Primary Care Coding Alert

OIG finds numerous claims include procedure, not separate E/M documentation

Get ready: Carriers will increasingly scrutinize your separate and distinct service submissions. But you can prevent paybacks if your documentation supports the family physician's services.

In a recent study, the Office of Inspector General (OIG) cast a spotlight on your use of modifiers 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 59 (Distinct procedural service), and the results weren't pretty. The OIG found a 40 percent error rate for modifier 59 in its sample of claims and a 35 percent error rate for modifier 25.

Result: The OIG is encouraging CMS- Part B carriers and Recovery Audit Contractors to scrutinize your claims that use these modifiers--and you can expect to see a lot more pre- and post-payment audits for both modifiers. To protect your claims, use these strategies. Confirm Separate Region Before Using 59 Pull a sample of your modifier 59 submissions and verify that those claims properly represent a distinct procedural service. Fifteen percent of OIG's audited claims using modifier 59 had procedures that weren't distinct because -they were performed at the same session, same anatomical site, and/or through the same incision,- says Daniel R. Levinson, inspector general, in -Use of Modifier 59 to Bypass Medicare's National Correct Coding Initiative Edits.-

Make sure the physician is working in a separate body area before you use modifier 59, says Margie Scalley Vaught, CPC, CPC-H, PCE, CCS-P, MCS-P, a coding consultant in Ellensburg, Wash. Or if your FP is performing lesion biopsy and destruction, confirm that he's treating multiple lesions and not just multiple procedures on the same lesion. You should also make sure you use separate ICD-9 Codes for the diagnoses behind the separate procedures, she says.

Here's how: Suppose you pull a claim that contains modifier 59 on 17000 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions; first lesion) and 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion).

The National Correct Coding Initiative (NCCI) edits show 17000 as the column 1 or comprehensive code and 11100 as the column 2 or component code. This bundle makes the biopsy (11100) a component of the destruction (17000), unless -the procedures are performed on separate lesions or at separate patient encounters,- according to the CMS in -Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service.-

Documentation included in the notes shows that the FP biopsied and destroyed different lesions, so your claim meets the first test. You next step is to check to be sure you:

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