Coding/ Billing: The Business Side of Wound Care

Coding/ Billing: The Business Side of Wound Care

Coding/ Billing: The Business Side of Wound Care Kathleen D. Schaum, MS President Kathleen D. Schaum & Associates, Inc. [email protected] Office: 561-964-2470 Mobile: 561-670-7176 Objectives

Review Review process issues that are problematic Discuss Discuss frequent coding errors Recognize Recognize the importance of coverage guidelines Understand Understand current payment regulations

Incorporate internal and external audits into your Incorporate revenue cycle Disclai mer Information on coding, coverage, and payment systems is provided as a courtesy, but does not constitute a guarantee or warranty that payment will be provided. Do obtain current regulations and policies

pertinent to your practice from the Medicare contractor and the private payers that process your claims. Workbook Tab 1 Tab 2 Tab 3 Tab 4 Tab 5 Tab 5 Tab 7

Acronyms Presentation Global Surgery Booklet 2019 National Average Allowable Medicare Fee Schedules NCCI Edit Examples NCCI Modifier Resource Targeted Probe and Educate Process Process Issues Reimburse ment Resources

Keep Up with Coding, Coverage, and Payment Guidelines Purchase coding books each year Sign up for your MACs Listserv: read pertinent updates and attend pertinent webinars Review your private payer contracts and medical policies Medicare Advantage, Private Payers, Medicaid, etc. Read and comment on draft payment system rules: read final rules and implement them by January 1 Review NCCI edit manual every October and review the quarterly updates (January, April, July, October)

Direct Supervision Direct Supervision is Required in the Provider-Based Department (PBD) for Most Services Physician or qualified healthcare professional (QHP) must be immediately available to furnish assistance and direction throughout the performance of the procedure Immediately available means "physically present, interruptible, and able to furnish assistance and direction throughout the performance of the procedure but without reference to any particular physical boundary." (CY 2011 OPPS Final Rule, 75 Fed. Reg. 71800, 72259 (Nov. 24, 2010)

Read More Details in the Medicare Benefit Policy Manual, Chapter 6 www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c06.pdf 40 Services Nurses Can Provide in PBDs When a Physician/ QHP is Not Immediately Available? Application of Unna Boot Application of multi-layer compression bandage Smoking cessation services

Incident to Guidelines for Physician Offices "Incident to" services must be performed under the direct supervision of the physician Services must be an integral, although incidental, part of the physicians professional service Commonly rendered without charge or included in the physicians bill Of a type that is commonly furnished in physicians offices or clinics The physician must perform the initial service to establish the physician/patient relationship; includes the history and physical examination portion of the service and the treatment plan Note: Nursing services in PBDs and physician offices are always Incident to a physician Note: Hospital and skilled nursing facility services (SNF) cannot be billed as "incident to" at any time

www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf Charge Description Master (CDM) The CDM is the Aorta of the PBD Revenue Cycle Update the CDM when new services, procedures, and/or products are added Update the CDM when prices of products change Update the CDM when labor costs change Create some test claims to verify the CDM is functioning as planned

Educate staff how the CDM is programmed Billing for Wound Care Supplies Routine Supplies Routine supplies associated with a service or procedure should not be separately billed to the payer or the patient Not patient-specific supplies Floor stock e.g. cotton swabs, wipes The cost for routine supplies should be rolled into the charge for visits and procedures

Non-Routine Supplies Non-routine supplies are: Patient-specific non reusable supplies e.g. surgical dressings Specifically ordered and documented in the medical record Non-routine supplies should be separately charged with the most appropriate revenue code in the covered column of the claim Revenue codes 270 and 271 are appropriate for non-sterile supplies Revenue code 272 is appropriate for sterile supplies Only report HCPCS codes for non-routine supplies with the OPPS status indicator of H or N; NOTE: All surgical dressing HCPCS codes have H status indicator. Payment is packaged into the visit or procedure Medicare allowable payment rate (not

separately paid), but the charge influences future OPPS allowable payment rates Medicare Beneficiary Identifier (MBI) The MBI . . . Is no longer based upon the Medicare beneficiarys social security number Cards were released in phases by geographic location Must be used by all providers on January 1, 2020

Insurance Benefit Verification Top 10 Payers Verify If Consolidated Billing (CB) Pertains to the Patient Contract with HHA and SNF for

