General Surgery Coding Alert

Check your modifier 25 claims for erroneous denials.

Since July 1, you’ve been facing hundreds of Correct Coding Initiative (CCI) E/M bundles with your general surgery procedures, compliments of CCI 19.2. Now you can forget about some of those edit pairs, because CCI 19.3 (effective Oct. 1) terminates the bundles.

Recap: You read about some of these edits in General Surgery Coding Alert Vol. 15 No. 8 “Greet E/M Bundles for Nearly Every Integumentary Surgery.” In addition to integumentary procedures, the E/M bundles also impacted endovascular codes (such as many codes 34800-37790), and the vast majority of digestive system procedures (40490-49906) that general surgeons perform.

Terminated Edits May be Temporary

Eliminating some of the CCI 19.2 edit pairs that restricted reporting E/M codes with so many surgical and other procedures may come as a surprise. But, “what is even more surprising is that, of the 10,580 edit pairs that were put into the terminated column, nearly all of them were terminated retroactive to July 1, 2013,” states Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla.

Here’s why — modifier 25 glitch: CMS has determined that there is an electronic claims processing system problem that is not allowing modifier 25 to bypass [the edits], according to Niles R. Rosen, MD, NCCI medical director. Because of that problem, “CMS is suspending these edits in NCCI 19.3 scheduled for Oct. 1, 2013 retroactive to July 1, 2013, the implementation date of these edits,” Rosen says.

Expect return: Once the modifier 25 glitch is resolved, CMS is likely to re-implement these edits, according to Rosen.

Recoup Payment for Rightful Claims

What if you’ve filed a legitimate claim for a procedure and a separate E/M service using modifier 25 and got a denial?

Fortunately, you should be able to recoup the money you lost from those troublesome CCI edits once version 19.3 is active. That’s the word from an Aug. 27 CMS Open Door Forum, in which CMS’s Chris Ritter acknowledged the problem.

Even if your doctor billed correctly in the first place for these services, MACs will not automatically reprocess claims, Ritter stressed. Instead, you will have to resubmit the bill to your MAC after Oct. 1. You should resubmit the claim at that point as if you’re sending the bill for the first time, Ritter clarified—you do not need to send in an appeal.

Recall Correct E/M Plus Procedure Coding

Not all edit pairs from CCI 19.2 for surgical procedures with E/M services are terminated in CCI 19.3 — many remain in effect. That means you’ll need to remember when and how you can report together surgical procedures and E/M services on the same day.

Notice indicator: The modifier indicator for the myriad edit pairs that bundle surgical procedures with E/M services have a modifier indicator of “1.” That means you can override the bundling edits with the proper modifier in certain clinical scenarios.

Background: Minor procedures (0- and 10-day global periods) may include a minor E/M service, and major procedures (90-day global) bundle E/M services provided the day of and the day before the procedure.

“The CPT^® surgical package definition says that surgical procedure codes include, subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure,” points out Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

“The inclusion of the E/M services have always been by definition part of the global period,” concurs Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

However, you may be able to bill a distinct E/M service in conjunction with a procedure if you document clinical circumstances that involve a “significant and separately identifiable” E/M. Billing rules have always required a modifier in these circumstances, such as one of the following:

• 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period)
• 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)
• 57 (Decision for surgery).