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Journal of the Dermatology Nurses' Association:
doi: 10.1097/JDN.0000000000000036
Feature Articles

Lifting the Veil off Reporting Evaluation and Management Services on the Same Date of Service as a Procedure

McNicholas, Faith C. M.

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Author Information

Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Coding & Reimbursement/Government Affairs, Schaumburg, IL.

The author declares no conflicts of interest.

Correspondence concerning this article should be addressed to Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, P.O. Box 682, Skokie, IL 60077-0682. E-mail: coracle@coraclebilling.com

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Abstract

ABSTRACT: The Centers for Medicare and Medicaid Services added enhanced narrative under the Integumentary section of the National Correct Coding Initiative code edits that affect the reporting of an evaluation and management (E/M) service on the date of service (DOS) as a procedure.

Although the enhanced narrative indicates that an E/M service is included in the minor procedure when reported on the same DOS, it does not preclude providers from reporting a separate E/M service—when performed and accurately documented.

For successful, stress-free reporting of E/M services and procedures on the same DOS, providers must remember that the safest, practical policy is to ensure that the E/M documentation indicates that the service was above and beyond that which is included in the procedure and, upon review, must stand on its own merit to support the level of service reported.

In the past few years, payers have increased their scrutiny on medical record documentation to ensure the reimbursement for services rendered matches that documented in the patient record. Most healthcare providers have either had a claim denied or received a request for medical records when an evaluation and management (E/M) service is performed on the date of service (DOS) as a procedure.

Furthermore, the National Correct Coding Policy Manual for Part B Medicare Carriers (NCCI), revised every quarter, released Version 19.2, which went into effect on July 1, 2013, through September 30, 2013. In this version, the Centers for Medicare and Medicaid Services (CMS) added enhanced narrative under the Integumentary section code edits that affect the reporting of an E/M service on the DOS as a procedure.

Because NCCI edits are applied to same-day services performed by the same provider to the same patient, certain global rules are applicable. An E/M service performed on the same DOS as a procedure with a global period of either “0”, “10”, or “90” days can be separately reported under limited circumstances.

The new NCCI narrative states, “If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E/M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.”

Although the NCCI edits are considered to be exhaustive and all-inclusive, they still do not contain all carrier or payer edits, as some Medicare carriers may have separate edits not included in the NCCI. For example, the use of modifier 25 varies among CMS carriers; some prefer providers to include modifier 25 when reporting a new patient E/M service with a procedure, whereas others do not. Therefore, dermatologists are encouraged to clarify with their regional Medicare carriers to establish their preference on whether to report modifier 25 on a new patient code or not.

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The new NCCI narrative further states that “for major and minor surgical procedures, postoperative E&M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package as are E&M services related to complications of the surgery that do not require additional trips to the operating room. Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed unless related to a complication of surgery may be reported separately on the same day as a surgical procedure with modifier 24 (“Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period”).

Although the statements above indicate that the E/M service is included in the minor procedure, it does not preclude one from reporting a separate E/M service—when performed and accurately documented.

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According to NCCI, modifier 25 can be appended to an E/M service code when reported with minor surgical procedures or procedures not covered by global surgery rules to indicate that the E/M service is separate and significantly identifiable from other services reported on the same DOS. Because all procedures include preprocedural, intraprocedural, and postprocedural works that are inherent in the procedure, providers must not report an E/M service code for this work (Table 1).

Table 1
Table 1
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For example, the work descriptor for CPT Code 11100-Biopsy of Skin Lesion includes the following:

Preoperative work: Before biopsy of lesion, obtain pertinent history from patient to include previous skin cancer, prior treatment history, sun protection history, and so forth. Discussion with patient will include indication for biopsy procedure, risks, and benefits; description of biopsy procedure method; and expected result and/or scarring. In addition, patient agreement/informed consent is obtained, and staff is advised for preparation of patient and necessary anesthetic, supplies, and instrument tray preparation.

Intraservice work: Inspection and palpation of the lesion to assess depth and to select most representative site to obtain specimen. Cleanse biopsy site with suitable antiseptic; inject appropriate local anesthetic; apply sterile drapes; and obtain skin specimen with scalpel, skin punch, or suitable instrument depending on depth and amount of tissue needed. Collect specimen in a labeled formalin container. Undermine wound edges as needed to facilitate repair. Suture to approximate wound edges, or achieve hemostasis with pressure, chemical, or electrocautery or application of topical hemostatic agents. Apply antibiotic ointment and sterile dressing.

Postoperative work: Instruction of patient and/or family on postoperative wound care, dressing changes, and follow-up. Patient is advised how to recognize significant complications, for example, bleeding or allergic reaction to antibiotic ointment or adhesive dressings. Patient is advised when results will be available and how they will be communicated, completion of medical record, and communication of results to referring physician as appropriate.

On the other hand, a procedure with a global period of “90” days is defined as a major surgical procedure. An E/M service performed on the same day as a major surgical procedure for deciding whether to perform the surgical procedure is separately reportable with modifier 57. Other preoperative E/M services on the same DOS as a major surgical procedure are included in the global payment for the procedure and are not separately reportable. NCCI does not contain edits based on this rule because Medicare contractors have separate edits, so check with your local carrier for clarification.

For successful, stress-free reporting of E/M services and procedures on the same DOS, one must understand the global surgical package as designed in the CMS Internet-Only Manual (IOM; Claims Processing Manual, Publication 100-04), Chapter 12 (physicians/nonphysician practitioners), Section 40.1 (definition of a global surgical package), (C) (minor surgeries and endoscopies), which defines all procedures with a global surgery indicator of “0” or “10” as minor surgical procedures. This IOM section further states that E/M services on the same day as the surgery are included in the payment for the procedure unless a significant and separately identifiable E/M service is performed. The significant and separately identifiable E/M service may be reported separately with modifier 25—“Significant separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service.”

The IOM, under Definition of a Global Surgical Package (A) (components of a global surgical package) and (B) (services not included in the global surgical package), further defines all procedures with a global surgery indicator of “90” as major surgical procedures. Preoperative E/M services on the day of surgery are included in the global surgical fee except an E/M service for deciding whether to perform the major surgical procedure. The latter may be reported with modifier 57—“Decision for surgery.”

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THE GLOBAL SURGICAL PACKAGE

For major and minor surgical procedures, postoperative E/M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package, as are E/M services related to complications of the surgery that do not require additional trips to the operating room.

Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed unless related to a complication of surgery may be reported separately on the same day as a surgical procedure with modifier 24—“Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period.”

Below are a few examples of appropriate and inappropriate use of modifier 25:

Q: Patient presents for the first time with a lesion on the back that won’t heal. A problem focused history, and examination with a straightforward medical decision making to perform a biopsy is performed. How do you code this service?

A: According to CPT Code 11100-Biopsy of Skin, work descriptor obtained from the AMA RBRVS Data Manager, efforts to obtain pertinent history, and performing a limited/straightforward examination are all included in the procedure work requirement as shown below:

Preservice work: Before biopsy of lesion, obtain pertinent history from patient to include previous skin cancer, prior treatment history, sun protection history, and so forth. Discussion with patient will include indication for biopsy procedure, risks, and benefits; description of biopsy procedure method, and expected result and/or scarring. In addition, patient agreement/informed consent is obtained….

Intraservice work includes inspection and palpation of the lesion to assess depth and to select the most representative site to obtain specimen. Cleanse biopsy site with suitable antiseptic; inject appropriate local anesthetic; apply sterile drapes; and obtain skin specimen with scalpel, skin punch, or suitable instrument depending on depth and amount of tissue needed. Collect specimen in a labeled formalin container. Undermine wound edges as needed to facilitate repair….

NCCI further states that “the fact the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E/M service on the same DOS as a minor surgical procedure, nor is the decision to perform surgery—unless this was a major procedure (90-day global period).”

So in this case, an E/M service cannot be justified to be distinct, above and beyond, significant and separately identifiable from the procedure. You would only report CPT code 11100.

Q: Patient presents for follow-up of clinically premalignant lesion or nodule of the face, which was treated with Efudex with exacerbation. Decision is made to treat lesion with LN2. Patient also requires a refill of a topical steroid to treat lichen planus. How do you code this service?

A: The premalignant lesion was addressed with no improvement, and the provider obtains a problem-focused history from the patient regarding prior treatment and a problem-focused examination of the lesion site(s) and then decides to treat the lesion with LN2.

The provider then reviews the medical history form completed by the patient and vital signs obtained by clinical staff. Obtain an expanded problem focused history and examination. Formulate and develop a treatment plan for the lichen planus. Discuss diagnosis and treatment options with the patient. Reconcile medication(s), and write prescription(s). Complete the medical record documentation. Handle (with the help of clinical staff) any treatment failures or adverse reactions to medications that may occur after the visit. Provide necessary care coordination, telephonic or electronic communication assistance, and other necessary management related to this office visit.

It is therefore appropriate to report an E/M service at the same time as the procedure in the case.

Q: Patient presents for the first time with a clinically benign lesion or nodule of the lower leg, which has been present for many years. Biopsy is performed. Code this encounter.

A: Provider should review the medical history form completed by the patient and vital signs obtained by clinical staff. Obtain a problem-focused history examination. Formulate a diagnosis, and develop a treatment plan (diagnostic skin biopsy). Complete the medical record documentation. Provide necessary care coordination, telephonic or electronic communication assistance, and other necessary management related to this office visit. Receive and respond to any interval testing results or correspondence.

An E/M service is not appropriate to be reported in this case.

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RESOURCES

American Medical Association. (2013). RBRVS data manager. Retrieved from http://www.ama-assn.org/ama/no-index/physician-resources/ruc-rbrvs-data-manager.page

Centers for Medicare and Medicaid Services. (2013). Global surgery fact sheet. Retrieved from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf

Centers for Medicare and Medicaid Services. (2013). Medicare claims processing manual chapter 12—Physicians/nonphysician practitioners. Retrieved from http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Centers for Medicare and Medicaid Services. (2013). National correct coding initiative. Retrieved from http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

Keywords:

Billing; CMS; Coding; Evaluation and Management; Modifiers; Procedure

Copyright © 2014 by the Dermatology Nurses' Association.

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