Lesion destruction

When reading this article, it would be helpful to have your copy of the CPT book for reference. This article is meant as a companion to the codes listed in the book, and isn’t a replacement for your book or electronic access to CPT codes.

CPT describes destruction as “destruction means the ablation of benign, premalignant or malignant tissues by any method, with or without curettement, including local anesthesia and not usually requiring closure.” The services are now defined by the type of lesion that is destroyed. CPT notes that any method includes laser surgery, electrosurgery, cryosurgery, chemosurgery and surgical curettement. Also, anesthesia for these services provided by the physician/PA/NP who performs them may not be billed separately.

These codes have a ten-day global period and are considered minor procedures.

Let’s start with skin tags. There are two codes for the destruction of skin tags. 11200 is used for removal of skin tags up to and including 15 lesions, with an add-on code 11201 for each additional 10 lesions or part thereof. The method of the destruction doesn’t affect the code selection. If 1 to 15 skin tags are removed, report 11200 with one unit. If 16 to 25 skin tags are removed report 11200 with one unit and 11201 with one unit –not an additional unit for each skin tag. The CPT code description says each additional 10 lesions, not each additional lesion. That is why the add-on code is reported only once. Use ICD-10 code L91.8 for skin tags. Before you remove skin tags, warn the patient that the insurance company may consider it cosmetic, and may not pay for the service based on medical necessity.

The destruction of premalignant lesions, i.e, actinic keratoses are reported with codes 17000, 17003, and 17004. 17000 is reported for the destruction of a single lesion. Each additional lesion is reported with an add-on code 17003. If four AKs are are destroyed, Report 17000 one unit and report 17003 three units. Use 17003 for the second through the 14th lesion. If 15 lesions are destroyed, use code 17004 with one unit. The ICD-10 code for actinic keratosis is L57.0.

17110 is the code to use for destroying benign lesions such as warts or seborrheic keratoses. The definition of the code specifically states to use this for benign lesions other than skin tags or cutaneous vascular proliferative lesions. Code 17110 is reported once if 1 to 14 lesions are destroyed. If 15 or more lesions are destroyed, use 17111. For common warts, use B07.8, other viral warts. There are two codes in the category L82 for SKs.

In the editorial comments under the heading “destruction” and before code 17000 there is an instruction on reporting destruction of lesions in specific anatomic sites. Specifically, CPT instructs us to use other codes for lesions destruction of the mouth, eyelid, conjunctiva, penis, anus, vulva and vagina.

40820—Mouth

46900—46917—Anus Code selection varies by method, and if simple or extensive

46924–Anus

54050—54057—Penis Code selection varies by method, and if simple or extensive

54065–Penis

56501—Vulva Code selection depends on simple or extensive

56515—Vulva

57061—Vagina Code selection depends on simple or extensive

57065–Vagina

67850—Eyelid

68135–Conjunctivae

If a physician destroys a lesion on the mouth, eyelid, or conjunctiva, use a code from the organ system to which they relate. Those codes are listed above. For destruction of the lesion of the anus or the penis the codes are defined as simple or extensive. If the destruction is simple, the method of the destruction determines the code. For lesions of the vulva or vagina, code selection depends on whether the destruction is simple or extensive.

There is also a series of codes for destruction of malignant lesions using any method. These codes are defined by location and the lesion diameter. There is one set of codes for trunk arms and legs (17260—17266). There is a second set of codes for lesions on the scalp, back, hands, feet and genitalia (17270—17276). And there is a third set of codes for lesions on the face, ears, eyelids, nose, lips, and mucous membranes (17280—17286). For these codes we are measuring the diameter of the lesion to select the code, after determining the correct code set by body area. The distinctions are.5 cm or less, .6 cm to 1 cm, 1.1 to 2 cm, 2.1 to 3 cm, 3.1 to 4 cm, or a lesion diameter of over 4 cm.

End confusion about modifier -57 (and get paid for initial evaluations)

Recently I completed an audit for a general surgery practice. Included in the audit were two services for an initial hospital visit on the day of an emergency surgery. Both of these were reported with modifier -25 on the evaluation and management (E/M) service and both were denied by the payer. The practice did not appeal the denials.

