Latest CCI edits make it tougher to report E/M service with minor procedures

New changes to Medicare coding rules will make it tougher to report evaluation and management (E/M) services provided on the same date as many minor procedures.

The latest version of the Correct Coding Initiative (CCI) edits, designated CCI 19.2 and effective July 1, 2013, bundle E/M services with many common outpatient procedures, including, but not limited to:

• Skin procedures, such as simple (12001-12021) and intermediate (12031-12057) repair of a laceration and destruction of benign and premalignant skin lesions (17000-17250);
• Musculoskeletal procedures, such as therapeutic injections of tendons and trigger points (20526-20553), aspiration and/or injection of a joint (20600-20610), and application of casts and strapping (29000-29750);
• External ear procedures, such as foreign body removal (69200) and impacted cerumen removal (69210).

Affected E/M codes include:

• Established patient office/outpatient visits (99211-99215)
• Hospital inpatient visits (99221-99239)
• Consultation codes (99241-92255)
• Critical care codes (99291-99292)
• Nursing facility codes (99304-99316)
• Established patient domiciliary, rest home, or custodial (assisted living) care codes (993234-99337)
• Home visits with established patients (99347-99350)
• Care plan oversight (99374-99378)

The new edits mean that if you report both services for the same patient on the same date without an appropriate modifier appended to the E/M code, Medicare (and any other payer that uses the CCI edits) will only pay for the procedure code.

The CPT surgical package definition says that surgical procedure codes include, subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure. That means these procedures, by definition, include a certain amount of “evaluation and management” in them, and the CCI edits reinforce that presumption.

Thankfully, the modifier indicator for all of these edits is "1." That means you can override the edits with the proper modifier. In this case, the most appropriate modifier will typically be modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

All of this means that any time you do an E/M service and a procedure on the same date of service, you should consider whether or not there is an applicable CCI edit. If there is, your documentation should support that the E/M service was significant and separately identifiable before you report it, and if so, you should add modifier 25 to the E/M code to make sure it gets paid.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Posted on Aug 29, 2013 by David Twiddy