Podiatry Coding & Billing Alert

CMS takes aim at modifier 25.

If you’re accustomed to collecting for both an E/M and foot strapping when done on the same visit, prepare to change your coding practices if CMS finalizes the proposed Medicare Physician Fee Schedule for 2017.

A key provision in the proposed rule focuses on 83 codes for 0-day global services that are “potentially misvalued.” The Centers for Medicare & Medicaid Services (CMS) cites Medicare claims data from 2015 that shows that, 50 percent of the time or more, 19 percent of 0-day global services codes were billed with a separate E/M service, on the same day of service, with the same physician, and the same beneficiary.

0-Day Global Procedures with E/M Services and Modifier 25

The definition of a “0-day global” procedural service includes the E/M services associated with providing the global procedure. Modifier 25 allows the physician to be paid for the separate E/M service that would be denied as bundled otherwise. Different diagnoses are not required for reporting the E/M service on the same day as the procedure. When a significant, separately identifiable E/M service beyond the usual care associated with it is performed by the same physician on the same day, modifier “25” is reported with the E/M code.

Because routine E/M is included in the valuation of 0-day global services, CMS believes 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.

Of CMS’s list of 83 codes, these are the most relevant to podiatrists:

• 11000 – (Removal of inflamed or infected skin, up to 10% of body surface)
• 11740 – (Removal of blood accumulation between nail and nail bed)
• 17250 – (Application of chemical agent to excessive wound tissue)
• 20550 – (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar “fascia”])
• 20551 – (Injections of tendon attachment to bone)
• 20600 – (Aspiration or injection of small joint or joint capsule)
• 20604 – (Arthrocentesis, aspiration or injection, small joint or bursa [e.g., fingers, toes]; with ultrasound guidance, with permanent recording and reporting)
• 20605 – (Aspiration or injection of medium joint or joint capsule)
• 29515 – (Application of short leg splint [calf to foot])
• 29540 – (Strapping of ankle or foot)
• 29550 – (Strapping of toes)

While podiatrists will find the codes above to be the most pertinent, other codes on the list will have a ripple effect touching practices’ bottom line reimbursements if the proposal goes through.

Medical associations take issue with the CMS rationale

A visit with a modifier 25 on the same day as a minor procedure is supported only if there is “separately identifiable” E/M beyond the procedure’s normal evaluation and management. CMS considers the decision to perform the procedure to be part of a minor procedure.

As the American Podiatric Medical Association (APMA) pointed out in its official comment on the proposed fee schedule, CMS’s findings are more consistent with a patient coming to a physician with a new complaint that requires a separate E/M service and not a “misvalued” procedure. Some of those patients will need a procedure that is also a 0-day global service and want them on the same day, which results in the E/M being billed with modifier 25.

The AMA’s official comment indicated only “19 services met the criteria for this screen and these services have not been reviewed specifically to address an E/M performed on the same data.  38 codes identified by RUC do not meet the screen criteria because they were either reviewed in the last five years and/or typically not reported with an E/M.”

Provision will lead to more denials

It’s still unclear how CMS will implement proposed changes to the 83 codes on the “potentially misvalued” list, but analysts agree that practices likely won’t benefit.

“It’s possible that the 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,” Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting said.

Cobuzzi says the changes will have two impacts for payers. Historically, about half of practices will not appeal the denials. “The other 50 percent will give the payers a chance to audit the documentation via the appeals and they can collect data on practice performance on the modifier 25 use and their documentation success and failure.”

Note: Read the proposed Medicare Physician Fee Schedule for 2017 rule here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-P.html.