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Explore This IssueApril 2016
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1. D: All of the above
Rationale: Per CPT, if time spent counseling and/or coordinating care dominates the session, then total time must be documented; greater than 50% of the time must be for face-to-face counseling and/or coordinating care, and must be documented as such. Additionally, the extent of the counseling and/or coordination of care must be documented.
2. C: It should only be appended to an E/M service code
Rationale: Modifier -25 is used to identify a significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare provider on the same day of the procedure or other service. This modifier may only be appended to an E/M code when a distinct E/M service is provided on the same day, at the same encounter as a minor. It will be necessary to document that on the date of service the patient’s condition required a significant, separately identifiable E/M above and beyond the usual care associated with the procedure that was performed. The significant and separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective level of service that is reported.
3. C: Work RVUs + Non-Facility Practice Expense RVUs + Malpractice RVUs
Rationale: Work relative value units (RVUs; which account for physician effort) and malpractice (MP) RVUs (which account for the cost of malpractice insurance) do not change according to place of service. Practice expenses (PEs) RVUs are different for facility (e.g., hospital) and non-facility (e.g., physician office) settings. Because the cost of practicing medicine varies by geographic location, CMS applies separate geographic practice cost indices (GPCIs) to each of the three relative values (work, MP and PEs) to adjust payments.
4. B: False
Rationale: You should not append modifier XS Separate Structure if a secondary procedure occurs in the same anatomic site (e.g., the same knee). Per Chapter I of the National Correct Coding Initiative Policy Manual for Medicare Services, General Correct Coding Policies, “From an NCCI perspective, the definition of different anatomic sites includes different organs, different anatomic regions, or different lesions in the same organ. It does not include treatment of contiguous structures of the same organ.”1 Append modifiers LT (left side) and RT (right side), rather than modifier XS.
Arthrocentesis for the shoulder or hip on the same date of service would require an XS modifier, since these are different anatomic sites and they share the same CPT code for reporting.