Practice Management Alert

Changes to skin repair, A-line placement, and temporary pacemaker coding could halt your claims if you don't alter your billing.

If your payer(s) follow Correct Coding Initiative (CCI) edits and rules, you'll want to pay close attention to CCI 18.3, which took effect on Oct. 1, 2012. This edition of CCI brings a huge number of changes that you'll need to incorporate into your billing before you start seeing countless denials.

"In the 15 years or so that I have been analyzing the NCCI database, this release will go down in history as the Ripley's Believe it or Not quarterly change," warns Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. "Effective October 1, 2012, there will be 233,241 new edit pairs added to the database. So, in addition to the overwhelming volume of reasons that payers use to deny payment to a practice, you can add 1 million more, which is just about the size of the new NCCI database. Over 97 percent of these were surgical procedures (codes 10000 through 69999) and almost all fell within the policy statement of 'Misuse of Column 2 code with Column 1 code.'

"Adding insult to injury, there were 474 edit pairs where the modifier indicator was changed from '1' (you may be able to bypass the policy using a modifier) to '0' (modifiers are not permitted under any circumstance)," Cohen explains.

Good news: Not all of the thousands of changes will directly impact your billing. Our experts have combed the huge database so you don't have to. Read on to learn about some of the new code pairs on which you should focus.

Suture Repair Is a 'No-Go' With Integumentary Codes

CCI 18.3 does bundle all of the repair codes (12001-12018 for simple repair, 12020-12021 for superficial wound dehiscence, 12031-12057 for intermediate repair, and 13100-13153 for complex repair) into all the integumentary I&D codes. Suture repair of skin incisions, punctures, or lacerations, including CPT® codes 12001-13153 are now included, for example, in the following:

• 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) and 10061 (... complicated or multiple)
• 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) and 10121 (... complicated)

10180 to 19396 (many other integumentary procedure codes).

All of these bundles have a modifier indicator of "1," which means you can bypass the edits in certain clinical circumstances, using a modifier such as 59 (Distinct procedural service). For Medicare, that means the repair must be in a different location than where the physician performed the I&D. 

Modifier 59 Is Key to Suture Plus Surgery Coding

Skin suture repair codes 1200-13153 are also included in many surgical codes including, for example, all urological codes from 50010-55920, all gynecology codes 56405-55920, as well as all neurology codes.

These pairings have a modifier indicator of "1," so you can break the bundles under specific clinical scenarios. "Remember that these edits indicate that the surgical treatment of skin lesions or other procedures of the skin as well as surgical incisions of the skin always include suture repair of the operative site," explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

"Regardless of the massive number of edits involving these codes, it shouldn't really change the way you code," says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash.

"Surgical practice standards have always included the wound closure as part of a surgical procedure such as skin grafting, hernia repair, hemorrhoidectomy, etc.," Bucknam says. "These edit pairs just enforce the standards."

Focus on the Lesion Excision Exception

If your surgeon performs either a benign or malignant lesion excision, the fee includes only a simple closure. According to CPT® instruction for the following codes "Repair by intermediate or complex closure should be reported separately":

• 11400-11446 -- Excision, benign lesion including margins, except skin tag ...
• 11601-11646 -- Excision, malignant lesion including margins ...

That's why codes in the range 11400-11646 are just about the only surgical procedures that CCI 18.3 doesn't add to the list of 12001-13153 bundles.

For example: Your surgeon removes a 3.5 cm malignant lesion (including margins) from the patient's mid-back. The surgeon closes the wound in layers after extensive irrigation and undermining of tissues. When filing the claim, you should report 11604 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 cm to 4.0 cm) for lesion excision and 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm) for the complex repair.

Choose A-Line, Cath Insertion Over Wound Repair

Nearly 50 edits from CCI 18.3 focus on arterial line placement and wound repair. If you're billing for an anesthesiologist who is present and places an A-line during the procedure, you'll bill 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous) instead of a code for simple, intermediate, or complex repair.

The edit applies to the following codes: 12001-12021, 12031-12057, and 13100-+13153.

Four codes for insertion of a tunneled or non-tunneled central venous catheter also override the codes for simple, intermediate, or complex wound repair (as listed with the A-line insertion edits above). The codes you should submit during these situations are:

• 36555 (Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age)
• 36556 (... age 5 years or older)
• 36557 (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; younger than 5 years of age)
• 36558 (... age 5 years or older).

Anesthesiologists are "typically reporting anesthesia (ASA) codes instead of surgical codes, so this edit might not have much effect on anesthesiologists," says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. "But I've learned to never say never, so it's good to be aware of the change."

Each edit listed above is considered a comprehensive/component edit, meaning the services shouldn't be billed together because one service inherently includes the other (also known as bundled services). When you have adequate documentation and submit both codes for the same patient during the same encounter, Medicare (and many other payers) ordinarily will pay only for the higher-valued procedure.

Exception: The line placement edits in CCI 18.3 all carry a modifier indicator of "1," meaning you can sometimes append a modifier and report both codes from the edit pair. You would append a modifier (usually 59) to the lower-value code before submitting the claim.

Ensure 'Separate Procedure' for Temp PMs

The latest edits also make it clear that you need to think twice before reporting temporary pacemaker codes 33210 (Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter [separate procedure]) and 33211 (Insertion or replacement of temporary transvenous dual chamber pacing electrodes [separate procedure]).

You'll find hundreds of edits for these codes with a modifier indicator of 0, which means you can't override the edit using a modifier. Hundreds of previously existing edits with 33210 or 33211 in the column 2 position have been updated to change the modifier indicator to 0 from 1 (the 1 meant that you could override the edit).