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:

- appended modifier 59 to 11100 (the component or column 2 code), not to 17000 (the comprehensive or column 1 code) as you did

- linked the procedures to appropriate diagnoses, such as 17000 to 702.0 (actinic keratosis) and 11100 to 195.8 (Malignant neoplasm of other and ill-defined sites; other specified sites).

Put 59 on the Secondary Code
 
The checklist in the above lesion example includes attaching modifier 59 to the secondary code. NCCI publishes a -list of mutually exclusive codes that contains edits consisting of two codes (procedures) that cannot reasonably be performed together based on the code definitions or anatomic considerations,- says Laurie Green, CPC, coding and compliance analyst at Group Health Cooperative in Seattle. -Each edit consists of a column 1 and column 2 code.-

How bundles work: If a physician reports the two codes of an edit for the same beneficiary for the same date of service without an appropriate modifier, the carrier pays only the column 1 code, Green says. The carrier may allow payment for both codes if clinical circumstances justify appending a modifier to the column 2 code of a code pair edit.

Although attaching the modifier to the column 2 code may seem elementary, the OIG found numerous application errors. The study found that 11 percent of claims had modifier 59 attached to the primary code instead of the secondary code, and another 13 percent had modifier 59  attached to both primary and secondary codes.

Close call: Your modifier 59 payment was almost restricted to adhering to the -59 on the second code- guideline. The OIG encouraged carriers to pay claims only when modifier 59 is attached to the secondary code, not the primary, but CMS responded that it lacks the technical ability to put in place such an edit. Such an edit would have rejected payment for the following nail-care claim:

An FP codes a chart as 11719 (Trimming of nondystrophic nails, any number) and 11720 (Debridement of nail[s] by any method[s]; one to five). Documentation shows that the physician trimmed and debrided different nails--trimming of the left-foot fifth-digit nail (T4) and debriding of the right-foot great toe nail (T5). You submit the procedures as:

- 11720-T5
- 11719-59-T4.

The error? The claim incorrectly appends modifier 59 to the comprehensive or column 1 code (11719) instead of the component or column 2 code (11720). Action: -If you notice that you have put modifier 59 on the wrong code, resubmit the claim,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. In the event of an audit, payers should look positively on your proactive stance, she adds.

Reserve 25 for Separate E/M HEM

Another documentation problem area involves modifier 25, but the modifier's descriptor of a significant, separately identifiable E/M service isn't at the root of most of the claim problems. Only 2 percent of improperly coded modifier 25 claims involved E/M services that weren't significant and separately identifiable, according to the OIG.

Reality: Some 27 percent of modifier 25 claims had documentation of the procedure, but not the separate E/M. For example: Documentation showed that the provider gave the patient a flu shot (90655-90658, Influenza virus vaccine - with 90465-90474, Immunization administration ...) but offered no information about a separate E/M service (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient or 99381-99397, preventive medicine service) even when one was rendered.

The OIG wants CMS to educate providers and reinforce the requirement that you should only use modifier 25 with services that are -significant, separately identifiable- and -above and beyond the usual preoperative and postoperative care associated with the procedure.-

Best bet: When using modifier 25, you should remember the maxim -If you don't have a HEM, you can't bill an E/M,- says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute in Absecon, N.J.

Here, -HEM- stands for -history, exam and medical decision-making.- All procedures include some service  related to patient evaluation and management, but a separate E/M should include its own HEM, Jandroep says.

Scratch Modifier 25 From Single-Code Claims

Although the news that all procedures contain a minor related E/M service may surprise you, you probably know that modifier 25 submissions require a minimum of two codes. But that lesson escaped coders in 9 percent of the OIG's reviewed cases.

Modifier 25 was contained in 2.6 million claims even though the E/M visit was the only service the physician reported that day--meaning the modifier was unnecessary. -Without an accompanying initial service or procedure, you can't have a significant, separately identifiable service,- says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan. When submitting claims consisting solely of an E/M code, make sure you don't include modifier 25, he says.

Note: To read the OIG's modifier reports, visit http://oig.hhs.gov/w-new.html. Downloads include -Use of Modifier 59 to Bypass Medicare's National Correct Coding Initiative Edits- and -Use of Modifier 25.- You can test your modifier 59 skills with examples from the CMS -Modifier 59 Article- available online at www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf.