General Surgery Coding Alert

Forsake separate assessment and management, too.

Sometimes you’ll see a lull in new Correct Coding Initiative (CCI) edit pairs by the third quarter — but not this year.

The July 1, 2014 CCI version 20.2 update brings 20,729 new edit pairs. “With only 212 terminations, we see a net gain this quarter of 20,517 new edit pairs for a total of 1,334,994 active edit pairs (or reasons not to pay you for what you do) in the database,” says Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla.

A significant number of those new edit pairs could impact your general surgery practice. That’s why we’ve assembled this break-down to make sure you know when you can, and can’t, report certain services together for the same patient on the same day.

Beware Hospital Outpatient Clinic Bundles

If your surgeon performs procedures in a provider based clinic (also called a provider based entity, or PBE), meaning that the hospital owns the clinic, you might have some concerns when billing 99201-99215 (Office or other outpatient visit for the evaluation and management of a … patient…). That’s because, this year, CMS collapsed that 10-code sequence into a single code that the hospital bills for outpatient payment: G0463 (Hospital outpatient clinic visit for assessment and management of a patient). 

Now CMS adds more than 5000 edit pairs for G0463 (Hospital outpatient clinic visit for assessment and management of a patient) with surgical procedures. 

Do this: If your surgeon performs an unrelated evaluation and management service for a hospital outpatient at a PBE, you’ll continue to bill the appropriate code from the range 99201-99215. But the hospital billing for the service would need to check whether the procedure is bundled with G0463 before reporting that code. 

Caveat: These CCI edits won’t apply if you’re billing for your surgeon’s services in most physician offices (place-of-service 11).

Avoid Separate Blood Vessel Repair Codes

When your surgeon performs any of a number of vascular procedures, such as injection or catheter placement codes in the range 36005-37500, or balloon angioplasty codes in the range 35450-35476, you’ll be facing new CCI 20.2 edit pairs with the following blood vessel repair codes in the column 2 position:

• 35201 — Repair blood vessel, direct; neck
• 35206 — … upper extremity
• 35226 — … lower extremity
• 35231 — Repair blood vessel with vein graft; neck
• 35236 — … upper extremity
• 35256 — … lower extremity
• 35261 — Repair blood vessel with graft other than vein; neck
• 35266 — … upper extremity
• 35286 — … lower extremity.

“These bundles make sense if the two procedures, such as catheter placement and blood vessel repair, involve the same vessel,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash. “But if the two procedures involve distinct services on different vessels, the CCI modifier indicator of ‘1’ allows you to bill both services with a modifier such as 59 (Distinct procedural service),” she says.

Learn Other Surgical Bundles

CCI 20.2 holds many more edit pairs that you need to know about for your general surgery practice. 

For instance, there are new edit pairs for 17000 and 17004 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [e.g., actinic keratosis] …) as column 1 codes with many of the following codes:

• 11300-11313 (Shaving of epidermal or dermal lesion, single lesion …)
• 11400-11471 (Excision, benign lesion including margins…)
• 11600-11646 (Excision, malignant lesion including margins, …)
• 17260-17286 (Destruction, malignant lesion [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement]…).

If your surgeon performs the bundled procedures on different lesions at different sites, you can use modifier 59 to override the edit pairs. 

Don’t break these bundles: You might need to be aware of new edit pairs with the following HCPCS Level II codes for hospital billing if your surgeon performs the services at a PBE. CCI 20.2 lists these with a modifier indicator of “0,” meaning that you can’t override the edit pairs under any circumstances.

• C5271-C5278 — Application of low cost skin substitute graft…
• C9735 — Anoscopy; with directed submucosal injection(s)...

Specifically, CCI 20.2 creates edit pairs for skin substitute graft codes C5271-C5278 with 15271-15278 (Application of skin substitute graft to …). Due to large variations in cost for skin substitute materials, Medicare instituted a two-tier coding system for skin substitute graft application beginning Jan. 1, 2014. Codes C5271-C5278 are for procedures using low-cost materials, and 15271-15278 are for procedures using high-cost materials. The material classification as low- or high-cost is based on CMS’s designation, which you can find in MLNMatters Number MM8572. 

Anoscopy edits: If your surgeon performs pretty much any procedure involving rectum, anus, or colon in the code range 45000-46947, you’ll find the procedure bundled with C9735 (Anoscopy; with directed submucosal injection[s], any substance) for hospital billing.