Payment if You Perform Services on the CB Lists Hot SNF CB News Effective October 1, 2019 the following procedures will be added to the SNF CB list: 29580 paste/unna boot 29581lower extremity application of strapping any age 29584upper extremity application of strapping any age

Per Encounter Claim Submission DME Rental 0290-0299 Revenue Codes That Should Be Billed Monthly Respiratory Therapy 0410, 0412, 0419 Physical Therapy 0420-0429

Occupational Therapy 0430-0439 Speech-Language Pathology 0440-0449 Skilled Nursing 0550-0559 Kidney Dialysis Treatments 0820-0859 Cardiac Rehabilitation Services 0482, 0943 Pulmonary Rehabilitation Services 0948 Physicians Beware! Do Not Request Payment for Work You Did Not Perform in a PBD 29445 Application of total contact cast

29580Application of Unna boot 29581Application of multi-layer compression bandage 97605Application of NPWT durable medical equipment 97607Application of NPWT disposable equipment 98610Low frequency, non-contact, non-thermal ultrasound 99183Hyperbaric oxygen therapy attendance and supervision Do Not Select Codes by the Payment Rates that You Prefer to Receive If a code exists, you should use it Example: Do not select an E&M code when a code, such as 97597, exists

If a procedure code in column 2 of the NCCI Edits has a higher payment rate than the procedure code in column 1, report the procedure code in column 1 Example: 97597 ($24.51) in column 1 should be reported instead of 29445 ($105.95) in column 2 Verify Patients in Global Surgical Periods See Tab 3 Global Day Assignment Only Applies to Physicians - Does Not Apply to PBDs!

000 or 010 90 days XXX YYY ZZZ Minor surgical procedure (includes E/M on day of procedure) Major surgical procedure (Medicare pays for an E/M service on the day of or on the day before a procedure, if modifier 57 is appended to the E/M code) Global concept does not apply Global period determined by the MAC Procedures are related to other procedures and have the

same global period 30 Services Included in Global Surgery Period Pre-op visitsthis means E/M is included! BEWARE of modifier -25! Surgical procedure Post-op visits Post-op pain management Treatment for complications that do not require a return trip to the O.R. Miscellaneous services (i.e., dressing changes, cast removal, etc.) NOTE: If a less extensive procedure fails and a more extensive procedure is required, the second procedure is separately payable

Services Not Included in Global Surgery Period Decision for Surgery (modifier -57) major 90-day procedures only Visits unrelated to the surgerys diagnosis, unless related to a complication Treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery Diagnostic procedures Treatment for complications that requires a return trip to the O.R. Distinct procedures or services unrelated to the surgery and which are not complications Transfer

of Care During Global Surgery Period www.cms.gov/Outreachand-Education/MedicareLearning-Network-MLN/ MLNProducts/downloads/ GloballSurgeryICN907166.pdf Surgeon appends modifier -54 to surgical procedure code

Modifier -54: Surgical Care Only Postoperative Services Provided by Another Physician/QHP Physician/QHP appends modifier -55 to same surgical procedure code; includes 1) date of surgery as date of service, or 2) date care assumed - if other than

date of surgery or discharge Modifier -55: Postoperative Management Postoperative Services Provided by Other Physician/QHP Questions Coding

Justify Medical Necessity with Specific Primary, Secondary Diagnosis Codes Affect Payment Determine Determine if procedure/product is medically necessary and meets

coverage requirements Determine Determine accumulative Hierarchical Condition Categories (HCC) Risk Adjustment Factor (RAF) score of patients attributed to specific physician

Determine Determine Physician/ QHP HCC RAF Score HCC to RAF Process Diagnosis codes are sorted into diagnosis groups Diagnosis groups are sorted into condition categories Related conditions are assigned to one category and only the most serious is counted A higher ranked condition causes lower ranked conditions in same category to be ignored (with a few exceptions) Unrelated conditions in different categories are both counted; the score is additive

Condition categories are given a RAF score, which is used by numerous payment programs HCC RAF Score RAF score of 1 = patient who uses an average amount of resources RAF score less than 1 = patient who will use fewer than the

average amount of resources RAF score greater than 1 = patient with greater than average resource use Clinic Visits and Procedures During Same Encounter

