Pediatric Coding Alert

CMS doesn’t appear happy with the rampant modifier 25 usage on cerumen removal and more.

If modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) is your best friend, it may be time that you take some time apart.

At least that will be the case if CMS gets its way, thanks to changes that the agency suggests in its 2017 Medicare Fee Schedule Proposal, which was released on July 7, 2016. Although pediatricians do not frequently see Medicare patients, the Fee Schedule is important because many private payers follow Medicare’s lead when setting rates.

Agency Looks Carefully at 83 Codes’ Modifier Use

“Medicare claims data for CY 2015 show that 19 percent of the codes that describe 0-day global services were billed over 50 percent of the time with an E/M with Modifier 25,” CMS says in the proposed Fee Schedule. “Since routine E/M is included in the valuation of 0-day global services, we believe that the routine billing of separate E/M services may indicate a possible problem with the valuation of the bundle, which is intended to include all the routine care associated with the service.”

The agency is therefore taking a look at the CPT^® codes that practices typically report with an E/M and modifier 25, and has classified 83 of them as “potentially misvalued,” meaning that the agency could be considering making changes to the payment model for these codes. “We identified 0-day global codes billed with an E/M 50 percent of the time or more, on the same day of service, with the same physician and same beneficiary,” CMS said in its explanation of how it created the list of potentially misvalued codes. 

Cerumen Removal, Strapping Among the 83 Codes

Pediatricians will be disappointed to see that the cerumen removal code 69210 (Removal impacted cerumen requiring instrumentation, unilateral) is on the list of these targeted procedures, which could mean changes to payment for them if CMS’ proposed rule is eventually finalized.

“I have preached for many years that the wax has to be impacted for it to be a true procedure,” says Donelle Holle, RN, president of Peds Coding, Inc.

In addition, “the documentation has to show that it required the skill of a physician and involved the use of instruments, forceps, cerumen spoon, etc.,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J. “You would not use 69210 for an ear wash.  CPT^® 2015 added a code for an ear wash, which is 69209 (Removal impacted cerumen using irrigation/lavage, unilateral). This code applies to non-physicians who do the ear wash as well,” she says.

Strapping, FBR Also on CMS’ Target List

Also on the list of 83 potentially misvalued codes are some of the strapping codes (29540, 29550), nosebleed control (30901, 30903), removal of foreign body from the eye and ear (69200, 65205, 65210), and some lesion shaving codes (such as 11300-11310).

With the list of codes that impact pediatricians being so high and CMS’s continued scrutiny of them, you should keep a close eye on your documentation to make sure you can justify your modifier use. “Paying attention to that 25 modified visit and what it means is important,” Holle says.

Although it’s unclear what CMS plans to do with the 83 potentially misvalued codes on the list, the consensus is that it probably won’t be good. “It’s possible that they payers will either pay for the E/M or the procedure, but not both, requiring the practice to appeal, supplying the notes to prove the E/M was a significant, separately identifiable E/M,” Cobuzzi says. “The denials create two things for the payers—first, some practices (about 50 percent) will not appeal the denials. And second, the other 50 percent will give them a chance to audit the documentation via the appeals which send in the documentation without requesting to do an appeal and they can collect data on practice performance on the modifier 25 use and their documentation.”

Keep an eye on Pediatric Coding Alert for more on this as CMS finalizes issues within the 2017 Fee Schedule.

Resource: To read the complete Proposed Fee Schedule, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-16097.pdf.