Oncology & Hematology Coding Alert
Confused by Recent Biopsy Denials? Latest Round of CCI Edits May Be to Blame
These modifier indicator updates may be the subtlest changes to learn. As is typical of the first round of edits for a new year, many of the new National Correct Coding Initiative (CCI) version 25.0 edits focus on the new code additions, deletions, and changes for CPT® 2019. Additionally, you don’t have much time to digest this news, as these edits went into effect January 1. Check out the new edits, deletions, and the modifier indicator switches affecting oncology practices. These Category III Edits Demonstrate Modifier Indicator Basics The 2019 CPT® code set added 0537T–0540T to track the use and efficacy of a new treatment for cancer. The treatment therapy, called CAR-T (Chimeric antigen receptor T-cell), described by these new codes utilizes the patient’s own immune system to destroy cancer cells. Remember: Category III codes are temporary codes CPT® adds to report new procedures, services, and technologies. Some payers may consider CAR-T therapy investigational, so check with the payer regarding their policies on payment. Payers following CCI 25.0 will consider the following codes inclusive of 0537T-0540T: Also, 0540T (Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration, autologous) includes the work of 96373 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra-arterial). Heads up: All these edits have a modifier indicator of “1.” When the modifier indicator is “1,” this means you may be able to report both codes of an edit pair under certain circumstances by using a modifier. For example, you can overcome the edit, if appropriate, with the use of a modifier such as modifier 59 (Distinct procedural service), explains Mary I. Falbo, MBA, CPC, president and CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. Caveat: Just because you can add a modifier, doesn’t mean you should. Be sure you have the documentation supports both codes should be reimbursed before adding a modifier to the bundled pair. “Modifier 59 and other CCI-associated modifiers should not be used to bypass a CCI edit unless the proper criteria for use of the modifier 59 are met,” Falbo adds. “Documentation in the medical record must satisfy the criteria required by any CCI-associated modifier that is used.” You can use modifier 59 when the surgeon performs the bundled procedures for different anatomic sites/regions, different organs, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ, Falbo explains. Keep in mind: The Centers for Medicare and Medicaid Services (CMS) introduced the following modifiers (XU, XS, XP, XE) as a subset of modifier 59 and your payer may want these more specific modifiers to more fully describe the rational for separate payment instead of merely override the edit with modifier 59. Definitions for these modifiers are as follows: Apply These Fine Needle Aspiration Edit Additions Code +10004 (Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure)) is a new add on code to report with 10021 (Fine needle aspiration biopsy, without imaging guidance; first lesion). In other words, +10004 represents each additional lesion. Previously, you would report a unit of 10021 for each lesion, says Leah Fuller, CPC, Consultant, Pinnacle Enterprise Risk Consulting Services, LLC, CO. The following Column 2 codes are still separately reportable, if supported by documentation: Also, CPT® 2019 added new fine needle aspiration (FNA) with imaging guidance codes (10005-+10012) to specify the type of imaging guidance utilized, and CCI 25.0 took notice. The following codes are bundled into these FNA codes as column 2 codes: Note: You should have deleted 10022, which means you’ll see all the associated edits deleted in CCI 25.0. Check Out These Major Changes for Skin Biopsies CPT® 2019 added three primary skin biopsy codes (11102 for tangential biopsy, 11104 for punch biopsy, and 11106 for incisional biopsy) and three add on codes (+11103, +11105 and +11107 for each separate/additional lesion). The new codes are more specific (identify technique utilized) and more accurately reflect the difference in work. Note: Because of these additions, CPT® 2019 deleted 11100 and 11101! The deleted codes had high utilization but were found to be used in distinct and inconsistent ways. Therefore, you can also expect CCI 25.0 deletions for these codes. You can separately report these column 2 codes if supported by documentation: Also, the above mentioned primary skin biopsy codes are bundled into 11400 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less) and 11600 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less). If the oncologist performs biopsy and excisions on separate lesions and supported in the documentation, you can separate these codes requesting separate payment for each procedure by adding modifier XS. Bundle These Bone Marrow Biopsies with Spinal Procedures Code 38221 (Diagnostic bone marrow; biopsy(ies)) is now bundled into these excision procedures on the spine (vertebral column) (22100-+22116), vertebral corpectomy codes (63081-+63091, 63101-+63103), and laminectomy codes (63265-63273). Meanwhile, 38220 (Diagnostic bone marrow; aspiration(s)), 38221 (Diagnostic bone marrow; biopsy(ies)), and 38222 (Diagnostic bone marrow; biopsy(ies) and aspiration(s)) will include the new FNA with imagine guidance codes (10005-10011). You can request separate reimbursement for each service when documentation supports the services were performed at separate sites and adding the most appropriate modifier to override the CCI edit. Highlight These Lymph Node Biopsy Additions 2019 CPT® code set added 38531 (Biopsy or excision of lymph node(s); open, inguinofemoral node(s)) to report an open biopsy or excision of lymph nodes in the groin area and upper thighs. An open biopsy or excision requires an incision through skin and dissection down through subcutaneous and other tissues to reach the lymph nodes in question. Prior to this addition, you really had no specific code for this procedure, which was being incorrectly reported with codes for other procedures on the lymph nodes. This code now includes the work represented by: Deleted Codes Mean Deleted Edits As previously mentioned, you should delete the edits involving the deleted codes 11100, 11101 and 10022. However, you should also delete the edits associated with the following deleted codes: Finally, Note These Subtle Modifier Indicator Changes You may be used to the edit bundling 58542 (Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)) and 58558 (Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C) — but CCI 25.0 changes that dynamic. As of January 1, the modifier indicator changes from “0,” meaning you cannot separate the bundle reimbursement under any circumstance, to “1,” meaning that you can. In other words, if the ob-gyn performed a hysteroscopic D&C prior to the laparoscopic supracervical hysterectomy, you could bill it with the addition of a modifier 59 (Distinct procedural service), says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico. Heads up: Keep in mind the hysteroscopic procedure must meet the definition of a “distinct procedure,” Witt says. “Medicare, for instance, would view this a viable combination if the biopsy was done to determine whether it was appropriate to perform the supracervical hysterectomy if cancer was suspected.” Additionally, you’ll see a modifier indicator change for 81435 (Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include sequencing of at least 10 genes, including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4, and STK11). The following column 2 codes are no longer separable: You won’t be able to separate the following codes from 81436 (Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); duplication/deletion analysis panel, must include analysis of at least 5 genes, including MLH1, MSH2, EPCAM, SMAD4, andSTK11) either:
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