Do Not Routinely Report an E&M Code and a Procedure During the Same Encounter Most wound management procedures have 0-Day or 10-Day global period E&M services are built into procedure codes with 0-day and 10-day global period Only use modifier -25 for a significant, separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure. The E&M service and minor surgical procedure do not require different diagnosis codes If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is new to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure PBD Coding and Physician/

QHP Coding Do Not Always Match Example In a hospital outpatient PBD, when a physician assesses an established patients chronic wound and writes orders for the PBD staff to apply a total contact cast, the physician reports the appropriate E&M code and the PBD reports the code for

the application of the total contact cast. Debridem ent Code Selection Select Debridement Code Based on Depth of Tissue Removed From Surface of the Wound Single Wound: Report based on deepest level of tissue debrided

Multiple Wounds: Total surface area of wounds debrided at same depth Do not combine surface area of wounds debrided at different depths Then Select Code by the Amount of Tissue Debrided Report (in sq. cm) the Amount of the Ulcer Surface Debrided Do Not Select the Code

Based on the Size of the Ulcer, Unless the Entire Ulcer Was Debrided Active Wound Management Codes Should Be Used by All Professionals Certified to Debride

Wounds Removal of: Fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm Method of Debridement: High pressure waterjet with or without suction Sharp selective debridement with scissors, scalpel, and forceps

97597 Debridement of open wound, first 20 sq. cm, per session 97598 Add-on code to 97597, for each additional 20 sq. cm debrided Never use 97598 alone: it must be used WITH 97957 Do not use modifier 59 on 97598 with 97597, because 97598 is an add-on code Example s

One ulcer: 4 cm x 4 cm (16 sq. cm) of dermis removed 16 sq. cm total 97597 1 unit Two ulcers: 1st ulcer: 2 cm x 2 cm (4 sq. cm) 2nd ulcer: 4 cm x 4 cm (16 sq. cm) of dermis removed 20 sq. cm total

97597 1 unit Three ulcers: 1st ulcer: 2 cm x 2 cm (4 sq. cm) 2nd ulcer: 3 cm x 2 cm (6 sq. cm) 3rd Ulcer: 2 cm x 2 cm (4 sq. cm) of dermis removed 14 sq. cm total 97597 1 unit

Example s One ulcer: 5 cm X 5 cm (25 sq. cm) of dermis removed Two ulcers: 1st ulcer 4 cm X 4 cm (16 sq. cm) 2nd ulcer 4 cm x 3 cm (12 cm) of dermis removed

25 sq. cm total 28 sq. cm total 97597 1 unit (for first 20 sq. cm) 97598 1 unit for additional 5 sq.cm) 97597 1 unit (for first 20 sq. cm) 97598 1 unit (for additional 8 sq. cm)

97602 Removal of devitalized tissue from wound(s), nonselective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion) including topical application(s), wound assessment, and instruction(s)

for ongoing care, per session No Relative Value Unit (RVU) assignment for physicians and other QHPs: no Medicare payment attached to 97602 Medicare payment is attached to 97602 for PBDs Surgical Debridement

Codes Not excision 11042 and 11045 11042: Debridement of subcutaneous tissue, first 20 sq. cm or less 11045: Add-on

code: each additional 20 sq. cm or part thereof NOTE: Includes epidermis and dermis, if performed 11043 and 11046 11043 Debridement of muscle/fascia, first 20 sq. cm or less 11046 Add-on code: Debridement of muscle/fascia, each additional 20 sq. cm or part thereof

NOTE: Includes epidermis, dermis, and subcutaneous tissue, if performed NOTE: Verify if payer requires a pathology report? 11044 and 11047 11044: Debridement of bone, first 20 sq. cm or less 11047: Add-on code: Debridement of bone, each additional 20 sq. cm or part thereof NOTE: Includes epidermis, dermis, subcutaneous tissue, and muscle/fascia if performed NOTE: Verify if payer requires a pathology report? 4 cm x 3 cm (12 sq. cm) of subcutaneous tissue is debrided

from an ulcer that is 6 cm x 6 cm (36 sq.cm) with exposed bone Example 11042 1 unit (because debrided portion is 12 sq. cm of subcutaneous tissue)

