ED Coding and Reimbursement Alert

Wound repairs, eye FBRs and intubation procedures are among the common ED procedures under consideration

As stated in the 2017 Medicare Physician Fee Schedule Proposed Rule, CMS believes that reviewing the procedure codes typically billed with an E/M and modifier 25 (Significant, separately identifiable E/M service on the same day…) as potentially misvalued may be one avenue to review valuation of these services. Consequently, CMS developed a proposed list of potentially misvalued services in this category, by identifying zero-day global codes billed with an E/M 50 percent of the time or more, on the same day of service, with the same physician and same beneficiary. Priority review of these potentially misvalued services will be based on codes that have not been reviewed in the last five years that have utilization of greater than 20,000 allowed services, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company in Bedford, Mass.

Table seven, “000-Day Global Services Billed with E/M,” in the proposed rule lists 83 codes that meet the review criteria that CMS is proposing as potentially misvalued for CY 2017. The agency is requesting request public input on additional ways to address appropriate valuations for all services that are typically billed with an E/M with modifier 25 appended. Almost a third of the identified codes are commonly performed in the ED setting. You will want to monitor this issue in the final rule to see how it might impact your 2017 coding, warns Granovsky.