EM Coding Alert

You’ll have three options for recouping your reimbursement.

The newest update to the Correct Coding Initiative (CCI), version 19.2 that went into effect July 1, 2013, bundled most E/M codes with many procedures, such as catheterization and EKGs. As if learning the quarterly bundling edits and implementing the changes into your coding wasn’t enough, an error in some payers’ systems has led to many unwarranted denials in the past few months.

Read on to find out what CMS is saying about denials relating to CCI 19.2 and modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) — and what you need to do to get your deserved reimbursement.

Determine the Source of Denials

All of these E/M + procedure bundles have a modifier indicator of “1,” which means you can append a modifier to the E/M code and override the bundle. In most cases, modifier 25 would be the appropriate choice to override the bundling of an E/M and a minor procedure when clinical circumstances allow bundle breaking.

The problem: Errors in some Medicare contractors’ software programs began denying all claims relating to these new CCI bundlings, even when separate payment was warranted.

Good news: Many practices have not been affected by the denials. “My practice has not seen any significant new issues with payers denying E/M codes with a 25 modifier based upon the CCI 19.2 edits starting 7/1/2013,” says Jonathan Rubenstein, MD, director of coding and physician compliance for Chesapeake Urology Associates in Baltimore.

Resubmit After Oct. 1

The Centers for Medicare and Medicaid Services (CMS) has released a plan to resolve denied claims related to the CCI edits implemented on July 1. According to CMS, the denials were — and are still in some cases — occurring as a result of a computer system failure to recognize the appropriate modifiers, including modifier 25. The new edits applied to any global surgical code billed with an established patient visit code appended with one of the appropriate modifiers listed above, CMS says.

The solution: CMS said it will discontinue the new denial edits that went into effect on July 1, 2013. A permanent solution will be effective with CCI version 19.3 edits that start on October 1, 2013. The changes, however, will be retroactive to July 1, 2013. Some MACs, including First Coastal of Florida, WPS, and Noridian, have already fixed the problem, but others may not have a fix until Oct. 1.

You have a few options for resubmitting denied claims:

• If your MAC has a temporary fix in place, you may submit claims and they should be processed normally.
• If your MAC has not implemented a temporary fix, CMS suggests holding claims until October 1, 2013 at which time those and others that have been inappropriately denied may be submitted or resubmitted for payment.

CCI Errors Struck Opthalmology Codes, Too

If ophthalmological evaluations are a big part of your practice’s revenue, you’ve probably been experiencing a level of stress beyond frustration thanks to CCI 19.2, which also bundled 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) and 92014 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits) into scores of procedure codes. Fortunately, however, you will be able to recoup the money you lost from those troublesome CCI edits in October.

That’s the word from an Aug. 27 CMS Open Door Forum, in which CMS’s Chris Ritter acknowledged that edits bundling 92012 and 92014 have caused challenges for coders.

“NCCI will be suspending edits beginning Oct. 1, and claims that been denied after July 1 because of the lack of a 25 modifier on either of those two codes can go ahead and be resubmitted after that time,” Ritter said. CMS plans to work on making edits more appropriate for these two E/M codes, she added.

In black and white: You can read an Aug. 20 letter from CCI’s Niles Rosen, MD to the American Academy of Ophthalmology’s Michael Repka, MD confirming the upcoming edit reversal, which the AAO posted on its website at www.aao.org/aao/outofcs/wre/CMS_NCCI_letter.pdf. In the letter, CMS admits that even modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) was not allowing legitimate claims to bypass the edit as it should have, which is what led CMS to decide that deleting the edits was the best idea going forward.

Even if your doctor billed correctly in the first place for these services, MACs will not automatically reprocess claims, Ritter stressed. Instead, you will have to resubmit the bill to your MAC after Oct. 1. You should resubmit the claim at that point as if you’re sending the bill for the first time, Ritter clarified—you do not need to send in an appeal.

Watch for Other Payer Issues with 25

Across the country, practices are seeing more and more denials relating to modifier 25. The CCI denials are only one part of the trend, experts say.

“It is becoming more evident to me that payers are looking at this as a cost-containment issue, rather than quality of care issue,” says Alice Kater, CPC, PCS, coder for a practice in South Bend, Ind.

Some payers are denying procedures that are diagnostic in nature, Kater explains. “I have been reviewing our modifier 25 claims and find that most of the time it’s the result of an E/M service in conjunction with some form of diagnostic study,” she says. “These codes are not in the medicine section or the radiology section or the lab section of the CPT^® but rather in the surgical section. And payers consider surgeries to be therapeutic, not diagnostic. So we have a conundrum.”

Strategy: To overcome payer denials you may need to schedule procedures and services, such as injections or diagnostic examinations, on a different day than the office visit.

Warning: If you take this approach, however, you may upset patients. “One could see a scenario occurring where providers may not provide the service due to the fact that it is a non-billable service, and make the patient return on a separate date and time, which would cause significant inconvenience for the patient, and add costs (time lost to work, co-pays, etc),” Rubenstein says. “If the patient is already at a face-to-face encounter where it would be best to evaluate and treat the separate condition at this time, it is in everyone’s best interest to have this be a separately billable service.”

Best bet: Know your payer’s rules. “I have seen payers interpret rules differently from one another,” Rubenstein says. “The best advice is to understand the rules, only ask for payment for services that truly fit within the guidelines, and to be honest about what payments are being requested.”