Daniel M. Siegel, MD, MS

Winter is the time when many religions celebrate a renewal of the year as the days begin to get longer. On January 1 of each year in the United States we celebrate the official activation of new and revised Current Procedural Terminology (CPT) codes with which physicians report their services, and if they are lucky, they are compensated when these services are provided. In 2018, there are new sets of codes for photodynamic therapy (PDT) and lasers that all dermatologists should be aware of.

Photodynamic Therapy

Use of PDT is said to date back as early as the 1900s,1 but it did not become a mainstream treatment modality in the United States until 2002 when the first CPT code for PDT (96567) became effective.² Treatment involved application of a photosensitizing drug and its subsequent activation with a special blue light. Physicians faced an uphill battle for many years, as payers would either not reimburse the CPT code itself or the corresponding Healthcare Common Procedure Coding System supply code J7308, which became effective on January 1, 2004,3 to allow for reimbursement of a 354-mg, single-dose ampoule preparation of aminolevulinic acid hydrochloride as the photosensitizing drug. By deeming the procedure experimental and/or medically unnecessary, insurers often refused payment when 96567 was used—a situation that still occurs today with regard to PDT reimbursement, although less often. In my experience, this code was considered by the American Medical Association/Specialty Society Relative Value Scale Update Committee to be a nonphysician work code with the assumption that the procedure was done by nonprovider staff (eg, medical assistant, licensed practical nurse, registered nurse) and that the physician did nothing but order the treatment.

In 2004, a methyl aminolevulinate cream that was activated with a red light source was brought to market; however, after failing to gain a substantial market share, the product is no longer available in the United States. In May of 2016, a nanoemulsion gel formulation of aminolevulinic acid hydrochloride 10% was approved by the US Food and Drug Administration4 for use with a red light source. Unlike 5-aminolevulinic acid hydrochloride solution, which was approved for application with no prior debridement of the skin,⁵ the new gel formulation was meant to be applied after degreasing with an ethanol- or isopropanol-soaked cotton pad and removal of any scaling or crusts, followed by roughening of the lesion surfaces (with care taken to avoid bleeding).⁴ The product must be administered by a health care provider and is reported using CPT codes 96573 and 96574, which are new in 2018 and are discussed in more detail below. Effective January 1, 2018, the Healthcare Common Procedure Coding System supply code for the product is J7345 (aminolevulinic acid hydrochloride gel for topical administration, 10% gel, 10 mg).6 A single tube contains 200 mg, so when an entire tube is used (which is typical), 200 units must be reported. Partial tubes may be used in some patients and should be reported appropriately based on actual usage.

The development of new CPT codes for PDT revealed a middle ground in which many physicians, including myself, have applied the photosensitizing drug themselves instead of a nonphysician provider in order to use their professional judgment to ensure the entire treatment area was covered and also allow for multiple applications of the drug to lesions that in their opinion may have warranted greater dosing, which led to the creation of CPT code 96573. The revision and refinement from one code to 3 (96567, 96573, and 96574) also involved rewording of the preamble for all 3 codes so that the phrase “premalignant and/or malignant lesions” was simplified to “premalignant lesions.” This change was made so that if and when this therapeutic approach is refined enough to be used on malignant lesions, new codes can be created to distinguish between the work performed for both types of lesions.

The new PDT codes include 96573 (photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug[s] provided by a physician or other qualified healthcare professional, per day) and 96574 (debridement of premalignant hyperkeratotic lesion[s][ie, targeted curettage, abrasion] followed with photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug[s] provided by a physician or other qualified healthcare professional, per day). According to the 2018 CPT manual,² these codes should be used to report nonsurgical treatment of cutaneous lesions using PDT (ie, external application of light to destroy premalignant lesions of the skin and adjacent mucosa by activation of photosensitizing drug). A treatment session is defined as an application of a photosensitizer to all lesions within an anatomic area (eg, face, scalp) with or without debridement of all premalignant hyperkeratotic lesions in that area followed by illumination and activation with an appropriate light source. Providers should not report codes for debridement (11000, 11001, 11004, 11005), lesion shaving (11300–11313), biopsy (11100, 11101), or lesion excision (11400–11471) within the treatment area on the same day that PDT is administered.²

With the inclusion of these new PDT codes, the older code 96567 (photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitive drug[s], per day)—which is the base or parent code of the set—should only be used for reporting PDT when a physician or other qualified health care professional is not directly involved in the delivery of the service. Code 96573 is an upgrade to 96567 to account for physician work, while code 96574 captures the extra work of disruption of the skin barrier by debridement.

The novelty here is that old codes often are replaced when new codes come along. The reader should be aware of the distinct differences, as the total value expressed in relative value units for code 96567 is lower than it was in 2017 (3.24 vs 3.80), while the 2 newer codes have higher values (codes 96573 and 96574, 5.37 and 6.92, respectively). Additionally, the reader should note that only one of the 3 codes can be used on a given anatomic area (ie, face and scalp) on a given day. In general, a single-dose package of either of the approved photosensitizing drugs can usually treat an entire anatomic area. The codes themselves are not reserved for specific anatomic areas, but the US Food and Drug Administration clearances are for only face and scalp for both drugs, so the use of more than 2 PDT codes on a given day might raise payer queries.

Whatever you do, be sure your documentation includes an explicit notation about who applied the photosensitizing drug and the technique used for debridement, if performed. Code 96574 explicitly refers to targeted curettage and abrasion but does not include other destructive modalities (eg, chemical peeling), which an auditor may or may not consider an acceptable method of debridement. Personally, I will not be using peels as a justifier for this code.

Lasers

Lasers have played a role in the treatment of severe scarring in wounded warriors and other patient populations.⁷ Until 2018, there were no CPT codes that allowed precise reporting of these therapies. We now have a series of tracking codes, which are not valued by the Specialty Society Relative Value Scale Update Committee process but are nonetheless reportable, for this valuable treatment.⁸

The base code for a new pair of codes for reporting fractional ablative laser treatment, which is modeled after the skin graft code series, is 0479T (fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm² or part thereof, or 1% of body surface area of infants and children). The add-on code is 0480T (fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm², or each additional 1% of body surface area of infants and children, or part thereof [list separately in addition to code for primary procedure]), which means the code can be reported multiple times in addition to a single unit of 0479T. The aggregate treatment area should only be reported once per day regardless of the number of passes of one or more lasers over the area that day, and codes 0479T and 0480T should not be reported with codes 0491T or 0492T, which are a new family of tracking codes used for ablative laser treatment of chronic open wounds. If the scars are excised in a full-thickness manner, the benign excision codes 11400 to 11446 should be used instead.

For laser treatment of open wounds, 0491T (ablative laser treatment, noncontact, full-field and fractional ablation, open wound, per day, total treatment surface area; first 20 cm² or less) is the base code for this pair of codes, and 0492T (ablative laser treatment, noncontact, full-field and fractional ablation, open wound, per day, total treatment surface area; each additional 20 cm², or part thereof [list separately in addition to code for primary procedure]) is the add-on code, similar to the 0479T and 00480T codes described above. Keep in mind that all 4 of these tracking codes do not have defined values, and payment is at the discretion of the payer. If utilization of the procedures increases along with the development of appropriate evidence-based literature to support it, it is possible these will be converted into standard category I CPT codes that will be valued and covered by payers.

Final Thoughts

For more details on the new codes for PDT and lasers, I would strongly suggest obtaining a copy of CPT Changes 2018: An Insider’s View (https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod2800018&navAction=push), as well as the 2018 CPT manual for those who are actively practicing. Members of the American Academy of Dermatology also can get the new CPT manual as part of the group’s Coding Value Pack (https://store.aad.org/products/11383) along with Principles of Documentation for Dermatology and 2018 Coding & Billing for Dermatology.

Winter is the time when many religions celebrate a renewal of the year as the days begin to get longer. On January 1 of each year in the United States we celebrate the official activation of new and revised Current Procedural Terminology (CPT) codes with which physicians report their services, and if they are lucky, they are compensated when these services are provided. In 2018, there are new sets of codes for photodynamic therapy (PDT) and lasers that all dermatologists should be aware of.

Photodynamic Therapy

Use of PDT is said to date back as early as the 1900s,1 but it did not become a mainstream treatment modality in the United States until 2002 when the first CPT code for PDT (96567) became effective.² Treatment involved application of a photosensitizing drug and its subsequent activation with a special blue light. Physicians faced an uphill battle for many years, as payers would either not reimburse the CPT code itself or the corresponding Healthcare Common Procedure Coding System supply code J7308, which became effective on January 1, 2004,3 to allow for reimbursement of a 354-mg, single-dose ampoule preparation of aminolevulinic acid hydrochloride as the photosensitizing drug. By deeming the procedure experimental and/or medically unnecessary, insurers often refused payment when 96567 was used—a situation that still occurs today with regard to PDT reimbursement, although less often. In my experience, this code was considered by the American Medical Association/Specialty Society Relative Value Scale Update Committee to be a nonphysician work code with the assumption that the procedure was done by nonprovider staff (eg, medical assistant, licensed practical nurse, registered nurse) and that the physician did nothing but order the treatment.

In 2004, a methyl aminolevulinate cream that was activated with a red light source was brought to market; however, after failing to gain a substantial market share, the product is no longer available in the United States. In May of 2016, a nanoemulsion gel formulation of aminolevulinic acid hydrochloride 10% was approved by the US Food and Drug Administration4 for use with a red light source. Unlike 5-aminolevulinic acid hydrochloride solution, which was approved for application with no prior debridement of the skin,⁵ the new gel formulation was meant to be applied after degreasing with an ethanol- or isopropanol-soaked cotton pad and removal of any scaling or crusts, followed by roughening of the lesion surfaces (with care taken to avoid bleeding).⁴ The product must be administered by a health care provider and is reported using CPT codes 96573 and 96574, which are new in 2018 and are discussed in more detail below. Effective January 1, 2018, the Healthcare Common Procedure Coding System supply code for the product is J7345 (aminolevulinic acid hydrochloride gel for topical administration, 10% gel, 10 mg).6 A single tube contains 200 mg, so when an entire tube is used (which is typical), 200 units must be reported. Partial tubes may be used in some patients and should be reported appropriately based on actual usage.

The development of new CPT codes for PDT revealed a middle ground in which many physicians, including myself, have applied the photosensitizing drug themselves instead of a nonphysician provider in order to use their professional judgment to ensure the entire treatment area was covered and also allow for multiple applications of the drug to lesions that in their opinion may have warranted greater dosing, which led to the creation of CPT code 96573. The revision and refinement from one code to 3 (96567, 96573, and 96574) also involved rewording of the preamble for all 3 codes so that the phrase “premalignant and/or malignant lesions” was simplified to “premalignant lesions.” This change was made so that if and when this therapeutic approach is refined enough to be used on malignant lesions, new codes can be created to distinguish between the work performed for both types of lesions.

The new PDT codes include 96573 (photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug[s] provided by a physician or other qualified healthcare professional, per day) and 96574 (debridement of premalignant hyperkeratotic lesion[s][ie, targeted curettage, abrasion] followed with photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug[s] provided by a physician or other qualified healthcare professional, per day). According to the 2018 CPT manual,² these codes should be used to report nonsurgical treatment of cutaneous lesions using PDT (ie, external application of light to destroy premalignant lesions of the skin and adjacent mucosa by activation of photosensitizing drug). A treatment session is defined as an application of a photosensitizer to all lesions within an anatomic area (eg, face, scalp) with or without debridement of all premalignant hyperkeratotic lesions in that area followed by illumination and activation with an appropriate light source. Providers should not report codes for debridement (11000, 11001, 11004, 11005), lesion shaving (11300–11313), biopsy (11100, 11101), or lesion excision (11400–11471) within the treatment area on the same day that PDT is administered.²

With the inclusion of these new PDT codes, the older code 96567 (photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitive drug[s], per day)—which is the base or parent code of the set—should only be used for reporting PDT when a physician or other qualified health care professional is not directly involved in the delivery of the service. Code 96573 is an upgrade to 96567 to account for physician work, while code 96574 captures the extra work of disruption of the skin barrier by debridement.

The novelty here is that old codes often are replaced when new codes come along. The reader should be aware of the distinct differences, as the total value expressed in relative value units for code 96567 is lower than it was in 2017 (3.24 vs 3.80), while the 2 newer codes have higher values (codes 96573 and 96574, 5.37 and 6.92, respectively). Additionally, the reader should note that only one of the 3 codes can be used on a given anatomic area (ie, face and scalp) on a given day. In general, a single-dose package of either of the approved photosensitizing drugs can usually treat an entire anatomic area. The codes themselves are not reserved for specific anatomic areas, but the US Food and Drug Administration clearances are for only face and scalp for both drugs, so the use of more than 2 PDT codes on a given day might raise payer queries.

Whatever you do, be sure your documentation includes an explicit notation about who applied the photosensitizing drug and the technique used for debridement, if performed. Code 96574 explicitly refers to targeted curettage and abrasion but does not include other destructive modalities (eg, chemical peeling), which an auditor may or may not consider an acceptable method of debridement. Personally, I will not be using peels as a justifier for this code.

Lasers

Lasers have played a role in the treatment of severe scarring in wounded warriors and other patient populations.⁷ Until 2018, there were no CPT codes that allowed precise reporting of these therapies. We now have a series of tracking codes, which are not valued by the Specialty Society Relative Value Scale Update Committee process but are nonetheless reportable, for this valuable treatment.⁸

The base code for a new pair of codes for reporting fractional ablative laser treatment, which is modeled after the skin graft code series, is 0479T (fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm² or part thereof, or 1% of body surface area of infants and children). The add-on code is 0480T (fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm², or each additional 1% of body surface area of infants and children, or part thereof [list separately in addition to code for primary procedure]), which means the code can be reported multiple times in addition to a single unit of 0479T. The aggregate treatment area should only be reported once per day regardless of the number of passes of one or more lasers over the area that day, and codes 0479T and 0480T should not be reported with codes 0491T or 0492T, which are a new family of tracking codes used for ablative laser treatment of chronic open wounds. If the scars are excised in a full-thickness manner, the benign excision codes 11400 to 11446 should be used instead.