Experienced coders are shaking their heads as they read this. They know that the (E/M) service should have been reported with modifier-57 not modifier -25. Why? Modifier-25 is used on an E/M services on the same day as a minor surgical procedure to indicate that the E/M service was separate and distinct from the minor procedure. A minor procedure is defined by Medicare––and this is accepted by all commercial payers—as a procedure with 0 or 10 global days. The global days are found in the Medicare Physician Fee Schedule and available in many coding programs. A major procedure is a procedure with 90 global days. An initial evaluation prior to a major surgical procedure is always payable. When this initial evaluation results in the decision for surgery on that calendar day on the next calendar day, append modifier -57 to the E/M service.

Key points to remember:

  • Use modifier -25 on an E/M service provided on the same day as a minor procedure. Remember, the NCCI edits require that the E/M is separate and distinct, that the physician or NPP needed to evaluate a condition prior to the decision to perform the procedure. Payment for the decision to perform the procedure is included in the payment for the procedure. For example, if an evaluation for bleeding and anemia results in the decision for an endoscopy. Report both the E/M and the endoscopy.
  • Append modifier -57 to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to go to surgery.
  • Appeal denials up to the Medical Director of the plan. A surgeon should always be paid for the E/M prior to an urgent/emergency surgery.
  • Do not append modifier -57 on the E/M for the decision for surgery if the surgery is scheduled later than the day after the E/M service.

 

 

 

Not billing consult codes? You are losing $$$$

In 2010, Medicare stopped recognizing consultation codes. In their discussion, they stated that they still did pay for consultations, but they used other codes to pay for them such as office visits, emergency department visits, and initial hospital services. Practices adjusted to this change, and continued to bill Medicare for services. Some groups stopped billing all consults, thinking that the private payers would follow Medicare’s lead. This was a mistake. In many States and localities, commercial payers still recognize and pay for consultations using the outpatient and inpatient consultation codes. If you are not billing consultation codes to your private payers, you are losing money.

Someone in your practice needs to verify which payers still accept consultations. I did a presentation recently to a group of surgeons and their staff members and most of the practices said that their commercial payers still accepted the consultation codes and paid for those visits. Half a dozen people in the room were billing no consult services and these people were the same state and billed the same payers as the others. Essentially, they were losing their practices money because they did not bill for consultations.

Consultations have higher work relative value units (RVUs) and higher total payments than new patient visits or established patients visits. (See the chart at the end of this article) The definition of the CPT book says the consultations may be billed for new or established patients. If the practice is reporting new patients in place of consultations, there is a small but significant decrease in RVUs and payment. But if the patient is established to the practice and the practice must report established patient visits, there is a large and significant difference in work RVUs and payment. All specialty practices need to review this.

What insurances don’t pay for consultations? Medicare fee for service, Medicare replacement plans and most managed Medicaid programs. There are still some state Medicaid programs that do pay for consults but these are fewer and fewer. Many commercial payers recognize and pay for consults—have I mentioned that?

 Let’s look at the rules regarding consults. Since Medicare no longer recognizes consults, any old Medicare guidance about consults is no longer relevant. The rules related to consults are found in the CPT book and in other CPT references. According to the CPT book , “A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.” This definition of a consult was amended in 2010 when Medicare stopped recognizing consults. Notice that it still requires a request from another healthcare professional.   CPT says that physician or NPP may perform a consult to “determine whether to accept responsibility for ongoing management of patients entire care for the care of the specific condition or problem.” That is, I a consult can be billed for an evaluation to determine whether to accept the character patient.

As I mentioned earlier consultations may be reported for new or established patients. The consulting clinician may initiate therapeutic treatments or order diagnostic tests and still bill a consult. A service requested by a family member is not considered a consult. A request for a consultation may be verbal or in writing and must be documented in the patient’s medical record by either of the requesting or consulting physician/NPP. A written report of course is required. Here is the CPT exact language about that. “The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated by written report to the requesting physician or other appropriate source. “

CPT introduced the concept of transfer of care in 2010. It’s stated that if there is a transfer of care visit is no longer a consultation. I’m going to quote the CPT description of transfer of care, and then give a few examples of instances in which there is a transfer of care and a consultation would not be billed. CPT says “Transfer of care is the process whereby a physician or other qualified health care professional who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician or other qualified health care professional who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. The physician or other qualified health care professional transferring care is then no longer providing care for these problems though he or she may continue providing care for other conditions when appropriate. Consultation codes should not be reported by the physician or other qualified health care professional who has agreed to accept transfer of care before an initial evaluation but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial consultation evaluation, regardless of site of service.”