If 2 Ulcers Are Debrided, Should 2 Debridement Codes be Billed? If the same type of tissue was removed from both ulcers, add the number of sq. cm debrided and report 1 debridement code If different types of tissue were removed from both ulcers, report 2 different debridement codes Example 2 cm x 2 cm (4 sq. cm) of dermis debrided

from ulcer on foot 6 cm x 6 cm (36 sq. cm) of muscle debrided from ulcer on leg 97597 + modifier 59 1 unit (for 4 sq. cm of dermis debrided) 11043 1 unit (for first 20 sq. cm of muscle

debrided) 11046 1 unit (for additional 16 sq. cm of muscle debrided) Note the Work Included in all the Debridement Codes Wound assessment

Dressing application / change Education of patient and / or caregiver Topicals applied Application of Cellular and/or

Tissue-Based Products for Skin Wounds (CTPs) CTP is correct term that replaces old term: skin substitute Appropriate Use of CTP Application Codes The CTP is anchored using the physicians/QHPs choice of fixation The measurements for the application of CTP codes refer to the size of the recipient area not to the size of the product purchased Removal of current CTP and/or simple cleansing of the wound, when performed, is included in the application of the CTP code

DO NOT USE THE CTP APPLICATION CODES FOR APPLICATION OF NONGRAFT PRODUCTS (E.G. GEL, POWDER, OINTMENT, FOAM, LIQUID) OR INJECTED PRODUCTS Correctly Select CTP Application Codes Size of Wound Surface Area 25 sq. cm increments up to 100 sq. cm First 100 sq. cm and additional 100 sq. cm increments Anatomic Location of Wound Face, scalp, eyelids, mouth, neck, ears,

orbits, genitalia, hands, feet, digits Trunk, buttocks, arms (includes wrists), legs (includes ankles) Application of CTPs for Wound Surface Area Smaller Than 100 Square Centimeters CPT Code Description 15271 Application of skin substitute graft to trunk, arms, legs, total

wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area +15272 each additional 25 sq cm wound surface area, or part thereof 15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first

25 sq cm or less wound surface area +15276 each additional 25 sq cm wound surface, or part thereof Application of CTPs for Wound Surface Area Greater Than or Equal to 100 Square Centimeters CPT Code 15273 +15274

15277 +15278 Description Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound

surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children each additional 100 sq cm wound surface, or part thereof, or each additional 1% of body area of infants and children, or part thereof Code Wound Surface Area Smaller Than 100 Square Centimeters Description C5271

Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area +C5272 each additional 25 sq cm wound surface area, or part thereof C5275 Application of skin substitute graft to face, scalp, eyelids,

mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area +C5276 each additional 25 sq cm wound surface, or part thereof Application of Low-Cost CTPs for Wound Surface Area Greater Than or Equal to 100 Square Centimeters Code C5273 +C5274

C5277 +C5278 Description Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound

surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children each additional 100 sq cm wound surface, or part thereof, or each additional 1% of body area of infants and children, or part thereof Report Q Code Assigned to the CTP in Square Centimeters Report the number of sq. cm opened Do Not Report a Unit of 1

JC Skin substitute used as a graft JW Skin substitute not applied to wound, wastage Add Appropriate Modifiers to Q Code Report wastage on 2 claim lines Q41xxJC units used Q41xxJW units waste

A PBD purchased 21 sq. cm of a covered CTP; the entire piece was applied to a 15 sq. cm diabetic foot ulcer on the left heel 15275 1 unit (because wound was less 20 sq. cm) Q4xxxJC 21 units (because 21 units were purchased and applied)

than Example A PBD purchased 100 sq cm of a covered CTP: 21 sq. cm was applied to a 15 sq. cm venous stasis ulcer on the left leg, and 70 sq. cm of the same CTP was applied to a 65 sq. cm venous stasis ulcer on the right leg Example The total wound size was 80 sq. cm

15271 1 unit (for first 25 sq. cm of the ulcer) 15272 3 units (for the additional 55 sq. cm of the ulcer) Q4XXXJC 100 units (for the 100 sq. cm purchased) A physician office purchased 140 sq. cm of a covered CTP and applied 110 sq. cm to a 100 sq. cm venous stasis ulcer on the right leg 152731 unit (because the ulcer was exactly 100 sq. cm) Q4XXXJC 110 units (for the 110 sq. cm applied)

Q4XXXJW 30 units (for the 30 sq. cm wasted) Example Use Site Preparatio n Codes 1500215005 With Caution Novitas Solutions LCD, Application of Bioengineered Skin Substitutes to Lower

Extremity Chronic Non-Healing Wounds (L35041), states: Repeat use of surgical preparation services in conjunction with skin substitute application codes will be considered not reasonable and necessary. It is expected that each wound will require the use of an appropriate wound preparation code at least once at initiation of care prior to placement of the skin substitute graft.