For laser treatment of open wounds, 0491T (ablative laser treatment, noncontact, full-field and fractional ablation, open wound, per day, total treatment surface area; first 20 cm² or less) is the base code for this pair of codes, and 0492T (ablative laser treatment, noncontact, full-field and fractional ablation, open wound, per day, total treatment surface area; each additional 20 cm², or part thereof [list separately in addition to code for primary procedure]) is the add-on code, similar to the 0479T and 00480T codes described above. Keep in mind that all 4 of these tracking codes do not have defined values, and payment is at the discretion of the payer. If utilization of the procedures increases along with the development of appropriate evidence-based literature to support it, it is possible these will be converted into standard category I CPT codes that will be valued and covered by payers.

Final Thoughts

For more details on the new codes for PDT and lasers, I would strongly suggest obtaining a copy of CPT Changes 2018: An Insider’s View (https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod2800018&navAction=push), as well as the 2018 CPT manual for those who are actively practicing. Members of the American Academy of Dermatology also can get the new CPT manual as part of the group’s Coding Value Pack (https://store.aad.org/products/11383) along with Principles of Documentation for Dermatology and 2018 Coding & Billing for Dermatology.

Winter is the time when many religions celebrate a renewal of the year as the days begin to get longer. On January 1 of each year in the United States we celebrate the official activation of new and revised Current Procedural Terminology (CPT) codes with which physicians report their services, and if they are lucky, they are compensated when these services are provided. In 2018, there are new sets of codes for photodynamic therapy (PDT) and lasers that all dermatologists should be aware of.

Photodynamic Therapy

Use of PDT is said to date back as early as the 1900s,1 but it did not become a mainstream treatment modality in the United States until 2002 when the first CPT code for PDT (96567) became effective.² Treatment involved application of a photosensitizing drug and its subsequent activation with a special blue light. Physicians faced an uphill battle for many years, as payers would either not reimburse the CPT code itself or the corresponding Healthcare Common Procedure Coding System supply code J7308, which became effective on January 1, 2004,3 to allow for reimbursement of a 354-mg, single-dose ampoule preparation of aminolevulinic acid hydrochloride as the photosensitizing drug. By deeming the procedure experimental and/or medically unnecessary, insurers often refused payment when 96567 was used—a situation that still occurs today with regard to PDT reimbursement, although less often. In my experience, this code was considered by the American Medical Association/Specialty Society Relative Value Scale Update Committee to be a nonphysician work code with the assumption that the procedure was done by nonprovider staff (eg, medical assistant, licensed practical nurse, registered nurse) and that the physician did nothing but order the treatment.

In 2004, a methyl aminolevulinate cream that was activated with a red light source was brought to market; however, after failing to gain a substantial market share, the product is no longer available in the United States. In May of 2016, a nanoemulsion gel formulation of aminolevulinic acid hydrochloride 10% was approved by the US Food and Drug Administration4 for use with a red light source. Unlike 5-aminolevulinic acid hydrochloride solution, which was approved for application with no prior debridement of the skin,⁵ the new gel formulation was meant to be applied after degreasing with an ethanol- or isopropanol-soaked cotton pad and removal of any scaling or crusts, followed by roughening of the lesion surfaces (with care taken to avoid bleeding).⁴ The product must be administered by a health care provider and is reported using CPT codes 96573 and 96574, which are new in 2018 and are discussed in more detail below. Effective January 1, 2018, the Healthcare Common Procedure Coding System supply code for the product is J7345 (aminolevulinic acid hydrochloride gel for topical administration, 10% gel, 10 mg).6 A single tube contains 200 mg, so when an entire tube is used (which is typical), 200 units must be reported. Partial tubes may be used in some patients and should be reported appropriately based on actual usage.

The development of new CPT codes for PDT revealed a middle ground in which many physicians, including myself, have applied the photosensitizing drug themselves instead of a nonphysician provider in order to use their professional judgment to ensure the entire treatment area was covered and also allow for multiple applications of the drug to lesions that in their opinion may have warranted greater dosing, which led to the creation of CPT code 96573. The revision and refinement from one code to 3 (96567, 96573, and 96574) also involved rewording of the preamble for all 3 codes so that the phrase “premalignant and/or malignant lesions” was simplified to “premalignant lesions.” This change was made so that if and when this therapeutic approach is refined enough to be used on malignant lesions, new codes can be created to distinguish between the work performed for both types of lesions.

The new PDT codes include 96573 (photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug[s] provided by a physician or other qualified healthcare professional, per day) and 96574 (debridement of premalignant hyperkeratotic lesion[s][ie, targeted curettage, abrasion] followed with photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug[s] provided by a physician or other qualified healthcare professional, per day). According to the 2018 CPT manual,² these codes should be used to report nonsurgical treatment of cutaneous lesions using PDT (ie, external application of light to destroy premalignant lesions of the skin and adjacent mucosa by activation of photosensitizing drug). A treatment session is defined as an application of a photosensitizer to all lesions within an anatomic area (eg, face, scalp) with or without debridement of all premalignant hyperkeratotic lesions in that area followed by illumination and activation with an appropriate light source. Providers should not report codes for debridement (11000, 11001, 11004, 11005), lesion shaving (11300–11313), biopsy (11100, 11101), or lesion excision (11400–11471) within the treatment area on the same day that PDT is administered.²

With the inclusion of these new PDT codes, the older code 96567 (photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitive drug[s], per day)—which is the base or parent code of the set—should only be used for reporting PDT when a physician or other qualified health care professional is not directly involved in the delivery of the service. Code 96573 is an upgrade to 96567 to account for physician work, while code 96574 captures the extra work of disruption of the skin barrier by debridement.

The novelty here is that old codes often are replaced when new codes come along. The reader should be aware of the distinct differences, as the total value expressed in relative value units for code 96567 is lower than it was in 2017 (3.24 vs 3.80), while the 2 newer codes have higher values (codes 96573 and 96574, 5.37 and 6.92, respectively). Additionally, the reader should note that only one of the 3 codes can be used on a given anatomic area (ie, face and scalp) on a given day. In general, a single-dose package of either of the approved photosensitizing drugs can usually treat an entire anatomic area. The codes themselves are not reserved for specific anatomic areas, but the US Food and Drug Administration clearances are for only face and scalp for both drugs, so the use of more than 2 PDT codes on a given day might raise payer queries.

Whatever you do, be sure your documentation includes an explicit notation about who applied the photosensitizing drug and the technique used for debridement, if performed. Code 96574 explicitly refers to targeted curettage and abrasion but does not include other destructive modalities (eg, chemical peeling), which an auditor may or may not consider an acceptable method of debridement. Personally, I will not be using peels as a justifier for this code.

Lasers

Lasers have played a role in the treatment of severe scarring in wounded warriors and other patient populations.⁷ Until 2018, there were no CPT codes that allowed precise reporting of these therapies. We now have a series of tracking codes, which are not valued by the Specialty Society Relative Value Scale Update Committee process but are nonetheless reportable, for this valuable treatment.⁸

The base code for a new pair of codes for reporting fractional ablative laser treatment, which is modeled after the skin graft code series, is 0479T (fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm² or part thereof, or 1% of body surface area of infants and children). The add-on code is 0480T (fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm², or each additional 1% of body surface area of infants and children, or part thereof [list separately in addition to code for primary procedure]), which means the code can be reported multiple times in addition to a single unit of 0479T. The aggregate treatment area should only be reported once per day regardless of the number of passes of one or more lasers over the area that day, and codes 0479T and 0480T should not be reported with codes 0491T or 0492T, which are a new family of tracking codes used for ablative laser treatment of chronic open wounds. If the scars are excised in a full-thickness manner, the benign excision codes 11400 to 11446 should be used instead.

For laser treatment of open wounds, 0491T (ablative laser treatment, noncontact, full-field and fractional ablation, open wound, per day, total treatment surface area; first 20 cm² or less) is the base code for this pair of codes, and 0492T (ablative laser treatment, noncontact, full-field and fractional ablation, open wound, per day, total treatment surface area; each additional 20 cm², or part thereof [list separately in addition to code for primary procedure]) is the add-on code, similar to the 0479T and 00480T codes described above. Keep in mind that all 4 of these tracking codes do not have defined values, and payment is at the discretion of the payer. If utilization of the procedures increases along with the development of appropriate evidence-based literature to support it, it is possible these will be converted into standard category I CPT codes that will be valued and covered by payers.

Final Thoughts

For more details on the new codes for PDT and lasers, I would strongly suggest obtaining a copy of CPT Changes 2018: An Insider’s View (https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod2800018&navAction=push), as well as the 2018 CPT manual for those who are actively practicing. Members of the American Academy of Dermatology also can get the new CPT manual as part of the group’s Coding Value Pack (https://store.aad.org/products/11383) along with Principles of Documentation for Dermatology and 2018 Coding & Billing for Dermatology.

The year is moving ahead, and we are in the first year with a new president and a new administration. There have been multiple attempts to defund, revoke, or otherwise eliminate the Patient Protection and Affordable Care Act. As a physician, you may be asking, “What should I be doing for MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and MIPS (Merit-Based Incentive Payments System)?” Everyone wants help, and there are lots of resources.¹ The American Academy of Dermatology has excellent resources focused on how to survive in the new world of acronymic programs that seem to create more unfunded mandates and paperwork for every one of us.²

RELATED VIDEO: Update on Coding Changes: Report From the Mount Sinai Fall Symposium

What is MACRA?

The sustainable growth rate formula that had determined Medicare Part B reimbursement rates was repealed with MACRA. The sustainable growth rate, a flawed concept since it came into play under the Balanced Budget Act of 1997,³ in essence kept track of health care spending and tracked the increasing deficit that was accruing to providers, which led to statutory cuts in the Medicare conversion factor that usually were followed by Band-Aid fixes from Congress and increased each subsequent year to pay back that debt. In addition, MACRA provides a positive annual update of 0.5% in the Medicare fee schedule until 2019. This aspect of MACRA is good for providers, as was the reauthorization of the Children’s Health Insurance Program. It would be difficult to argue against the benefits of these aspects of the law.

Of course, there is no such thing as a free lunch. The less pleasant side of MACRA is the Quality Payment Program under which providers will be paid based on the quality and effectiveness of the care provided; physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists also will be under the new system in addition to physicians. We are to be paid based on value, not volume. Heady stuff. The devil, as always, is in the details, as the factors we will be measured against are diverse. Having an electronic medical record (EMR) can make capturing data for some of these measures a bit less onerous. If you do not have an EMR, the cost of transitioning to one, especially if you are a small solo practice or approaching the end of your career, may outweigh the benefits.

RELATED VIDEO: Update on Coding Changes: Report From the Mount Sinai Fall Symposium

What is MIPS?

Your traditional fee-for-service payment is linked to your performance on an overall physician quality score by MIPS. Most of us will take this route. The old systems that determined pleasure or pain for providers, including the Physician Quality Reporting System, meaningful use, and the Value-Based Payment Modifier (Value Modifier) are now gone.

A small group of providers, most likely those in large multispecialty groups or academic settings, will instead participate in advanced Alternative Payment Models that will provide a lump sum bonus payment of 5% of their Medicare charges from 2019 to 2024. Not for the faint of heart, this method is more complex for anyone who is not employed by a large enterprise.

For those taking the more common MIPS pathway, beginning in 2019 you can see a penalty of up to 4% on your Medicare payments if you do nothing and a bonus of up to 4% if you do it all. This rate will increase to a 5% penalty or a reward of up to 5% in 2020, 7% in 2021, and 9% in 2022. The penalty is a result of nonparticipation, while complete participation might get you to the maximum bonus. Of course, the bonus pool is limited, and if everyone does it all, the bonus would be much less, assuming the program is not changed or eliminated by the current administration. At the time of writing this column, Senate Majority Leader Mitch McConnell (R-KY) has failed multiple times to pass a Patient Protection and Affordable Care Act repeal bill following rebellions in his own party.⁴

So what do you, dear colleague, need to do right now, or at least before the end of the calendar year? You could do it all and try to grab the brass ring 4% bonus for 2019, putting time, effort, and expense into going after what could be an elusive reward. Or you could simply avoid the penalty and go back to work knowing you have locked in normal payments (whatever that will be!) for 2019. We are both doing the latter, and so might you, especially if you have not done anything yet this year.

MIPS Made Merry

To learn what you need to do or can do, pay a visit to the Quality Payment Program website (https://qpp.cms.gov/) where you can look yourself up with your national provider identifier number and find out what system you are under. Unless you are part of a large enterprise, you are likely under MIPS, but it never hurts to check.

It will then give you the options for reporting as an individual or a group. Either way, you can send in quality data through your routine Medicare claims process, which is our suggested route; no registry, no EMR, just an extra line on a claim form. You can review the complete list of quality measures that are available on the Quality Payment Program website (https://qpp.cms.gov/mips/quality-measures). There are 271 measures to read through and ponder, but by now you already have a headache, so take the following advice:

• Filter with the “Data Submission Method” by checking off “Claims,” which gives you 74 choices.
• Filter further with the “Specialty Measure Set”by checking off “Dermatology,” which gives you 4 choices.
• The top choice and probably the easiest one to get your staff to help with is “Documentation of Current Medications in the Medical Record,” which if you click on it further identifies it as “Quality ID: 130,” the official name of this measure.

You can see the MIPS program information in all its bureaucratic glory on the Quality Payment Program website (https://qpp.cms.gov/resources/education); click on “Quality Measure Specifications” to download a 250 MB zip file that contains information on all the measures in detail. The Measure #130 (Documentation of Current Medications in the Medical Record) file indicates that the clinician must use a G code (G8427) to report that current medications have been documented. The measure reads: “Eligible clinician attests to documenting, updating or reviewing a patient’s current medications using all immediate resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration.”⁵

You likely already confirm current medications with patients in some form or other, so simply look at the list of medications and supplements with all their dosages, frequencies, and routes of administration and sign the sheet of paper your practice likely already uses as an extra way of confirming that you have reviewed it. You report code G8427 as you would any Current Procedural Terminology code and link it to any International Classification of Diseases, Tenth Revision, code in your claim along with any evaluation and management and/or procedure codes that you would otherwise report for that encounter.

Some clearinghouses will not accept $0 charges, so we recommend you place a $0.01 charge for G8427 and write it off later. Upon receiving your explanation of benefits, you should notice 2 remark codes relating to the G8427 line: CO-246 and N620. Both of these codes indicate that the Centers for Medicare & Medicaid Services acknowledge your quality submission. To avoid that 4% penalty in 2019, you only need to do it once, but doing it a few times until you get back an explanation of benefits acknowledging it may help you sleep better.

