Primary Care Coding Alert

In addition: Watch for these bundles affecting negative wound pressure therapy.

Apply the brakes to your reporting of evaluation and management services with procedural codes, thanks to the latest version of the Correct Coding Initiative (CCI) edits, effective July 1. CCI 19.2 includes a host of bundles that do not allow you to report these services together.

Mammoth: “In CCI version 19.2 the number of edits approaches 300,000, so this one is a whopper,” according to Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. “For column 2 codes, E/M led the pack with almost 95% of the total, so we can expect the changes in this release to affect everyone.”

Check Modifier Indicator to Unbundle Codes

CCI 19.2 adds almost every office procedure code that you normally use and bundles them with E/M services. Affected Column 1 surgical procedure codes include, but are not limited to, the following:

• skin, subcutaneous and accessory structure codes 10040-11646;
• surgical procedure on the nail codes 11730-11765;
• simple repair procedures on the integumentary system codes 12001-12021;
• intermediate repair procedures on the integumentary system codes 12031-12057;
• local treatment procedures for burns codes 16000-16030;
• destruction procedures on benign and premalignant lesions of the integumentary system codes 17000-17250;
• musculoskeletal procedure codes such as therapeutic injections of tendons and trigger points (20526-20553), aspiration and/injection of a joint (20600-20610), and application of casts and strapping (29000-29750);
• removal of foreign body procedures on the nose codes 30300-30320;
• rectal endoscopic procedure codes 45300-45392;
• anal endoscopic  procedure codes 46600-46615;
• external ear procedure codes, such as foreign body removal(69200) and impacted cerumen removal (69210)

All of those column 1 codes bundle all of the following column 2 codes:

• Office/outpatient (established patient) and inpatient problem-oriented E/M codes (99211-99239)
• Consultation codes (99241-92255)
• Critical care codes (99291-99292)
• Nursing care codes (99304-99316)
• Domiciliary, rest home, or custodial (assisted living) care codes (established patient) (99334-99337)
• Home visit (established patient) codes (99347-99350)
• Care plan oversight code (99374-99378)

Global background:  Minor procedures (generally those with 0- and 10-day global periods) may include a minor E/M service that was not “significant and separately identifiable.” Major procedures (with a 90-day global period) have always included any E/M services provided the day of and the day before the procedure.

“The CPT^® surgical package definition says that surgical procedure codes include, subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure,” points out Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Thus, these procedures, by definition, include a certain amount of ‘evaluation and management’ in them. These CCI edits reinforce that presumption,” adds Moore.

“The inclusion of the E/M services have always been by definition part of the global period,” says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “Now, it seems that CCI wishes to emphasize these included E/M services by virtue of bundles in addition to the global definitions.”

Reminder: The modifier indicator for all of these edits is “1,” which means you can override the bundling edits with the proper modifier in certain clinical scenarios. While the first modifier you’ll think of when talking about CCI edits is modifier 59 (Distinct procedural service), the modifiers most often used to break edits with E/M services in column 2 will be modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Translation: “That means any time you do an E/M service and a procedure on the same date of service, you should consider whether or not there is an applicable CCI edit,” cautions Moore. “If there is, your documentation should support that the E/M service was significant and separately identifiable before you report it, and if so, you should append modifier 25 to the E/M code to facilitate its payment,” adds Moore.

Red flag: In addition to these above mentioned procedural codes, you should also take care to check bundling when you are thinking of reporting an E/M code with any procedures that you may report with a G code. Some of the G codes that you’d normally use that are covered under CCI version 19.2 include the following:

• G0127 (Trimming of dystrophic nails, any number)
• G0168 (Wound closure utilizing tissue adhesive[s] only)
• G0268  (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing)

Be Aware of Negative Wound Pressure Therapy Bundles

When your family physician performs negative wound pressure therapy, you’ll have to check for bundling with other codes that you normally use. So, when you report G0456 (Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing[s], topical application[s], wound assessment, and instructions for ongoing care, per session; total wounds[s] surface area less than or equal to 50 square centimeters) or G0457 (…greater than 50 square centimeters), be aware that they are column 2 codes for the following codes that you may also use:

• Surgical procedure on the skin, subcutaneous and accessory structures codes (10060-11057)
• Surgical procedure on the nail codes (11719-11765)
• Simple repair procedures on the integumentary system codes (12001-12021)
• Intermediate repair procedures on the integumentary system codes (12031-12057)
• Local treatment procedures for burns codes (16000-16030)
• Destruction procedures on benign and premalignant lesions of the integumentary system codes (17000, 17004, 17110, and 17250)
• Selected surgical procedures on the musculoskeletal system codes (20005-28825)

The modifier indicator for the bundling between the above mentioned codes and G0456/G0457 is ‘1,’ indicating that you can break the bundling by adding a suitable modifier such as 59 (Distinct procedural service). You will append this modifier to G0456 and G0457 as these form the column 2 codes.