Podiatry Coding & Billing Alert

Hint: Always pay attention to the modifier indicator for PTP edits.

You've learned about the 2018 CPT^® code additions, changes, and revisions in previous issues of Podiatry Coding & Billing Alert. Now that the Correct Coding Initiative (CCI) 24.0 edits are out, you'll also need to know how these edits will impact your practice's reimbursement this year.

As is typical of the first round of bundlings for a new year, many of the new CCI 24.0 edits focus on the updated CPT^® codes. The good news for podiatry coders is that 2018 brought very few CPT® changes to the specialty, so the impact your practice sees should be very slight, according to Arnold Beresh, DPM, CPC, CSFAC in Newport News, Virginia. However, even if your specialty doesn't expect a major impact from the CCI edits, this shouldn't take away from the importance of reviewing these edits and putting them in place as soon as possible, Beresh says.

Read on to learn more.

Focus on PTP Edits for New Code 97763

In one particular procedure-to-procedure (PTP) edit, 97755 (Assistive technology assessment (eg, to restore, augment or compensate for existing function , optimize functional tasks and/or maximize environmental accessibility), direct...) is the Column 1 code, and new 2018 option 97763 (Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes) is the Column 2 code. This means if you report both 97755 and 97763 for the same patient on the same date of service, 97755 is eligible for payment, but your payer will deny payment for 97763.

Although CCI bundles indicate which CPT^® and HCPCS codes you should normally not report together, Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, manager of clinical compliance with PeaceHealth in Vancouver, Washington, reminds coders that CCI is more than just a list of codes that bundle together.

"There are general rules for all codingconcepts and general rules for each CPT^® chapter," Bucknam says. "Read through these rules and be sure you understand the concepts for the chapters you work in most often. This will help you understand what is likely to bundle and will guide you even if you don't have software that tells you when you make a bundling error."

Mind the modifier indicator: You should note that the modifier indicator for the 97755/97763 edit pair is 1, which means you might be able to report both codes under certain circumstances using a modifier.

"For example, this edit can be overcome, if appropriate, with the use of modifier 59 (Distinct procedural service)," says Mary I. Falbo, MBA, CPC, president and CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. If so, you should append a modifier to the Column 2 code.

Caveat: Just because you can add a modifier, that doesn't mean you should. Be sure you have the supporting documentation for requesting payment for both codes 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.

Caution: You should never append modifier 59 to an evaluation and management (E/M) service.

See Relationship Between These Revised Codes and Edits

Other recent PTP edits you should be aware of are those for 97763 and the following orthotic and prosthetic management codes, which you may recall have revised descriptors for 2018:

• 97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(ies) and/or trunk initial orthotic(s) encounter, each 15 minutes)
• 97761 (Prosthetic training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes).

For the 97760/97763 or 97761/97763 edit pairs, if you report both codes of the pair for the same patient on the same date of service, either 97760 or 97761 is available for reimbursement, but your payer will not pay you for 97763.

Note: The modifier indicators for both the 97760/97763 and 97761/97763 edit pairs are 0, which means you cannot override the edit under any circumstances.