Conclusion

Although the future of the Patient Protection and Affordable Care Act is still unclear, one thing is for sure: MACRA and MIPS are here to stay. Avoid the 4% penalty in 2019 and take good care of your patients and, if eligible, make donations to the American Academy of Dermatology Association Political Action Committee (skinPAC). It is going to be a wild ride.

The year is moving ahead, and we are in the first year with a new president and a new administration. There have been multiple attempts to defund, revoke, or otherwise eliminate the Patient Protection and Affordable Care Act. As a physician, you may be asking, “What should I be doing for MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and MIPS (Merit-Based Incentive Payments System)?” Everyone wants help, and there are lots of resources.¹ The American Academy of Dermatology has excellent resources focused on how to survive in the new world of acronymic programs that seem to create more unfunded mandates and paperwork for every one of us.²

RELATED VIDEO: Update on Coding Changes: Report From the Mount Sinai Fall Symposium

What is MACRA?

The sustainable growth rate formula that had determined Medicare Part B reimbursement rates was repealed with MACRA. The sustainable growth rate, a flawed concept since it came into play under the Balanced Budget Act of 1997,³ in essence kept track of health care spending and tracked the increasing deficit that was accruing to providers, which led to statutory cuts in the Medicare conversion factor that usually were followed by Band-Aid fixes from Congress and increased each subsequent year to pay back that debt. In addition, MACRA provides a positive annual update of 0.5% in the Medicare fee schedule until 2019. This aspect of MACRA is good for providers, as was the reauthorization of the Children’s Health Insurance Program. It would be difficult to argue against the benefits of these aspects of the law.

Of course, there is no such thing as a free lunch. The less pleasant side of MACRA is the Quality Payment Program under which providers will be paid based on the quality and effectiveness of the care provided; physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists also will be under the new system in addition to physicians. We are to be paid based on value, not volume. Heady stuff. The devil, as always, is in the details, as the factors we will be measured against are diverse. Having an electronic medical record (EMR) can make capturing data for some of these measures a bit less onerous. If you do not have an EMR, the cost of transitioning to one, especially if you are a small solo practice or approaching the end of your career, may outweigh the benefits.

RELATED VIDEO: Update on Coding Changes: Report From the Mount Sinai Fall Symposium

What is MIPS?

Your traditional fee-for-service payment is linked to your performance on an overall physician quality score by MIPS. Most of us will take this route. The old systems that determined pleasure or pain for providers, including the Physician Quality Reporting System, meaningful use, and the Value-Based Payment Modifier (Value Modifier) are now gone.

A small group of providers, most likely those in large multispecialty groups or academic settings, will instead participate in advanced Alternative Payment Models that will provide a lump sum bonus payment of 5% of their Medicare charges from 2019 to 2024. Not for the faint of heart, this method is more complex for anyone who is not employed by a large enterprise.

For those taking the more common MIPS pathway, beginning in 2019 you can see a penalty of up to 4% on your Medicare payments if you do nothing and a bonus of up to 4% if you do it all. This rate will increase to a 5% penalty or a reward of up to 5% in 2020, 7% in 2021, and 9% in 2022. The penalty is a result of nonparticipation, while complete participation might get you to the maximum bonus. Of course, the bonus pool is limited, and if everyone does it all, the bonus would be much less, assuming the program is not changed or eliminated by the current administration. At the time of writing this column, Senate Majority Leader Mitch McConnell (R-KY) has failed multiple times to pass a Patient Protection and Affordable Care Act repeal bill following rebellions in his own party.⁴

So what do you, dear colleague, need to do right now, or at least before the end of the calendar year? You could do it all and try to grab the brass ring 4% bonus for 2019, putting time, effort, and expense into going after what could be an elusive reward. Or you could simply avoid the penalty and go back to work knowing you have locked in normal payments (whatever that will be!) for 2019. We are both doing the latter, and so might you, especially if you have not done anything yet this year.

MIPS Made Merry

To learn what you need to do or can do, pay a visit to the Quality Payment Program website (https://qpp.cms.gov/) where you can look yourself up with your national provider identifier number and find out what system you are under. Unless you are part of a large enterprise, you are likely under MIPS, but it never hurts to check.

It will then give you the options for reporting as an individual or a group. Either way, you can send in quality data through your routine Medicare claims process, which is our suggested route; no registry, no EMR, just an extra line on a claim form. You can review the complete list of quality measures that are available on the Quality Payment Program website (https://qpp.cms.gov/mips/quality-measures). There are 271 measures to read through and ponder, but by now you already have a headache, so take the following advice:

• Filter with the “Data Submission Method” by checking off “Claims,” which gives you 74 choices.
• Filter further with the “Specialty Measure Set”by checking off “Dermatology,” which gives you 4 choices.
• The top choice and probably the easiest one to get your staff to help with is “Documentation of Current Medications in the Medical Record,” which if you click on it further identifies it as “Quality ID: 130,” the official name of this measure.

You can see the MIPS program information in all its bureaucratic glory on the Quality Payment Program website (https://qpp.cms.gov/resources/education); click on “Quality Measure Specifications” to download a 250 MB zip file that contains information on all the measures in detail. The Measure #130 (Documentation of Current Medications in the Medical Record) file indicates that the clinician must use a G code (G8427) to report that current medications have been documented. The measure reads: “Eligible clinician attests to documenting, updating or reviewing a patient’s current medications using all immediate resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration.”⁵

You likely already confirm current medications with patients in some form or other, so simply look at the list of medications and supplements with all their dosages, frequencies, and routes of administration and sign the sheet of paper your practice likely already uses as an extra way of confirming that you have reviewed it. You report code G8427 as you would any Current Procedural Terminology code and link it to any International Classification of Diseases, Tenth Revision, code in your claim along with any evaluation and management and/or procedure codes that you would otherwise report for that encounter.

Some clearinghouses will not accept $0 charges, so we recommend you place a $0.01 charge for G8427 and write it off later. Upon receiving your explanation of benefits, you should notice 2 remark codes relating to the G8427 line: CO-246 and N620. Both of these codes indicate that the Centers for Medicare & Medicaid Services acknowledge your quality submission. To avoid that 4% penalty in 2019, you only need to do it once, but doing it a few times until you get back an explanation of benefits acknowledging it may help you sleep better.

Conclusion

Although the future of the Patient Protection and Affordable Care Act is still unclear, one thing is for sure: MACRA and MIPS are here to stay. Avoid the 4% penalty in 2019 and take good care of your patients and, if eligible, make donations to the American Academy of Dermatology Association Political Action Committee (skinPAC). It is going to be a wild ride.

The year is moving ahead, and we are in the first year with a new president and a new administration. There have been multiple attempts to defund, revoke, or otherwise eliminate the Patient Protection and Affordable Care Act. As a physician, you may be asking, “What should I be doing for MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and MIPS (Merit-Based Incentive Payments System)?” Everyone wants help, and there are lots of resources.¹ The American Academy of Dermatology has excellent resources focused on how to survive in the new world of acronymic programs that seem to create more unfunded mandates and paperwork for every one of us.²

RELATED VIDEO: Update on Coding Changes: Report From the Mount Sinai Fall Symposium

What is MACRA?

The sustainable growth rate formula that had determined Medicare Part B reimbursement rates was repealed with MACRA. The sustainable growth rate, a flawed concept since it came into play under the Balanced Budget Act of 1997,³ in essence kept track of health care spending and tracked the increasing deficit that was accruing to providers, which led to statutory cuts in the Medicare conversion factor that usually were followed by Band-Aid fixes from Congress and increased each subsequent year to pay back that debt. In addition, MACRA provides a positive annual update of 0.5% in the Medicare fee schedule until 2019. This aspect of MACRA is good for providers, as was the reauthorization of the Children’s Health Insurance Program. It would be difficult to argue against the benefits of these aspects of the law.

Of course, there is no such thing as a free lunch. The less pleasant side of MACRA is the Quality Payment Program under which providers will be paid based on the quality and effectiveness of the care provided; physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists also will be under the new system in addition to physicians. We are to be paid based on value, not volume. Heady stuff. The devil, as always, is in the details, as the factors we will be measured against are diverse. Having an electronic medical record (EMR) can make capturing data for some of these measures a bit less onerous. If you do not have an EMR, the cost of transitioning to one, especially if you are a small solo practice or approaching the end of your career, may outweigh the benefits.

RELATED VIDEO: Update on Coding Changes: Report From the Mount Sinai Fall Symposium

What is MIPS?

Your traditional fee-for-service payment is linked to your performance on an overall physician quality score by MIPS. Most of us will take this route. The old systems that determined pleasure or pain for providers, including the Physician Quality Reporting System, meaningful use, and the Value-Based Payment Modifier (Value Modifier) are now gone.

A small group of providers, most likely those in large multispecialty groups or academic settings, will instead participate in advanced Alternative Payment Models that will provide a lump sum bonus payment of 5% of their Medicare charges from 2019 to 2024. Not for the faint of heart, this method is more complex for anyone who is not employed by a large enterprise.

For those taking the more common MIPS pathway, beginning in 2019 you can see a penalty of up to 4% on your Medicare payments if you do nothing and a bonus of up to 4% if you do it all. This rate will increase to a 5% penalty or a reward of up to 5% in 2020, 7% in 2021, and 9% in 2022. The penalty is a result of nonparticipation, while complete participation might get you to the maximum bonus. Of course, the bonus pool is limited, and if everyone does it all, the bonus would be much less, assuming the program is not changed or eliminated by the current administration. At the time of writing this column, Senate Majority Leader Mitch McConnell (R-KY) has failed multiple times to pass a Patient Protection and Affordable Care Act repeal bill following rebellions in his own party.⁴

So what do you, dear colleague, need to do right now, or at least before the end of the calendar year? You could do it all and try to grab the brass ring 4% bonus for 2019, putting time, effort, and expense into going after what could be an elusive reward. Or you could simply avoid the penalty and go back to work knowing you have locked in normal payments (whatever that will be!) for 2019. We are both doing the latter, and so might you, especially if you have not done anything yet this year.

MIPS Made Merry

To learn what you need to do or can do, pay a visit to the Quality Payment Program website (https://qpp.cms.gov/) where you can look yourself up with your national provider identifier number and find out what system you are under. Unless you are part of a large enterprise, you are likely under MIPS, but it never hurts to check.

It will then give you the options for reporting as an individual or a group. Either way, you can send in quality data through your routine Medicare claims process, which is our suggested route; no registry, no EMR, just an extra line on a claim form. You can review the complete list of quality measures that are available on the Quality Payment Program website (https://qpp.cms.gov/mips/quality-measures). There are 271 measures to read through and ponder, but by now you already have a headache, so take the following advice:

• Filter with the “Data Submission Method” by checking off “Claims,” which gives you 74 choices.
• Filter further with the “Specialty Measure Set”by checking off “Dermatology,” which gives you 4 choices.
• The top choice and probably the easiest one to get your staff to help with is “Documentation of Current Medications in the Medical Record,” which if you click on it further identifies it as “Quality ID: 130,” the official name of this measure.

You can see the MIPS program information in all its bureaucratic glory on the Quality Payment Program website (https://qpp.cms.gov/resources/education); click on “Quality Measure Specifications” to download a 250 MB zip file that contains information on all the measures in detail. The Measure #130 (Documentation of Current Medications in the Medical Record) file indicates that the clinician must use a G code (G8427) to report that current medications have been documented. The measure reads: “Eligible clinician attests to documenting, updating or reviewing a patient’s current medications using all immediate resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration.”⁵

You likely already confirm current medications with patients in some form or other, so simply look at the list of medications and supplements with all their dosages, frequencies, and routes of administration and sign the sheet of paper your practice likely already uses as an extra way of confirming that you have reviewed it. You report code G8427 as you would any Current Procedural Terminology code and link it to any International Classification of Diseases, Tenth Revision, code in your claim along with any evaluation and management and/or procedure codes that you would otherwise report for that encounter.

Some clearinghouses will not accept $0 charges, so we recommend you place a $0.01 charge for G8427 and write it off later. Upon receiving your explanation of benefits, you should notice 2 remark codes relating to the G8427 line: CO-246 and N620. Both of these codes indicate that the Centers for Medicare & Medicaid Services acknowledge your quality submission. To avoid that 4% penalty in 2019, you only need to do it once, but doing it a few times until you get back an explanation of benefits acknowledging it may help you sleep better.

Conclusion

Although the future of the Patient Protection and Affordable Care Act is still unclear, one thing is for sure: MACRA and MIPS are here to stay. Avoid the 4% penalty in 2019 and take good care of your patients and, if eligible, make donations to the American Academy of Dermatology Association Political Action Committee (skinPAC). It is going to be a wild ride.

All physicians will see changes in reimbursement in 2017. A new president with a new agenda makes for an interesting time ahead for health care in the United States. However, in this time of flux, there is one constant: the Final Rule, an informal term for the annual update on how the Medicare system will function and how much you will get paid for what you do.¹ The document is 393 pages and outlines what is new in the Medicare system, with lots of supplements giving granular details about physician work, overhead, and supply and labor costs. In this column, I have taken the liberty of dissecting the Final Rule for you and to bring attention to its high and low points for dermatologists.

Changes in Relative Value Units

The conversion factor has gone up, meaning you will be paid a bit more this year for what you do; it is not enough to account for inflation or the increasing cost of unfunded mandates, but it is better than nothing. Although the conversion factor was $35.8043 in 2016, it increased by more than 0.2% on January 1, 2017, to $35.8887.¹ How is this conversion factor calculated? We go up 0.5% due to MACRA (Medicare Access and CHIP Reauthorization Act), down 0.013% due to budget neutrality, down 0.07% due to multiple procedure payment reduction changes, and down another 0.18% due to the misvalued code target.¹ The misvalued code target is related to targets established by statute for 2016 to 2018 and payment rates are reduced across the board if they are not met.

If payments suffer from reductions in work value, they may not happen all at once. If the Centers for Medicare & Medicaid Services (CMS) reduce total relative value units (RVUs) by more than 20%, reductions will take place over at least 2 years with a single year drop maximum of 19%.¹ Unfortunately, such limits do not apply to revised codes, which can take as big a hit as the CMS cares to make.

