Modifier 25

We have had a claim denied by Medicare for the following:


1. Patient has a personal history of Malignant Neoplasm so they came in for a skin check of suspicious lesions a full skin exam was performed and some benign lesions were discovered and no treatment needed, but provider did find some Actinic Keratosis, pre-malignant lesions, and treated these lesions. Our Medicare contractor is stating that the E/M is bundled into the surgery for the same day. This happens all the time in Dermatology and I don't feel it is correct. The E/M was a separate identifiable service from the surgery and different diagnosis were sent in showing all the findings on this visit.

2. Their reasoning was "modifier 25 should only be reported on the claim when there is a separate and identifiable evaluation and management service from other procedures performed on the same day. The submitted medical record supports that all services performed on the billed date of service were all related to the procedure performed. Therefore, the denial is upheld.

3. The note clearly shows that a full skin exam was performed and other lesions besides the one treated were found.

4. I am not sure what to tell my providers about charging out an E/M on same day as surgery if this is the case. Following this justification almost every patient that comes into our office would only be charged for the surgery performed and no E/M no matter how many other problems were found.

Any insight would be appreciated. How do others explain this to your providers to get them to understand what CMS wants when I'm not even sure CMS knows what they want.




Christine M Liles, CPC
Insurance Supervisor
P-865-342-5811
F-865-637-5057

[cid:image003.jpg@01D12E9A.EB757600]
Serving East Tennessee's Dermatology Needs for 40 Years

Comments

  • edited May 2017
    Were there specific lesions that the patient came in for or was it just for a full skin exam to look for lesions?
    If it was just a full skin exam looking for lesions, Medicare could consider this preventive. For an E&M to be charged there would need to be a problem, i.e. specific lesions to be evaluated.

    LeeAnn Raab RN, CPC
    AHIMA Approved ICD10 CM/PCS Trainer
    Senior Compliance Analyst
    St. Mary's Health
    3700 Washington Avenue
    Evansville, Indiana 47750
    812-485-7631
    lraab@stmarys.org




  • Here is an excerpt from an article that I just read..................

    Here is a SIMPLE way to look at it...

    Take the chart note for the date of service in question, take a highlighter, and highlight all the documentation related to performing the procedure including the documentation required for evaluating, diagnosing, examining the patient, making the decision to perform the procedure in question, performing the procedure, and providing postoperative instructions and any prescriptions. Now, if the remaining documentation from that date of service can stand alone as a billable E/M visit (with all the appropriate elements required), then there is a high probability that this will stand as a "separate and identifiable" E/M visit.



    Lisa R Berger, CPC
    Denials Management Team
    Revenue Integrity & Coding Advisor
    EXT 50839, Mail Stop NCA3-01
    lrberger@gundersenhealth.org



  • I have always recommended in this instance to have a separate note for the E/M and a separate note for the surgeries. Certainly if an E/M is charged there is a HX, EX and MDM.
    Maxine

    [Description: Description: R:GeneralGraphicsScrogginsGrearCorrect ColorsScrogginsGrear One Line Signature.png]

    Maxine Lewis, CMM, CPC, CPC-I, CCS-P, CPMA
    Main: 513-771-7070
    Direct: 513-672-4363
    Fax: 513-326-7640
    200 Northland Blvd
    Cincinnati, OH 45246
    mlewis@scrogginsgrear.com
    www.scrogginsgrear.com


  • It's hard to advise without the full documentation. If it were me and I truly believed the E/M was supported in addition to the "treated" lesions, I'd appeal the denial, or at least call and request to talk with a/the reviewer to determine what didn't meet their definition of separate and significant.

    Kris

    Kris Cuddy, CPC, CIMC
    Healthcare Compliance Analyst
    Compliance Office
    Michigan State University HealthTeam
    East Lansing, MI
    Ofc: 517-355-4547
    Fax: 517-353-5292

  • I have always recommended in this instance to have a separate note for the E/M and a separate note for the surgeries. Certainly if an E/M is charged there is a HX, EX and MDM.
    Maxine


    [Description: Description: R:GeneralGraphicsScrogginsGrearCorrect ColorsScrogginsGrear One Line Signature.png]

    Maxine Lewis, CMM, CPC, CPC-I, CCS-P, CPMA
    Main: 513-771-7070
    Direct: 513-672-4363
    Fax: 513-326-7640
    200 Northland Blvd
    Cincinnati, OH 45246
    mlewis@scrogginsgrear.com
    www.scrogginsgrear.com

  • edited May 2017
    Total skin exam (TSE) does not qualify as a preventive visit according to USPSTF http://www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care and as such may not carry the day as the basis for an E/M encounter.

