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					 Coding Update

   Dirk M. Elston, MD
Geisinger Medical Center
      Danville, PA
• AAD representative to the CPT
  Editorial Panel Advisory
  Committee
• CoChair AMA Skin Cancer
  Performance Measure Workgroup
• Chair AAD P4P Workgroup

• No conflict of interest
   Coding Changes for 2008

• Destruction
• Modifiers
• Mohs
• Lab self-referral
  Destruction codes

–17000 series: premalignant
 only
–17110: Up to 14 benign lesions
–17111: 15 or more benign
 lesions (stand alone)
  Destruction codes

–17000-59 if used with either
  • 17110: Up to 14 benign lesions
  • 17111: 15 or more benign
    lesions (stand alone)
  Destruction codes

–17110/17111-59 if used with
 17004
               Premalignant
• AK
• Leukoplakia lesion found in the mouth would
  most likely be appropriately reported with CPT
  code 40820. However, if the lesion is on the lip,
  17000 could be reported. One would need to
  check their Carrier's policy on the destruction of
  premalignant lesions to determine whether
  codes 702.8 or 528.6 are covered. If not a
  covered diagnosis, one would need to have the
  patient sign an ABN.
  Destruction codes

Plantar warts: Even though they
 may evolve to verrucous CA
–17110: Up to 14 benign lesions
–17111: 15 or more benign
 lesions (stand alone)
                17110
• Destruction (eg laser surgery,
  electrosurgery, cryosurgery,
  chemosurgery, surgical curettement)
  of benign lesions other than skin tags
  or cutaneous vascular proliferative
  lesions
             Modifiers
• Language has changed to
  eliminate the word “physician” in
  the explanatory text
         Mohs Codes
• Complex or ill-defined tumors
• Single physician is both surgeon
  and pathologist
  –Do not report 88305 separately
• Repair still reported separately
• 51 exemption lost Jan 2008
         Mohs Codes
• Biopsy on same day because
  no prior histologic confirmation
 –Must determine subsequent
  procedure
 –Report 11100/11101, 88331
 –59 to override CCI edit
     Mohs Codes 2007
• 17304-17310 deleted
• 17311-17315
 –Includes first routine stain
 –Additonal special stains or
  immunostains use 88311
  (decalcification), 88314 (special
  stain), 88342 (immunostain per
  antibody, not per slide), add -59
           Mohs Codes
• 17311: Head/neck/hands/feet/genitalia,
  first stage up to 5 blocks
• 17312: Add-on code
  Head/neck/hands/feet/genitalia, additional
  stage up to 5 blocks
• 17313: Trunk/arms/legs, first stage up to 5
  blocks
• 17314: Add-on code Trunk/arms/legs,
  additional stage up to 5 blocks
          Mohs Codes

• 17315: Each block after first 5
  –Used for any body site
• 88314: Additional non-routine
  special stain (in additon to
  toluidine blue or H&E)
  –Add -59 to override CCI edit
             Lab Self-referral
• Anti-mark-up restrictions for purchased
  technical or professional component
  – When purchased or performed outside the
    billing physician’s office
  – Bill the lesser of
     • Supplier’s net charge
     • Physician’s actual charge
     • Amount if supplier had billed directly
• Derm Coding Consult Winter 2007
              PQRI
• Dermatology and other specialty
  measures not included by CMS
• Can still report other codes to
  qualify for incentive pay
                  PQRI
• Electronic Health Record
  – G8447 reported for all patients 18 and
    older
  – CCHIT certified HER or capable of
    generating medication list, problem list
    and entering lab tests as searchable
    data elements
                    PQRI
• e-Prescribing
  – GH448 all patients 18 and older
  – G8446 some handwritten or phoned in
    because required by law, patient request or
    system down
  – System capable of generating med list,
    receiving data from drug plans, conducting
    safety checks, cost comparison, alternatives,
    tiered formulary, patient eligibility and
    authorization reqirements
             15731: 2007
• Forehead flap with preservation of
  vascular pedicle; (e.g., axial pattern
  flap, paramedian forehead flap).
• Complex myocutaneous with
  admission for airway management
  now separate family of codes
   Excision of Excessive Skin
• 15830 (includes lipectomy): Used with
  panniculectomy to prevent intertrigo
  after weight loss
• 15832: Thigh
• 15847: Add on code to report
  abdominoplasty (umbilical
  transposition, fascial plication) used in
  conjunction with 15830
      Skin Grafts/Substitutes
• 15100-15431: Grafts/substitutes
• 15150 series: Autologous tissue cultured
  epidermal grafts
• 15170 series: Acellular dermal
  replacement
• 15999: Excision pressure sore
• 15002 series: To close ulcer or donor site
  (burn or wound preparation/contracture
  release requiring graft)
      Skin Grafts/Substitutes
• 15002: Trunk/arms/legs first 100 sq cm
• 15003: Add on code: Trunk/arms/legs
  each additional 100 sq cm
• 15004: Face/genitalia/hands/feet first 100
  sq cm
• 15005: Add on code:
  Face/genitalia/hands/feet each additional
  100 sq cm
     Skin Grafts/Substitutes
• 15002 series: Report separately
  with code for graft or replacement
  –For excision to create recipient site
   for dressing or material not listed in
   15040-15431, use 15002-15005
   only
  –Not used for stasis ulcer
   debridement
          Key Issues
• Inappropriate bundling of services
  –E&M
  –Procedural
• Future of Destruction and Mohs
  codes
• Pay for Performance
 Excision and Repair Codes
• CPT 2001 specifically states that
  repair by intermediate or complex
  closure should be reported separately
  – 11400 – 11446
  – 11600-11646
• Complex bundled by some carriers
• Always document indication, depth
  and extent
 Excision and Repair Codes
• CPT 2003: Excision includes the
  margins (benign and malignant)
• Narrowest margin required to remove
  the tumor in its entirety
• Tumor plus “standard” margin
    Excision and Repair
• Measurement of lesion and the most
  narrow margin is made prior to
  excision
• Malignant tumor excisions continue to
  be worth more because of the greater
  risk, pre and post-service work
  involved
         Flap Closure
• CPT 2004: Defect includes
  primary and secondary defects
• Square cm area of primary plus
  secondary defect if single repair,
  separate if distinct repairs
• Includes zone of undermining
Adjacent Tissue Transfer
• Bundles the excision
• Do not code separately for the
  excision
• “Slow Mohs” doesn’t exist in CPT
 –If the surgeon does not also read
  the path, it is NOT Mohs
 –Excision of malignant, bundled in
  ATT
         Skin Biopsy
• CPT 2004: Distinct procedure
  unrelated to other services
  provided the same day
• Precludes inappropriate bundling
  by payers
          Skin Biopsy
• Excision of a BCC, specimen sent
  to lab
  –Do not code biopsy separately
• Excision of a BCC on cheek,
  biopsy of lesion on nose, both
  specimens sent to lab
  –Code biopsy separately
               Mohs
• CPT 2003: Appropriate to code for
  preoperative biopsy on the same date
  as Mohs if the biopsy interpretation
  determines the subsequent treatment
• Code skin biopsy 11100 and frozen
  section pathology 88331 with -59
• DO NOT report the biopsy if it is done
  but only sent to the lab prior to Mohs
                Lab
• CPT 2001: KOH (87220)
  redefined as Tissue examination
  of skin, hair or nails for fungi or
  ectoparasites
• Frozen section (88331) clarified
  as first block, single specimen
            Laser
• CPT 2003: Inflammatory skin
  disease (psoriasis)
• 96920-96922 based on square
  cm
        Multiple Surgeries
• Primary procedure: 100%
• Second through 5th: 50% (represents
  intraservice work only)
• Reductions to 25% for 3rd + procedure
  does not represent intraservice work
  appropriately
• Add-on codes exempt
        Multiple Surgeries
• Refers to number of procedures, not
  number of lesions
• 4 BCCs, 3 complex repairs = 7
  procedures (2 not paid)
• If you cannot cover your practice
  expenses, reasonable to delay some
  procedures
What Has Not Changed?
• CPT defines procedures
• RUC determines value
  –Physician Survey Data
  –Practice Expense
What Has Not Changed?
• Physicians are responsible for
  selecting diagnosis and
  procedure codes
• Should be selected with the
  highest degree of specificity
     Document Clearly
• All components of E&M
• Location and size of lesions, what
  was done, why it was done (valid
  indication for procedure)
• Submit only medically necessary
  services
   Ultimate Goal of Coding
• Accurate capture of the work
  actually provided for medically
  necessary conditions
• Fair reimbursement for those
  services
      Coding Basics

