Primary Care Coding Alert

Latest round targets numerous lesion shaving, excision, and destruction procedures.

Unlike the huge first round of Correct Coding Initiative (NCCI, or CCI) procedure-to-procedure (PTP) edits for 2019 that we reported on in Primary Care Coding Alert volume 21 number 2, this latest round is far more manageable. Thankfully, if you code for primary care providers, very few of the 11,811 additions and 182 deletions will concern you directly.

Still, there are some important changes that could have an impact on your coding. We’ve highlighted the most important here, so you won’t look like an April fool when the edits take effect on April 1.

Lesion Destruction Codes Subject to Numerous Adds …

The largest group of codes to be affected this time around are the benign, premalignant, and malignant lesion destruction codes:

• 17000-17004 — Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions …;
• 17106-17108 — Destruction of cutaneous vascular proliferative lesions (eg, laser technique) …;
• 17110-17111 — Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions …; and
• 17260-17286 — Destruction, malignant lesion (eg, laser surgery, electro­surgery, cryosurgery, chemosurgery, surgical curettement ….

CMS has made changes to the edits involving codes 17000 and 17004 and those in the 11055 through 11057 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus) …) group. The edit involving code 17000 in column 1 and 11056 in column 2 is unchanged. However, all the other edit pairs flip the column 1 and column 2 codes. That means, effective April 1, code 17004 becomes the column 1 code to each of the codes in the 11055-11057 family, and code 17000 becomes the column 1 code for the pair with 11055, which flips to column 2.

The one exception to having 17000 or 17004 in column 1 is the edit pair involving 17000 and 11057. For that pair, 11057 becomes the column 1 code on April 1. To be consistent, CMS has also issued a modifier indicator of 1 to these changes, so you will be able to code different combinations of the two codes groups together providing you append the appropriate modifier to the column 2 code.

A number of the malignant lesion destruction codes have also become PTP pairs. Codes 17262-17264, 17266, 17270-17274, 17276, 17281-17284, and 17286 have now all been paired as column 1 codes with 17000, 17004, 17110, and 17111, though you will again be able to unbundle the services with the appropriate modifier to the column 2 code as the pairs have modifier indicators of 1.

Experts believe that the edits are both necessary and logical. “These procedures have now been considered mutually exclusive, which means these procedures typically cannot be performed together during the same session or encounter,” explains Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas, Texas. “The good news is that a modifier is allowed to be used if the two procedures were performed on different body parts during the same session/encounter,” Charles notes.

“All these edits make sense, given that the codes in question describe different kinds of lesions,” agrees Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “A lesion can’t be both premalignant and malignant at the same time, so reporting codes such as 17000 and 17262 together without modification might suggest someone was reporting destruction of the same lesion twice using two different codes,” adds Moore.

However, “the edits allow a modifier to override the edit, so if one is destroying two different lesions then one could report 17000 and 17262 together, provided the column 2 code had an appropriate modifier such as modifier 59 [Distinct procedural service] appended to it,” Moore clarifies.

Coding alert: NCCI has made many more codes in the 17260-17286 group column 1 codes to other destruction codes, so be sure to check the updated edit list closely before it becomes effective on April 1.

… and Deletions

NCCI has also deleted a number of PTP pairs in this round of edits, though in reality, they are not really deletions at all. Most of them affect 17000, which is no longer a column 1 pair with 11300-11313 (Shaving of epidermal or dermal lesion …), 11400-11471 (Excision, benign lesion …/other benign lesion …/of skin and subcutaneous tissue for hidrenitis …), 11600-11644 (Excision, malignant lesion …), and 17260-17286.

Code 17004, too, is no longer a column 1 pair with 11303, 11307-11308, 11312-11313, 11401-11471, 11600-11646, 17106-17107, and several codes in the 17260-17286 group, while 17110 and 17111 are now also no longer paired with a number of these codes.

The reason for the deletions is also pretty straightforward. “CCI has just flipped the edits,” explains Moore. “In the additions for the second quarter, 17000 is now the column 2 code, while the other codes have become the corresponding column 1 codes. Since 17000 generally has fewer work RVUs [relative value units] than the other codes, it probably makes sense that it should be the secondary rather than primary code in the pair,” Moore elaborates.

Lesion Shaving, Excision PTP Pairs Also Added

Like the malignant lesion destruction codes, many codes in the 11300-11313, 11400-11471, and 16000-11644 groups have also been added as column 1 codes with some or all the premalignant and benign lesion removal codes 17000, 17004, 17110, and 17111. Again, though, the pairs have a modifier indicator of 1, so you will be able to append an appropriate NCCI-associated modifier to the column 2 code to bypass the edit if, in the words of CMS, “the appropriate clinical circumstances are met.”

For the full list of the most recent PTP edits, go to: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html and download the zip file “Quarterly Additions, Deletions, and Modifier Indicator Changes to NCCI edits for Physicians/Practitioners ... Effective April 1, 2019.”