Changes to Global Periods

In 2015, we learned that 10- and 90-day global periods would be eliminated in 2017 and 2018, respectively, with great concern on the part of the government about the number and level of evaluation and management services embedded in these codes. The implementation of global policy elimination was prohibited by MACRA and the CMS was required to develop and implement a process to gather data on services furnished in the global period from a representative sample of physicians, which they will use to value surgical services beginningin 2019.¹ The CMS decided to capture this data with a new set of time-based G codes (which would be onerous for all practicing physicians), not just the unlucky folks who were to be the sample mandated under MACRA.² During the comment period, it became obvious to the CMS that this concept was flawed for many reasons and it decided to hold a town hall meeting at the CMS headquarters on August 25, 2016, on data collection on resources used in furnishing global services in which 90 minutes of live testimony in the morning was followed by another 90 minutes by telephone in the afternoon.³ This meeting, which I attended, resulted in the CMS changing the all-practitioner reporting program to a specified sample with others allowed to opt in. Practitioners in groups of less than 10 are exempt, and only physicians in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island must capture data beginning in July 2017.¹ These data only have to be captured on codes that are used by more than 100 practitioners and are furnished at least 10,000 times or have allowed charges of greater than $10,000,000 annually. If you are lucky enough to live in one of the testing states, you must start on July 1 but can start before July 1 if you wish. Practitioners in smaller practices or in other geographic areas are encouraged to report data if feasible but are not required to do so. Current Procedural Terminology (CPT) code 99024 will be used for reporting postoperative services rather than the proposed onerous set of G codes, and reporting will not be required for preoperative visits included in the global package or for services not related to the patient’s visit.

Changes to Chronic Care Management

There are new and modified chronic care management codes that are not of use to you unless you are the primary provider for the patient and you and the patient meet multiple stringent requirements.⁴ The patient must have multiple illnesses, use multiple medications, be unable to perform activities of daily living, require a caregiver, and/or have repeat admissions or emergency department visits. Typical adult patients who receive complex chronic care management services are treated with 3 or more prescription medications and may be receiving other types of therapeutic interventions (eg, physical therapy, occupational therapy). Typical pediatric patients receive 3 or more therapeutic interventions (eg, medications, nutritional support, respiratory therapy). All patients have 2 or more chronic continuous or episodic health conditions that are expected to last at least 12 months or until the death of the patient and place the patient at serious risk for death, acute exacerbation/decompensation, or functional decline.⁴

Changes to Moderate Sedation Codes

The economic value of providing moderate sedation (eg, drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation) used to be embedded in a variety of CPT codes, which is no longer the case in 2017. Diazepam or similar drugs swallowed or dissolved under the tongue are not included. The new CPT codes 99151, 99152, 99153, 99155, 99156, and 99157 are not to be used to report administration of medications for pain control or minimal sedation (anxiolysis). An independent trained observer, an individual who is qualified to monitor the patient during the procedure and who has no other duties (eg, assisting at surgery) during the procedure, must be present. If you are thinking of using these codes, read the entire section in the CPT manual,⁴ check your state laws, and consult your malpractice carrier and perhaps even your health care attorney.

Changes to Nail Procedure Codes

Current Procedural Terminology code 11752 (excision of nail and nail matrix, partial or complete [eg, ingrown or deformed nail], for permanent removal; with amputation of tuft of distal phalanx) is now gone, while base code 11750 remains. If you are doing nail surgery and removing underlying bone, instead use code 26236 (partial excision [craterization, saucerization, or diaphysectomy] bone [eg, osteomyelitis]; distal phalanx of finger), 28124 (partial excision [craterization, saucerization, sequestrectomy, or diaphysectomy] bone [eg, osteomyelitis or bossing]; phalanx of toe), or other codes in the same section of the CPT manual if they more precisely describe the procedure performed.

Changes to Slide Consultation Codes

The slide consultation codes 88321 (consultation and report on referred slides prepared elsewhere), 88323 (consultation and report on referred material requiring preparation of slides), and 88325 (consultation, comprehensive, with review of records and specimens, with report on referred material) were revalued this year, with the first 2 showing no change but the latter showing an increase in value from 2.50 to 2.85 RVUs.¹ None are meant to be routine. If you have every slide looked at by someone else for “quality assurance reasons,” the consultation is not reportable. If you use these consultation codes too often, the CMS might have concerns about fraud and abuse. Visit http://data.cms.gov to see how you compare to your peers.

Changes to Reflectance Confocal Microscopy Codes

Reflectance confocal microscopy had new codes for 2016, which were carrier priced, and in 2017 they have real RVUs per the CMS. The payments for these codes have a national average reimbursement of $161.85 for 96931 (reflectance confocal microscopy for cellular and subcellular imaging of skin; image acquisition and interpretation and report, first lesion), $104.80 for 96932 (image acquisition only, first lesion), and $45.94 for 96933 (interpretation and report only, first lesion).⁵ The respective add-on codes have values of $83.26 for 96934 (image acquisition and interpretation and report, each additional lesion [list separately in addition to code for primary procedure]), $35.17 for 96935 (image acquisition only, each additional lesion [list separately in addition to code for primary procedure]), and $43.78 for 96936 (interpretation and report only, each additional lesion [list separately in addition to code for primary procedure]).

Other Coding Changes

There are a whole bunch of new codes in the “Genomic Sequencing Procedures and Other Molecular Multianalyte Assays” (MMAAs) section of CPT. The important thing for you to remember is these codes are for the laboratory performing the assay to report, not the physician ordering it. There is a new Appendix O for proprietary laboratory analysis MMAAs, including those that do not have a Category I code. These MMAAs are identified in Appendix O by a 4-digit number followed by the letter M.⁴

There are some revisions to psychotherapy codes 90832 to 90847. These codes are outside our scope of practice and should only be used by psychiatrists, social workers, psychologists, or other appropriate mental health workers.

Final Thoughts

It has not been a breakout year for telehealth and we still do not have payment for store-and-forward teledermatology, except in a few designated rural areas. With the advent of the rhetoric we have heard after the presidential election, any speculation on what will happen to the brave new world of the merit-based incentive payment system, alternative payment models, and other regulations are anyone’s guess.

All physicians will see changes in reimbursement in 2017. A new president with a new agenda makes for an interesting time ahead for health care in the United States. However, in this time of flux, there is one constant: the Final Rule, an informal term for the annual update on how the Medicare system will function and how much you will get paid for what you do.¹ The document is 393 pages and outlines what is new in the Medicare system, with lots of supplements giving granular details about physician work, overhead, and supply and labor costs. In this column, I have taken the liberty of dissecting the Final Rule for you and to bring attention to its high and low points for dermatologists.

Changes in Relative Value Units

The conversion factor has gone up, meaning you will be paid a bit more this year for what you do; it is not enough to account for inflation or the increasing cost of unfunded mandates, but it is better than nothing. Although the conversion factor was $35.8043 in 2016, it increased by more than 0.2% on January 1, 2017, to $35.8887.¹ How is this conversion factor calculated? We go up 0.5% due to MACRA (Medicare Access and CHIP Reauthorization Act), down 0.013% due to budget neutrality, down 0.07% due to multiple procedure payment reduction changes, and down another 0.18% due to the misvalued code target.¹ The misvalued code target is related to targets established by statute for 2016 to 2018 and payment rates are reduced across the board if they are not met.

If payments suffer from reductions in work value, they may not happen all at once. If the Centers for Medicare & Medicaid Services (CMS) reduce total relative value units (RVUs) by more than 20%, reductions will take place over at least 2 years with a single year drop maximum of 19%.¹ Unfortunately, such limits do not apply to revised codes, which can take as big a hit as the CMS cares to make.

Changes to Global Periods

In 2015, we learned that 10- and 90-day global periods would be eliminated in 2017 and 2018, respectively, with great concern on the part of the government about the number and level of evaluation and management services embedded in these codes. The implementation of global policy elimination was prohibited by MACRA and the CMS was required to develop and implement a process to gather data on services furnished in the global period from a representative sample of physicians, which they will use to value surgical services beginningin 2019.¹ The CMS decided to capture this data with a new set of time-based G codes (which would be onerous for all practicing physicians), not just the unlucky folks who were to be the sample mandated under MACRA.² During the comment period, it became obvious to the CMS that this concept was flawed for many reasons and it decided to hold a town hall meeting at the CMS headquarters on August 25, 2016, on data collection on resources used in furnishing global services in which 90 minutes of live testimony in the morning was followed by another 90 minutes by telephone in the afternoon.³ This meeting, which I attended, resulted in the CMS changing the all-practitioner reporting program to a specified sample with others allowed to opt in. Practitioners in groups of less than 10 are exempt, and only physicians in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island must capture data beginning in July 2017.¹ These data only have to be captured on codes that are used by more than 100 practitioners and are furnished at least 10,000 times or have allowed charges of greater than $10,000,000 annually. If you are lucky enough to live in one of the testing states, you must start on July 1 but can start before July 1 if you wish. Practitioners in smaller practices or in other geographic areas are encouraged to report data if feasible but are not required to do so. Current Procedural Terminology (CPT) code 99024 will be used for reporting postoperative services rather than the proposed onerous set of G codes, and reporting will not be required for preoperative visits included in the global package or for services not related to the patient’s visit.

Changes to Chronic Care Management

There are new and modified chronic care management codes that are not of use to you unless you are the primary provider for the patient and you and the patient meet multiple stringent requirements.⁴ The patient must have multiple illnesses, use multiple medications, be unable to perform activities of daily living, require a caregiver, and/or have repeat admissions or emergency department visits. Typical adult patients who receive complex chronic care management services are treated with 3 or more prescription medications and may be receiving other types of therapeutic interventions (eg, physical therapy, occupational therapy). Typical pediatric patients receive 3 or more therapeutic interventions (eg, medications, nutritional support, respiratory therapy). All patients have 2 or more chronic continuous or episodic health conditions that are expected to last at least 12 months or until the death of the patient and place the patient at serious risk for death, acute exacerbation/decompensation, or functional decline.⁴

Changes to Moderate Sedation Codes

The economic value of providing moderate sedation (eg, drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation) used to be embedded in a variety of CPT codes, which is no longer the case in 2017. Diazepam or similar drugs swallowed or dissolved under the tongue are not included. The new CPT codes 99151, 99152, 99153, 99155, 99156, and 99157 are not to be used to report administration of medications for pain control or minimal sedation (anxiolysis). An independent trained observer, an individual who is qualified to monitor the patient during the procedure and who has no other duties (eg, assisting at surgery) during the procedure, must be present. If you are thinking of using these codes, read the entire section in the CPT manual,⁴ check your state laws, and consult your malpractice carrier and perhaps even your health care attorney.

Changes to Nail Procedure Codes

Current Procedural Terminology code 11752 (excision of nail and nail matrix, partial or complete [eg, ingrown or deformed nail], for permanent removal; with amputation of tuft of distal phalanx) is now gone, while base code 11750 remains. If you are doing nail surgery and removing underlying bone, instead use code 26236 (partial excision [craterization, saucerization, or diaphysectomy] bone [eg, osteomyelitis]; distal phalanx of finger), 28124 (partial excision [craterization, saucerization, sequestrectomy, or diaphysectomy] bone [eg, osteomyelitis or bossing]; phalanx of toe), or other codes in the same section of the CPT manual if they more precisely describe the procedure performed.

Changes to Slide Consultation Codes

The slide consultation codes 88321 (consultation and report on referred slides prepared elsewhere), 88323 (consultation and report on referred material requiring preparation of slides), and 88325 (consultation, comprehensive, with review of records and specimens, with report on referred material) were revalued this year, with the first 2 showing no change but the latter showing an increase in value from 2.50 to 2.85 RVUs.¹ None are meant to be routine. If you have every slide looked at by someone else for “quality assurance reasons,” the consultation is not reportable. If you use these consultation codes too often, the CMS might have concerns about fraud and abuse. Visit http://data.cms.gov to see how you compare to your peers.

Changes to Reflectance Confocal Microscopy Codes

Reflectance confocal microscopy had new codes for 2016, which were carrier priced, and in 2017 they have real RVUs per the CMS. The payments for these codes have a national average reimbursement of $161.85 for 96931 (reflectance confocal microscopy for cellular and subcellular imaging of skin; image acquisition and interpretation and report, first lesion), $104.80 for 96932 (image acquisition only, first lesion), and $45.94 for 96933 (interpretation and report only, first lesion).⁵ The respective add-on codes have values of $83.26 for 96934 (image acquisition and interpretation and report, each additional lesion [list separately in addition to code for primary procedure]), $35.17 for 96935 (image acquisition only, each additional lesion [list separately in addition to code for primary procedure]), and $43.78 for 96936 (interpretation and report only, each additional lesion [list separately in addition to code for primary procedure]).

Other Coding Changes

There are a whole bunch of new codes in the “Genomic Sequencing Procedures and Other Molecular Multianalyte Assays” (MMAAs) section of CPT. The important thing for you to remember is these codes are for the laboratory performing the assay to report, not the physician ordering it. There is a new Appendix O for proprietary laboratory analysis MMAAs, including those that do not have a Category I code. These MMAAs are identified in Appendix O by a 4-digit number followed by the letter M.⁴

There are some revisions to psychotherapy codes 90832 to 90847. These codes are outside our scope of practice and should only be used by psychiatrists, social workers, psychologists, or other appropriate mental health workers.

Final Thoughts

It has not been a breakout year for telehealth and we still do not have payment for store-and-forward teledermatology, except in a few designated rural areas. With the advent of the rhetoric we have heard after the presidential election, any speculation on what will happen to the brave new world of the merit-based incentive payment system, alternative payment models, and other regulations are anyone’s guess.

All physicians will see changes in reimbursement in 2017. A new president with a new agenda makes for an interesting time ahead for health care in the United States. However, in this time of flux, there is one constant: the Final Rule, an informal term for the annual update on how the Medicare system will function and how much you will get paid for what you do.¹ The document is 393 pages and outlines what is new in the Medicare system, with lots of supplements giving granular details about physician work, overhead, and supply and labor costs. In this column, I have taken the liberty of dissecting the Final Rule for you and to bring attention to its high and low points for dermatologists.

Changes in Relative Value Units

The conversion factor has gone up, meaning you will be paid a bit more this year for what you do; it is not enough to account for inflation or the increasing cost of unfunded mandates, but it is better than nothing. Although the conversion factor was $35.8043 in 2016, it increased by more than 0.2% on January 1, 2017, to $35.8887.¹ How is this conversion factor calculated? We go up 0.5% due to MACRA (Medicare Access and CHIP Reauthorization Act), down 0.013% due to budget neutrality, down 0.07% due to multiple procedure payment reduction changes, and down another 0.18% due to the misvalued code target.¹ The misvalued code target is related to targets established by statute for 2016 to 2018 and payment rates are reduced across the board if they are not met.