• Evaluation and Management
  Codes

• Procedure Codes
 Evaluation and Management


• History
• Physical Exam
• Medical Decision Making
  Evaluation and Management


• History
• Physical Exam
• Medical Decision Making

• All 3 for a New patient or Consult
  Evaluation and Management


• History
• Physical Exam
• Medical Decision Making

• 2 of 3 for an Established patient
                     V codes
•   V10.82 Personal history of melanoma
•   V10.83 Personal history of other skin CA
•   V16.8 Family Hx CA
•   V19.4 Family hx skin condition
•   V58.41 Planned postop wound closure
•   V58.69 Longterm use of high risk
    medication
            New patient
• Patient has not received any
  professional services within the last
  three (3) years from the physician or
  a physician of the same specialty who
  belongs to the same practice group.
       Established Patient
• Patient has received professional
  services within the last three years
  from the physician or another
  physician from the same specialty
  who belongs to the same practice.
            Consultation
• Seen at the request of another
  physician or provider for evaluation
  and management (documented)
• E&M documented
• Documentation of communication
  back to the referring physician
• Regardless of whether new or
  established
• Documented in referring MD record
   CHIEF COMPLAINT (CC)


• Must be stated
• May be included in HPI
    CC, ROS, PMFSH
• CC, ROS and PMFSH may be listed as
  separate elements, or may be included
  in the HPI

• My advice: List separately
HISTORY OF PRESENT ILLNESS
•   location
•   quality
•   severity
•   duration
•   timing
•   context
•   modifying factors
•   associated signs and symptoms
HISTORY OF PRESENT ILLNESS


• Some carriers do not allow negatives
• Some allow only the physician to
  document HPI
                       Template
• CC:
• HPI:
    –   Location:
    –   Duration:
    –   Timing:
    –   Associated signs and symptoms:
    –   Severity:
    –   Modifying factors:
•   ROS:
•   PMH:
•   FH:
•   SH:
    REVIEW OF SYSTEMS (ROS)
•   • Constitutional symptoms (e.g., fever, weight loss)
•   • Eyes
•   • Ears, Nose, Mouth, Throat
•   • Cardiovascular
•   • Respiratory
•   • Gastrointestinal
•   • Genitourinary
•   • Musculoskeletal
•   • Integumentary (skin and/or breast)
•   • Neurological
•   • Psychiatric
•   • Endocrine
•   • Hematologic/Lymphatic

•   • Allergic/Immunologic
REVIEW OF SYSTEMS (ROS)

One should relate to Skin
    PAST, FAMILY AND/OR
   SOCIAL HISTORY (PFSH)
• Complete two or all three of the PFSH
  history areas, depending on the
  category of the E/M service.
• At least two of the three: outpatient
  services, established patient
• Each of the three: outpatient services,
  new patient; consultations
           Established Patient

• ROS or PFSH does not have to be re-
  recorded as long as the physician indicates
  that he reviewed and updated the information
             Established Patient

• ROS or PFSH does not have to be re-recorded as
  long as the physician indicates that he reviewed and
  updated the information

** To indicate this, the physician may describe a new
   ROS or PFSH, note there are no changes from
   previous ROS and PFSH and note the date and
   location of the previous ROS/PFSH referred to in the
   present note.
           Established Patient

• ROS or PFSH does not have to be re-
  recorded as long as the physician indicates
  that he reviewed and updated the information