Pass-Through Status of CTPs When a CTP has Outpatient Prospective Payment System (OPPS) PassThrough Status, the PBD Receives:

APC GROUP APC NATIONAL AVERAGE ALLOWABLE RATE COPAYMENT DEVICE OFFSET

AMOUNT 5054 $1,548.96 $309.80 $737.11 5055 $2,766.13

$553.23 $185.54 Packaged payment for the appropriate APC group Payment for the CTP is equal to the difference between the average sales price (ASP) of the particular size CTP purchased and the device offset amount for the appropriate APC group No Cost PBD Billing for Packaged CTPs

Report appropriate application code (15271-15278/C5271C5278) with the FB modifier (item provided without cost to provider, supplier, or practitioner, or credit received for replacement device [example, free sample] Report Q code for CTP acquired at no cost Report total number of units acquired at no cost Report a charge less than $1.01 in the 1) non-covered charge field

and 2) total charge field of claim The Medicare allowable payment will be reduced by the device offset amount affiliated with the appropriate APC assignment Positively or Negatively CTP Charges Affect Future Payments

Steps to Verify that Your Charging System is Set Up Correctly for the Application of CTPs Does it charge for number of sq cm of specific CTP purchased for each

application? Does the CDM multiply the number of sq. cm purchased by the PBDs charge per sq. cm? Do claims include the correct number of sq. cm of the CTP purchased and the correct marked-up charge? Questions Coverage National and Local Coverage

Determinations (NCDs & LCDs) Components of an LCD Novitas Solutions, Inc. Coverage guidance: indications, limitations, medical necessity Documentation requirements Utilization guidelines Place of service restrictions Attached and/or separate Articles may provide coding guidance

NOTE: Physicians/QHPs are responsible to comply with all LCD guidelines Review Medicare LCDs and Articles https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.as px Review Review all pertinent active LCDs and Articles: educate entire medical and revenue cycle team Assign

Assign someone to review all revised, draft, new, and retired LCDs and Articles: educate entire medical and revenue cycle team Provide Provide oral and written comments about draft LCDs Develop an LCD/Article Review Process Advance Beneficiary Notice of Noncoverage

ABN Experimental and investigational or considered research only Not indicated for diagnosis and/or treatment in this case Not considered safe and effective More than the number of services Medicare allows in a specific period for the corresponding diagnosis Note: Private insurers may require similar forms (Waiver of Liability) Use a Medicare ABN When the Service is:

An ABN Should . . . Be given to a patient when a service that is normally covered by Medicare may not be covered for that patient Include a description of the service, procedure, or products you expect Medicare may not cover Include the reason Medicare may not cover Include the estimated cost to the beneficiary Questions Payment

See Tab 4 Outpatient Prospective Payment System (OPPS) APC Groups Status Indicators National Average Allowable Rates and Co-Payments Factors that Determine If

Medicare Will Reimburse for 2 Procedures Performed During the Same Encounter Does an NCD, LCD, and/or Article allow for billing of both procedures? For PBDs, what does the OPPS allow?

For Physicians/QHPs, what does the MPFS allow? Does a National Correct Coding Initiative (NCCI) edit exist for the 2 procedures? National Correct Coding Initiative (NCCI) Edit National Correct Coding Initiative (NCCI) Procedure-To-Procedure Edits https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI -Coding-Edits.html

Column 1 Column 2 15271 15271 15271 15271 15271 15271 15271

15271 15271 15271 15271 15271 15271 15271 15271 15271 15271 15271 15271 15271

15271 15271 11000 11001 11004 11005 11006 11042 97602 97605 97606 97607

97608 99148 99149 99150 99155 99156 99157 99211 99212 99213 99214 99215

*=in existence prior to 1996 Effective Date Deletion Date *=no data 20120101 20161001 20161001

