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Business Briefs: 2018 NCCI Policy Manual & Edits

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure information accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying information accuracy lies with the reader.   

Happy New Year to all of our readers! I missed writing about and sharing with you the latest pertinent information for outpatient wound clinic providers and program directors while I was on hiatus — a three-month vacation cruise that my husband and I took to Asia and the South Pacific. I want to take this time to first thank Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, and Valerie A. Rinkle, MPA, for ensuring that this Business Briefs column remained afloat with some very insightful articles during my absence. Now, I want to discuss the No. 1 topic that dominated the hundreds of emails that were waiting for me upon my return – take a moment and guess what that was! …  Actually, I was surprised that I received so many questions about the National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits. This article is in response to all the wound care professionals who had questions about NCCI edits during the last quarter of 2017 and the beginning of 2018.  

PTP BACKGROUND 

The PTP edits encourage consistent and correct coding and prevent inappropriate payment of services that should not be reported together. Each edit has a Column 1 and Column 2 Healthcare Common Procedure Coding System (HCPCS) code/Current Procedural Terminology (CPT®) code. If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the Column 1 code is eligible for payment, but the Column 2 code is denied, unless a clinically appropriate NCCI-associated modifier is also reported. PTP edits are utilized by Medicare claims-processing contractors to adjudicate provider claims for physician services, outpatient hospital services, and outpatient therapy services. They are not applied to facility claims for inpatient services. However, all therapy claims at most sites of service are subject to PTP edits. These include, but are not limited to, therapy services reported by skilled nursing facilities, comprehensive outpatient rehabilitation facilities, home health agencies, and outpatient rehabilitation agencies. In addition, PTP edits are utilized for ambulatory surgical center claims. NOTE: CPT codes representing services denied based on PTP edits may not be billed to Medicare beneficiaries. Since these denials are based on incorrect coding rather than medical necessity, the provider cannot utilize an Advanced Beneficiary Notice form to seek payment from a Medicare beneficiary. 

The PTP edits undergo continuous refinement and revised edit tables are published quarterly. The NCCI’s Policy Manual for Medicare Services is published annually. The edits and policies do not include all possible combinations of correct coding edits or types of
unbundling that exist.  Providers are obligated to code correctly, even if edits do not exist, to prevent the use of an inappropriate code combination. If a provider determines that he/she has been coding incorrectly, the provider should contact the Medicare Administrative Contractor about potential payment adjustments. What follows are some NCCI directives that answer most of the questions that readers have asked: 

Physicians must avoid downcoding. If a HCPCS/CPT code exists that describes the services performed, the physician must report this code rather than report a less comprehensive code with other codes describing the services not included in the less comprehensive code. 

Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. 

Physicians must report units of service correctly. Each HCPCS/CPT code has a defined unit of service for reporting purposes. A physician shall not report units of service for a HCPCS/CPT code using a criterion that differs from the code’s defined unit of service. 

PTP edits are based on services provided by the same physician to the same beneficiary on the same date of service. Physicians shall not inconvenience beneficiaries nor increase risks to beneficiaries by performing services on different dates of service to avoid PTP edits.

Since determination of ankle-brachial indices requires both upper and lower extremity Doppler studies, an upper extremity Doppler study is not separately reportable. 

The HCPCS/CPT codes for lesion removal include the procurement of tissue from the same lesion by biopsy at the same patient encounter. CPT codes for the biopsy (11100-11101) shall not be reported separately. However, CPT codes 11100-11101 may be separately reportable with lesion removal HCPCS/CPT codes, if the biopsy is performed on a different lesion than the removal procedure. 

If a biopsy is performed on the same lesion on which a more extensive procedure is performed, it is separately reportable only if the biopsy is utilized for immediate pathologic diagnosis prior to the more extensive procedure and the decision to proceed with the more extensive procedure is based on the diagnosis established by the pathologic examination. If a biopsy is performed and submitted for pathologic evaluation that will be completed after the more extensive procedure is performed, the biopsy is not separately reportable with the more extensive procedure. 

NCCI has a PTP edit with Column 1 CPT Code 11055 (paring or cutting of benign hyperkeratotic lesion ...) and Column 2 CPT Code 11720 (debridement of nail[s] by any method; 1-5). Modifier 59 shall not be used to bypass the edit if these two procedures are performed on the same distal phalanx, including the skin overlying the distal interphalangeal joint. 

Debridement of a skin wound (eg, CPT codes 11000, 11042-11047, 97597-97598) prior to a skin graft/skin substitute is included in the skin graft/skin substitute procedure (CPT codes 15050-15278) and shall not be reported separately. If the recipient site requires excision of open wounds, burn eschar, or scar or incisional release of scar contracture, CPT codes 15002-15005 may be separately reportable for certain types of skin grafts/skin substitutes – if the payer’s coverage policies permit. 

