Does your practice perform any minor or major procedures? If so, this post is for you!
Primary care practices and urgent care centers should pay special attention to these issues and avoid these four, costly errors.
1) Thinking a major procedure is a minor procedure
If you have heard me speak about the global surgical package you know how I define a major procedure. A major procedure is anything that you do on me!
Sadly, neither CPT nor CMS accepts my definition. Global days are assigned in the Medicare Fee Schedule. Although CPT doesn’t discuss global days, insurers and practices use these definitions:
a procedure with 0 or 10 global days
Major procedure :
a procedure with 90 global days
Why does it make a difference? Simple. Lost revenue. In a review recently, I found a 10% error rate in a fast track audit related to minor procedures that were actually major procedures. These major procedures were billed with an E/M service (fine) but the E/M service was reported with modifier 25 instead of 57!
Why do we care? Because the claims editing system will deny these claims. The medical practice will lose the revenue for the initial evaluation performed on the same day as the major surgical procedure.
What were these procedures? Fracture care and lip laceration repair. The group incorrectly thought these were minor surgical procedures. The claims for the E/M services were submitted with modifier 25 and were denied. Denied because the modifier was incorrect. And, the rules related to an E/M service on the day of a minor procedure and on the day of a major procedure are different. The global days for fracture care vary.
Look up the global days for all procedures performed. You can download an excel sheet from the CMS site.
Review CMS’s global surgery fact sheet. It’s a quick read, but it is packed with information.
2) Using the wrong lesion destruction code
If only all of the codes for destruction of lesions were in one section of the CPT® book like, maybe, the integumentary system section.
And, if only all of the destruction codes were defined in the same way. By the method, by the size of the lesion, by the number of lesions, by whether it was simple or extensive.
Unfortunately, none of those are true. And the result is that practices too often select the wrong code and often a code that pays less. The difficulty of searching for codes in electronic health records doesn’t help, because clinicians will often pick any code, just to get out of the field and close the record. And, we coders don’t always catch these and find the right code.
There are codes for destruction of benign, pre-malignant and malignant lesions in the integumentary system. But there are also codes in other chapters for destruction of benign lesions. I have created a sheet that you can download for benign and pre-malignant lesion destruction.
3) Ignoring the global period for minor surgical procedures
Everyone remembers post-op visits after a major surgical procedure are not separately billable. Everyone remembers that a procedure that occurs in the post-op period after a major surgical procedure will need a modifier.
But we forget about these things for minor procedures. Minor procedures have either 0 or 10-day global days assigned to them.
If a procedure has 10 global days that means that related follow-up is not separately reported for ten days after the procedure.
That is, when the patient returns to have their stitches removed or for a post-op check, the correct code is 99024, which has no RVUs or payment associated with it.
That is, we don’t charge for the post-op visit. But what if the patient returns within the global period?
For example, a patient has an I&D of an abscess on June 1, and returns on June 5 because of worsening symptoms. The physician does a second I&D on that day. This second procedure is related to the first procedure and occurs during the global period. The E/M service is not separately billable, but the procedure is. The practice must append modifier 58 to that stage or related procedure. Otherwise, the practice does not get paid.
Similarly, perhaps the patient returns on June 5 for a cough. This cough is unrelated to the I&D of the abscess done on June 1st. The practice reports the E/M service with modifier 24. And of course, the diagnosis code must be the cough or final diagnosis related to the cough.
4) Falling into the “always” or “never” trap
Let’s review what the NCCI manual says about billing for an E/M service on the same day as a minor procedure.
“The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should 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.”
This often leads to disagreements among reasonable people about whether a separate E/M service should be reported. In the newest edition of Principles of CPT® Coding published by the American Medical Association there is a chart that provides some guidance. 1
It asks these questions when deciding whether to bill an E/M service.
- Does documentation support that the patient’s condition required a separate and significant E/M service, above and beyond the usual preoperative and post-operative service for the procedure?
The NCCI manual has an example of what the pre-work would be for a laceration repair.
“Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable.” 2
The NCCI example adds that if the patient’s neurological status needs to be evaluated, an E/M would be reported. Two other questions in the Principles of CPT® Coding:
2. Does documentation in the medical record support a significant circumstance?
3. Does documentation define the medical necessity for the E/M service with the procedure?
Here are some examples:
When you need to evaluate the patient’s symptom, condition, problem prior to doing the procedure—and both are documented.
- Patient is sent from her primary care physician for a breast lump. An E/M service and a biopsy may be billed on the same day.
- Patient reports an episode of dizziness, falls and needs a laceration repair. Both an E/M service and the repair are billable.
- Patient presents at the office with a one year history of bleeding hemorrhoids with pain. Physician evaluates medical problems and performs an anoscopy.
When will you bill only the minor surgical procedure? (A planned procedure)
- When you perform and document only the minor surgical procedure.
Some payers have a policy that prohibits billing an E/M with lesion destruction or excision when that is the reason for the visit. Check payer policies.
- Planned, repeat procedure (such as wound debridement) when the medical decision making occurred at a previous visit
- Excision/destruction of small lesions
- Breast biopsy or bronchoscopy scheduled at a previous visit
 Principles of CPT® Coding 9th ed (American Medical Association, Chicago, 2017) 594
 NCCI manual, accessed 08/24/17 https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html
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