Pediatric Coding Alert

The guidelines finally address how you should break down your time-based codes.

The Correct Coding Initiative (CCI) manual has an updated version effective Jan. 1, 2016, and there are several changes that affect your pediatric practice. Here’s what you need to know for time-based coding, skin procedures, and modifier 59 usage. 

Begin With a CCI Manual Background

Pediatric coders typically know to check for quarterly CCI updates, also called NCCI (National Correct Coding Initiative) edits. New versions go into effect every January 1, April 1, July 1, and October 1. The edits show you which procedures most payers will allow you to report together, and which will be considered “bundled” together.

Manual: In addition to the CCI code pair edits, there is a CCI manual, which you can download from www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. When this manual receives updates, you’ll find the changes in the file italicized in red font. Although you may consider the bundles to be irrelevant to your practice because they are posted on the CMS site—which some coders equate with Medicare only—the reality is that most other payers from Medicaid to private insurers use the CCI edits when determining whether to pay your claims.

The three changes to the manual discussed below can help you clarify when you’re able to report certain codes together and when you should refrain from doing so.

Consider Modifier 59 Adjustments

If you’ve ever wanted to use modifier 59 (Distinct procedural service) when billing two timed procedures together but were unsure of how it impacted the timing guidelines, the 2016 CCI Manual updates take that into account. The following changes relate to general coding guidelines and are in Chapter I of the manual.

2015 way: Last year, the CCI manual had this to say about reporting timed services together: “There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two timed services are provided in time periods that are separate and distinct and not interspersed with each other (i.e., one service is completed before the subsequent service begins), modifier 59 may be used to identify the services.”

That verbiage left many coders scratching their heads about how to count the time period that overlapped the two services. Therefore, the CCI Manual has clarified the guidelines for this year.

2016 way: This year, the manual states the following (with new verbiage in italics): “If two separate and distinct timed services are provided in separate and distinct time blocks, modifier 59 may be used to identify the services. The separate and distinct time blocks for the two services may be sequential to one another or split. When the two services are split, the time block for one service may be followed by a time block for the second service followed by another time block for the first service. All Medicare rules for reporting timed services are applicable. For example, the total time is calculated for all related timed services performed. The number of reportable units of service is based on the total time, and these units of service are allocated between the HCPCS/ CPT^® codes for the individual services performed. The physician is not permitted to perform multiple services, each for the minimal reportable time, and report each of these as separate units of service. (e.g., A physician or therapist performs eight minutes of neuromuscular reeducation (CPT^® code 97112) and eight minutes of therapeutic exercises (CPT^® code 97110). Since the physician or therapist performed 16 minutes of related timed services, only one unit of service may be reported for one, not each, of these codes.)”

Takeaway: You absolutely can use modifier 59 to report two timed services that overlap one another, but the overlapping time period doesn’t count toward both services—only one. Use the total time as the guide for how many codes you can report.

Different Body Sites Make A Difference

In Chapter III (Integumentary system) of the CCI Manual, you’ll now find more specific direction about how to report multiple lesion removals on the same date.

2015 way: When it comes to billing lesion removals, the previous edition of the CCI manual laid out the rules thusly: “Lesion removal may require closure (simple, intermediate, or complex), adjacent tissue transfer, or grafts. If the lesion removal requires dressings, strip closure, or simple closure, these services are not separately reportable. Thus, CPT^® codes 12001-12021 (simple repairs) are integral to the lesion removal codes. Intermediate or complex repairs, adjacent tissue transfer, and grafts may be separately reportable if medically reasonable and necessary. However, excision of benign lesions with excised diameter of 0.5 cm or less (CPT^® codes 11400, 11420, 11440) includes simple, intermediate, or complex repairs which should not be reported separately.”

2016 way: This year, however, the manual adds the following verbiage after last year’s paragraph: “If more than one lesion is removed and one of those lesions is larger than 0.5 cm, an intermediate or complex repair may be reported, if performed, for a lesion larger than 0.5 cm. Removal of one lesion smaller than 0.5 cm does not preclude also reporting an intermediate or complex repair for a larger lesion.”

Takeaway: The manual makes it clear that you will be able to collect for all of your lesion removal services going forward, even if one lesion is smaller than 0.5 centimeters.

Splinting and Strapping Clarified

Although pediatricians don’t often apply casts, pediatric offices frequently perform splinting and strapping to sprains, and even to fractures that are temporarily stabilized before an orthopedist can be consulted. The latest CCI manual addresses that in chapter IV (Musculoskeletal system).

2015 way: Last year, the CCI manual stated, “If a cast, strapping, or splint applied after an open or percutaneous treatment of a fracture also treats a closed fracture without manipulation, a closed fracture without manipulation CPT^® code should not be reported separately.”

2016 way: The new edition of the manual adds to that regulation, with the following new verbiage: “These principles also apply to the treatment of multiple dislocations or combinations of multiple closed fractures and dislocations. If multiple dislocations and/or fractures are treated without manipulation and stabilized with a single cast, strapping, or splint, only one CPT^® code for closed dislocation or fracture treatment (without manipulation) may be reported. Additionally, if a single cast, strapping, or splint treats any combination of closed dislocations and/or closed fractures without manipulation in addition to at least one closed dislocation or fracture that did require manipulation, only a single CPT^® code for closed treatment with manipulation of the dislocation or fracture may be reported.

Similarly, if multiple dislocations and/or fractures are treated with or without manipulation and do not require a cast, strapping, or splint, only one CPT^® code for closed dislocation or fracture treatment CPT^® code may be reported for the anatomic area that would have been treated by a single cast, strap or splint.

Takeaway: If you treat multiple dislocations or fractures on the same limb, bill just one CPT^® code, as long as one cast/strap/splint would be sufficient to stabilize the area.