Wiki Medicare E/M with PDT (CPT 96567) not billable unless separately identifiable

[ellzeycoding]

I'm having a brain fart moment here..

I need to find the official "policy" for to explain why Medicare doesn't pay for an E/M with Photodynamic Therapy (PDT) CPT 96567 unless separately identifiable.

I don't see this combo in the NCCI edits, (unlike some of the the other light therapy codes).

I can't find it in the NCCI narratives or instructions.

Is this in the Medicare provider manual policy?

I'm having trouble locating it and someone wants to see the policy!

 

[CodingKing]

Isn't this the same as any other E&M w/ procedure claim. Seems the policy would be no difference than knee injections?

 

[ellzeycoding]

I think I'm just messed up and overthinking today. I've been looking at policies and tables for the past 3 days.

Most of the procedures that are bundled with new or established E/M visits have NCCI edits.

As we all know, per NCCI, Minor surgical procedures (codes with 0 or 10 postop days) have the E/M included in the minor procedures. Most of these edits were reflected in the addition of the NCCI edits in July 2013.

And we know that E/Ms can be billed separately with major surgeries (90 postop days) if the E/M visit led to the decision to perform the major surgery. Modifer 57 is added.

There are a bunch of bundles added in the NCCI edits for things like light therapy (UVA/UVB), even these codes don't have postop days (concept doesn't apply). Status indicator of 1 indicates that an E/M is billable if separately identifiable.

Column I Coluimn II
96910 99212-99215
96912 99212-99215
96913 99212-99215
96920 99211-99292


96567 doesn't appear in the NCCI listings and the global concept also doesn't apply to 96567.

So that's what's throwing be off. Why didn't CMS add these 96567 to the NCCI edit tables?

 

[CodingKing]

NCCI doesn't cover every possible scenario so cant just go by NCCI.

 

[ellzeycoding]

Yeah, I'm overthinking it.

Thanks.... too much data on the brain.

 

[ellzeycoding]

Disregard. I figured it out. Yes, brain fart.

Even if a new Medicare patient came in TODAY and a thourogh E/M was performed for multiple AKs and the decision was made to treat with PDT (vs. traditional AK destrution with LN2) the provider (or patient) still has to apply the Levulan and wait before exposure to the UV light. It is usally applied one day and the patient returns the following day for exposure to the light. It's normally a 2-day process.

The PDT would always occur the day following any E/M related to it making the decision to perform it. This an E/M related to it would never occur the same day.

If, however, an E/M was necessary immediately after PDT for a side-effect, like pain, it would be permissible to bill the E/M. The second unrelated DX would be R20.2 or whatever the complication which would allow it to be billed.