I know this is a long post, but I see a lot of posts on here where responders as for more information - so, I'm trying to avoid that.
I've broken it into sections in case you want to skin around Section I = Problems (my question basically); II = Situation (the context for my question); III = Proposed coding (how I currently think the encounter should be coded); and IV = Reasoning (why I chose the coding structure)
I. Problems:
(a) Deciding between modifiers -22, -51, -59, -76, and -XS.
(b) MUEs calculation method and assigned number.
II. Situation:
For one patient, during one encounter, at a wound clinic in Florida, we applied 128 units of Q4262 (a skin sub) without waste to one region (left lower leg) with a wound area of 130 sq cm (15273 = 1 unit, 15274 = 1 unit), which is greater than the # of MUEs (however, Ive yet to find what the actual MUE is, but I'm using 10). On the right lower leg (separate region) a selective debridement of 92. 07 sq cm was performed (97597 = 1 unit, 97598 = 4 units). For both regions, a total of 16 units (1 tube) of Omeza (A2014) was applied. The payer (Medicare/MAC = First Coast) has a limit on how much the total charge can be on a single claim ($99,999). We bill on a CMS-1500 claim form.
Our charges work out to the following:
Q4262 @ $1,750 per unit * 128 units = charge of $224,000
15273 @ $1,120 per unit * 1 unit = $1,120
15274 @ $695 per unit * 1 unit = $695
A2014 @ $150 per unit * 16 units = $2,400
97597 @ $205 per unit * 1 unit = $205
97598 @ $90 per unit * 4 units = $360
Total charges for the one encounter = $228,780
Total charges / Charge limit per claim = $228,780 / $90,000 = 2.5 = 3 claims
III. Proposed Coding:
Here is how I think the encounter should be coded, including modifiers, units, order, and claim notes -
/Claim A:
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 6 units = $10,500
Total charges on claim = $98,000
Total units of Q4262 = 56
> Note = "Claim 1 of 3. Separate claim. Not a duplicate."
/Claim B:
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 6 units = $10,500
Total charges on claim = $98,000
Total units of Q4262 = 56
> Note = "Claim 2 of 3. Separate claim. Not a duplicate."
/Claim C:
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 6 units = $10,500
> 15273 @ 1 unit = $1,120
> 15274 @ 1 unit = $695
> A2014 @ 16 units = $2,400
> 97597-99-51-XS @ 1 unit = $205
> 97598 @ 4 units = $360
Total charges on claim = $32,780
Total units of Q4262 = 16
> Note = "Claim 3 of 3. Separate claim. Not a duplicate."
IV. Reasoning:
> Modifier -JZ because there was no waste of Q4262.
> Modifier -99 because the line has multiple other modifiers.
> Modifier -51 because the procedure (a selective debridement) is usually not paid when a skin sub is performed.
> Modifier -XS to indicate why the -51 modifier is applicable (XS = separate structure).
> It is my understanding that some MUEs are calculated based on 'units per line item' instead of 'units per date of service'. However, I dont know which method is used for skin sub products. So, I'm basing my coding on the 'units per line item' method (wishful thinking at its best).
> CPTS 15274 and 97598 are add-on codes so definitely don't need modifier -51. *But maybe CPT 97598 needs the -XS modifier since the principle code has it?
> I thought modifier -59 could be used to override MUEs, but I'm not sure it would apply if the MUEs are calculated via the 'units per line method'.
I've broken it into sections in case you want to skin around Section I = Problems (my question basically); II = Situation (the context for my question); III = Proposed coding (how I currently think the encounter should be coded); and IV = Reasoning (why I chose the coding structure)
I. Problems:
(a) Deciding between modifiers -22, -51, -59, -76, and -XS.
(b) MUEs calculation method and assigned number.
II. Situation:
For one patient, during one encounter, at a wound clinic in Florida, we applied 128 units of Q4262 (a skin sub) without waste to one region (left lower leg) with a wound area of 130 sq cm (15273 = 1 unit, 15274 = 1 unit), which is greater than the # of MUEs (however, Ive yet to find what the actual MUE is, but I'm using 10). On the right lower leg (separate region) a selective debridement of 92. 07 sq cm was performed (97597 = 1 unit, 97598 = 4 units). For both regions, a total of 16 units (1 tube) of Omeza (A2014) was applied. The payer (Medicare/MAC = First Coast) has a limit on how much the total charge can be on a single claim ($99,999). We bill on a CMS-1500 claim form.
Our charges work out to the following:
Q4262 @ $1,750 per unit * 128 units = charge of $224,000
15273 @ $1,120 per unit * 1 unit = $1,120
15274 @ $695 per unit * 1 unit = $695
A2014 @ $150 per unit * 16 units = $2,400
97597 @ $205 per unit * 1 unit = $205
97598 @ $90 per unit * 4 units = $360
Total charges for the one encounter = $228,780
Total charges / Charge limit per claim = $228,780 / $90,000 = 2.5 = 3 claims
III. Proposed Coding:
Here is how I think the encounter should be coded, including modifiers, units, order, and claim notes -
/Claim A:
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 6 units = $10,500
Total charges on claim = $98,000
Total units of Q4262 = 56
> Note = "Claim 1 of 3. Separate claim. Not a duplicate."
/Claim B:
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 6 units = $10,500
Total charges on claim = $98,000
Total units of Q4262 = 56
> Note = "Claim 2 of 3. Separate claim. Not a duplicate."
/Claim C:
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 6 units = $10,500
> 15273 @ 1 unit = $1,120
> 15274 @ 1 unit = $695
> A2014 @ 16 units = $2,400
> 97597-99-51-XS @ 1 unit = $205
> 97598 @ 4 units = $360
Total charges on claim = $32,780
Total units of Q4262 = 16
> Note = "Claim 3 of 3. Separate claim. Not a duplicate."
IV. Reasoning:
> Modifier -JZ because there was no waste of Q4262.
> Modifier -99 because the line has multiple other modifiers.
> Modifier -51 because the procedure (a selective debridement) is usually not paid when a skin sub is performed.
> Modifier -XS to indicate why the -51 modifier is applicable (XS = separate structure).
> It is my understanding that some MUEs are calculated based on 'units per line item' instead of 'units per date of service'. However, I dont know which method is used for skin sub products. So, I'm basing my coding on the 'units per line item' method (wishful thinking at its best).
> CPTS 15274 and 97598 are add-on codes so definitely don't need modifier -51. *But maybe CPT 97598 needs the -XS modifier since the principle code has it?
> I thought modifier -59 could be used to override MUEs, but I'm not sure it would apply if the MUEs are calculated via the 'units per line method'.