HCFA Suspends CCI Edits; Significant, Separately Identifiable E/M Still Required
Published on Thu Feb 01, 2001
HCFA has suspended edits of evaluation and management (E/M) services with diagnostic tests. In a monthly conference call with representatives of specialty societies, HCFA announced the suspension but gave no reason for it.
The edits, published in version 6.3 of the national Correct Coding Initiative, became effective Oct. 30, 2000, and bundled 66 E/M codes with more than 800 diagnostic tests and other services listed in the Medicare fee schedule as having XXX global days.
When HCFA first announced its intention to bundle E/M services with diagnostic tests in the November 1999 Federal Register, it stipulated that if the E/M service was significant and separately identifiable, it would be separately payable if modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) was attached to the E/M code.
Physicians across the nation, however including cardiologists have reported an increase in denials of E/M services when performed on the same day as diagnostic tests (such as echocardiograms, stress echoes and pacemaker checks) even when modifier -25 was attached. HCFA now says that before it reintroduces the edits, it will strengthen efforts to educate physicians and its own carriers about the appropriate use of modifier -25 and what constitutes a significant, separately identifiable E/M service.
The suspension of this new class of edits is welcome news for cardiologists and their coders, many of whom took strong issue with diagnostic tests being bundled to E/M services.
The edits were not consistent with how coding works, says Stacey Elliott, CPC, head of contracts, compliance and information systems with COR Healthcare Medical Consultants, an 11-physician practice in Torrance, Calif. When cardiologists examine a patient, ordering tests and reviewing test results contribute to the medical decision-making component of the visit, but providing the test itself is separate and deserves to be paid separately. She notes that her practice has received hundreds of denials for E/M services performed since Oct. 30, of which at least 90 percent were due to the new edits.
Append Modifier -25 as Necessary
When HCFA announced the new policy in November 1999, it stated the edits were designed to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself. As a basis for its policy, HCFA reasoned, Because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record.
Although HCFA now says that any claims involving E/M services and diagnostic tests after Oct. 30 should be resubmitted, it recommends that physicians continue to attach modifier -25 to the E/M service [...]