Remember that one of the first statements in the CPT book about consultations is that a physician may report a consultation to determine whether to accept the care of the patient.

Examples of transfer of care:

  • Physician is called at home by the emergency department doctor about a patient and does not need to see the patient in the ED. The physician instructs the ED doctor have the patient call the office for an appointment. This is a transfer of care, not consultation from the emergency department physician. Bill a new or established patient visit.
  • The patient is seeing an oncologist in Philadelphia and moves to Harrisburg. The Philly oncologist transfers the care to the new oncologist in Harrisburg. The physician in Harrisburg does not bill for a consultation.
  • In a single specialty group, there are only rare instances of consultations. Although physicians in a single specialty group may have different areas of expertise, transferring the patient from one physician in the group to another is rarely a consult.

One word about the word “referral.” Some coders think that if the word “referral” is used then it can’t possibly be a consult. I’m not sure what the origin of this is. Look at the CPT book’s editorial comments for the current rules related to consult. There is nothing there that differentiates between referral and consult. There is a differentiation only for transfer of care, described above.

In summary:

  • A consult requires a request from another health care professional for a new or established problem for your evaluation, assessment or opinion
  • After service is provided, a report is returned to the requesting clinician
  • Document request in the medical record
  • Transfer of care is not a consult
  • Consults are not defined as new or established

If the service does not meet the requirements of consultation, or if the payer does not recognize consultations then report the service as a new or an established patient visit in the office.

 CPT definition:

“Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician or another physician of the exactly same specialty and subspecialty who belongs to the same group practice within the past three years.”

CMS definition:

Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.

For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

Questions to ask?

  • What specialty code did you use when you enrolled in Medicare and private insurance?
  • Are all of your partners in your group the same specialty?

Have you or has one of your same specialty partners had a professional service with this patient in the past three years, in any location, for any problem?

An established patient is a patient who has been seen by you or your same specialty partner (in your group) for any problem, any location, any face-to-face service in the past three years.

  • Use for office services out of global period.
  • Whether or not the patient has a new problem is not a factor.
  • Specialty designation is key.

The reason that groups stopped billing consultations was that it was difficult to keep track of what payers paid for consults and what payers didn’t. Physicians did not want to be responsible for remembering what insurance the patient had and what category of code to select. Groups that have successfully continued to report and bill for consultations usually have the physician or NPP select a consultation code if the criteria for a consultation are met. Then, behind the scenes there are edits that stop consultation codes from being submitted if the payer doesn’t recognize consults. The staff or the system can cross walk the consultation code to the correct category of code. In the office, this is a new or established patient visit. In the hospital it is an initial hospital service or emergency department visit.

Not billing for consults? Take another look.

 

New patient visits
  Work RVUs Total Facility RVUs Total Non Facility RVUs
99201 0.48 0.75 1.23
99202 0.93 1.43 2.1
99203 1.42 2.17 3.04
99204 2.43 3.67 4.64
99205 3.17 4.77 5.82
Established patient visits
  Work RVUs Total Facility RVUs Total Non Facility RVUs
99211 0.18 0.26 0.56
99212 0.48 0.71 1.22
99213 0.97 1.44 2.05
99214 1.5 2.21 3.02
99215 2.11 3.13 4.07
Office/outpatient consults  
  Work RVUs Total Facility RVUs Total Non Facility RVUs
99241 0.64 0.92 1.34
99242 1.34 1.93 2.52
99243 1.88 2.7 3.45
99244 3.02 4.34 5.16
99245 3.77 5.37 6.29

 

Performing services that increase primary care revenue

Article posted on http://www.kevinmd.com April 24, 2016

CMS states it wants to increase pay to primary care physicians. And while we might quarrel with their strategies or with the speed of achieving the goal, few would quarrel with the goal itself. In recent years, CMS has developed HCPCS codes and adopted CPT codes, some limited to primary care and some not specialty restricted but all likely to be reported by primary care practices. Meanwhile, although payment systems are moving to outcome and value measures, the revenue for most primary care practices continues to be fee-for-serviced based, and alternate payment models (APM) are built on top of fee-for-service.