**(EMR template - @ROS, @PMH, @FH,
  @SH)
  New, Consult or Established

If the PFSH and/or ROS was recorded
  by ancillary staff (including residents) or
  a form was completed by the patient,
  the physician must document that he
  reviewed, confirmed and/or
  supplemented the information.
 CMS and Medicaid May 2007
• Only the physician or non-physician
  practitioner can perform the HPI and chief
  complaint (CC)
• Shall not be relegated to ancillary staff
• Noridian Applies to the states of: AK,
  AZ, CO, HI, IA, MT, ND, NV, OR, SD, UT,
  WA & WY.
• Effective May 21, 2007.
   New, Consult or Established

• If the physician is unable to obtain a
  history from the patient, family or other
  source, the documentation should
  describe the patient's condition and
  other circumstances that precludes
  obtaining a history.
        History (4 categories)
• Problem Focused -- requires
  documentation of a chief complaint, and
  brief history of patient's present illness or
  problem

• Expanded Problem Focused -- includes
  chief complaint, brief history of present
  illness and a problem pertinent review
      History (4 categories)
• Problem Focused –
  CC, HPI (N1 99201, C1 99241, E2 99212)

• Expanded Problem Focused --
  CC, HPI, 1 ROS (N2, C2, E3)
       History (4 categories)
• Problem Focused –
  CC, HPI (N1, C1, E2)

• Expanded Problem Focused --
  CC, HPI, 1 ROS (N2, C2, E3)
        History (4 categories)
• Detailed -- chief complaint, extended history of
  present illness, problem pertinent system review
  (which includes a limited examination of
  additional systems) and pertinent past, family,
  and/or social history which directly relate to the
  patient's problem

• Comprehensive -- chief complaint, extended
  HPI, review of systems related directly to
  patient's problem, a review of additional body
  systems and complete past, family and social
  history
       History (4 categories)
• Detailed -- CC, 4HPI, 2ROS, 1 PFSH
  (N3, C3, E4)

• Comprehensive -- CC, 4HPI, full ROS, 1
  each PFSH
  (N4, C4)
       History (4 categories)
• Detailed -- CC, 4HPI, 2ROS, 1 PFSH
  (N3, C3, E4)

• Comprehensive -- CC, 4HPI, full ROS, 1
  each PFSH
  (N4, C4)
                   HPI

• 4 HPI
• or 1 HPI + the status of at least three
  chronic or inactive conditions
                  ROS
• Complete (full) ROS inquires about the
  system(s) directly related to the
  problem(s) identified in the HPI plus all
  additional body systems.
• At least 1 specifically stated
• For the remaining systems, a notation
  indicating all other systems are
  negative is permissible.
      Inpatient vs Outpatient
• Consultation elements similar (IP vs
  OP) except when coding by time
• New pt. elements differ (IP vs OP)
  – For in-patients: New and Established
    elements are the same
  – Neither matches outpatient elements
          My Recommendation
• 95 for almost everything
• 97 for detailed exam (N3 99203,
• C3 99243, E4 99214)
  – 12 bullets
     •   Alert, oriented,
     •   pleasant 47 year old
     •   in no apparent distress
     •   Eyelids
     •   Lips
     •   Digits and nails
     •   6 skin sites
                 Examination
•   Body areas :
•   • Head, including the face
•   • Neck
•   • Chest, including breasts and axillae
•   • Abdomen
•   • Genitalia, groin, buttocks
•   • Back, including spine
•   • Each extremity
•   • Hematologic/lymphatic/immunologic
                       Examination
•   Organ systems :
•   • Constitutional (e.g., vital signs, general appearance)
•   • Eyes
•   • Ears, nose, mouth and throat
•   • Cardiovascular
•   • Respiratory
•   • Gastrointestinal
•   • Genitourinary
•   • Musculoskeletal
•   • Skin
•   • Neurologic
•   • Psychiatric
•   • Hematologic/lymphatic/immunologic
 Examination -95 (4 categories)
• Problem Focused -- a limited examination
  of the affected body area or organ system.

• Expanded Problem Focused -- a limited
  examination of the affected body area or
  organ system and other symptomatic or
  related organ systems.
 Examination -95 (4 categories)
• Problem Focused –
  Skin

• Expanded Problem Focused –
  Skin + one other system (2 – 7)
 Examination -95 (4 categories)
• Problem Focused –
  Skin

• Expanded Problem Focused –
  Skin + Alert and oriented and in no
  apparent distress
 Examination -95 (4 categories)
• Problem Focused –
  Skin

• Expanded Problem Focused –
  Skin + General + Neuro + Psych
 Examination -95 (4 categories)
• Detailed -- an extended examination of
  affected body area(s) and other related
  systems.

• Comprehensive -- a general multi-system
  examination or a complete examination of
  a single organ system.
 Examination -95 (4 categories)
• Detailed –
  Skin + 2 – 7 other systems
  (4X4 method or clinical inference)
  – Under the 1995 guidelines both the expanded
    problem focused examination and the detailed
    examination provide for the examination of up
    to 7 systems or 7 body areas.
 Examination -95 (4 categories)
• Detailed –
  Skin + 2 – 7 other systems
  (4X4 method or clinical inference)
• 4X4: 4 elements examined in 4 body
  areas or 4 organ systems satisfies a
  detailed examination
• Less than such can be a detailed exam
  based on the reviewer’s clinical judgment
  – 5X3, 3X5, 2X6
 Examination -95 (4 categories)

• Comprehensive -- 8 or more systems or a
  complete examination of a single organ
  system.
  – 97 guidelines required complete skin exam
    plus one bullet in every unshaded box
    1995 DOCUMENTATION
  GUIDELINES (EXAMINATION)
• Problem Focused -- a limited
  examination of the affected body area
• Expanded Problem Focused -- a limited
  examination of the affected body area
• Detailed -- an extended examination of
  the affected body area(s)
• Comprehensive -- a general multi-system
  examination or complete examination of a
  single organ system.
              97 Guidelines
• Problem Focused Examination-should
  include performance and documentation of
  one to five elements identified by a bullet (•)
  in one or more organ system(s) or body
  area(s).
• Expanded Problem Focused Examination-
  should include performance and
  documentation of at least six elements
  identified by a bullet (•) in one or more organ
  system(s) or body area(s).
• Detailed Examination--should include at least six
  organ systems or body areas. For each system/area
  selected, performance and documentation of at least
  two elements identified by a bullet (•) is expected.
  Alternatively, a detailed examination may include
  performance and documentation of at least twelve
  elements identified by a bullet (•) in two or more
  organ systems or body areas.