    However, one must also realize that every dermatology procedure includes a minimum of level 2 E/M service. Unless one has enough documentation (not that related to the procedure e.g. history of the lesion, decision to treat the lesion etc) to support a separately identifiable E/M, it is difficult to convince the payer that a separate E/M was indeed performed.

    Consider extracting all documentation pertaining to the lesion treated and use whatever documentation is left and see if that supports an E/M and if so, then you have a separately identifiable E/M that is above and beyond that related to the procedure.

    Thank you and Have a Great Day!

    Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC
    Manager
    Coding & Reimbursement/Government Affairs
    American Academy of Dermatology
    930 E Woodfield Road
    Schaumburg, IL 60173

    AAPC ICD-10-CM/PCS Expert
    AHIMA ICD-10-CM/PCS Approved Trainer
    2014 AMA CPT Specialty Staff Liaison Excellence Award


    Email: fmcnicholas@aad.org
    Web: www.aad.org

    Direct: 847-240-1829
    Fax: 847-330-1120

    P please consider the environment before printing this e-mail

  • edited May 2017
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    Medicare is really cracking down on modifier -25. If there was =20
    documentation of additional HPI and ROS indicating the provider was lookin=
    g for =20
    something more significant (i.e., spread of cancer) and then the documenta=
    tion =20
    clearly indicates other areas were examined outside of the immediate area=
    of =20
    treatment, I would appeal. =20
    =20
    Someone mentioned the full skin exam without complaints would be =20
    preventive. If the patient has a history of skin cancer it is not preven=
    tive, it is=20
    surveillance. Also remember a full skin exam includes genitalia!
    =20
    =20
    =20
    =20
    In a message dated 6/2/2016 10:22:26 A.M. Central Daylight Time, =20
    cliles@knoxderm.com writes:

    =20
    We have had a claim denied by Medicare for the following:=20
    1. Patient has a personal history of Malignant Neoplasm so they came=
    =20
    in for a skin check of suspicious lesions a full skin exam was performed=
    =20
    and some benign lesions were discovered and no treatment needed, but prov=
    ider=20
    did find some Actinic Keratosis, pre-malignant lesions, and treated these=
    =20
    lesions. Our Medicare contractor is stating that the E/M is bundled into=
    =20
    the surgery for the same day. This happens all the time in Dermatology=
    and=20
    I don=E2=80=99t feel it is correct. The E/M was a separate identifiable=
    service=20
    from the surgery and different diagnosis were sent in showing all the=20
    findings on this visit. =20
    2. Their reasoning was =E2=80=9Cmodifier 25 should only be reported=
    on the=20
    claim when there is a separate and identifiable evaluation and management=
    =20
    service from other procedures performed on the same day. The submitted=
    medical=20
    record supports that all services performed on the billed date of service=
    =20
    were all related to the procedure performed. Therefore, the denial is =
    =20
    upheld. =20
    3. The note clearly shows that a full skin exam was performed and=20
    other lesions besides the one treated were found. =20
    4. I am not sure what to tell my providers about charging out an E/M=
    =20
    on same day as surgery if this is the case. Following this justification=
    =20
    almost every patient that comes into our office would only be charged fo=
    r=20
    the surgery performed and no E/M no matter how many other problems were=
    =20
    found.=20
    Any insight would be appreciated. How do others explain this to your=20
    providers to get them to understand what CMS wants when I=E2=80=99m not=
    even sure CMS=20
    knows what they want.=20
    Christine M Liles, CPC=20
    Insurance Supervisor=20
    P-865-342-5811=20
    F-865-637-5057=20
    =20
    Serving East Tennessee=E2=80=99s Dermatology Needs for 40 Years=20

  • edited May 2017
    That is a good definition, can I ask where it came from?

    LeeAnn Raab RN, CPC
    AHIMA Approved ICD10 CM/PCS Trainer
    Senior Compliance Analyst
    St. Mary's Health
    3700 Washington Avenue
    Evansville, Indiana 47750
    812-485-7631
    lraab@stmarys.org




  • It was from a Derm Coder Alert, I sent you a separate email with the entire Q&A.

    Thanks Lisa


    Lisa R Berger, CPC
    Denials Management Team
    Revenue Integrity & Coding Advisor
    EXT 50839, Mail Stop NCA3-01
    lrberger@gundersenhealth.org



  • edited May 2017
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    Absolutely, I agree.



    When documenting services, either a separate note for the surgery is
    documented, or in the case of paper records, dropping down a line to
    separate out the actual procedure.



    This is eye candy for the auditor and is actually a good way to design the
    record keeping process. It also helps providers to distinguish the billing
    possibility of separate procedures that may be billable the same day.



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



  • edited May 2017
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    Excellent advice.



