use of the NCCI Policy Manual for Medicare and the use of the hospital and provider PTP files, I hope this real-life scenario will motivate all PBD program directors, physicians, and coders for both PBDs and physicians to verify that you are not incorrectly placing modifiers on codes that are bundled. Remember that the modifier tells your Medicare Administrative Contractor that you performed the second procedure on a separate anatomic location from the anatomic location where the first procedure was performed. Therefore, they will pay the claim. However, when you are audited, the repayments and fines for false claim submission are steep.

Many of my clients say they believe the application of the total contact cast should not be bundled into the Medicare payment for the common wound/ulcer management procedures. I always remind them, and I am reminding you, that you and/or your professional society have the opportunity to provide evidence why an NCCI PTP edit should be removed. The request and evidence should be sent to:

National Correct Coding Initiative Contractor
Email: NCCIPTPMUE@cms.hhs.gov
P.O. Box 368
Pittsboro, IN 46167

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net.

Click here to download a PDF of this article.

References

1. National Correct Coding Initiative Edits. Last accessed June 18, 2021.
2. The NCCI Policy Manual for Medicare. Last accessed June 18, 2021.
3. NCCI PTP Coding Edits. Last accessed June 18, 2021.
4. CPT is a registered trademark of the American Medical Association. All Rights Reserved.
5. The NCCI Policy Manual for Medicare Chapter III Surgery: Integumentary System CPT^® Codes 10000-19999. Last accessed June 18, 2021.
6. How to Use the Medicare National Correct Coding Initiative (NCCI) Tools MLN Booklet. Last accessed June 18, 2021.