• • Comprehensive Examination--should include at
  least nine organ systems or body areas. For each
  system/area selected, all elements of the
  examination identified by a bullet (•) should be
  performed, unless specific directions limit the
  content of the examination. For each area/system,
  documentation of at least two elements identified by
  a bullet is expected.
      SINGLE ORGAN SYSTEM
          EXAMINATIONS
• Problem Focused Examination--should
  include performance and documentation of
  one to five elements identified by a bullet (•),
  whether in a box with a shaded or unshaded
  border.
• Expanded Problem Focused Examination--
  should include performance and
  documentation of at least six elements
  identified by a bullet (•), whether in a box
  with a shaded or unshaded border.
     SINGLE ORGAN SYSTEM
         EXAMINATIONS
• Detailed Examination--at least twelve
  elements identified by a bullet (•), whether in
  box with a shaded or unshaded border.
• Comprehensive Examination--should include
  performance of all elements identified by a
  bullet (•), whether in a shaded or unshaded
  box. Documentation of every element in each
  box with a shaded border and at least one
  element in each box with an unshaded
  border is expected.
        My Recommendation
• 95 for almost everything
• Check with your local carriers regarding
  criteria for detailed exam (N3, C3, E4)
• N3, C3, E4
  – Highmark Medicare: 4 elements in 4 organ
    systems. Clinical inference overrides the 4 x
    4 tool. Reviewers utilize either the 95 or the
    97 guidelines. The method chosen must be
    the one that is most beneficial to the
    physician.
          My Recommendation
• 95 for almost everything
• 97 for detailed exam (N3, C3, E4)
  – 12 bullets
     •   Alert, oriented,
     •   pleasant 47 year old
     •   in no apparent distress
     •   Eyelids
     •   Lips
     •   Digits and nails
     •   6 skin sites
            Physical Exam
• 1. Abnormal or unexpected findings should
  be described.
• 2. A notation of "negative" or "normal" is
  sufficient for unaffected areas or organs.
• 3. If a specific element of the examination
  has been deferred (i.e., a pelvic or rectal
  examination), the reasons for the deferral
  should be documented.
E3
     1 HPI, 1 ROS
     Alert and oriented + Skin



                     N3




                                 IPN3
E3
     1 HPI, 1 ROS
     Alert and oriented + Skin



                     N3
                                 4 HPI, 1PFSH, 2 ROS

                                 12 bullets
                                 Low

                                              IPN3
   E3
            1 HPI, 1 ROS
            Alert and oriented + Skin



                            N3
                                        4 HPI, 1PFSH, 2 ROS

                                        12 bullets
                                        Low

                                                     IPN3
4 HPI, 3PFSH, full ROS
        Full skin exam
                High
       Established Patient
• History
• Physical Exam
• Medical Decision Making

• Only need 2 of 3
E3
     1 HPI, 1 ROS
     Alert and oriented + Skin



                     N3




                                 IPN3
Medical Decision Making
     Medical Decision Making
          (4 categories)
• Straightforward -- involves a minimal
  number of diagnoses or treatment options,
  minimal amount of data to be reviewed
  and a minimal risk of morbidity or mortality
  (M&M).
• Low Complexity -- involves a limited
  number of diagnoses, limited amount of
  data to be reviewed and a low risk of
  M&M.
     Medical Decision Making
          (4 categories)
• Moderate Complexity -- multiple number of
  diagnosis or treatment options, moderate
  amount of data to be reviewed and a
  moderate risk of M&M.
• Extensive -- extensive number of
  diagnosis and treatment options, extensive
  amount of data to be reviewed and a high
  risk of M&M.
       Established diagnosis
• Document status of each problem
• The record should reflect:
   a) improved, well controlled, resolving or
  resolved
   or
   b) inadequately controlled, worsening, or
  stable
Medical Decision Making
D. Tabulation of Medical Decision Making Elements


A. Diagnoses/Management Options                                                  Minimal Limited                           Multiple              Extensive
                                                                                 (< 1)   (2)                               (3)                   (> 4)


B. Amount/Complexity of Data                                                     Minimal Limited                           Moderate Extensive
                                                                                 (< 1)   (2)                               (3)      (> 4)



C. Highest Risk (from any category)                                              Minimal Low                               Moderate High


Medical Decision Making                                                          SF                   Low                  Moderate High


  Circle the intensities of the three components. If two or three circles appear in one column, look at the bottom of that column for the type of decision
  making. Otherwise, if there is only one circled element (intensity per column), pick the middle column of the three columns containing one circled
  element.
Circle the intensities of the three
components. If two or three circles appear in
one column, look at the bottom of that column
for the type of decision making. Otherwise, if
there is only one circled element (intensity per
column), pick the middle column of the three
columns containing one circled element.
Circle the intensities of the three
components. If two or three circles appear in
one column, look at the bottom of that column
for the type of decision making. Otherwise, if
there is only one circled element (intensity per
column), pick the middle column of the three
columns containing one circled element.
D. Tabulation of Medical Decision Making Elements


A. Diagnoses/Management Options                                                  Minimal Limited                           Multiple              Extensive
                                                                                 (< 1)   (2)                               (3)                   (> 4)


B. Amount/Complexity of Data                                                     Minimal Limited                           Moderate Extensive
                                                                                 (< 1)   (2)                               (3)      (> 4)



C. Highest Risk (from any category)                                              Minimal Low                               Moderate High