If payments suffer from reductions in work value, they may not happen all at once. If the Centers for Medicare & Medicaid Services (CMS) reduce total relative value units (RVUs) by more than 20%, reductions will take place over at least 2 years with a single year drop maximum of 19%.¹ Unfortunately, such limits do not apply to revised codes, which can take as big a hit as the CMS cares to make.

Changes to Global Periods

In 2015, we learned that 10- and 90-day global periods would be eliminated in 2017 and 2018, respectively, with great concern on the part of the government about the number and level of evaluation and management services embedded in these codes. The implementation of global policy elimination was prohibited by MACRA and the CMS was required to develop and implement a process to gather data on services furnished in the global period from a representative sample of physicians, which they will use to value surgical services beginningin 2019.¹ The CMS decided to capture this data with a new set of time-based G codes (which would be onerous for all practicing physicians), not just the unlucky folks who were to be the sample mandated under MACRA.² During the comment period, it became obvious to the CMS that this concept was flawed for many reasons and it decided to hold a town hall meeting at the CMS headquarters on August 25, 2016, on data collection on resources used in furnishing global services in which 90 minutes of live testimony in the morning was followed by another 90 minutes by telephone in the afternoon.³ This meeting, which I attended, resulted in the CMS changing the all-practitioner reporting program to a specified sample with others allowed to opt in. Practitioners in groups of less than 10 are exempt, and only physicians in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island must capture data beginning in July 2017.¹ These data only have to be captured on codes that are used by more than 100 practitioners and are furnished at least 10,000 times or have allowed charges of greater than $10,000,000 annually. If you are lucky enough to live in one of the testing states, you must start on July 1 but can start before July 1 if you wish. Practitioners in smaller practices or in other geographic areas are encouraged to report data if feasible but are not required to do so. Current Procedural Terminology (CPT) code 99024 will be used for reporting postoperative services rather than the proposed onerous set of G codes, and reporting will not be required for preoperative visits included in the global package or for services not related to the patient’s visit.

Changes to Chronic Care Management

There are new and modified chronic care management codes that are not of use to you unless you are the primary provider for the patient and you and the patient meet multiple stringent requirements.⁴ The patient must have multiple illnesses, use multiple medications, be unable to perform activities of daily living, require a caregiver, and/or have repeat admissions or emergency department visits. Typical adult patients who receive complex chronic care management services are treated with 3 or more prescription medications and may be receiving other types of therapeutic interventions (eg, physical therapy, occupational therapy). Typical pediatric patients receive 3 or more therapeutic interventions (eg, medications, nutritional support, respiratory therapy). All patients have 2 or more chronic continuous or episodic health conditions that are expected to last at least 12 months or until the death of the patient and place the patient at serious risk for death, acute exacerbation/decompensation, or functional decline.⁴

Changes to Moderate Sedation Codes

The economic value of providing moderate sedation (eg, drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation) used to be embedded in a variety of CPT codes, which is no longer the case in 2017. Diazepam or similar drugs swallowed or dissolved under the tongue are not included. The new CPT codes 99151, 99152, 99153, 99155, 99156, and 99157 are not to be used to report administration of medications for pain control or minimal sedation (anxiolysis). An independent trained observer, an individual who is qualified to monitor the patient during the procedure and who has no other duties (eg, assisting at surgery) during the procedure, must be present. If you are thinking of using these codes, read the entire section in the CPT manual,⁴ check your state laws, and consult your malpractice carrier and perhaps even your health care attorney.

Changes to Nail Procedure Codes

Current Procedural Terminology code 11752 (excision of nail and nail matrix, partial or complete [eg, ingrown or deformed nail], for permanent removal; with amputation of tuft of distal phalanx) is now gone, while base code 11750 remains. If you are doing nail surgery and removing underlying bone, instead use code 26236 (partial excision [craterization, saucerization, or diaphysectomy] bone [eg, osteomyelitis]; distal phalanx of finger), 28124 (partial excision [craterization, saucerization, sequestrectomy, or diaphysectomy] bone [eg, osteomyelitis or bossing]; phalanx of toe), or other codes in the same section of the CPT manual if they more precisely describe the procedure performed.

Changes to Slide Consultation Codes

The slide consultation codes 88321 (consultation and report on referred slides prepared elsewhere), 88323 (consultation and report on referred material requiring preparation of slides), and 88325 (consultation, comprehensive, with review of records and specimens, with report on referred material) were revalued this year, with the first 2 showing no change but the latter showing an increase in value from 2.50 to 2.85 RVUs.¹ None are meant to be routine. If you have every slide looked at by someone else for “quality assurance reasons,” the consultation is not reportable. If you use these consultation codes too often, the CMS might have concerns about fraud and abuse. Visit http://data.cms.gov to see how you compare to your peers.

Changes to Reflectance Confocal Microscopy Codes

Reflectance confocal microscopy had new codes for 2016, which were carrier priced, and in 2017 they have real RVUs per the CMS. The payments for these codes have a national average reimbursement of $161.85 for 96931 (reflectance confocal microscopy for cellular and subcellular imaging of skin; image acquisition and interpretation and report, first lesion), $104.80 for 96932 (image acquisition only, first lesion), and $45.94 for 96933 (interpretation and report only, first lesion).⁵ The respective add-on codes have values of $83.26 for 96934 (image acquisition and interpretation and report, each additional lesion [list separately in addition to code for primary procedure]), $35.17 for 96935 (image acquisition only, each additional lesion [list separately in addition to code for primary procedure]), and $43.78 for 96936 (interpretation and report only, each additional lesion [list separately in addition to code for primary procedure]).

Other Coding Changes

There are a whole bunch of new codes in the “Genomic Sequencing Procedures and Other Molecular Multianalyte Assays” (MMAAs) section of CPT. The important thing for you to remember is these codes are for the laboratory performing the assay to report, not the physician ordering it. There is a new Appendix O for proprietary laboratory analysis MMAAs, including those that do not have a Category I code. These MMAAs are identified in Appendix O by a 4-digit number followed by the letter M.⁴

There are some revisions to psychotherapy codes 90832 to 90847. These codes are outside our scope of practice and should only be used by psychiatrists, social workers, psychologists, or other appropriate mental health workers.

Final Thoughts

It has not been a breakout year for telehealth and we still do not have payment for store-and-forward teledermatology, except in a few designated rural areas. With the advent of the rhetoric we have heard after the presidential election, any speculation on what will happen to the brave new world of the merit-based incentive payment system, alternative payment models, and other regulations are anyone’s guess.

When you pick up the Current Procedural Terminology (CPT) manual and read it, you may wonder what certain terms mean and how they may be looked at by payers and auditors. As your eyes glaze over from reading mind-numbing descriptions, a few points should be obvious, but conversations with friends, colleagues, and US Office of Inspector General and Centers for Medicare & Medicaid Services forensic investigators have convinced me that it is time for a refresher.

Excisions

For excisions (11400–11646), size is easy to determine. You measure the longest diameter of the lesion and the smallest margin required based on your judgment. The sum of the diameter and twice the margin is your lesion size. For benign lesions, the margin can be as small as 0 to 1 mm. For malignancies, it might be 5 to 9 mm for a melanoma in situ, 1 cm or more for an invasive melanoma with similar margins for squamous cell carcinoma, and somewhat less than 1 cm for basal cell carcinomas and more than 1 cm for Merkel cell carcinomas or spindle cell neoplasms. Unlike the shave removal codes (11300–11313), which do not involve subcutaneous tissue, an excision is at least full thickness through the dermis, which means a clever auditor would expect to see at least some fat on sections in most cases. Assuming you are through to fat, you may or may not close the wound. If you close the wound in a nonlayered manner, the repair is included and is not separately reportable. If you need to perform an intermediate layered closure (12031–12057) to get optimal function and cosmesis, the repair is separately reportable, as is a complex repair (13100–13163), which often includes wide undermining and other factors that differentiate it from an intermediate repair. If a more demanding repair is needed, you might use an adjacent tissue transfer (14000–14061), but the excision is included and not separately reportable. Skin grafts, most commonly split-thickness grafts, do not include the excision, which can be reported separately; direct closure of the graft donor site also is included.

There are times when you may delay a repair for medical reasons, which you would document in the medical record, but if you systematically delay a repair overnight to avoid the multiple procedure payment reduction, you may become “a person of interest,” which is a bad thing.

The shave removal codes (11300–11313) do not require repair and hemostasis is included. The size of the lesion determines the size of the lesion reported, and margins are not included. Hemostasis is included in the value of the CPT code and is not separately reportable.

It is not uncommon for a patient, usually one well known to you, to present with another skin cancer that has classic clinical findings. You review options with your patient and proceed to take one of the following approaches.

Option 1: You can tangentially remove or curette the tumor bulk and send the specimen for pathology review. At the same time, you curette and cauterize the base. In this case, you should hold your bill and await pathology. If the lesion is malignant, you would report the appropriate malignant destruction code (17260–17286) only. If it is benign, you would report a biopsy based on site or a benign destruction (17110) if for some reason the destruction was medically necessary. If it is an actinic keratosis, you could report either a biopsy or a premalignant destruction (17000).

Option 2: You perform a full-thickness excision of the lesion with a margin to remove it and send the specimen for pathology review. You should hold your bill and await pathology. If the lesion is malignant, you would report the appropriate malignant excision (11600–11646) and repair as discussed above. If it is benign, you would report the appropriate benign excision (11400–11446) and repair as discussed above.

If a shave, excision, or destruction is performed, a biopsy of the tissue should never be reported separately simply because the tissue may be sent to the laboratory. In other words, a biopsy is not separately reportable when another procedure was done at the same site on the same day.

Biopsy

Biopsies come in 2 varieties: general and site specific. All dermatologists are familiar with the basic skin biopsy codes 11110 and 11101 (biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed). Many are not aware of site-specific biopsy codes that often are more appropriate and should be used when their localization is more precise than the general skin biopsy.

Biopsies of the nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) are reported using CPT code 11755. A simple nail clipping for culture or periodic acid–Schiff stain is not a nail biopsy and should not be separately reported from the evaluation and management component of the visit.

The lip biopsy code (40490) is used appropriately when the vermilion is sampled, not the skin around it. If the skin and vermilion are contiguously sampled, only report 40490. Specific codes exist for the vestibule of the mouth (40808), the anterior two-thirds (41100) and posterior one-third (41105) of the tongue, the floor (41108) and roof (42100) of the mouth, and the salivary glands by needle (42400) or by incision (42405).

The penis can be biopsied on the surface (54100) or deep structures can be sampled (54105), though the latter is uncommon in dermatology practices. The vulva can be sampled with codes comparable to general biopsy, with 54605 for the first biopsy and 54606 used for each additional one.

An incisional biopsy of the eyelid margin is reported with 67810, while conjunctival biopsy is reported with 68100; 68510 describes a lacrimal gland biopsy. The ear, not to be left out, has its own biopsy codes, with 69100 for the external ear and 69105 for the auditory canal.

Clipping of hair or tape stripping of skin (similar to nail clipping described above) are not biopsies and are not separately reportable, as the work involved is considered incident to the cognitive visit taking place.

Final Thoughts

These points should all be fairly straightforward—yes, the skin biopsy includes mucosa, but if a mucosal site such as the mouth has a more specific code, then that code is correct—and the simplest test for the clinician is to ask yourself, “If I were reviewing the claim, what would I expect to see?” As always, document what you do, do what you document, and report that which is medically necessary.

When you pick up the Current Procedural Terminology (CPT) manual and read it, you may wonder what certain terms mean and how they may be looked at by payers and auditors. As your eyes glaze over from reading mind-numbing descriptions, a few points should be obvious, but conversations with friends, colleagues, and US Office of Inspector General and Centers for Medicare & Medicaid Services forensic investigators have convinced me that it is time for a refresher.

Excisions

For excisions (11400–11646), size is easy to determine. You measure the longest diameter of the lesion and the smallest margin required based on your judgment. The sum of the diameter and twice the margin is your lesion size. For benign lesions, the margin can be as small as 0 to 1 mm. For malignancies, it might be 5 to 9 mm for a melanoma in situ, 1 cm or more for an invasive melanoma with similar margins for squamous cell carcinoma, and somewhat less than 1 cm for basal cell carcinomas and more than 1 cm for Merkel cell carcinomas or spindle cell neoplasms. Unlike the shave removal codes (11300–11313), which do not involve subcutaneous tissue, an excision is at least full thickness through the dermis, which means a clever auditor would expect to see at least some fat on sections in most cases. Assuming you are through to fat, you may or may not close the wound. If you close the wound in a nonlayered manner, the repair is included and is not separately reportable. If you need to perform an intermediate layered closure (12031–12057) to get optimal function and cosmesis, the repair is separately reportable, as is a complex repair (13100–13163), which often includes wide undermining and other factors that differentiate it from an intermediate repair. If a more demanding repair is needed, you might use an adjacent tissue transfer (14000–14061), but the excision is included and not separately reportable. Skin grafts, most commonly split-thickness grafts, do not include the excision, which can be reported separately; direct closure of the graft donor site also is included.

There are times when you may delay a repair for medical reasons, which you would document in the medical record, but if you systematically delay a repair overnight to avoid the multiple procedure payment reduction, you may become “a person of interest,” which is a bad thing.

The shave removal codes (11300–11313) do not require repair and hemostasis is included. The size of the lesion determines the size of the lesion reported, and margins are not included. Hemostasis is included in the value of the CPT code and is not separately reportable.

It is not uncommon for a patient, usually one well known to you, to present with another skin cancer that has classic clinical findings. You review options with your patient and proceed to take one of the following approaches.

Option 1: You can tangentially remove or curette the tumor bulk and send the specimen for pathology review. At the same time, you curette and cauterize the base. In this case, you should hold your bill and await pathology. If the lesion is malignant, you would report the appropriate malignant destruction code (17260–17286) only. If it is benign, you would report a biopsy based on site or a benign destruction (17110) if for some reason the destruction was medically necessary. If it is an actinic keratosis, you could report either a biopsy or a premalignant destruction (17000).

Option 2: You perform a full-thickness excision of the lesion with a margin to remove it and send the specimen for pathology review. You should hold your bill and await pathology. If the lesion is malignant, you would report the appropriate malignant excision (11600–11646) and repair as discussed above. If it is benign, you would report the appropriate benign excision (11400–11446) and repair as discussed above.