Some of the new services defined by CPT HCPCS codes haven’t pleased primary care physicians, either because of the definition of the services or the payment for them. Working with and listening to primary care physicians, I think that some of these services can be embraced and some should be ignored, for the time being. I’m an advocate of implementing Medicare Wellness Visits and transitional care management services into primary care and setting aside chronic care management for most practices. Advance care planning will be relevant in selected practices, but not all. And many other prevention services just don’t pay enough.

There can be significant variation in work RVUs per encounter (or revenue per encounter) within a group. I report on this in an upcoming article in Family Practice Management. When I look at this variance, some of it comes from differences in level of service reporting, but more is from the use of wellness visits and transitional care management.

Thumbs up to wellness visits and problem visits at the same encounter

Some physicians objected to the definition of the Welcome to Medicare and initial annual and subsequent annual wellness visits (AWV) because there was no required physical exam. These visits don’t prohibit doing an exam. The Welcome to Medicare and initial wellness visit have high work RVUs and payment. Medicare allows a physician to bill a problem oriented visit on the same day, as long as the documentation for the wellness visit isn’t used to select the level of problem oriented visit. The wellness visits don’t require HPI, ROS, exam or assessment and plan of a problem. When I review documentation, I find that many of these visits document the requirements of the wellness visit and the key components of a problem-oriented visit. In practices that have implemented the wellness visits successfully, staff members collect and record the data for the wellness visit, and the physician or non-physician practitioner (NPP) documents the personalized prevention plan and, if relevant, the problem-oriented visit. Of course, both must be documented—describe the status of the patient’s chronic diseases in the HPI, do an exam and note the assessment and treatment at the end of the note. Reporting wellness visits and when relevant, wellness visits and problem-oriented visits on the same day is good for the patient and good for the practice.

Thumbs up to transitional care management (TCM)

Primary care practices are already managing the transition for hospitalized patients to home, and getting paid only for the office visit. TCM allows the group to be paid for the work the physician, NPP and staff are already doing.   It requires a phone call to the patient in two business days, a visit in 7 or 14 days (depending on the code), reviewing the discharge summary and medication reconciliation. It is not for every discharge. It is for patients who need additional non-face-to-face support by the medical and clinical staff in the transition to home. It has high work RVUs and reimbursement. CMS changed the rules January 1, 2016 allowing the visit to be billed on the day of the E/M office visit, rather than waiting 30 days from the date of discharge. This is a definite yes: get paid for the work the practice is now doing for free.

Thumbs down to chronic care management (CCM)

CMS states it does not have statutory authority to provide a per member per month benefit for managing patients with chronic diseases. Instead, they can pay monthly for 20 minutes of clinical staff time for patients with two or more significant chronic illnesses. Staff must count minutes, and only report the service in months they have 20 minutes. A care plan must be developed at a “comprehensive” E/M service, the patient must sign informed consent, and other physicians who care for the patient must have electronic access to the care plan, not via fax. There are practices that can do this, but not most. All for about $40/month. My advice: wait on CCM unless you have a very sophisticated case management program in place.

Thumbs up, equivocally, to advance care planning (ACP)

Beginning in 2016, physicians and NPPs can be paid for discussion of end of life issues with patients and/or family members. The Medicare payment is about $86 for a discussion of 30 minutes. Since coding is through the looking glass, a clinician must meet over half of 30 minutes, 16 minutes, to bill for the service. That’s a long time for a service in the office. It can be billed with an office visit, but the time of the office visit and the time of the ACP can’t be double counted. When I think it will be useful is for a patient’s family member who wants to come in to discuss a change in the patient’s condition and long term plans. Or, for a physician and family member of a hospitalized patient. After rounding in the morning, a physician could have a discussion with a family member in making end of life decisions. This isn’t a code that can be used every day of a hospitalization, but when the patient’s condition changes and warrants the discussion. When it is done on the same day a wellness visit and submitted with modifier 33, there is no co-pay or deductible. But, it might be difficult to perform on the day of a wellness visit because the wellness visit is time consuming on its own.