Medical Decision Making                                                          SF                   Low                  Moderate High


  Circle the intensities of the three components. If two or three circles appear in one column, look at the bottom of that column for the type of decision
  making. Otherwise, if there is only one circled element (intensity per column), pick the middle column of the three columns containing one circled
  element.
B. Amount/Complexity
of Data Reviewed

Categories of Data Reviewed                           Points

Order and/or review clinical lab tests                1
Order and/or review tests from radiology              1
Order and/or review tests from medicine/allergy       1
Discussion of test results with performing provider   1
Independent review of image, tracing or specimen      2
Decision to obtain old records/discuss case w/        1
another provider
D. Tabulation of Medical Decision Making Elements


A. Diagnoses/Management Options                                                  Minimal Limited                           Multiple              Extensive
                                                                                 (< 1)   (2)                               (3)                   (> 4)


B. Amount/Complexity of Data                                                     Minimal Limited                           Moderate Extensive
                                                                                 (< 1)   (2)                               (3)      (> 4)



C. Highest Risk (from any category)                                              Minimal Low                               Moderate High


Medical Decision Making                                                          SF                   Low                  Moderate High


  Circle the intensities of the three components. If two or three circles appear in one column, look at the bottom of that column for the type of decision
  making. Otherwise, if there is only one circled element (intensity per column), pick the middle column of the three columns containing one circled
  element.
 Number of Diagnoses or Treatment Options



Categories of Problem                            Number   Points

Self-limited or minor problem - stable, improved max=2 1
or worsening
Established problem to examining provider -            1
stable, improved
Established problem to examining provider –            2
worsening
New problem to examining provider - no           max=1 3
additional work up planned
New problem to examining provider - additional         4
work up planned
                                                       Total:
 Number of Diagnoses or Treatment Options



Categories of Problem                            Number   Points

Self-limited or minor problem - stable, improved max=2 1
or worsening
Established problem to examining provider -            1
stable, improved
Established problem to examining provider –            2
worsening
New problem to examining provider - no           max=1 3
additional work up planned
New problem to examining provider - additional         4
work up planned
                                                       Total:
 Number of Diagnoses or Treatment Options



Categories of Problem                            Number   Points

Self-limited or minor problem - stable, improved max=2 1
or worsening
Established problem to examining provider -            1
stable, improved
Established problem to examining provider –            2
worsening
New problem to examining provider - no           max=1 3
additional work up planned
New problem to examining provider - additional         4
work up planned
                                                       Total:
 Number of Diagnoses or Treatment Options



Categories of Problem                            Number   Points

Self-limited or minor problem - stable, improved max=2 1
or worsening
Established problem to examining provider -            1
stable, improved
Established problem to examining provider –            2
worsening
New problem to examining provider - no           max=1 3
additional work up planned
New problem to examining provider - additional         4
work up planned
                                                       Total:
D. Tabulation of Medical Decision Making Elements


A. Diagnoses/Management Options                                                  Minimal Limited                           Multiple              Extensive
                                                                                 (< 1)   (2)                               (3)                   (> 4)


B. Amount/Complexity of Data                                                     Minimal/L Limited                         Moderate Extensive
                                                                                 ow (< 1) (2)                              (3)      (> 4)



C. Highest Risk (from any category)                                              Minimal Low                               Moderate High


Medical Decision Making                                                          SF                   Low                  Moderate High


  Circle the intensities of the three components. If two or three circles appear in one column, look at the bottom of that column for the type of decision
  making. Otherwise, if there is only one circled element (intensity per column), pick the middle column of the three columns containing one circled
  element.
 Number of Diagnoses or Treatment Options



Categories of Problem                            Number   Points

Self-limited or minor problem - stable, improved max=2 1
or worsening
Established problem to examining provider -            1
stable, improved
Established problem to examining provider –            2
worsening
New problem to examining provider - no           max=1 3
additional work up planned
New problem to examining provider - additional         4
work up planned
                                                       Total:
D. Tabulation of Medical Decision Making Elements


A. Diagnoses/Management Options                                                  Minimal Limited                           Multiple              Extensive
                                                                                 (< 1)   (2)                               (3)                   (> 4)


B. Amount/Complexity of Data                                                     Minimal/L Limited                         Moderate Extensive
                                                                                 ow (< 1) (2)                              (3)      (> 4)



C. Highest Risk (from any category)                                              Minimal Low                               Moderate High


Medical Decision Making                                                          SF                   Low                  Moderate High


  Circle the intensities of the three components. If two or three circles appear in one column, look at the bottom of that column for the type of decision
  making. Otherwise, if there is only one circled element (intensity per column), pick the middle column of the three columns containing one circled
  element.
 Number of Diagnoses or Treatment Options



Categories of Problem                            Number   Points

Self-limited or minor problem - stable, improved max=2 1
or worsening
Established problem to examining provider -            1
stable, improved
Established problem to examining provider –            2
worsening
New problem to examining provider - no           max=1 3
additional work up planned
New problem to examining provider - additional         4
work up planned
                                                       Total:
 Number of Diagnoses or Treatment Options



Categories of Problem                            Number   Points

Self-limited or minor problem - stable, improved max=2 1
or worsening
Established problem to examining provider -            1
stable, improved
Established problem to examining provider –            2
worsening
New problem to examining provider - no           max=1 3
additional work up planned
New problem to examining provider - additional         4
work up planned
                                                       Total:
D. Tabulation of Medical Decision Making Elements


A. Diagnoses/Management Options                                                  Minimal Limited                           Multiple              Extensive
                                                                                 (< 1)   (2)                               (3)                   (> 4)


B. Amount/Complexity of Data                                                     Minimal/L Limited                         Moderate Extensive
                                                                                 ow (< 1) (2)                              (3)      (> 4)



C. Highest Risk (from any category)                                              Minimal Low                               Moderate High


Medical Decision Making                                                          SF                   Low                  Moderate High


  Circle the intensities of the three components. If two or three circles appear in one column, look at the bottom of that column for the type of decision
  making. Otherwise, if there is only one circled element (intensity per column), pick the middle column of the three columns containing one circled
  element.




