Primary Care Coding Alert

No modifier can separate the new edits bundling codes in the 99304-99316 range

The new edition of NCCI is in effect as of Oct. 1, and you-ll have to rein in your nursing facility care coding if you want to stay on the right side of the rules.

Most family medicine coders are familiar with Medicare's E/M guidelines, which state that practices can generally report only one E/M code per date of service. But some coders aren't aware of the fact that Medicare follows the same rules for nursing facility care codes.

You won't make that mistake anymore, now that version 12.3 of the National Correct Coding Initiative (NCCI) restricts you from billing these codes together. The new bundles affect the following codes:

- 99304-99306 -- Initial nursing facility care, per day, for the evaluation and  management of a patient ...

- 99307-99310 -- Subsequent nursing facility care, per day, for the evaluation and management of a patient ...

- 99315-99316 -- Nursing facility discharge day management...

All of the codes from this range will become mutually exclusive with most of the other codes from the Nursing Facility Services section, which was overhauled in 2006. Also, every code from 99305 and higher is mutually exclusive with every lower code.

Don't Try to Unbundle the Nursing Facility Edits

Previously, the nursing facility E/M codes were components of each other but were not mutually exclusive, so you could use a modifier to override those edits. But these new edits have a -0- in the modifier column, meaning you can't append a modifier to sidestep them.

Fortunately, most family medicine coders don't feel that this should affect their payment too drastically, since they figured these codes shouldn't have been billed together in the first place.

These bundles make sense, says Christine DuBois, CPC, coding coordinatorcompliance officer and HIPAA privacy officer at Western Mass Physicians Associates in Chicopee, Mass. -The initial evaluation codes 99304-99306 are -per day- codes, as are the subsequent codes 99307-99310,- she says. -I equate it to a hospital inpatient admit or observation  admit -- they are -per day- codes. I bill for nursing home visits, and I-ve never come across a situation where the provider chose both initial and subsequent visits on the same day.-

-I think if NCCI had previously allowed these to be -unbundled,- it was an oversight on their part,- DuBois adds.

Lesion Shaving/Destruction Codes Take Hit
 
The NCCI also turns its attention to the lesion removal codes this time around. As of Oct. 1, Medicare and all other payers that follow NCCI will bundle the lesion shaving codes 11300, 11303, 11308 and 11313 into 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). You can use a modifier to override these edits if you perform both procedures.

Use Modifier for Separate Sites

-Medicare is probably trying to demonstrate the fact that these codes represent separate types of lesion removal. And if you are doing a lesion shaving and it doesn't work, so you switch over to laser surgery or another type of destruction, you can't bill both. You should just report 17000,- says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

If you perform the procedures at separate sites, you can still report both codes, Corcoran says.

For example, if the physician shaves a 0.5-cm sunspot off of a patient's forearm and then performs cryosurgery on an actinic keratosis lesion on the patient's chest, you can bill both 11300 (Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less) and 17000.

Different ICD-9 Codes Help Your Claim

Remember to append modifier 59 (Distinct procedural service) to 11300 so the insurer won't bundle it into the cryosurgery, and link a separate diagnosis to each code.

Therefore, your claim will appear as follows:

- 17000 linked to ICD-9 code 702.0 (Actinic keratosis)

- 11300-59 linked to diagnosis code 692.74 (Other chronic dermatitis due to solar radiation).