Primary Care Coding Alert

Know which edit pairs CMS has deleted effective July 1.

The Centers for Medicare and Medicaid Services (CMS) has just released the latest round of Correct Coding Initiative (CCI) edits, and several of them will affect the way you code vision screenings during a preventive medicine visit.

To find out why CMS has revised these component codes, and how this decision will impact your coding, we reached out to our experts, and here’s what they had to say.

What Are CCI PTP Edits?

First, here’s a refresher on what CCI procedure-to-procedure (PTP) edits are. Basically stated, CMS creates edit pairs for one of 14 different reasons, though for the most part, the reasons reinforce CPT® guidelines or procedure definitions that indicate one procedure (the column two code) is, in part or completely, included in another procedure (the column one code).

CMS then assigns a correct coding modifier indicator (CCMI) of 0 or 1 to the pair:

“If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service and the CCMI is 0, the column two code is denied, and the column one code is eligible for payment. If the CCMI is 1 and if an NCCI-associated modifier is used because the appropriate clinical circumstances are met, the NCCI PTP edit will be bypassed. If the CCMI is 1 and an NCCI-associated modifier is not used, the column two code is denied” (Source: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/ncci_correspondence_language_manual.pdf).

What Primary Care PTP Edits Are Affected in This Round?

This quarter, CMS has decided that it will delete the pairing of preventive medicine evaluation and management (E/M) codes 99381-99397 (Initial/Periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new/established patient) as column one codes from a trio of column two visual screening codes that are used in primary care settings.

Effective July 1, 99172 (Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision (may include all or some screening of the determination[s] for contrast sensitivity, vision under glare)), which previously had a modifier indicator of 0, and 99173 (Screening test of visual acuity, quantitative, bilateral) along with 99174 (Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report), which had modifier indicators of 1, will no longer be paired with preventive medicine E/M codes as PTP edits.

This means you will now be able to bill both a preventive E/M visit and 99172 at the same encounter, and you will be able to bill for the preventive E/M and 99173 and 99174 without having to attach 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).

Of the three, “the edit involving 99173, because it is a straight test of visual acuity intended primarily for pediatric patients, is likely to have the most impact in primary care,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Code 99172 is mostly used in occupational medicine and is intended for adults working in fields where there are vision safety standards or where excellent sight is required,” Moore clarifies, “while 99174 involves no physician work as it describes the transfer of screening images to a remote site where the images are analyzed for a report, which is then sent back.” So, the deletion of edit pairs involving these two codes will have less impact.

Why Is the Change Needed? And Why Delete the PTP?

Quite why CMS instituted these particular PTP edit pairs is puzzling. Current CPT^® guidelines for 99381-99397 state that “vaccine/toxoid products, immunization administrations, ancillary studies involving laboratory, radiology, other procedures, or screening tests (e.g., vision, hearing, developmental) identified with a specific CPT® code are reported separately.” In other words, CPT^® did not see the need to bundle vision screenings with preventive medicine services, whereas CMS did.

This points to both philosophical and practical reasons for deleting the edit pairs now. “The wording of these CPT® guidelines speaks specifically to the important distinction of these services as payable with well care, according to the American Medical Association/CPT^®,” says Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC. “Even though private payers are not legally obligated to follow CPT® guidelines, continuing to maintain the CMS exclusion would be antithetical to preventive care ideals,” Blanchard argues.

So, rather than changing the modifier indicators to 9, which would indicate that “an NCCI edit does not apply to this PTP code pair” in CMS’s wording, CCI has opted to delete these pairs and not maintain the edit at all. “Maintaining an edit means there is some obligation on the part of CMS to ensure the edit is being properly followed by reporting physicians,” explains Moore. “It creates a program integrity burden for CMS and its contractors, so it’s preferable to delete an edit that no longer has merit than to maintain that edit,” Moore concludes.  

(To find the full list of third-quarter edits for 2018, effective July 1, go to www.cms.gov/Medicare/Coding/NationalCor­rectCodInitEd/Version_Update_Changes.html.)