Medicare Compliance & Reimbursement

It was bound to happen. CMS took a hard look at the CCI and apparently realized that some of the individual components of annual wellness visits (AWVs, G0438- G0439) were still separately billable with the AWV. Effective July 1, that won't be the case.

CCI version 17.2, which takes effect July 1, offers 2,367 new edit pairs and deletes 336 bundles, according to an analysis by Frank Cohen, MPA, MBB, principal and senior analyst with The Frank Cohen Group, LLC. The majority of edits impact the codes from the musculoskeletal code range (20000-29999), but bundles did occur to codes throughout the CPT® manual.

Because the AWV is a preventive wellness visit, many of its components cross over with the health and behavior assessment/intervention codes (96150-96154) as well as the medical nutrition therapy (MNT) codes (97802- 97804). Because of that, CMS will no longer allow you to report any of these codes with an AWV. If you do report them together, you'll collect for the AWV but not for the assessment or MNT, because you cannot separate these bundles under any circumstances.

Better news awaits when it comes to reporting AWVs with E/M visits. Although the CCI now bundles office visit codes 99201-99215 into both G0438 and G0439, you can use a modifier (such as 25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code if you have a medically necessary reason to separate these bundles.

In black and white: CMS already requested that you append modifier 25 when reporting an E/M code with an AWV -- the new edition of CCI simply makes it official. CMS Transmittal 2159, issued on Feb. 15, noted, "When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT® codes 99201-99215 may be reported depending on the clinical appropriateness of the circumstances. CPT® Modifier 25 shall be appended to the medically necessary E/M service."

Keep in mind: CMS went on to remind practices not to double dip for any AWV and E/M services, stating, "Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable, E/M service."

ECGs, Eye Visits Bundled: You'll also find ophthalmological exam codes 92002-92014 and ECG codes 93000-93010 bundled into AWVs, but you can use a modifier to separate these bundles when both services were medically necessary and performed as distinct procedures.

Although the CCI previously appeared to do a thorough job of bundling fine needle aspiration (FNA) codes 10021-10022 into most biopsy, excision, and resection codes, the new version of CCI takes it a step further. Effective July 1, you'll find these FNA codes bundled into scores of additional musculoskeletal procedures, from the 24071-24079 range (Upper arm excision/resection) to the 26250-26262 range (Finger resection) and beyond.

Here's why: The FNA/biopsy code pairs are bundled under the CMS policy of "sequential procedures." The policy states, "On occasions where it is necessary that the same provider attempts several procedures in direct succession at a patient encounter to accomplish the same end, only the procedure that successfully accomplishes the expected result is reported." Under this policy, the listing of the FNA code in the component column, paired with a multitude of biopsy or resection codes in the comprehensive column, indicates that an FNA procedure is not separately billable when followed by a biopsy of the same anatomic site. (To read the "sequential procedures" rule in its entirety, visit www.cmms.hhs.gov/manuals/downloads/com109c05.pdf).

If the physician can provide documentation that the FNA and other procedure were for separate sites (separate lesions or masses), you can code both services. In that case, you would need to override the CCI edit pair by appending a modifier such as 59 to the FNA code.