EM Coding Alert

You can exhale: Modifier indicator “1” outnumbers “0” on E/M bundles.

As of July 1, you need to familiarize yourself with a new flood of E/M edits with Correct Coding Initiative (CCI) version 20.2. The edits impacting E/M encompass anything from CPT® pediatric critical care and cardiology codes, to eight HCPCS codes.

“There are a fair number of new edit pairs: 20,729 to be exact,” states Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. But you won’t have to sort through those thousands of edits. We have broken down the bundles and highlighted the ones you need to focus on to help you manage their impact on your coding and billing.

Some Edits State the Obvious

You’ll see the latest CCI edits bundle E/M codes 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, …) with codes 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient, …). These bundles have a modifier indicator of “1,” meaning you can use a modifier to override the edit if the circumstance warrants the codes being billed separately.

“This actually reinforces a long held and known coding policy that a physician and/or an NPP may not bill for more than one office visit per day unless each visit represents a separate and different medical problem,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

“These codes were disallowed by definition, but there are exceptions in the clinic setting,” agrees Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “If the E/Ms are bundled in the physician fee schedule, it applies, but not with the facility spin. To me it is a ‘duh, of course, we know that a single physician can’t bill more than one E/M in a day.”

You’ll also find 99211-99215, 99281-99285 (Emergency department visit for the evaluation and management of a patient, …), and 99347-99350 (Home visit …) bundled with the other codes in those ranges with a modifier indicator of “1.”

No Hope of a Modifier with Some G0463 Bundles

A whopping 5,961 new edits involve HCPCS code G0463 (Hospital outpatient clinic visit for assessment and management of a patient). Of the 486 new E/M bundles, 32 of them involve G0463. The following codes bundle with G0463 and carry a modifier indicator of “0”:

• Hospital discharge services codes 99238, 99239
• Nursing facility services codes 99304-99306
• Behavior Change Interventions, individual services codes 99408, 99409
• Non-face-to-face services codes 99446-99449
• Special evaluation and management services codes 99455, 99456
• Newborn care services code 99463
• Inpatient neonatal intensive care services and pediatric and neonatal critical care services codes 99466, 99469, 99472, 99476-99480, 99485, 99486

Some G0463 bundles have a modifier indicator of “1” as follows:  

• Office or other outpatient services codes 99201-99205, 99211-99215
• Hospital observation services codes 99218-99226
• Hospital inpatient services codes 99234-99236
• Inpatient neonatal intensive care services and pediatric and neonatal critical care services codes 99468, 99471, 99475.

Watch out: Often modifier 59 (Distinct procedural service) is the appropriate modifier for unbundling codes that would be deemed separately billable per CCI. However, that is not always the case. 

For example, G0463 would not take a modifier 59 because it represents an E/M service, and the only modifiers that would apply would be modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period), 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), or 57 (Decision for surgery).

“It will be important to review all available Status Indicator ‘V’ codes to determine if other codes more specifically describe the services rendered than the single new code G0463,” says Peggy Pugh, RN, CPC, CPC-H, CIPP/G, CCP, president of Coding Concepts in Steubenville, Ohio. “I would think modifier 25 or 57 would be more appropriate in support of other services rendered with this new hospital outpatient clinic visit code.”

Review the HCPCS Skin Substitute Bundles

Out of the eight new HCPCS C codes that were effective January 1, 2014, four have new edits. Skin graft codes C5271, C5273, C5275, and C5277 are bundled with E/M codes with either the “0” or the “1” modifier indicator as shown in the following table:

You’ll also find CCI adds bundles involving three other HCPCS codes —  C9733 (Non-ophthalmic fluorescent vascular angiography), C9735 (Anoscopy; with directed submucosal injection[s], any substance), and C9737 (Laparoscopy, surgical, esophageal sphincter augmentation with device [eg, magnetic band]) — as shown in the following table:

Watch for These Additional Bundles

Another fairly logical change is the bundling of the initial inpatient neonatal intensive care code 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) with the code for subsequent care: 99469 (Subsequent inpatient neonatal critical care …). This bundle has an indicator of “0,” meaning that you cannot append a modifier and unbundle the codes to report both services.

Plus: Cardiovascular procedure 93318 (Echocardiography, transesophageal [TEE] for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing [continuous] assessment of [dynamically changing] cardiac pumping function and to therapeutic measures on an immediate time basis) bundles with critical care codes 99291-99292 and pediatric critical care codes (99466-99486) with a modifier indicator of “1.”