Medical Coding Pro

Measuring total removal lengths is a no-no … here’s why.

Your ED physician removes a pair of benign lesions from the patient’s left thigh; you add the repair lengths and code based on those numbers. You’ve coded correctly … right?

Wrong: Many coders get tripped up by lesion removal codes, which are governed by different rules than lesion excision codes. Get the real lowdown on coding multiple lesion excisions right here, and you’ll get it right every time.

CPT, Experts Agree: Don’t Add Lengths

When your physician removes multiple lesions, “code for each individual lesion; this is not like laceration repairs, where you combine the length of all of the same body area/complexity wounds,” explains Sharon Richardson, RN, compliance officer at Emergency Groups’ Office in Arcadia, Calif.

“Report separately each benign [or malignant] lesion excised,” reads the CPT 2010 guidelines preceding each lesion excision section: Depending on the nature and location of the lesions, however, you may need to employ modifiers on multiple lesion removals.

Example: A patient presents with one lesion on his forehead and one on his neck. The patient cannot stop scratching them, which is causing bleeding. The ED physician performs an expanded problem focused history and physical exam. During the history portion of the E/M,the patient reports that he has no access to a dermatologist, so the ED physician chooses to excise the lesions.

The physician performs a pair of simple benign lesion excisions: a 1.3 cm lesion from the patient’s face and a 1.8 cm lesion from the patient’s neck. The physician then writes a five-day antibiotic prescription and a 10-day prescription for Tylenol #3.

On this claim, Richardson recommends reporting the following codes:

• 11422 (Excision, benign lesion including margins,except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm) forthe neck lesion removal
• 11442 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm) for the facial lesion removal
• modifier 59 (Distinct procedural service) appended to 11442 to indicate the separate nature of the removals — if the insurer requires it**
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity …) for the E/M service
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and lesionremovals were separate services

**Alternate scenario: If the patient in the above example had both lesions removed from his face, you could report 11442 and 11442-59 for the repairs.

You Won’t Always Need Modifier 59

If the lesions are in different anatomic areas – or if the lesions differ in pathology – the payer might want you to code the removals separately without any modifiers. Other payer peculiarities might include wanting  o see modifier 51 (Multiple procedures) on multiple lesion removal claims.

Best bet: Check with the carrier before coding multiple lesion removals, as there can be some coding differences among insurers for these services.

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Find out which you can report separately: a tunneled or a non-tunneled line.

Question: What code should we bill when we remove a central venous pressure (CVP) line and insert a Hickman catheter at a different site?

New York Subscriber

Answer: You can’t determine the proper code based on type of catheter (such as CVP line or Hickman).

Selecting the proper code depends on the patient’s age, whether the surgeon places the catheter centrally or peripherally, where the catheter tip is at the end of placement, and whether the catheter is tunneled or non-tunneled.

Surgeons typically place Hickman catheters as central lines, and they usually place them centrally, although they can be tunneled or non-tunneled. For an adult patient, that makes the most likely codes for your scenario either 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) or 36558 (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older).

Caution: Before using these codes, you should verify that there was no port or pump attached to the catheter. Also check to be sure that the catheter was actually placed into the subclavian, innominate, or iliac veins, the inferior or superior vena cava, or the right atrium through a central vein (such as jugular or femoral). If any of these facts don’t match your case, you should select a code other than 36556 or 36558.

Tip: Carefully read the directions preceding 36555 before you choose the code. Don’t guess if the procedure note doesn’t specify everything that you need to know. Hickmans are versatile catheters and you can’t be sure what the surgeon did unless it’s in the note.

Separate removal: You can bill separately for the removal of a tunneled central line (such as 36589, Removal of tunneled central venous catheter, without subcutaneous port or pump), but not a non-tunneled line.

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Knowing how to use add-on codes can net you up to $258 in additional reimbursement.

CPT is full of “add-on” codes, additions to minor and major surgical procedures as well as to E/M services. Fortunately for urology there are not many “add-on codes,” but that makes it essential for you to know the special rules that apply to these codes when you do have to use them. If you learn just a few main guidelines, you can gain the best possible reimbursement for your urologist’s procedures including all add-on codes.

Look for the ‘+’ Symbol

There’s an easy way to tell if a CPT code is designated as an add-on code…

Just look for a plus sign (+) symbol to the left of the code in your CPT manual. Another hint is that in their code descriptors all add-on codes contain a variation of the phrase “List separately in addition to code for primary procedure.”

“You will also find a listing of the CPT code range in which that add-on code may be used in addition with,” says Nicole Martin, CPC, owner of Innovative Coding Analysis in Coplay, Penn. That listing follows the add-on code descriptor in the CPT manual.

Example: For urology a typical add-on code listing appears as follows:

• +57267 — Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure).

Pointer: CPT designates some E/M services as add-on codes as well. For instance, you may report prolonged services — such as +99354 (Prolonged physician service in the office or other outpatient setting …) — in addition to other primary E/M services such as an outpatient visit.

Tip: Remember you can find a complete list of add-on codes in Appendix D of your CPT manual.

