Primary Care Coding Alert

NCCI deletes 'absurd' new patient OV-nail debridement edit

CMS has realized that a policy under which you cannot report a new patient office visit in addition to nail debridement just doesn't make sense.
 
This epiphany triggered the National Correct Coding Initiative, version 11.2, to remove a longstanding edit that bundled new patient office visit codes CPT 99201 - 99202 with nail debridement codes CPT 11720 -CPT 11721 . "CMS probably realized that this was an absurd edit, and so the agency deleted it," says Barbara J. Cobuzzi, MBA, CPC,   CPC-H, CHBME, president of CRN Healthcare Solutions in Shrewsbury, N.J.
 
Luckily, the bundle never really caused any payment problems. Here's why:

Modifier 25 Describes Service-Procedure Relation

You can usually appropriately code a low-level new patient office visit with nail debridement. "The physician has to evaluate the patient prior to performing the procedure," says Deborah Cook, CPC, coding specialist at Foothill Podiatry Clinic of Grass Valley in Grass Valley, Calif. If the documentation supports the E/M as separately identifiable from the debridement, you can report 99201-99202 (Office or other outpatient visit for the evaluation and management of a new patient ...) appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in addition to 11720-11721 (Debridement of nail[s] by any method[s] ...).
 
Modifier 25 indicates that, during the service, the family physician decided to perform the procedure. "The FP has to determine the class findings and decide whether the patient qualifies for Medicare nail treatment coverage," Cobuzzi says.

Payment Hinges on Medicare Criteria

Claim reimbursement hinges on the patient meeting Medicare's medical-necessity criteria, not on the now withdrawn edit (as of July 1, 2005). "We've had no problems with payment for a low-level new patient office visit with debridement," Cook says. You have to make sure the patient has a systemic condition with symptoms, and you use the modifier to indicate this.
 
Example: A new patient who is on Coumadin for chronic thrombophlebitis of the lower extremities (451.0-451.2, Phlebitis and thrombophlebitis) presents with a complaint of pain in the limb and discomfort. The FP performs an evaluation and management service in which he determines the patient meets Medicare's qualifications for routine foot-care coverage.
 
The physician documents that the patient has a systemic condition (chronic thrombophlebitis), with an absent posterior tibial pulse and three trophic changes (thickening nails, shiny skin texture, and redness) and needs two nails debrided. A separate paragraph in the doctor's documentation details the nail debridement.
 
Because the FP performs and documents a significant, separate E/M from the debridement, you should report the appropriate office visit code, such as 99201-99202, appended with modifier 25, in addition to the nail treatment procedure (11720, ... one to five).
 
To indicate the patient exhibited two class B findings (absent pulse and three appearance changes, which equal one class B finding), append modifier Q8 (Two Class B findings) to 11720. Link the complaint of pain (729.5, Pain in limb) to the E/M and the mycotic nail (110.1, Dermatophytosis; of nail) to the debridement, Cook says.