Debridement (eg, CPT codes 11000, 11042-11047, 97597-97598) of the site of a tissue transfer is included in the tissue transfer procedure and is not separately reportable. 

Debridement CPT codes (eg, 11042-11047, 97597-97598) and grafting CPT codes (eg, 15040-15776) shall not be reported with a casting/splinting/strapping CPT code (eg, 29445, 29580, 29581) for the same anatomic area. 

Debridement CPT codes 97597-97598 shall not be reported in conjunction with surgical debridement CPT codes 11042-11047 for the same wound. Similarly, CPT Code 97602 shall not be reported in conjunction with CPT codes 97597 and 97598 for the same wound. 

CPT Code 97610 (low-frequency, noncontact, nonthermal ultrasound, per day) is not separately reportable for treatment of the same wound with other active wound care management CPT codes (97597-97606, 11042-11047). 

With few exceptions, the payment for a surgical procedure includes payment for dressings, supplies, and local anesthesia. These items are not separately reportable under their own HCPCS/CPT codes. Wound closures utilizing adhesive strips or tape alone are not separately reportable. In the absence of an operative procedure, these types of wound closures are included in an evaluation and management (E&M) service. Under limited circumstances, wound closure utilizing tissue adhesive may be reported separately. If a practitioner utilizes a tissue adhesive alone for a wound closure, it may be reported separately with HCPCS Code G0168 (wound closure utilizing tissue adhesive[s] only). If a practitioner utilizes tissue adhesive in addition to staples or sutures to close a wound, HCPCS Code G0168 is not separately reportable but is included in the tissue repair. NOTE: HCPCS Code G0168 is not recognized and not paid in the Outpatient Prospective Payment System.

Application of a multilayer compression system (CPT codes 29581-29584) includes manual therapy in the anatomic region of the multilayer compression system. CPT Code 97140 (manual therapy techniques …) shall not be reported for any type of manual therapy at the same patient encounter in the anatomic region where a multilayer compression system is applied. 

Treatment of a complication of a primary surgical procedure is not separately reportable if: 1) it represents usual and necessary care in the operating room (OR) during the procedure or 2) it occurs postoperatively and does not require return to the OR. 

If a procedure has a global period of 000 or 010 days, it is defined as a “minor surgical procedure.” In general, E&M services on the same date of service as minor surgical procedures are included in the payment for the procedures. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with Modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. 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. 

For major and minor surgical procedures, postoperative E&M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package, as are E&M services related to complications of the surgery. Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed, unless related to a complication of surgery, may be reported separately on the same day as a surgical procedure with Modifier 24. 

An occupational therapist may report only one evaluation/re-evaluation (CPT codes 97165-97168) on a single date of service. A physical therapist may report only one evaluation/re-evaluation (CPT codes 97161-97164) on a single date of service. A physician or facility shall not report both an occupational therapy evaluation/re-evaluation service and physical therapy evaluation/re-evaluation service if performed by the same practitioner. If the two services are performed by two different practitioners on the same date of service, both procedures may be reported. 

With one exception (CPT codes 97010-97028), providers shall not report more than one physical medicine and rehabilitation therapy service for the same 15-minute time period. Some CPT codes for physical medicine and rehabilitation services include an amount of time in their code descriptions. Some PTP edits pair a “timed” CPT code with another “timed” CPT code or a “non-timed” CPT code. These edits may be bypassed with a modifier if the two procedures of a code pair edit are performed in different timed intervals (even if sequential during the same patient encounter). 

Physician attendance and supervision of hyperbaric oxygen therapy (HBOT) (CPT Code 99183) includes E&M services related to the HBOT. E&M services integral to this procedure include, but are not limited to, updating history and physical; examining the patient; reviewing laboratory results and vital signs with special attention to pulmonary function, blood pressure, and blood sugar levels; clearing patient for procedure; monitoring and/or assisting with patient positioning; evaluating and treating the patient for barotrauma and other complications; and prescribing appropriate medications. A physician shall not report an E&M CPT code for these services. If a physician performs unrelated, significant, and separately identifiable E&M services on the same date of service, the physician may report those E&M services with Modifier 25. 

Modifiers that may be used under appropriate clinical circumstances to bypass a PTP edit include: 

  • anatomic modifiers: E1-E4, FA,
  • F1-F9, TA, T1-T9, LT, RT, LC, RC, LM, RI
  • global surgery modifiers: 24, 25, 57, 58, 78, 79
  • other modifiers: 27, 59, 91, XE, XP, XS, XU

Each PTP edit has an assigned modifier indicator. A modifier indicator of “0” indicates that NCCI-associated modifiers cannot be used to bypass the edit. A modifier indicator of “1” indicates that NCCI-associated modifiers may be used to bypass an edit under appropriate circumstances. A modifier indicator of  “9” indicates that the edit has been deleted and the modifier indicator is not relevant. 