    I might add to the discussion that without the specific E/M code and the
    surgery code(s) reported - the diagnosis codes (linked appropriately to the
    right line) , and the denial codes - we are still left pondering the real
    reason for the denial of the separate service.



    We have 2 factors - the provider's documentation and the subjective view of
    the auditor. Add in the above, and then we could make a real decision on
    whether the auditor is correct in their opinion.



    The review of the claim is either an appeal written from an original denial
    (where the claim structure is incorrect per the reported services), or a
    random audit by the carrier.



    Requires all parts to determine the reason for non-payment and for
    re-education purposes.



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



  • It all comes down to the documentation and the intent of the visit.

    If the patient came in for their annual full-body exam because of a history of Malignant Neoplasms, and that was documented as the chief complaint and reason for the visit AND the FBE exam was fully documented with any abnormalities noted, appropriate history taken, etc. then you have a better possibility of that encounter standing on it's own.

    If the patient came in with a complaint of itchy, irritated lesions, and you examined multiple areas of the body and made the decision to freeze the AKs, you might have trouble justifying a separate E/M for the "personal history of malignant neoplasms". But again, it depends on the documentation.

    Next, is how the E/M was billed with linked Diagnoses. The personal HX of malignant neoplasms should have been listed as the primary DX, and possible other conditions listed secondary, even if untreated. If so, this is helpful in your appeal.

    It is true, that any minor surgical service (0 or 10 postop days), like the AK destructions, DO include a certain portion of E/M and any of the E/M done in relation to the AKs should be subtracted from the separately identifiable E/M in determining your level of care. This usually means the that the separate and identifiable E/M gets bumped down a level or two. (i.e., you can't get credit for the E/M built into the AKs also for the separate E/M). That's double dipping.

    That all being said, it is important to note that according to CMS and the NCCI instructions, a separate DX is not needed for the E/M visit...

    “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. The E/M service and minor surgical procedure do not require different diagnoses.”

    Source: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/2016-NCCI-Policy-Manual.zip

    See the file within... CHAP1-gencorrectcodingpolicies_ final103115.pdf Page I-17.

    The above link and file will be helpful in your appeal, provided everything else is in order (i.e., documentation, ICD-10 coding, and correct level of care chosen).


    I hope this helps.

    Karl Ellzey
    Ellzey Coding Solutions, Inc.
    http://www.ellzeycodingsolutions.com
    http://www.dermcoder.com
  • edited May 2017
    I agree with all of this, but one minor detail......'intent of the visit.'

    The intent for any visit isn't really an issue, as medicine can't be based on presumptive information, or what the patient is scheduled for.

    Always go with the documented findings, which is the decision the provider makes to perform, decide, and help the patient.

    Karen A. Hurley, BS, CMM, CPC, CNA
    President, HPMSI
    PO Box 409
    Parrish, FL 34219-0409
    Tel: (941) 776-4822
    Fax: (240) 368-0059
    Web: www.hpmsi.com

  • Yes, Karen, you are correct and I didn't fully explain (or clearly explain) my thought process.

    If they were just there to have some lesions treated, and the provider fully examined the patient to see if there were other similar lesions that need treated, the intent of that visit was to treat the complaint of the lesions, it would be difficult to substantiate a separate and identifiable E/M.

    If the patient came in for lesions, and the doctor noted that they hadn't been in for a while, had a history of malignant neoplasms, and it was pertinent to do a FBE and check for any new or reoccurring lesions, then there is justifiable reason to perform, document, and bill a separate E/M. Being sure to discount the E/M components attributed to the AK destructions.

    Again, as others have stated, it all comes down to documentation, and how it was billed.

    Thanks for your feedback Karen.

    Sincerely,

    Karl Ellzey

    Ellzey Coding Solutions, Inc.
    http://www.ellzeycodingsolutions.com
    http://www.dermcoder.com
  • edited May 2017
    Amen, you are sooooo right, the documentation + the way the claim is sent (which can be far different than the charge slip, unfortunately).

    Karen A. Hurley, BS, CMM, CPC, CNA
    President, HPMSI
    PO Box 409
    Parrish, FL 34219-0409
    Tel: (941) 776-4822
    Fax: (240) 368-0059
    Web: www.hpmsi.com

    Since 1996, Celebrating 20 years of Service to Physicians

  • Or get the patient to sign an ABN and bill 992xx which really isn’t the most appropriate way but could be a low level ….they are stating that an exam of the affected area would be a given with the procedure you are performing. Established patient and condition doesn’t necessarily warrant an E&M code.

    Karyn Cardenas-Foray, CPC, CPMA, CEMC, CIMC
    AHIMA Approved ICD10 Trainer
    Government Reimbursement Analyst
    Sharp HealthCare-PFS/CCD Spectrum
    (858)499-4382 ph.: (858) 499-4300 fax


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