If a shave, excision, or destruction is performed, a biopsy of the tissue should never be reported separately simply because the tissue may be sent to the laboratory. In other words, a biopsy is not separately reportable when another procedure was done at the same site on the same day.

Biopsy

Biopsies come in 2 varieties: general and site specific. All dermatologists are familiar with the basic skin biopsy codes 11110 and 11101 (biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed). Many are not aware of site-specific biopsy codes that often are more appropriate and should be used when their localization is more precise than the general skin biopsy.

Biopsies of the nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) are reported using CPT code 11755. A simple nail clipping for culture or periodic acid–Schiff stain is not a nail biopsy and should not be separately reported from the evaluation and management component of the visit.

The lip biopsy code (40490) is used appropriately when the vermilion is sampled, not the skin around it. If the skin and vermilion are contiguously sampled, only report 40490. Specific codes exist for the vestibule of the mouth (40808), the anterior two-thirds (41100) and posterior one-third (41105) of the tongue, the floor (41108) and roof (42100) of the mouth, and the salivary glands by needle (42400) or by incision (42405).

The penis can be biopsied on the surface (54100) or deep structures can be sampled (54105), though the latter is uncommon in dermatology practices. The vulva can be sampled with codes comparable to general biopsy, with 54605 for the first biopsy and 54606 used for each additional one.

An incisional biopsy of the eyelid margin is reported with 67810, while conjunctival biopsy is reported with 68100; 68510 describes a lacrimal gland biopsy. The ear, not to be left out, has its own biopsy codes, with 69100 for the external ear and 69105 for the auditory canal.

Clipping of hair or tape stripping of skin (similar to nail clipping described above) are not biopsies and are not separately reportable, as the work involved is considered incident to the cognitive visit taking place.

Final Thoughts

These points should all be fairly straightforward—yes, the skin biopsy includes mucosa, but if a mucosal site such as the mouth has a more specific code, then that code is correct—and the simplest test for the clinician is to ask yourself, “If I were reviewing the claim, what would I expect to see?” As always, document what you do, do what you document, and report that which is medically necessary.

When you pick up the Current Procedural Terminology (CPT) manual and read it, you may wonder what certain terms mean and how they may be looked at by payers and auditors. As your eyes glaze over from reading mind-numbing descriptions, a few points should be obvious, but conversations with friends, colleagues, and US Office of Inspector General and Centers for Medicare & Medicaid Services forensic investigators have convinced me that it is time for a refresher.

Excisions

For excisions (11400–11646), size is easy to determine. You measure the longest diameter of the lesion and the smallest margin required based on your judgment. The sum of the diameter and twice the margin is your lesion size. For benign lesions, the margin can be as small as 0 to 1 mm. For malignancies, it might be 5 to 9 mm for a melanoma in situ, 1 cm or more for an invasive melanoma with similar margins for squamous cell carcinoma, and somewhat less than 1 cm for basal cell carcinomas and more than 1 cm for Merkel cell carcinomas or spindle cell neoplasms. Unlike the shave removal codes (11300–11313), which do not involve subcutaneous tissue, an excision is at least full thickness through the dermis, which means a clever auditor would expect to see at least some fat on sections in most cases. Assuming you are through to fat, you may or may not close the wound. If you close the wound in a nonlayered manner, the repair is included and is not separately reportable. If you need to perform an intermediate layered closure (12031–12057) to get optimal function and cosmesis, the repair is separately reportable, as is a complex repair (13100–13163), which often includes wide undermining and other factors that differentiate it from an intermediate repair. If a more demanding repair is needed, you might use an adjacent tissue transfer (14000–14061), but the excision is included and not separately reportable. Skin grafts, most commonly split-thickness grafts, do not include the excision, which can be reported separately; direct closure of the graft donor site also is included.

There are times when you may delay a repair for medical reasons, which you would document in the medical record, but if you systematically delay a repair overnight to avoid the multiple procedure payment reduction, you may become “a person of interest,” which is a bad thing.

The shave removal codes (11300–11313) do not require repair and hemostasis is included. The size of the lesion determines the size of the lesion reported, and margins are not included. Hemostasis is included in the value of the CPT code and is not separately reportable.

It is not uncommon for a patient, usually one well known to you, to present with another skin cancer that has classic clinical findings. You review options with your patient and proceed to take one of the following approaches.

Option 1: You can tangentially remove or curette the tumor bulk and send the specimen for pathology review. At the same time, you curette and cauterize the base. In this case, you should hold your bill and await pathology. If the lesion is malignant, you would report the appropriate malignant destruction code (17260–17286) only. If it is benign, you would report a biopsy based on site or a benign destruction (17110) if for some reason the destruction was medically necessary. If it is an actinic keratosis, you could report either a biopsy or a premalignant destruction (17000).

Option 2: You perform a full-thickness excision of the lesion with a margin to remove it and send the specimen for pathology review. You should hold your bill and await pathology. If the lesion is malignant, you would report the appropriate malignant excision (11600–11646) and repair as discussed above. If it is benign, you would report the appropriate benign excision (11400–11446) and repair as discussed above.

If a shave, excision, or destruction is performed, a biopsy of the tissue should never be reported separately simply because the tissue may be sent to the laboratory. In other words, a biopsy is not separately reportable when another procedure was done at the same site on the same day.

Biopsy

Biopsies come in 2 varieties: general and site specific. All dermatologists are familiar with the basic skin biopsy codes 11110 and 11101 (biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed). Many are not aware of site-specific biopsy codes that often are more appropriate and should be used when their localization is more precise than the general skin biopsy.

Biopsies of the nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) are reported using CPT code 11755. A simple nail clipping for culture or periodic acid–Schiff stain is not a nail biopsy and should not be separately reported from the evaluation and management component of the visit.

The lip biopsy code (40490) is used appropriately when the vermilion is sampled, not the skin around it. If the skin and vermilion are contiguously sampled, only report 40490. Specific codes exist for the vestibule of the mouth (40808), the anterior two-thirds (41100) and posterior one-third (41105) of the tongue, the floor (41108) and roof (42100) of the mouth, and the salivary glands by needle (42400) or by incision (42405).

The penis can be biopsied on the surface (54100) or deep structures can be sampled (54105), though the latter is uncommon in dermatology practices. The vulva can be sampled with codes comparable to general biopsy, with 54605 for the first biopsy and 54606 used for each additional one.

An incisional biopsy of the eyelid margin is reported with 67810, while conjunctival biopsy is reported with 68100; 68510 describes a lacrimal gland biopsy. The ear, not to be left out, has its own biopsy codes, with 69100 for the external ear and 69105 for the auditory canal.

Clipping of hair or tape stripping of skin (similar to nail clipping described above) are not biopsies and are not separately reportable, as the work involved is considered incident to the cognitive visit taking place.

Final Thoughts

These points should all be fairly straightforward—yes, the skin biopsy includes mucosa, but if a mucosal site such as the mouth has a more specific code, then that code is correct—and the simplest test for the clinician is to ask yourself, “If I were reviewing the claim, what would I expect to see?” As always, document what you do, do what you document, and report that which is medically necessary.

Just as Charlie Brown looks forward to the coming of the Great Pumpkin each Halloween, those of us who dance in the minefields of payment policy await the publication of the Proposed Rule, more formally known as the “Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2017.”^1,2 You could read the entire tome—a mere 316 pages (excluding the hundreds of pages of granular supplement data discussed in the last few columns)—or simply read what I have outlined as the good, the bad, and the ugly for the Proposed Rule for 2017.

The Good

In 2017, dermatology will increase its share of the pie by 1% to $3.505 billion of a total $89.467 billion expected to be expended for physician services.¹ The effect on individual providers will vary by geographic location and practice mix. Half is from the 0.5% increase that has come to all physicians across the board as mandated by the Medicare Access and CHIP Reauthorization Act (MACRA).³

Current Procedural Terminology (CPT) codes for reflectance confocal microscopy (96931–96936) will have Centers for Medicare & Medicaid Services valuations beginning in 2017, and individuals performing this service should be able to report it and be paid for their efforts.¹ The values are below the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) recommendations.

The Bad

Payment rates for 2017 will be based on a conversion factor of 35.7751,¹ a drop from the 2016 conversion factor of 35.8043. Cuts will be made for some specialties. Gastroenterology, nephrology, neurosurgery, radiology, urology, and radiation therapy centers will take a 1% hit; ophthalmology, pathology, and vascular surgery will take 2% cuts; and interventional radiology will lose 7%.¹ A special case within dermatology and pathology is a 15% cut to the technical component of slide preparation for CPT code 88305⁴ due to a redefinition of the valuation of eosin stains.² While the accuracy and precision of the value of these practice expense inputs can be debated, the government by definition makes the rules and involved specialties had an opportunity to appeal this change through the comment process that ended on September 6, 2016. The government can take comments into account, but substantial changes usually are not made from the Proposed Rule to the Final Rule, which usually arrives around the beginning of November; however, in an election year, the Final Rule can be a few weeks late.

The Ugly

The government will increase its unfunded mandates with the creation of new Medicare G codes (global services codes) that will allow the government to track the provision of postoperative care for all 010 and 090 global service periods (Table 1). The codes look mostly at time and do not clearly take into account the severity or complexity of the conditions being cared for and will be reported on claim forms as an unfunded mandate with more confusion and cost.¹ Because not all claim-paying intermediaries are likely to have these G codes smoothly set up in their systems, there will still be a cost to filing the claim. Unless changes occur in the Final Rule, which is unlikely, there will be no payment for the time and effort of submitting these claims. The goal of the US Government is to hone in on postoperative services and parse them down so they can cut payments wherever possible beginning in 2019.¹ Everyone wants to save money, from the consumer⁵ to the payer, and the ultimate payer is playing hardball. Additional validation efforts likely will lower physician fee-for-service payments further.

The US Government also is taking a shot at what they call “misvalued services” that have not had recent refinement within the RUC process.¹ The work list for 2017 includes a number of 000 global period codes where additional evaluation and management services are reported using modifier -25, which implies a substantial, separately identifiable cognitive service performed by the same physician on the day of a procedure above and beyond other services provided or beyond the usual preservice and postservice care associated with the procedure that was performed. Although codes such as biopsies (11100 and 11101) and premalignant destructions (17000–17004) have an adjustment built in and dermatologists who provide services on the same day are actually penalized for the multiple built-in reductions that are already additive, the government is concerned that 19% of the 000 global services were billed more than 50% of the time with an evaluation and management code with modifier -25. Eighty-three codes met the criteria for which the government believes it may be overpaying¹; the codes of interest to dermatology are shown in Table 2.¹

Final Thoughts

I end this column with an appeal to the dermatologists of America. Go to the American Academy of Dermatology Association Political Action Committee website (https://skinpac.org/), the home page for the only political action committee that represents the dermatology specialty, and consider making a donation. Emergency medicine physicians created the “Giving a Shift” campaign, which is a donation to their national political action committee of one shift’s earnings, and most of us could easily donate a half day’s income, as the only way to potentially change the increasingly onerous burdens on practitioners is through political action. As we say at RUC meetings, you can eat lunch or be lunch. The choice is yours.

Just as Charlie Brown looks forward to the coming of the Great Pumpkin each Halloween, those of us who dance in the minefields of payment policy await the publication of the Proposed Rule, more formally known as the “Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2017.”^1,2 You could read the entire tome—a mere 316 pages (excluding the hundreds of pages of granular supplement data discussed in the last few columns)—or simply read what I have outlined as the good, the bad, and the ugly for the Proposed Rule for 2017.

The Good

In 2017, dermatology will increase its share of the pie by 1% to $3.505 billion of a total $89.467 billion expected to be expended for physician services.¹ The effect on individual providers will vary by geographic location and practice mix. Half is from the 0.5% increase that has come to all physicians across the board as mandated by the Medicare Access and CHIP Reauthorization Act (MACRA).³

Current Procedural Terminology (CPT) codes for reflectance confocal microscopy (96931–96936) will have Centers for Medicare & Medicaid Services valuations beginning in 2017, and individuals performing this service should be able to report it and be paid for their efforts.¹ The values are below the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) recommendations.

The Bad

Payment rates for 2017 will be based on a conversion factor of 35.7751,¹ a drop from the 2016 conversion factor of 35.8043. Cuts will be made for some specialties. Gastroenterology, nephrology, neurosurgery, radiology, urology, and radiation therapy centers will take a 1% hit; ophthalmology, pathology, and vascular surgery will take 2% cuts; and interventional radiology will lose 7%.¹ A special case within dermatology and pathology is a 15% cut to the technical component of slide preparation for CPT code 88305⁴ due to a redefinition of the valuation of eosin stains.² While the accuracy and precision of the value of these practice expense inputs can be debated, the government by definition makes the rules and involved specialties had an opportunity to appeal this change through the comment process that ended on September 6, 2016. The government can take comments into account, but substantial changes usually are not made from the Proposed Rule to the Final Rule, which usually arrives around the beginning of November; however, in an election year, the Final Rule can be a few weeks late.

The Ugly

The government will increase its unfunded mandates with the creation of new Medicare G codes (global services codes) that will allow the government to track the provision of postoperative care for all 010 and 090 global service periods (Table 1). The codes look mostly at time and do not clearly take into account the severity or complexity of the conditions being cared for and will be reported on claim forms as an unfunded mandate with more confusion and cost.¹ Because not all claim-paying intermediaries are likely to have these G codes smoothly set up in their systems, there will still be a cost to filing the claim. Unless changes occur in the Final Rule, which is unlikely, there will be no payment for the time and effort of submitting these claims. The goal of the US Government is to hone in on postoperative services and parse them down so they can cut payments wherever possible beginning in 2019.¹ Everyone wants to save money, from the consumer⁵ to the payer, and the ultimate payer is playing hardball. Additional validation efforts likely will lower physician fee-for-service payments further.