              2 stable problems or 1 worsening problem
     Medical Decision Making
• 1. The highest level of risk in any one
  category determines the overall risk;
• 2. Determine the number of
  diagnosis/activities or management
  options;
• 3. Determine the amount and/or
  complexity of data to be reviewed
• 4. Determine the risk of complications
  and/or morbidity or mortality.
D. Tabulation of Medical Decision Making Elements


A. Diagnoses/Management Options                                                  Minimal Limited                           Multiple              Extensive
                                                                                 (< 1)   (2)                               (3)                   (> 4)


B. Amount/Complexity of Data                                                     Minimal Limited                           Moderate Extensive
                                                                                 (< 1)   (2)                               (3)      (> 4)



C. Highest Risk (from any category)                                              Minimal Low                               Moderate High


Medical Decision Making                                                          SF                   Low                  Moderate High


  Circle the intensities of the three components. If two or three circles appear in one column, look at the bottom of that column for the type of decision
  making. Otherwise, if there is only one circled element (intensity per column), pick the middle column of the three columns containing one circled
  element.



                                                1 New problem
Established Patient (2 of 3 required)
Code       History                     Physical Examination Medical Decision          Time (minutes)
                                                            Making
99211      - - - - - - - - - - Provider Not Required - - - - - - - - - -              5


99212      Problem Focused             Problem Focused             Straight Forward   10


99213      EPF                         EPF                         Low Complexity     15


99214      Detailed                    Detailed                    Moderate Complexity 25


99215      Comprehensive               Comprehensive               High Complexity    40
New Patient or Consultation (requires 3 of 3 elements)
History       Exam          Medical Decision Making   E/M Office or Other E/M Outpatient
                                                      Outpatient Visit    Consult



                                                      Minutes    Level    Minutes Level

PF            PF            SF                        10         99201    15      99241

EPF           EPF           SF                        20         99202    30      99242

Detailed      Detailed      Low                       30         99203    40      99243

Comprehensive Comprehensive Moderate                  45         99204    60      99244

Comprehensive Comprehensive High                      60         99205    80      99245
D. Tabulation of Medical Decision Making Elements


A. Diagnoses/Management Options                                                  Minimal Limited                           Multiple              Extensive
                                                                                 (< 1)   (2)                               (3)                   (> 4)


B. Amount/Complexity of Data                                                     Minimal Limited                           Moderate Extensive
                                                                                 (< 1)   (2)                               (3)      (> 4)



C. Highest Risk (from any category)                                              Minimal Low                               Moderate High


Medical Decision Making                                                          SF                   Low                  Moderate High


  Circle the intensities of the three components. If two or three circles appear in one column, look at the bottom of that column for the type of decision
  making. Otherwise, if there is only one circled element (intensity per column), pick the middle column of the three columns containing one circled
  element.




     1 Worsening problem, or 2 Stable problems
Established Patient (2 of 3 required)
Code       History                     Physical Examination Medical Decision          Time (minutes)
                                                            Making
99211      - - - - - - - - - - Provider Not Required - - - - - - - - - -              5


99212      Problem Focused             Problem Focused             Straight Forward   10


99213      EPF                         EPF                         Low Complexity     15


99214      Detailed                    Detailed                    Moderate Complexity 25


99215      Comprehensive               Comprehensive               High Complexity    40
New Patient or Consultation (requires 3 of 3 elements)
History       Exam          Medical Decision Making   E/M Office or Other E/M Outpatient
                                                      Outpatient Visit    Consult



                                                      Minutes    Level    Minutes Level

PF            PF            SF                        10         99201    15      99241

EPF           EPF           SF                        20         99202    30      99242

Detailed      Detailed      Low                       30         99203    40      99243

Comprehensive Comprehensive Moderate                  45         99204    60      99244

Comprehensive Comprehensive High                      60         99205    80      99245
1 New problem
1 New problem, 2 worsening, 3 stable,
 1 worsening/1 stable
E3
     1 HPI, 1 ROS
     Alert and oriented + Skin
     1 worsening, 2 stable




                                 IPN3
E3
     1 HPI, 1 ROS
     Alert and oriented + Skin
     1 worsening, 2 stable

                                 N3, C3, IP C3
                                 4 HPI, 1PFSH, 2 ROS

                                 12 bullets
                             1 worsening, 2 stable

                                                 IPN3
                             E3
                                      1 HPI, 1 ROS
                                      Alert and oriented + Skin
                                      1 worsening, 2 stable

                                                                  N3, C3, IP C3
                                                                  4 HPI, 1PFSH, 2 ROS

                                                                  12 bullets
                                                              1 worsening, 2 stable

                                                                                  IPN3
                        4 HPI, 3PFSH, full ROS
                        Full skin exam
1 severe worsening + 1 new, 1 worsening, or 2 stable
                  MDM
• If you remember that IP New is different

• E3, N3, C3, IPC3: 1 Worsening
                    2 Stable
• E4, N4, C4, IPC4: 1 New problem
                    2 Worsening
                    3 Stable
                    1 Worsening/1 Stable
D. Tabulation of Medical Decision Making Elements


A. Diagnoses/Management Options                                                  Minimal Limited                           Multiple              Extensive
                                                                                 (< 1)   (2)                               (3)                   (> 4)


B. Amount/Complexity of Data                                                     Minimal/L Limited                         Moderate Extensive
                                                                                 ow (< 1) (2)                              (3)      (> 4)



C. Highest Risk (from any category)                                              Minimal Low                               Moderate High


Medical Decision Making                                                          SF                   Low                  Moderate High


  Circle the intensities of the three components. If two or three circles appear in one column, look at the bottom of that column for the type of decision
  making. Otherwise, if there is only one circled element (intensity per column), pick the middle column of the three columns containing one circled
  element.
 Number of Diagnoses or Treatment Options