Always List “Add-Ons” With a Primary Procedure

As noted above, you should never report an add-on code without also listing a “primary” procedure code.

Here’s why: The add-on code describes additional intra-service work associated with specific primary procedures the physician performs during the same operative session or patient encounter. “Add-on codes do not get reported alone as they are an integral part of the primary procedure in which CPT and the AMA feels should be reimbursed in addition to the primary procedure,” Martin explains.

“In most cases, add-on codes represent the ‘above and beyond’ that a provider might do along with the usual services,” says Denae M. Merrill, CPC, CEMC, HCC coding specialist for The Coding Source and owner of Merrill Medical Management.

Example: Your urologist would never use an operating microscope (+69990, Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) in the absence of a surgical procedure that required microscopic visualization of a particular anatomic location. Because you would only bill +69990 in addition to another procedure, CPT lists this code as an add-on.

In most cases, the primary code(s) for a given add-on code immediately precede the add-on code in the CPT listings. For example, consider the following CPT code sequence:

• 51728 — Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure), any technique
• 51729 — … with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique
• +51797 — Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure).

In this case, the add-on code (+51797) follows the primary procedure codes (51728 and 51729) to which it is related, even though the code is not in numerical order in the CPT manual. Plus, CPT instructs, “Use 51797 in conjunction with codes 51728, 51729.”

Caveat: CPT doesn’t always list add-on codes directly after all of the primary procedure codes. In most cases when the add-on code and primary code(s) are not listed together, CPT will provide instructions on which code(s) should accompany the add-on code. For example, CPT states that you should report +57267 with 45560, 57240-57265, 57285. CPT only lists +57267 after 57265, however.

Skip Modifier 51 With Add-on Codes

You should never append modifier 51 (Multiple procedures) to a designated add-on code, Merrill says. Modifier 51 designates a procedure or service that can be performed independently but, in the cited case, is performed at the same time as another procedure.

CPT stresses this point by stating, “All add-on codes found in the CPT book are exempt from the multiple procedure concept.”

Reason: “Add-on codes have been given a separately reimbursable value that has already had the applicable discount for multiple procedure at the time the relative value unit (RVU) was assigned,” Martin says.

Check your payments: Always check your explanation of benefits (EOB) carefully for claims with add-on codes to be sure the payer reimburses you the entire fee schedule rate for the billed procedures or services. For example, if you report +57267 for a mesh insertion procedure, you should receive the full $258 fee for that code (7.16 relative value units [RVUs], based on the 2010 Medicare Physician Fee Schedule, and the conversion factor [CF] of 36.0846).

“Add-on codes should never be reduced for multiple procedure discounts,” Martin warns. “They should always be paid at 100 percent of the contract amount unless you have entered into an insurance contract agreeing to otherwise, such as hospital/facility insurance contracts.”

If you find a payer reducing the fees for your add-on codes, be sure to appeal the claims. Cite the definition of add-on codes as additional procedures exempt from modifier 51 rules.

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Attach your procedure notes and the OIG’s report to pack extra punch.

Even if you follow all of CMS’s rules in reporting modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), your Medicare payer may sometimes still choose to deny your claim.

If you feel you deserve the pay for the EM service you performed, you should appeal the denial. Alice Kater, CPC, PCS, coder with Urology Associates of South Bend in Indiana, offers the following sample appeal letter (below) as an example of how she has challenged her payer to collect rightful reimbursement.

What you should know: To improve her odds of success, Kater submits her physician’s documentation with the appeal letter, as well as a copy of a 2005 letter from Mark B. McClellan, MD, PhD, former HHS administrator, to Inspector General Daniel R. Levinson that was a response to the 2005 OIG report “Use of Modifier 25.”

In addition, Kater includes the first three pages of the OIG report, which outlines the appropriate way to report modifier 25. You can download McClellan’s letter, as well as the OIG report, at http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf.

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Make sure your documentation supports the additional substantial complexity of the hernia repair and mesh.

Question: A patient presented for a colectomy for colon cancer. The physician also discovered that the patient had a ventral incarcerated hernia that required a complex repair using mesh. Because of the separate work, we reported 44140 and then reported 49561 with modifier 59. The payer denied the claim. Were we wrong to append modifier 59?

Mississippi Subscriber

Answer: You might think you can append modifier 59 (Distinct procedural service) to the hernia repair code and bill it separately. After all, the hernia repair seems to qualify as a different reason for surgery than the colectomy — for example, if the patient has a recurrent hernia. But modifier 59 tells the payer the hernia repair happened at a separate session, which isn’t true in your case.

If the physician’s documentation proves justification, you might try …

… appending modifier 22 (Unusual procedural services) to the colectomy code because of the extra complexity, time, and effort required by the complex hernia repair with mesh.

The Correct Coding Initiative (CCI) considers hernia repair code 49561 (Repair initial incisional or ventral hernia; incarcerated or strangulated) to be part of partial colectomy code 44140 (Colectomy, partial; with anastomosis) because the hernia repair is integral to the closure. You may have to appeal for the additional money. So make sure the documentation supports the additional substantial complexity of the hernia repair and mesh implantation before appending modifier 22.