The US Government also is taking a shot at what they call “misvalued services” that have not had recent refinement within the RUC process.¹ The work list for 2017 includes a number of 000 global period codes where additional evaluation and management services are reported using modifier -25, which implies a substantial, separately identifiable cognitive service performed by the same physician on the day of a procedure above and beyond other services provided or beyond the usual preservice and postservice care associated with the procedure that was performed. Although codes such as biopsies (11100 and 11101) and premalignant destructions (17000–17004) have an adjustment built in and dermatologists who provide services on the same day are actually penalized for the multiple built-in reductions that are already additive, the government is concerned that 19% of the 000 global services were billed more than 50% of the time with an evaluation and management code with modifier -25. Eighty-three codes met the criteria for which the government believes it may be overpaying¹; the codes of interest to dermatology are shown in Table 2.¹

Final Thoughts

I end this column with an appeal to the dermatologists of America. Go to the American Academy of Dermatology Association Political Action Committee website (https://skinpac.org/), the home page for the only political action committee that represents the dermatology specialty, and consider making a donation. Emergency medicine physicians created the “Giving a Shift” campaign, which is a donation to their national political action committee of one shift’s earnings, and most of us could easily donate a half day’s income, as the only way to potentially change the increasingly onerous burdens on practitioners is through political action. As we say at RUC meetings, you can eat lunch or be lunch. The choice is yours.

Just as Charlie Brown looks forward to the coming of the Great Pumpkin each Halloween, those of us who dance in the minefields of payment policy await the publication of the Proposed Rule, more formally known as the “Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2017.”^1,2 You could read the entire tome—a mere 316 pages (excluding the hundreds of pages of granular supplement data discussed in the last few columns)—or simply read what I have outlined as the good, the bad, and the ugly for the Proposed Rule for 2017.

The Good

In 2017, dermatology will increase its share of the pie by 1% to $3.505 billion of a total $89.467 billion expected to be expended for physician services.¹ The effect on individual providers will vary by geographic location and practice mix. Half is from the 0.5% increase that has come to all physicians across the board as mandated by the Medicare Access and CHIP Reauthorization Act (MACRA).³

Current Procedural Terminology (CPT) codes for reflectance confocal microscopy (96931–96936) will have Centers for Medicare & Medicaid Services valuations beginning in 2017, and individuals performing this service should be able to report it and be paid for their efforts.¹ The values are below the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) recommendations.

The Bad

Payment rates for 2017 will be based on a conversion factor of 35.7751,¹ a drop from the 2016 conversion factor of 35.8043. Cuts will be made for some specialties. Gastroenterology, nephrology, neurosurgery, radiology, urology, and radiation therapy centers will take a 1% hit; ophthalmology, pathology, and vascular surgery will take 2% cuts; and interventional radiology will lose 7%.¹ A special case within dermatology and pathology is a 15% cut to the technical component of slide preparation for CPT code 88305⁴ due to a redefinition of the valuation of eosin stains.² While the accuracy and precision of the value of these practice expense inputs can be debated, the government by definition makes the rules and involved specialties had an opportunity to appeal this change through the comment process that ended on September 6, 2016. The government can take comments into account, but substantial changes usually are not made from the Proposed Rule to the Final Rule, which usually arrives around the beginning of November; however, in an election year, the Final Rule can be a few weeks late.

The Ugly

The government will increase its unfunded mandates with the creation of new Medicare G codes (global services codes) that will allow the government to track the provision of postoperative care for all 010 and 090 global service periods (Table 1). The codes look mostly at time and do not clearly take into account the severity or complexity of the conditions being cared for and will be reported on claim forms as an unfunded mandate with more confusion and cost.¹ Because not all claim-paying intermediaries are likely to have these G codes smoothly set up in their systems, there will still be a cost to filing the claim. Unless changes occur in the Final Rule, which is unlikely, there will be no payment for the time and effort of submitting these claims. The goal of the US Government is to hone in on postoperative services and parse them down so they can cut payments wherever possible beginning in 2019.¹ Everyone wants to save money, from the consumer⁵ to the payer, and the ultimate payer is playing hardball. Additional validation efforts likely will lower physician fee-for-service payments further.

The US Government also is taking a shot at what they call “misvalued services” that have not had recent refinement within the RUC process.¹ The work list for 2017 includes a number of 000 global period codes where additional evaluation and management services are reported using modifier -25, which implies a substantial, separately identifiable cognitive service performed by the same physician on the day of a procedure above and beyond other services provided or beyond the usual preservice and postservice care associated with the procedure that was performed. Although codes such as biopsies (11100 and 11101) and premalignant destructions (17000–17004) have an adjustment built in and dermatologists who provide services on the same day are actually penalized for the multiple built-in reductions that are already additive, the government is concerned that 19% of the 000 global services were billed more than 50% of the time with an evaluation and management code with modifier -25. Eighty-three codes met the criteria for which the government believes it may be overpaying¹; the codes of interest to dermatology are shown in Table 2.¹

Final Thoughts

I end this column with an appeal to the dermatologists of America. Go to the American Academy of Dermatology Association Political Action Committee website (https://skinpac.org/), the home page for the only political action committee that represents the dermatology specialty, and consider making a donation. Emergency medicine physicians created the “Giving a Shift” campaign, which is a donation to their national political action committee of one shift’s earnings, and most of us could easily donate a half day’s income, as the only way to potentially change the increasingly onerous burdens on practitioners is through political action. As we say at RUC meetings, you can eat lunch or be lunch. The choice is yours.

After reading the July 2016 column on global periods and Current Procedural Terminology (CPT) code 99024,¹ you may be wondering why you get paid what you do and how the procedure and visits all link together, which is associated with work intensity.

When CPT codes are given a value, the determination of the value of the work is performed via a survey process carried out by specialties for presentation to the American Medical Association/Specialty Society Relative Value Scale Update Committee, which is used by the Centers for Medicare & Medicaid Services (CMS) to help determine relative value units (RVUs) that determine payment. The work RVU (wRVU) is typically around half of the total RVU for each CPT code. The value is based on multiple factors including the time to perform the service, the technical skill needed, the physical effort involved, mental effort and judgment, and stress under which the physician works due to the potential risks to the patient.² A series of instruments and calculations have been used to determine a value called intraservice work per unit of time (IWPUT), which is used to examine the intraservice (skin-to-skin) work of a procedure relative to similar procedures.

Calculating the IWPUT

To determine the IWPUT value of a procedure, a formula is used to subtract all the preservice and postservice work and look at what is left based on the total RVUs for the procedure, which can be mathematically presented using the following construct: total wRVUs (the complete work you provide in performing the service) is the sum of preservice work (eg, evaluation and management [E&M] services, preparatory work [eg, scrub, dress, wait]), intraservice (skin-to-skin) work, immediate postservice work (eg, dressings, prescriptions, instructions given by the physician), and postoperative work at E&M visits (eg, hospital days, discharge day, global follow-up visits).

All of these activities defined as E&M services are simply subtracted from the total wRVU, while wRVUs for preservice and postservice work that is not linked to a CPT global period are calculated by simply subtracting the product of each specified time by their intensity (eg, day prior evaluation, same day evaluation, and immediate post have an intensity of 0.0224, while scrub/preparation has an intensity of 0.0081),³ leaving you with intraservice (skin-to-skin) work. This intraservice work is divided by the intraservice time to give you IWPUT. For more information on the concept as well as the process and controversies, an excellent review is available from the CMS.⁴

Understanding the IWPUT

The procedure with the highest IWPUT value in all of medicine is an emergency endotracheal intubation (CPT code 31500), which has a value of 0.4061.⁵ The procedure is short and intense, and if it fails, the patient is dead. All other procedures have lower IWPUT values. For example, a small malignant excision on the trunk, arms, or legs (CPT code 11600) has an IWPUT of 0.0324, while a laparoscopic cholecystectomy with exploration of the common duct (CPT code 47564) has an IWPUT of 0.0737.⁵ These small values have been the drivers behind much of the Relative Value Scale Update Committee’s valuation process for more than a decade. Some specialists who perform mostly 90-day global procedures wanted IWPUT to be the critical validation factor in the process, which led to problems for the first few years of this century. It may seem obvious that if there are 2 ways to fix a broken leg, the more complex one would likely have a higher IWPUT. Because IWPUT is a pure number with no values attached, this assumption would seem reasonable. If we compare a malignant excision to a benign one, we would expect higher intensity for the malignant one, as we are going deeper and have more concerns about clear margins and recurrences. Within a group of similar procedures, these pure numbers can be useful to validate a proposed value. More wRVUs in a shorter time period would result in a higher IWPUT; however, anomalies arise. There are eleven 000 global period CPT codes, ten 010 codes, and one hundred ninety 090 codes with negative IWPUTs, implying the skin-to-skin work has a value less than 0, which is an illogical conclusion. The more logical conclusion is that the codes are overloaded with preservice and postservice times. The real travesty is when one begins to compare apples to oranges—glaucoma surgery to belly surgery, endoscopy to skin surgery, or any other comparison you can come up with—taking a number that can be used to evaluate intensity between similar procedures and generalizing across all procedures, a concept that has never been validated. The wRVUs themselves define the relativity, but in many instances the IWPUT has been used in the process to justify forcing values lower based on cross-specialty comparisons, which may lead some to think we need better measures, as has been reported in the literature.^6-8 Reform likely will happen, but for now we must work within the constraints of this tiny number, the IWPUT.

Obtaining the IWPUT

You are probably wondering, “How can I learn the IWPUT for the codes I use?” You probably do not want or need to other than to gain an understanding of how they have been misused. Purchase a subscription to the Resource-Based Relative Value Scale (RBRVS) DataManager Online or access the data for free through the CMS website (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-P.html) by downloading the CY 2017 PFS Proposed Rule Addenda, which gives you total RVUs for all CPT codes, and the CY 2017 PFS Proposed Rule Physician Time, which gives you the preservice, intraservice, and postservice times for all CPT codes.

Using CPT code 11600 as an example, the total wRVU is 1.63, while preservice evaluation time is 10 minutes, intraservice time is 10 minutes, and immediate postservice time is 5 minutes. There is also 1 global follow-up visit, a CPT 99213, built in with a wRVU of 0.97 that determines the total value of the code. Using the IWPUT formula, we have the following: {1.63 – [(10 × 0.0224) + (5 × 0.0224) + 0.97]} / 10 = 0.0324.

These data also are useful if you are negotiating a contract based on RVUs, so learn a bit more about why you get paid what you are paid.

The Importance of IWPUT

Those interested in the academic discourse behind IWPUT should consult the literature,^3,9 which is open source and freely available, but for now we will concentrate on why IWPUT is an important concept. As global periods are reevaluated under the Medicare Access and CHIP Reauthorization Act of 2015,¹⁰ the removal of global period visits will cause changes in the IWPUT value of codes, which will make them outliers and therefore targeted for resurvey and revaluation. The intent of the CMS is to cut reimbursement under our fee-for-service system, so there will be pain for physicians who have flourished under the current policy. To avoid inappropriate decreases in reimbursement, we should all keep accurate records of which global postoperative services are indeed provided, which leads us back to CPT code 99024. If it is not tracked, then it may not be seen as having been done. So be sure to use it.

Remember that if you do what you document, document what you do, and report medically necessary CPT codes, you should have nothing to worry about for now.

After reading the July 2016 column on global periods and Current Procedural Terminology (CPT) code 99024,¹ you may be wondering why you get paid what you do and how the procedure and visits all link together, which is associated with work intensity.

When CPT codes are given a value, the determination of the value of the work is performed via a survey process carried out by specialties for presentation to the American Medical Association/Specialty Society Relative Value Scale Update Committee, which is used by the Centers for Medicare & Medicaid Services (CMS) to help determine relative value units (RVUs) that determine payment. The work RVU (wRVU) is typically around half of the total RVU for each CPT code. The value is based on multiple factors including the time to perform the service, the technical skill needed, the physical effort involved, mental effort and judgment, and stress under which the physician works due to the potential risks to the patient.² A series of instruments and calculations have been used to determine a value called intraservice work per unit of time (IWPUT), which is used to examine the intraservice (skin-to-skin) work of a procedure relative to similar procedures.

Calculating the IWPUT

To determine the IWPUT value of a procedure, a formula is used to subtract all the preservice and postservice work and look at what is left based on the total RVUs for the procedure, which can be mathematically presented using the following construct: total wRVUs (the complete work you provide in performing the service) is the sum of preservice work (eg, evaluation and management [E&M] services, preparatory work [eg, scrub, dress, wait]), intraservice (skin-to-skin) work, immediate postservice work (eg, dressings, prescriptions, instructions given by the physician), and postoperative work at E&M visits (eg, hospital days, discharge day, global follow-up visits).

All of these activities defined as E&M services are simply subtracted from the total wRVU, while wRVUs for preservice and postservice work that is not linked to a CPT global period are calculated by simply subtracting the product of each specified time by their intensity (eg, day prior evaluation, same day evaluation, and immediate post have an intensity of 0.0224, while scrub/preparation has an intensity of 0.0081),³ leaving you with intraservice (skin-to-skin) work. This intraservice work is divided by the intraservice time to give you IWPUT. For more information on the concept as well as the process and controversies, an excellent review is available from the CMS.⁴

Understanding the IWPUT

The procedure with the highest IWPUT value in all of medicine is an emergency endotracheal intubation (CPT code 31500), which has a value of 0.4061.⁵ The procedure is short and intense, and if it fails, the patient is dead. All other procedures have lower IWPUT values. For example, a small malignant excision on the trunk, arms, or legs (CPT code 11600) has an IWPUT of 0.0324, while a laparoscopic cholecystectomy with exploration of the common duct (CPT code 47564) has an IWPUT of 0.0737.⁵ These small values have been the drivers behind much of the Relative Value Scale Update Committee’s valuation process for more than a decade. Some specialists who perform mostly 90-day global procedures wanted IWPUT to be the critical validation factor in the process, which led to problems for the first few years of this century. It may seem obvious that if there are 2 ways to fix a broken leg, the more complex one would likely have a higher IWPUT. Because IWPUT is a pure number with no values attached, this assumption would seem reasonable. If we compare a malignant excision to a benign one, we would expect higher intensity for the malignant one, as we are going deeper and have more concerns about clear margins and recurrences. Within a group of similar procedures, these pure numbers can be useful to validate a proposed value. More wRVUs in a shorter time period would result in a higher IWPUT; however, anomalies arise. There are eleven 000 global period CPT codes, ten 010 codes, and one hundred ninety 090 codes with negative IWPUTs, implying the skin-to-skin work has a value less than 0, which is an illogical conclusion. The more logical conclusion is that the codes are overloaded with preservice and postservice times. The real travesty is when one begins to compare apples to oranges—glaucoma surgery to belly surgery, endoscopy to skin surgery, or any other comparison you can come up with—taking a number that can be used to evaluate intensity between similar procedures and generalizing across all procedures, a concept that has never been validated. The wRVUs themselves define the relativity, but in many instances the IWPUT has been used in the process to justify forcing values lower based on cross-specialty comparisons, which may lead some to think we need better measures, as has been reported in the literature.^6-8 Reform likely will happen, but for now we must work within the constraints of this tiny number, the IWPUT.

