Primary Care Coding Alert

The new Correct Coding Initiative (CCI) edits version 8.1 went into affect April 1. Family physicians (FPs) should be aware of several changes, mainly affecting vaccinations and wound care.

CMS releases the edits quarterly to restrict the use of certain codes together. The CCI edits are grouped into two categories: "comprehensive/component" and "mutually exclusive." Comprehensive/component edits describe a component procedure and a more extensive procedure (the comprehensive code) that is presumed to include the component procedure and, therefore, should not be reported separately. Mutually exclusive edits describe codes that cannot reasonably be performed together in the same session. The edits also indicate whether coders can override a bundle with the appropriate modifier. A 0 in the modifier column signals that a modifier is prohibited, while a 1 indicates that a modifier is allowed under the proper circumstances. Each quarter, CCI adds or deletes code combinations from the comprehensive/component or mutually exclusive categories.

The significant codes now bundled include:
 

Code 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) is bundled with 90723 (Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated [DtaP-HepB-IPV], for intramuscular use), 90740 (Hepatitis B vaccine, dialysis or immunosuppressed patient dosage [3 dose schedule], for intramuscular use) and 90743 (Hepatitis B vaccine, adolescent [2 dose schedule], for intramuscular use).

When the FP administers vaccine injections, such as those described in 90723, 90740 and 90743, it is appropriate to use the vaccine administration codes 90471-90472 (Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections] ...) or 90473-90474 (Immunization administration by intranasal or oral route ...), but not the therapeutic injection code. CMS bundled 90782 with these vaccine codes because it does not accurately describe the administration. Sometimes, however, an FP gives a patient a vaccine administration and therapeutic injection on the same day. When this is the case, practices can bill 90782 with the vaccine codes, but CMS now requires the appropriate modifier.

For example, a patient may come in for a diphtheria vaccination and a testosterone shot on the same day. You should bill 90723 and 90471 as well as 90782 and the HCPCS code for the testosterone (e.g., J3140, Injection, testosterone suspension, up to 50 mg). Append modifier -59 (Distinct procedural service) to 90782.

Note: When using a modifier to override CCI edits, always append it to the component code rather than the comprehensive code.

Code 90471 is mutually exclusive of 90782 and 90784 (... intravenous).

This edit in the mutually exclusive category echoes the edits bundling 90782 with the various vaccine codes. If the FP performs an immunization and a therapeutic injection on the same patient on the same day, correct coding stipulates the use of the appropriate modifier.

Code 97601 (Removal of devitalized tissue from wound[s]; selective debridement, without anesthesia [e.g., high pressure waterjet, sharp selective debridement with scissors, scalpel and tweezers], including topical application[s], wound assessment, and instruction[s] for ongoing care, per session) is mutually exclusive of 11000-11001 (Debridement of extensive eczematous or infected skin ...), 11010-11012 (Debridement including removal of foreign material associated with open fracture[s] and/or dislocation[s] ...), 11720-11721 (Debridement of nail[s] by any method[s] ...), 16000 (Initial treatment, first degree burn, when no more than local treatment is required), 16010-16030 (Dressings and/or debridement, initial or subsequent ...) and 16035-16036 (Escharotomy).

The edits stipulate that wound-care management cannot be performed with skin debridement, nail debridement or burn treatment. To properly code these procedures when performed with wound care, coders will need to attach the appropriate modifier to the component code.

Code 10021 (Fine needle aspiration; without imaging guidance) is bundled with 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed [separate procedure]; single lesion).

Although FPs would not normally perform these two procedures together, in rare cases they may perform a skin biopsy on one lesion and a fine needle aspiration on another lesion on the same patient on the same day. The coder will need to append modifier -59 to 10021 to get reimbursed for both services.

 

Code 69210 (Removal impacted cerumen [separate procedure], one or both ears) is bundled with 92552-92553 (Pure tone audiometry [threshold] ...), 92555-92556 (Speech audiometry threshold ...), 92557 (Comprehensive audiometry threshold evaluation and speech recognition), 92559 (Audiometric testing of groups) and 92586 (Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited).

Per the new CCI edits, if an FP cleans out the ears of a patient (69210) but he or she still complains of hearing problems, and the FP conducts a threshold hearing test (92552), the practice cannot be reimbursed for both services. No modifier will be accepted.

According to Medicare, CCI edits take precedence over any guidelines in CPT. Although private payers are not required to observe CCI edits, many do, either in whole or in part. Check with individual payers before billing. The new edits replace all preceding versions and remain in effect through July 1, 2002.

Note: The CCI is available by subscription from the National Technical Information Service (NTIS) in print or as a CD-ROM in searchable (pdf) format. Contact NTIS for more information at 800/363-2068.