Medicare Compliance & Reimbursement

CCI 2019 adds biopsy, care management, and psych test codes to the list.

With 45,727 additions, 19,729 deletions, and 41 changes, the latest round of National Correct Coding Initiative (CCI) edits, effective January 1, was a lot to handle.

Space and time don’t permit us to examine each procedure-to-procedure (PTP) edit in this issue of Medicare Compliance and Reimbursement. But the following highlights, and our experts’ opinions, should help you navigate this potential coding minefield.

New Biopsy Codes Bring New Edits …

Many edit pairs involve the new biopsy codes: 11102/+11103 (Tangential biopsy of skin ...), 11104/+11105 (Punch biopsy of skin ...), and 11106/+11107 (Incisional biopsy of skin ...). These are now column 2 codes with a modifier indicator of 1 (meaning that the PTP edit pair can be bypassed with a CCI-associated modifier when the appropriate clinical circumstances are met) for a number of integumentary surgery codes, including some fine needle biopsy (+10004-10021) and debridement procedures (11004-11006, 11010-11012).

The codes are also column 1 codes with other debridement procedures, including 11043-+11047 and numerous other integumentary surgery codes. But again, the modifier indicator of 1 means that if your provider performs both procedures, you should simply append the appropriate modifier to the column 2 code to receive full reimbursement for both codes.

“These edits are generally consistent with the guidelines preceding these biopsy codes in the 2019 CPT^® manual,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. Those guidelines state:

• “During certain surgical procedures in the integu­mentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination. The obtaining of tissue for pathology during the course of these procedures is a routine component of such procedures. This obtaining of tissue is not considered a separate biopsy procedure and is not separately reported.”

“Per CPT^®, the use of a biopsy procedure code indicates that the provider obtained tissue solely for diagnostic histopathologic examination, and that the provider performed the procedure independently, unrelated to, or distinct from other procedures/services provided at the time,” says Moore.

“Biopsies performed on different lesions or different sites on the same date of service may be reported separately, as they are not considered components of other procedures, which is why the edits allow a modifier to override them when appropriate,” Moore adds.

The edits also affect moderate sedation codes such as 99156 (Moderate sedation services provided by a physician or other qualified health care professional ... initial 15 minutes of intraservice time, patient age 5 years or older). These edits carry a 0 modifier indicator, so if you do code both codes in the pair together, know that the column 2 moderate sedation code will be denied by any payer following CCI edits, and only the column 1 code (i.e., the skin biopsy) will be eligible for payment.

... Especially With E/M Services

If you use the biopsy codes with some evaluation and management (E/M) codes, you’ll also get a mixed bag of results. The codes are currently not deemed an edit pair with new patient outpatient E/M codes 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) because “typically, for a new patient, a provider has to evaluate and go above and beyond a typical office visit to determine if the procedure would be required,” explains Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas, Texas.

However, with established patient visits 99211-99215 you will need a modifier as “the established visit is integral to the biopsy performed. In scenarios where the established visit goes above and beyond the normal workup of the biopsy it would be appropriate to use 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],” adds Charles.

The same will also be true for other E/M services, such as outpatient consultation codes 99241-99245, but not with telephone/internet/electronic health records (EHR) consultation codes 99446-99451, which all carry a 0 modifier indicator as column 2 codes.

Take Care with New Chronic Care Management Code …

Another CPT^® code introduced at the beginning of 2019, 99491 (Chronic care management services ...), is also a heavily featured column 1 code in numerous PTP pairs.

Among the column 2 codes that now have a 0 modifier with 99491 are the patient self-management codes (98960-98962), non-face-to-face non-physician service codes (98966-98969), and numerous E/M services, including prolonged E/M services (99358/+99359), medical team conferences (99366-99368), care plan oversight services (99374-99380), non-face-to-face services (99441-99444), care management services (99487-99491), and transitional care management services (99495-99496).

“This is consistent with CPT^® guidelines, which make clear that these services should not be reported during the same time as chronic care management services, although interestingly, CPT® 2019 only says that with respect to 99487, +99489, and 99490, not 99491,” says Moore. Additionally, 99487 (Complex chronic care management services ...) is not listed as a column 2 code with 99491. “Since 99487 includes the criteria for 99491, “it would be inappropriate and redundant to report both codes together,” Charles warns.

... and Don’t Let the New Psych Codes Psych You Out

Finally, another group of new codes that have also been affected by this latest round of CCI edits are the psychological and/or neuropsychological testing evaluation service codes (96130-96146) that CPT^® added this year. As column 1 codes to the new adaptive behavior assessment (97151-97152) and adaptive behavior treatment (97153-97158) codes, CCI has assigned them a modifier indicator of 0.

For the full list of the current PTP edits, go to www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html and download the zip file “Quarterly Additions, Deletions, and Modifier Indicator Changes to NCCI edits for Physicians/Practitioners ... Effective January 1, 2019.”