Categories of Problem                            Number   Points

Self-limited or minor problem - stable, improved max=2 1
or worsening
Established problem to examining provider -            1
stable, improved
Established problem to examining provider –            2
worsening
New problem to examining provider - no           max=1 3
additional work up planned
New problem to examining provider - additional         4
work up planned
                                                       Total:
                  MDM
• If you remember that IP New is different

• E3, N3, C3, IPC3: 1 Worsening
                    2 Stable
• E4, N4, C4, IPC4: 1 New problem
                    2 Worsening
                    3 Stable
                    1 Worsening/1 Stable
Services billed according to time
• More than 50% of the encounter is to
  counseling/coordination of care.
• For E/M services billed according to time,
  the teaching physician must be present
  during the time period for which the claim
  is made. Time spent by a Resident in the
  absence of a teaching physician may not
  be counted.
Services billed according to time
• Total length of time of the encounter (face-
  to-face) should be documented
• Record should describe the counseling
  and/or activities to coordinate care.
New Patient or Consultation (requires 3 of 3 elements)
History       Exam          Medical Decision Making   E/M Office or Other E/M Outpatient
                                                      Outpatient Visit    Consult



                                                      Minutes    Level    Minutes Level

PF            PF            SF                        10         99201    15      99241

EPF           EPF           SF                        20         99202    30      99242

Detailed      Detailed      Low                       30         99203    40      99243

Comprehensive Comprehensive Moderate                  45         99204    60      99244

Comprehensive Comprehensive High                      60         99205    80      99245
        SITE SPECIFIC BIOPSY CODES AND 2007 RVU VALUES
                                                                 2007
CPT                    DESCRPTOR
                                              RVU
11100          Biopsy of skin/subcutaneous tissue mucous membrane, 1
                 lesion                          2.25
11001          ach separate/additional lesion   0.78

11755          Biopsy of nail unit, any method 3.14

40490          Biopsy of lip                  3.02

54100          Biopsy of penis                4.94

56605          Biopsy of vulva                 2.26

67810          Biopsy of eyelid                5.03

69100          biopsy of external ear          2.59
        SITE SPECIFIC BIOPSY CODES AND 2007 RVU VALUES
                                                                 2007
CPT                    DESCRPTOR
                                              RVU
11100          Biopsy of skin/subcutaneous tissue mucous membrane, 1
                 lesion                          2.25
11001          ach separate/additional lesion   0.78

11755          Biopsy of nail unit, any method 3.14

40490          Biopsy of lip                  3.02

54100          Biopsy of penis                4.94

56605          Biopsy of vulva                 2.26

67810          Biopsy of eyelid                5.03

69100          biopsy of external ear          2.59
        SITE SPECIFIC BIOPSY CODES AND 2007 RVU VALUES
                                                                 2007
CPT                    DESCRPTOR
                                              RVU
11100          Biopsy of skin/subcutaneous tissue mucous membrane, 1
                 lesion                          2.25
11001          ach separate/additional lesion   0.78

11755          Biopsy of nail unit, any method 3.14

40490          Biopsy of lip                  3.02

54100          Biopsy of penis                4.94

56605          Biopsy of vulva                 2.26

67810          Biopsy of eyelid                5.03

69100          biopsy of external ear          2.59
    Procedure Codes

• Correct Coding Initiative
    Correct Coding Initiative
• On January 1, 1996, the Medicare
  program implemented the "Correct Coding
  Initiative," employing nearly 83,000 code
  edits, in an attempt to eliminate
  unbundling or other inappropriate reporting
  of CPT codes.
    Mutually exclusive codes
• Represent services that cannot reasonably
  be performed in the same session.
• “Comprehensive” code will be paid and the
  “component” code disallowed.
   Correct Coding Initiative
• Mutually exclusive codes
  – If you excise a lesion and send it to the
    lab, you can’t bill for both excision and
    biospy
• Bundling of procedural and cognitive
  services
  – Many procedures include pre and post
    service work
• The general rule in the coding manual, is
  that the item in column 1 of the mutually
  exclusive list precludes billing the item in
  column 2
• If they are separate and distinct lesions,
  add -59
• Column 1 is often not the item with the
  greater RVU value.
• Some software now allows the CCI
  override even if the -59 is placed on the
  wrong procedure of the pair, as long as
  one of the two has a -59

• For more information go to the AAD
  website and read Derm Coding Consult
  June 1997
                 Modifier 59

• Definition: Distinct Procedural Service
• Modifier 59 is used to clearly designate when
  distinct, independent and separate multiple
  procedures are provided. The procedure must
  not be a component of another procedure.
  –   Different procedures or surgeries
  –   Surgery on different sites or organ systems
  –   Separate incision/excision
  –   Separate lesions
                 Modifier 79

• Distinct Procedural Service during a post-
  operative period
• Modifier 79 is used to clearly designate when
  distinct, independent and separate multiple
  procedures are provided. The procedure must
  not be a component of another procedure.
  –   Different procedures or surgeries
  –   Surgery on different sites or organ systems
  –   Separate incision/excision
  –   Separate lesions
               Modifier 25

• Definition: Significant and Separately
  Identifiable Evaluation and Management
  Service by the Same Physician on the Same
  Day of the Procedure or Other Service.
• Modifier 25 is used to describe separate,
  distinctly identifiable services from other
  services or procedures rendered during the
  same visit. Always attach the modifier to the
  evaluation and management code.
              Modifier 24
• Definition: Unrelated Evaluation &
  Management Service by the same
  Physician during a PostOperative
  Period.
• Separate, unrelated service was
  performed during the global period of the
  surgical procedure.
             Modifier 24

• Treating poison ivy during a post-op
  global period
         Modifiers 24 and 25

• When an E/M service is provided and
  represents a separately identifiable service, it is
  reasonable for physicians to expect payment,
  assuming that the physician has documented a
  separate E/M service in the medical record.
• It is generally more convenient for the patient
  and more cost effective if multiple separate
  services can be provided on the same date
  rather than requiring multiple return visits.
      Modifiers 24 and 25

