General Surgery Coding Alert

Effective Oct. 30, 2000, evaluation and management (E/M) services performed at the same time as procedures that do not have a global period are considered bundled to those procedures unless they are significant and separately identifiable and have modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day as the procedure or other service) attached.

The new policy, which was proposed by the Health Care Financing Administration (HCFA) in the Nov. 2, 1999, Federal Register, has been implemented in version 6.3 of the national Correct Coding Initiative (CCI). More than 57,000 codes are affected by the policy shift.

Until now, HCFAs global surgery payment policies (which can be found in section 4820 of the Medicare Carriers Manual) have applied only to procedures with global periods of zero, 10 or 90 days, as shown on the national Physician Fee Schedule Database.

When the new policy was proposed, HCFA said it was designed to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself. According to HCFA, The basis for this policy is that 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.

The category of codes most affected by the new policy is radiology, where more than 27,000 edits with E/M codes have been published. There are 2,776 edits in the respiratory system/surgery section (30000-39999) of the CPT manual. The pathology/lab section (80000-89999) has 4,268 edits. The 90000 series (which includes E/M as well as medicine and diagnostic services ) has 17,354 edits, and supplemental (HCPCS) codes have 3,507 edits.

The remaining sections of the CPT manual included fewer edits. In the integumentary section (10000 series), only 726 edits have been made. The digestive system/surgery section (40000 series) includes 462 edits. The 50000 series (male and female reproductive and urinary systems) contains 162 edits; and the 60000 series has 132 edits. The musculoskeletal system (20000 series) contains no new edits.

How to Optimize General Surgery Coding

Although general surgery is less affected than other specialties by the changes, surgeons are likely to encounter situations when modifier -25 will need to be appended to an E/M procedure.

For example, if the surgeon performs significant, separately identifiable E/M (such as E/M that led to the service) on a new patient and then introduces a needle or intracatheter into one of the patients peripheral veins for diagnostic purposes (36000), the appropriate-level E/M code (9920x) would be billed with modifier -25 attached, in addition to the 36000.

If, however, the surgeon only performs a preprocedure evaluation of the patient and then proceeds with the needle or intracatheter insertion, no E/M should be billed.

General surgeons who operate an in-office noninvasive vascular laboratory have other edits to consider. These procedures, which often are performed at the same time as E/M services, allow the surgeon to determine if the patient has a blockage or peripheral vascular disease and whether more extensive vascular procedures are required.

Version 6.3 of the CCI bundles E/M services to codes in the extremity venous studies section (93965-93971), the visceral and penile vascular studies section (93975-93979, excluding penile codes 93980 and 93981), the extremity arterial-venous studies section (93990) and fine needle aspiration (88170).

Until now, the E/M service could be billed separately without the modifier. Practices that routinely bill E/M services when diagnostic tests or other medicine services are performed should take note that modifier -25 claims are watched closely by HCFA.

Nonspecific Edits

HCFA officials said in the Federal Register that the agency would not make a blanket requirement that modifier -25 be used with every code in a specific category of services, but would implement the policy for specific HCPCS codes when we believe there is abuse or the potential for abuse in the reporting of an E/M service.

There is, however, little evidence that specific HCPCS codes were targeted, says Barbara Cobuzzi, MBA, CPC, CPC-H, an independent coding and reimbursement specialist in Lakewood, N.J.

These edits were supposed to bundle E/M with non-surgical procedures, Cobuzzi says. In this version of the CCI, however, surgical codes, such as 38120 (laparoscopy, surgical, splenectomy) also bundle E/M, as do many codes that HCFA doesnt pay for, such as cosmetic surgery codes (e.g., 15824-15829). The only thing these codes have in common is that they all have XXX global days in the physician fee schedule, Cobuzzi says. She notes two other codes that are included in version 6.3 for which Medicare has never paid:

36823 insertion of arterial and venous cannula(s) for isolated extracorporeal circulation and regional chemotherapy perfusion to an extremity, with or without hyperthermia, with removal of cannula(s) and repair of arteriotomy and venotomy sites; and

36468 single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk.

In addition, among the 57,000 plus edits are several reimbursement anomalies, where relatively well-paid E/M codes are considered components of and bundled to small procedures that reimburse at a considerably lower rate.

For example, if the surgeon introduces a needle or intracatheter into the patients vein (36000) during the same session or on the same day as a level-five office consult (99245), 36000 is considered the comprehensive code and 99245 is a component, even when 36000 has a value of only 0.72 relative value units (RVUs), and 99245 has 6.07
RVUs.

Although both services will be paid as long as modifier -25 is attached to 99245 and supported by the documentation, this edit seems superfluous because it would be difficult to confuse a level-five consult (or any high-level E/M service) with the preservice evaluation for a vein stick.

Other New CCI Edits

Most, but not all, of these comprehensive/component edits are the result of HCFAs new E/M policy. Version 6.3, however, also contains more than 800 mutually exclusive code edits.

Although the vast majority of these edits bundle either psychotherapy, ophthalmology and physical therapy codes with E/M services, two HCPCS codes G0104 (colorectal cancer screening; flexible sigmoidoscopy) and G0105 (colorectal cancer screening; colonoscopy on individual at high risk) are now mutually exclusive with several CPT codes in the colonoscopy/sigmoidoscopy section.

In addition, there are some comprehensive/component edits that dont involve E/M codes of particular interest to general surgeons. For example, the codes for placement of central venous catheters (36488-36493) now bundle chest x-rays (71010 and 71020).