APMA News - May 2012 - (Page 60)

Reimbursement By Harry Goldsmith, DPM CCI Edit Primer: How, Why, What, and Where of the Correct Coding Initiative—Part One In the beginning, there was the Health Care Financing Administration (HCFA), and it was good, although we complained throughout its existence. Then HCFA begat the Centers for Medicare and Medicaid Services (CMS) so as to confuse health-care providers. But alas, only the name on the stationery changed. The buildings, the people, and the policies stayed the same. But wait, I’m getting ahead of myself. HCFA developed the National Correct Coding Initiative (NCCI) or, as it is better known, the CCI, and in 1996 implemented it into its claims processing system. The CCI was designed to prevent the inappropriate payment of services and/ or procedures that should not be reported together. The CCI identifies services or procedures that are considered components (or inherent to the performance) of more complex, more comprehensive services or procedures. Sometimes it even makes sense. For example: CPT 11750 (excision of nail and nail matrix, partial or complete, for permanent removal) is the comprehensive procedure, while the following partial listing represents CCI edit components of CPT 11750: CPT 10060—I&D of abscess; simple or single CPT 11720—Debridement of nail(s), 1-5 CPT 11730—Nail avulsion, partial or complete CPT 11755—Biopsy of nail unit CPT 11760—Repair of nail bed CPT 17250—Chemical cauterization of granulation tissue (proud flesh) In other words, these subsequent “component” CPT codes are considered to be (appropriately) included in the performance of CPT 11750 (the comprehensive code) when they are performed upon the same site/digit. But sometimes the edits really don’t make sense at all. For example: CPT 28299 (correction, hallux valgus [bunion], with or without sesamoidectomy; by double osteotomy) is the comprehensive procedure, while the following (partial) listing represents CCI edit components of CPT 28299: CPT 11750—Matrixectomy, partial or complete CPT 20527—Injection, enzyme, palmar fascial cord CPT 20690—Application of a uniplane external fixation system CPT 28080—Excision of Morton’s neuroma CPT 28160—Interphalangeal joint excision 60 APMA News May 2012 CPT 28286—Correction, cock-up fifth toe CPT 28312—Osteotomy, proximal phalanx, other-thanfirst toe CPT 36440—Push transfusion, blood, two years or under CPT 51701—Insertion of non-indwelling bladder catheter Whether it makes sense or not, until it is changed or deleted, for Medicare at least, a CCI edit is gospel. General Coding Principles The CCI Manual includes a number of “do’s” and “don’ts” that make a lot of sense. For instance, a provider should not fragment or unbundle a procedure code and bill its component parts. In other words, a provider should not report multiple HCPCS/CPT codes when a single comprehensive code exists that describes the procedures or services performed. If a code exists that describes a comprehensive service/ procedure performed, the provider must report that comprehensive code, rather than “downcoding” to a less comprehensive or component procedure code which, in aggregate, may either result in a higher payment or avert potential global day assignment. Obviously, providers should avoid upcoding. Billing a comprehensive code for services or procedures that are not evident (i.e., documented) as having been performed is, at best, upcoding. Providers must document and accurately report units of service. For example, CPT 97035 (application of a modality to one or more areas; ultrasound) is defined as billing for “each 15 minutes.” Documentation that fails to include the total time spent performing the ultrasound fails to qualify the service billed. Additionally, some physical therapy codes are designated as “per session” codes, such as CPT 28024 (application of a modality to one or more areas; diathermy [e.g., microwave]), and should not be reported with anything other than a “1” unit value. Stay tuned to the June issue of APMA News for CCI coding definitions, guidelines, and policies. n Contact Dr. Goldsmith at healthpolicy.hpp@apma.org.

Table of Contents for the Digital Edition of APMA News - May 2012

APMA News - May 2012
President’s Message
Contents
92nd House of Delegates: Advancing Education and the Profession
Special Section: APMA Educational Foundation
Being a Residency Director: What’s in it for You?
DPM versus MD: Letters to the Editor
JCRSB Update: May 2012
ACO Update: Are Commercial ACOs Getting a Leg Up on their Medicare Brethren?
APMA By the Decade: 1952–1961
Profiles in Progress: Medical Staff Leadership
2011 Podiatric Practice Survey: Determination of Income/Salary for Employed Professionals
Master Your Practice at the National
Annual Scientific Meeting Preliminary Program
Annual Scientific Meeting Registration Form
Annual Scientific Meeting Sponsors
Reimbursement
Federal Advocacy Forum
APMAPAC Chair Report
IT Consultant
Website Wisdom
Technofile
Small Business 101
Awards Nominations
APMA All Stars
In Short
Worthy of Note
Affiliates Corner
New Members
Death Notices
List of Affiliated Organizations
Insurance Advisor
APMAPAC Update
Development Update
Classified Advertising
Dates to Remember
Advertising Index
10 Questions
Your APMA

APMA News - May 2012