• The CPT definition of modifier -25
  states that an E/M service may be
  prompted by the system or condition
  for which a separate procedure or
  service is needed

• Does not require a separate
  diagnosis
• A skin biopsy code (11100) does not include an
  E/M service in the physician work, and a
  separate E/M service submitted with a -25
  modifier on the same date should not be
  bundled with the skin biopsy.
• A shave removal procedure, e.g. code 11311,
  does not include an E/M service in the physician
  work, and a separate E/M service submitted with
  a -25 modifier on the same date should not be
  bundled with the shave removal.
• The intralesional injection codes (11900 and
  11901) do not include an E/M service in their
  physician work and a separate E/M service
  submitted with a -25 modifier on the same date
  should not be bundled with the intralesional
  injection.
• A destruction procedure, e.g. code 17000, or an
  acne surgery, e.g. code 10040, are not
  components of an E/M service, and if an
  unrelated E/M service indicated by a -25
  modifier is provided on the same date as the
  other service, the separate E/M service should
  also be paid on the initial claim with the other
  services.
              Modifier 50

• Definition: Bilateral Procedure
              Modifier 51
Definition: Multiple Procedures
• After the first eligible procedure is
  reimbursed at 100% of our usual and
  customary allowance, the remaining
  procedures are reimbursed at 50% up to
  five procedures. No documentation is
  required. After the fifth procedure, the
  procedures will be considered ‘by report’
  and documentation is then required.
               Modifier 52

• Definition: Reduced Services.
• This modifier can be used in two different
  ways:
• To report when services were not
  completed in its entirety.
             Modifier 57

• Definition: Decision for Surgery
• 90 day global procedures
      Mutually exclusive lists:
• These would usually be bundled services
  if performed on the same lesion. When
  performed on separate and distinct
  lesions, add -59 to override the CCI edit.

• 1. Biopsy with any other skin procedure
• 2. Nail biopsy with skin biopsy
• 3. Incision and excision on the same day
    Biospy and procedure on the
            same lesion
• Biopsy service is appropriately bundled
  with excision or destruction and should not
  be reported separately unless it was done
  on a separate and distinct lesion or was a
  frozen biopsy interpreted prior to the
  procedure that leads to the decision to do
  a more comprehensive procedure.
                Examples:
1. Frozen biopsy done on a papule. Based on the
  biopsy, Mohs surgery, full thickness excision or
  destruction is done during the same office
  visit. Code both the biopsy and the subsequent
  procedure. Add -59 to the biopsy to override
  CCI edit.
2. You biopsy and curette a lesion suspected to
  be BCC. You hold for path before billing, but the
  biopsy did not determine the subsequent
  procedure. You should only code the
  destruction (either malignant or benign) after
  receiving the path report.
               Examples:
• a. You I&D a cyst on the chest and excise
  a BCC on the face - code both and add -
  59 to the excision or you will only be paid
  for the I&D

• b. You I&D a cyst to decompress it, then
  excise it -- code only the definitive
  procedure (the excision)
  Excision and destruction of a
 malignant lesion on the same day

a. You destroy a bcc on the back, and
  excise one on the face - code both and
  add the -59.

 b. You curette a BCC to define the
  margins, then excise it - code only the
  definitive procedure (the excision).
 Injection with most procedures
• a. You inject an inflamed cyst on the back
  and excise a BCC on the face - code both
  and add -59 to the injection

• b. You inject anesthetic into a BCC then
  excise it: Code only the excision. The
  excision code already includes (bundles)
  all pre and post op work, including
  injection of anesthetic.
       Destruction and Paring

• Destruction malignant or 17004 combined
  with paring of a distinct lesion.
  – Add -59 to the destruction code
                   Skin tags

•    Skin tags combined with any shave,
    excision or destruction code .
    – Add -59 to the shave, excision or destruction
      code.
     Multiple Surgery Rule
• Bases payment on the lesser of
  the actual charge or 100 percent
  of the fee schedule amount for
  the primary procedure and 50
  percent for the second through
  fifth procedures.
    Multiple Surgery Rule
• Codes designated in CPT as Add-
  On codes are already valued as
  secondary procedures and are
  exempt from the multiple surgery
  rule.
• Mohs
            Mohs
• Mohs surgery has 0 global
  days

• The repair has 10 – 90 global
  days (midnight prior for 90
  day)
          Justification for
       Intermediate Closure

• Never simply a single deep suture to
  upcode procedure
           Justification for
        Intermediate Closure

•   Dead space
•   Tension
•   Muscle pull
•   Wound direction
•   Risk of hematoma or spread scar
      Medically Unlikely Edits
• Began as anatomic edits
  – Can’t transplant 2 hearts
• Now based on statistics
  – How many shaves or destructions are “likely”
• CMS software uses the edits, but they are
  not made public
                   Fraud
• Medicare fraud is legally defined as follows:

  Knowingly and willfully executing, or attempting
  to execute, a scheme or artifice to defraud any
  health care benefit program or to obtain, by
  means of false or fraudulent pretenses,
  representation, or promises, any of the money or
  property owned by or under the custody of any
  health care benefit program.
                 Fraud
• Individuals who commit Medicare fraud
  intentionally obtain, or attempt to obtain,
  money or property owned by Medicare
  through false or fraudulent pretenses.
             Fraud
• A simple mistake is not fraud
                Fraud
• Medicare may consider a health care
  provider fraudulent if the provider
  identifies inappropriate actions or
  behaviors against the Medicare
  program but fails to remedy them.
  Medicare expects all health care providers
  who participate in the program to furnish
  and report services in accordance with the
  established regulations and policies.
               Fraud
• Health care providers should correct any
  billing or reporting errors that they
  identify. If the errors result in
  overpayments, the health care provider is
  required to return the overpaid amounts
  to Medicare.
               Fraud
• Health care providers should correct any
  billing or reporting errors that they
  identify. If the errors result in
  overpayments, the health care provider is
  required to return the overpaid amounts
  to Medicare.

• I recommend prospective audits

				
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