It is very important that NCCI-associated modifiers only be used when appropriate. In general, these circumstances relate to separate patient encounters, separate anatomic sites, or separate specimens. If the two corresponding procedures are performed at the same patient encounter and in contiguous structures, NCCI-associated modifiers generally should not be utilized. 

Modifier 59 is often used incorrectly and should not be used to bypass a PTP edit, unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used. Modifier 59 shall only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes. What follows is the 2018 CPT Manual definition of Modifier 59: 

Modifier 59 - Distinct Procedural Service: “Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E&M services performed on the same day. Modifier 59 is used to identify procedures/services (other than E&M services) that are not normally reported together, but are appropriate under the circumstances.  Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than Modifier 59. Only if a no-more-descriptive modifier is available, and the use of Modifier 59 best explains the circumstances, should Modifier 59 be used. Note: Modifier 59 should not be appended to an E&M service. To report a separate and distinct E&M service with a non-E&M service performed on the same date, see Modifier 25.”

On Jan. 1, 2015, the Centers for Medicare & Medicaid Services (CMS) released a change request (CR8863) that announced new modifiers (XE, XP, XS, XU) to provide greater reporting specificity in situations where Modifier 59 was previously reported. CMS officials referred to the new modifiers as the “-X” (EPSU) modifiers and said the new modifiers may be used instead of Modifier 59 whenever possible.  Then, in MLN Matters® No. SE1503, CMS officials stated: “Please note that providers may continue to use Modifier 59 after Jan. 1, 2015, in any instance in which it was correctly used prior to Jan. 1, 2015. The initial change request (CR8863) establishing the modifiers was designed to inform system developers that healthcare systems would need to accommodate the new modifiers. Additional guidance and education as to the appropriate use of the new ‘-X’ (EPSU) modifiers will be forthcoming as CMS continues to introduce the modifiers in a gradual and controlled fashion. That guidance will include additional descriptive information about the new modifiers. CMS will identify situations in which a specific “-X” (EPSU) modifier will be required and will publish specific guidance before implementing edits or audits. CR8863 states that providers who wish to use the new modifiers may use them in accordance with their published definitions, and “X” modifiers will function within CMS systems in the same manner as Modifier 59, bypassing PTP edits with a modifier indicator of “1,” for example. A modifier indicator of “1” indicates that NCCI-associated modifiers may be used to bypass an edit under appropriate circumstances.” 

Unfortunately, CMS did not provide any further guidance for the “-X” (EPSU) modifiers until MLN Matters No. SE1418 was released on Jan. 3, 2018. Therefore, most providers hesitated to use the modifiers and many payers did not require them. The Jan. 3, 2018, CMS guidance was precipitated by 2018 NCCI Policy Manual Chapter 1, which discusses the “-X” (EPSU) modifiers for the first time. The 2018 manual clearly states that Modifier 59 should only be utilized if no other more-specific modifier is appropriate. It also states that NCCI will eventually require the “-X” (EPSU) modifiers, rather than Modifier 59, with certain edits, and that providers have been allowed to use the “-X” (EPSU) modifiers on claims with dates of service on or after Jan. 1, 2015. Therefore, if the “-X” (EPSU) modifiers describe an NCCI code edit more specifically than does Modifier 59, CMS and the NCCI Manual encourage wound care professionals to use them.

Other payers may also begin requiring the “-X” (EPSU) modifiers because they often follow CMS’ lead. Therefore, wound care professionals should check with the major payers that process their claims to ascertain if their systems are ready to process the “-X” (EPSU) modifiers. Some private payers already include the “-X” (EPSU) modifiers in their medical policies. If one or more of your payers are ready for the more specific “-X” (EPSU) modifiers, you should train your professional staff, coders, and billers on how to use them when the medical record documentation warrants their usage. 

CONCLUSION 

All wound care professionals should visit the CMS website (www.cms.gov/medicare/coding/nationalcorrect codinited/index.html) to review the 2018 NCCI Policy Manual for Medicare Services and the NCCI’s PTP files. 

Kathleen D. Schaum is president and founder of her own consulting company, Kathleen D. Schaum & Associates Inc., Lake Worth, FL, and is host of the conference series Wound Clinic Business. She is also a founding editorial board member for Today’s Wound Clinic. 

She may be reached for consultation at kathleendschaum@bellsouth.net

Business Briefs
Kathleen D. Schaum, MS
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