20161001 20161001 20120101 20120101 20120101 20120101 20150101 20150101 20120101 20120101 20120101 20170101 20170101

20170101 20130701 20130701 20130701 20130701 20130701 * * * * * * *

* * * * 20161231 20161231 20161231 * * * * * *

* * Modifier 0=not allowed 1=allowed 9=not applicable 1 1 1 1 1

1 1 1 1 1 1 0 0 0 0 0 0 1

1 1 1 1 See Tab 5 PTP Edit Rationale CPT Manual or CMS manual coding instructions Misuse of column two code with column one code Misuse of column two code with column one code Misuse of column two code with column one code

Misuse of column two code with column one code CPT Manual or CMS manual coding instructions CPT Manual or CMS manual coding instructions Standards of medical / surgical practice Standards of medical / surgical practice Standards of medical / surgical practice Standards of medical / surgical practice Misuse of column two code with column one code Misuse of column two code with column one code Misuse of column two code with column one code HCPCS/CPT procedure code definition HCPCS/CPT procedure code definition HCPCS/CPT procedure code definition

CPT Manual or CMS manual coding instructions CPT Manual or CMS manual coding instructions CPT Manual or CMS manual coding instructions CPT Manual or CMS manual coding instructions CPT Manual or CMS manual coding instructions 93 59 Distinct procedure Use Distinct Procedure Modifiers

When Appropria te XE Separate encounter XS Separate structure XP Separate practitioner XU Unusual nonoverlapping service Rules for Reporting Distinct Procedure Modifiers See Tab 6 Through June 30, 2019

Medicare required that modifiers -59, -XE, -XS, -XP or -XU be appended to the column 2 code of a NCCI Procedure-to-Procedure (PTP) edit to bypass the edit and allow separate payment Effective July 1, 2019 Medicare allows modifiers -59, XE, XS, -XP or XU to be appended to either column 1 OR column 2 codes to bypass the NCCI edit and allow separate payment NCCI Edit: E/M or Clinic Visit w/a Procedure on the Same Day Report E/M CPT code with modifier -25 when a significant and separately identifiable E/M service (unrelated to the decision to perform a minor surgical

procedure) by the same physician/QHP on the same day the procedure is performed NCCI Edit Manual: The fact that the patient is new to the provider is not sufficient alone to justify reporting an E/M service on the same date of service as a minor surgical procedure. Per CPT Manual New patient is one who has not received any professional services from the physician, or another physician of the exact same specialty and subspecialty within the same group practice, within the past three years. NOTE: For PBD: Not seen in health system for the last 3 years 96 Medicare

Physician Fee Schedule (MPFS) Relative Value Units (RVU) Facility and Non-Facility Global Surgery Days and Associated % of Pre-op, Intra-op, and Post-op National Average Allowable Rates Facility and Non-Facility Multiple Procedure Reduction (MPR) Conversion Factor (CF) (Total RVU x CF = Medicare National Average) Questions Audits

To Prevent and/or Prepare for Audits, Conduct Self-Audits of Your Coding, Documentation and Paid/ Denied Claims Did documentation support medical necessity for codes on claims, such as debridement, application of cellular and/or tissue-based products for skin wounds (CTPs), hyperbaric oxygen therapy, surgical dressings ordered for home use? Did claims reflect correct codes, modifiers, units, and charges?

Did physician sign all orders and documentation? Perform Self-Audits on Pertinent Topics Targeted Probe and Educate (TPE) Audits MACs will pull claims for items/services that pose the greatest financial risk to the Medicare Trust Fund and/or those that have a high national error rate

Rather than a full code review for all providers, TPE audits will target specific providers and suppliers, with outlier tendencies, who have claims error and billing rates significantly outside the norm TPE Audit Facts See Tab 7 Verify Provide Verify your address

in the contacts section of the Provider Enrollment, Chain and Ownership System (PECOS) Provide requested documentation and meet required timelines (file in 30 days rather than 45 days)

Do not miss receiving the initial TPE letter from your MAC No response equals non-compliance and an increased error rate TPE Preparation Tips Take Advantage Take advantage of the complimentary education

Questions Thank you for inviting me to share reimbursement education with you . . . Kathleen Schaum

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