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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.
5. A: Medical Necessity
Rationale: Per the Medicare Claims Processing Manual, Chapter 12, Physicians/Nonphysician Practitioners, Section 30.6.1.A, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.”2 When medical necessity is demonstrated, however, medical decision making (MDM) is often the “pointer” in determining the level of service. Note, CPT guidelines do not specifically require MDM to be considered when two of three components must be met for a given service level; however, many coders interpret the discussion on medical necessity in Section 1862(a)(1)(A) of the Social Security Act to mean that MDM must be one of the two key components. In addition, instruction from the American Medical Association in CPT Assistant implies that the history or exam elements should be recorded only to the extent that MDM requires them.
6. B: False
Rationale: Per CMS, “In coding individual claims, it will be more efficient and accurate to work from the medical record documentation and then select the appropriate code(s),” rather than attempt to translate information from one code set to the other.3 Keep in mind, there is not a one-to-one match between ICD-9-CM and ICD-10-CM … there are instances where there is no plausible translation from a code in one system to any code in the other system. The safest method to choose a correct diagnosis code is using both the alphabetical index and tabular list of the official ICD-10-CM manual. Tip: As always, never code strictly from the alphabetical index. Always confirm your code choice in the tabular list to ensure the most appropriate code is selected for billing.
For questions or additional information on coding and billing for your practice, contact Melesia Tillman at email@example.com or 404-633-3777 x820.
- National Correct Coding Initiative Policy Manual for Medicare Services. American Medical Association. 2016 Jan 1.
- Medicare Claims Processing Manual. Chapter 12—Physicians/Nonphysician Practitioners. (Rev. 3402, 11-06-15).
- General Equivalence Mappings: Frequently Asked Questions. Department of Health and Human Services, Centers for Medicare and Medicaid Services. 2015 June.