Thumbs down to HCPCS codes with low RVUs

CMS is required to cover any service that the USPSTF gives an A or B rating. But, that doesn’t mean they have to pay adequately for the service. If you download the CMS preventive medicine chart (here https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-QuickReferenceChart-1TextOnly.pdf) you’ll see some of these services. G0442 screening for alcohol misuse, 15 minutes. Even using the CPT rule of meeting over half of the threshold, does alcohol screening take 8 minutes? And the payment is under $20. Annual depression screening is reported with code G0444, also a 15 minute code. The patient filling out the PHQ9 doesn’t take 8 or 15 minutes, and it also has a payment rate of under $20. 15 minutes of behavioral counseling for obesity, G0447, has a slightly higher reimbursement rate. Of course, practices will screen for alcohol misuse and depression, but the HCPCS G-codes will probably not describe the service that was performed.

If your primary care practice hasn’t adopted the wellness visits and TCM, I urge you to take a second look at implementing them. Both AAFP and ACP have resources that will help.

CMS Updates, TCM, CCM and ACP

At CMS’s Open Door Forum on April 13, 2016 CMS noted there were updates to the Frequently Asked Questions documents for Transitional Care Management, Chronic Care Management and Advance Care Planning. The CMS staff discussed these and answered questions about them. I’ve written about all three topics on this blog, and you can read about them in more detail. At the end of this article, I’ve attached the links to the CMS documents. I strongly recommend that you download and read these three resources. Here are some highlights.

TCM: CMS affirmed that a practice may bill for TCM on the day of the face-to-face visit, without waiting for the 30 day period to pass. Use the place of service in which the visit took place. The biggest change? CMS is following CPT rules about attempting (but failing) to have phone or other direct contact in two business days from the date of discharge. “If two or more separate attempts are made in a timely manner and documented in the medical record, but are unsuccessful, and if all other TCM criteria are met, the service may be reported. We emphasize, however, that we expect attempts to communicate to continue until they are successful, and TCM cannot be billed if the face-to-face visit is not furnished within the required timeframe.”

TCM and CCM in the same month: It is possible to report TCM services in the same month as CCM if and only if a) the 30 day TCM period ends before the end of the month, and b) 20 minutes of CCM time is provided between the end of the TCM service and the end of the calendar month.

CCM: In order to report CCM, individuals who are providing the 20 minutes CCM time need access to the patient’s medical record. However, CMS has clarified in this new document that the access must be to the care plan, not the entire record. “This article alerts providers that the Centers for Medicare & Medicaid Services (CMS) revised the Medicare Learning Network® Fact Sheet on CCM services (ICN 909188, released in March 2015) to clarify Medicare’s requirement for 24/7 access by individuals furnishing CCM services to the electronic care plan rather than the entire medical record.”

CMS continues to defer to CPT in the definition of clinical staff, and to refer to the Medicare Benefit Policy Manual for incident to guidance. Supervision of staff for CCM and TCM is general, not direct. That is, the physician or other billing provider does not have to be in the suite of offices when the service is performed.

A practice may bill for CCM on the date the twenty minutes in the month is achieved. The practice doesn’t have to wait until the end of the month to report CCM.

Advance Care Planning: 99497 and 99498 are time based codes, and CMS has affirmed that they follow CPT time rules. That is, in order to bill the code you need to have reached over half of the time listed in the code. To report 99497, the provider must have spent 16 minutes with the patient; to report 99498 the provider must have spent 46 minutes. CMS affirmed that this can be done by as a team service, if the physician or non-physician practitioner start the discussion with the patient. This does not mean medical assistant! But, a social worker or someone with palliative care experience could work with the patient in addition to the physician. CMS is clear that this is a provider service.

If you are performing these services, or thinking of performing them in your office, download and read the articles. They consist of frequently asked questions Medicare has received about these services. If you have a question, there is a good chance it is asked and answered in these three documents.

CCM:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1516.pdf

TCM

https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/downloads/faq-tcms.pdf

ACP

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-Advance-Care-Planning.pdf