Obtaining the IWPUT

You are probably wondering, “How can I learn the IWPUT for the codes I use?” You probably do not want or need to other than to gain an understanding of how they have been misused. Purchase a subscription to the Resource-Based Relative Value Scale (RBRVS) DataManager Online or access the data for free through the CMS website (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-P.html) by downloading the CY 2017 PFS Proposed Rule Addenda, which gives you total RVUs for all CPT codes, and the CY 2017 PFS Proposed Rule Physician Time, which gives you the preservice, intraservice, and postservice times for all CPT codes.

Using CPT code 11600 as an example, the total wRVU is 1.63, while preservice evaluation time is 10 minutes, intraservice time is 10 minutes, and immediate postservice time is 5 minutes. There is also 1 global follow-up visit, a CPT 99213, built in with a wRVU of 0.97 that determines the total value of the code. Using the IWPUT formula, we have the following: {1.63 – [(10 × 0.0224) + (5 × 0.0224) + 0.97]} / 10 = 0.0324.

These data also are useful if you are negotiating a contract based on RVUs, so learn a bit more about why you get paid what you are paid.

The Importance of IWPUT

Those interested in the academic discourse behind IWPUT should consult the literature,^3,9 which is open source and freely available, but for now we will concentrate on why IWPUT is an important concept. As global periods are reevaluated under the Medicare Access and CHIP Reauthorization Act of 2015,¹⁰ the removal of global period visits will cause changes in the IWPUT value of codes, which will make them outliers and therefore targeted for resurvey and revaluation. The intent of the CMS is to cut reimbursement under our fee-for-service system, so there will be pain for physicians who have flourished under the current policy. To avoid inappropriate decreases in reimbursement, we should all keep accurate records of which global postoperative services are indeed provided, which leads us back to CPT code 99024. If it is not tracked, then it may not be seen as having been done. So be sure to use it.

Remember that if you do what you document, document what you do, and report medically necessary CPT codes, you should have nothing to worry about for now.

After reading the July 2016 column on global periods and Current Procedural Terminology (CPT) code 99024,¹ you may be wondering why you get paid what you do and how the procedure and visits all link together, which is associated with work intensity.

When CPT codes are given a value, the determination of the value of the work is performed via a survey process carried out by specialties for presentation to the American Medical Association/Specialty Society Relative Value Scale Update Committee, which is used by the Centers for Medicare & Medicaid Services (CMS) to help determine relative value units (RVUs) that determine payment. The work RVU (wRVU) is typically around half of the total RVU for each CPT code. The value is based on multiple factors including the time to perform the service, the technical skill needed, the physical effort involved, mental effort and judgment, and stress under which the physician works due to the potential risks to the patient.² A series of instruments and calculations have been used to determine a value called intraservice work per unit of time (IWPUT), which is used to examine the intraservice (skin-to-skin) work of a procedure relative to similar procedures.

Calculating the IWPUT

To determine the IWPUT value of a procedure, a formula is used to subtract all the preservice and postservice work and look at what is left based on the total RVUs for the procedure, which can be mathematically presented using the following construct: total wRVUs (the complete work you provide in performing the service) is the sum of preservice work (eg, evaluation and management [E&M] services, preparatory work [eg, scrub, dress, wait]), intraservice (skin-to-skin) work, immediate postservice work (eg, dressings, prescriptions, instructions given by the physician), and postoperative work at E&M visits (eg, hospital days, discharge day, global follow-up visits).

All of these activities defined as E&M services are simply subtracted from the total wRVU, while wRVUs for preservice and postservice work that is not linked to a CPT global period are calculated by simply subtracting the product of each specified time by their intensity (eg, day prior evaluation, same day evaluation, and immediate post have an intensity of 0.0224, while scrub/preparation has an intensity of 0.0081),³ leaving you with intraservice (skin-to-skin) work. This intraservice work is divided by the intraservice time to give you IWPUT. For more information on the concept as well as the process and controversies, an excellent review is available from the CMS.⁴

Understanding the IWPUT

The procedure with the highest IWPUT value in all of medicine is an emergency endotracheal intubation (CPT code 31500), which has a value of 0.4061.⁵ The procedure is short and intense, and if it fails, the patient is dead. All other procedures have lower IWPUT values. For example, a small malignant excision on the trunk, arms, or legs (CPT code 11600) has an IWPUT of 0.0324, while a laparoscopic cholecystectomy with exploration of the common duct (CPT code 47564) has an IWPUT of 0.0737.⁵ These small values have been the drivers behind much of the Relative Value Scale Update Committee’s valuation process for more than a decade. Some specialists who perform mostly 90-day global procedures wanted IWPUT to be the critical validation factor in the process, which led to problems for the first few years of this century. It may seem obvious that if there are 2 ways to fix a broken leg, the more complex one would likely have a higher IWPUT. Because IWPUT is a pure number with no values attached, this assumption would seem reasonable. If we compare a malignant excision to a benign one, we would expect higher intensity for the malignant one, as we are going deeper and have more concerns about clear margins and recurrences. Within a group of similar procedures, these pure numbers can be useful to validate a proposed value. More wRVUs in a shorter time period would result in a higher IWPUT; however, anomalies arise. There are eleven 000 global period CPT codes, ten 010 codes, and one hundred ninety 090 codes with negative IWPUTs, implying the skin-to-skin work has a value less than 0, which is an illogical conclusion. The more logical conclusion is that the codes are overloaded with preservice and postservice times. The real travesty is when one begins to compare apples to oranges—glaucoma surgery to belly surgery, endoscopy to skin surgery, or any other comparison you can come up with—taking a number that can be used to evaluate intensity between similar procedures and generalizing across all procedures, a concept that has never been validated. The wRVUs themselves define the relativity, but in many instances the IWPUT has been used in the process to justify forcing values lower based on cross-specialty comparisons, which may lead some to think we need better measures, as has been reported in the literature.^6-8 Reform likely will happen, but for now we must work within the constraints of this tiny number, the IWPUT.

Obtaining the IWPUT

You are probably wondering, “How can I learn the IWPUT for the codes I use?” You probably do not want or need to other than to gain an understanding of how they have been misused. Purchase a subscription to the Resource-Based Relative Value Scale (RBRVS) DataManager Online or access the data for free through the CMS website (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-P.html) by downloading the CY 2017 PFS Proposed Rule Addenda, which gives you total RVUs for all CPT codes, and the CY 2017 PFS Proposed Rule Physician Time, which gives you the preservice, intraservice, and postservice times for all CPT codes.

Using CPT code 11600 as an example, the total wRVU is 1.63, while preservice evaluation time is 10 minutes, intraservice time is 10 minutes, and immediate postservice time is 5 minutes. There is also 1 global follow-up visit, a CPT 99213, built in with a wRVU of 0.97 that determines the total value of the code. Using the IWPUT formula, we have the following: {1.63 – [(10 × 0.0224) + (5 × 0.0224) + 0.97]} / 10 = 0.0324.

These data also are useful if you are negotiating a contract based on RVUs, so learn a bit more about why you get paid what you are paid.

The Importance of IWPUT

Those interested in the academic discourse behind IWPUT should consult the literature,^3,9 which is open source and freely available, but for now we will concentrate on why IWPUT is an important concept. As global periods are reevaluated under the Medicare Access and CHIP Reauthorization Act of 2015,¹⁰ the removal of global period visits will cause changes in the IWPUT value of codes, which will make them outliers and therefore targeted for resurvey and revaluation. The intent of the CMS is to cut reimbursement under our fee-for-service system, so there will be pain for physicians who have flourished under the current policy. To avoid inappropriate decreases in reimbursement, we should all keep accurate records of which global postoperative services are indeed provided, which leads us back to CPT code 99024. If it is not tracked, then it may not be seen as having been done. So be sure to use it.

Remember that if you do what you document, document what you do, and report medically necessary CPT codes, you should have nothing to worry about for now.

How does the global period affect dermatologists?

Global period is a term used to describe what is included in the payment for performance of a procedure using Current Procedural Terminology (CPT) codes. These global periods can either be 0 (000), 10 (010), or 90 (090) days. In dermatology, we have all three. Most codes used by dermatologists fall under global periods of 0 and 10 days, while 90-day codes are used for all adjacent tissue transfers and split- and full-thickness grafts. In documents listing global periods for CPT codes,¹ you also may see “XXX” when the global period concept does not apply to a particular code, “YYY” when the payer decides on whether a global period applies and what it will be, and “ZZZ” when a certain code is an add-on to another service and is therefore included in the global period for that service.

The contents of a service are defined by the global period. Although the procedure itself is an obvious component, CPT codes with a global period of 000 (eg, biopsy of a skin lesion, simple repairs) have no preoperative or postoperative periods, and an evaluation and management (E&M) service usually is not payable if it was done in relation to the procedure. If the patient returns the following day for any reason, including concerns about the procedure itself, these visits may be reported separately.

For CPT codes with global periods of 010 (eg, excisions, intermediate and complex repairs, destructions), there also is no preoperative period and a visit on the day of the procedure generally is not payable as a separate service. The day of the procedure and the 10 days after are included in the global period, and any visits relating to the procedure on that day and the 10 days following the procedure are not payable separately. Typically, the value of one 99212 or 99213 E&M visit is included in the payment for the procedure.

For CPT codes with global periods of 090, the day before the procedure, the day of the procedure, and 90 days following the procedure are all included. Typically, more than one established patient visit along with hospital management and discharge planning where deemed necessary by the Centers for Medicare & Medicaid Services (CMS) are included, which seems straightforward, but there is a sort of paradox here. An initial evaluation by the surgeon who determines the need for the 090 code (by definition, 090 means major surgery and major surgery means 090) can be separately reported for E&M using modifier -57 (decision for surgery), which means the surgeon seeing the hot abdomen in the emergency department can report an E&M code in addition to the procedure, as can the surgeon who decides to repair a defect after removal of a skin tumor with a flap or graft. The same is not applicable if one performs a simple repair (included with benign or malignant excisions) following Mohs micrographic surgery or an intermediate or complex repair after any form of skin cancer removal. In any event, you are making a decision about what repair is best for the patient and sharing that with him/her while obtaining patient consent, but only 090 codes allow the capture of the decision to perform the procedure.

Which modifiers can you use on the same day as a procedure during the global period?

All is not lost if you perform other activities on the same day as the procedure or during the global period if those other activities are unrelated, which means complications of the procedure cannot be separately reported. If the unrelated cognitive work is reported on the day of a procedure with an E&M code, it should be accompanied by modifier -25 (significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service). If you have an E&M visit unrelated to the procedure within the global period, report it using modifier -24 (unrelated E&M service by the same physician or other qualified health care professional during a postoperative period).

If you perform another procedure on the same day as the primary one, you can use modifier -51 (multiple procedures) to let the payer know you provided other services that are separately reportable. If you do multiples of the same procedure, use modifier -59 (distinct procedural service) to let the payer know that you indeed did multiple procedures and did not submit a typographical error. Modifier -59 also is used when you perform a pair of procedures on separate and distinct lesions that would be disallowed by Mutually Exclusive Edits if done on a single lesion. For example, if you perform a biopsy of a lesion and immediately curette it, you should wait for the pathology report; if the lesion is malignant, only the destruction should be reported, and if it is benign, the only medically necessary service was the biopsy. When biopsy and curettage are performed on 2 separate lesions on the same date of service, payer software will disallow the biopsy charge unless a -59 modifier is attached to indicate that the biopsy was performed on a separate lesion. Medicare has introduced the -XS modifier, which is planned to be phased in to replace the -59 modifier for Medicare patients,² if and when the CMS sets up their systems to accept the modifier.

If you repeat a procedure during the global period (eg, reexcision for a positive margin), it is appropriate to use modifier -58 (staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period). If an unrelated procedure is performed during the global period, such as removing another lesion at a different site, modifier -79 (unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) lets you report it.

There are 2 available modifiers that you might think twice before using. Modifier -76 (repeat procedure or service by same physician or other qualified health care professional) may be used if, for example, a wound opens and you have to sew it up again. The more common usage is more pedestrian; a second electrocardiogram reading on the same day is a common use.³ Modifier -78 (unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) is used when something goes awry, such as an aneurysm repair that is bleeding postoperatively, necessitating a trip back to the operating room.⁴

How might these modifiers be used in dermatology? One example may be if a wound dehisces or needs to be seen for a bleeding issue that might necessitate opening and exploring the wound; if a patient has one of these problems after fixing the plumbing and hits himself with a wrench, use of these modifiers is reasonable. On the other hand, if the patient is waiting in your office to be picked up and the problem happens, using these modifiers may not be the wisest thing to do. Let common sense prevail!

What is CPT code 99024?

Likely a code you have never used in your private office, the descriptor for 99024 states “postoperative follow-up visit, normally included in the surgical package, to indicate that an E&M service was performed during a postoperative period for a reason(s) related to the original procedure,” which translates to “here for an included visit so why am I billing this and having the cost of a claim with no reimbursement?” Why indeed. You may be using it as a space holder—one more check and balance so no patient leaves the office without a superbill or its electronic equivalent being submitted to your billing staff—or you may simply never use it. The CMS is interested in it as a way to see if the visits embedded in global periods actually take place. This is especially important as CMS is legally mandated under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)⁵ to see if these visits actually take place.⁶ There are billions of dollars paid out for visits that are part of the global package and this code is one way the government may track them. If you are not using this code at all, you might consider it, even if you do not submit a claim. Your staff will know you did not forget to report a service and the reporting of the code by you internally and it lets you document for the billing side of the practice that they were there and a code report has been performed and not simply forgotten.

Final Thoughts

Following this discussion of global periods and CPT code 99024, you may be wondering why you get paid what you do and how the visits all link together. The buzzword is intensity, and we will explore that concept and IWPUT (intraservice work per unit of time), which I have coined as meaning “I Will Persevere Until Then,” in the next column.

How does the global period affect dermatologists?

Global period is a term used to describe what is included in the payment for performance of a procedure using Current Procedural Terminology (CPT) codes. These global periods can either be 0 (000), 10 (010), or 90 (090) days. In dermatology, we have all three. Most codes used by dermatologists fall under global periods of 0 and 10 days, while 90-day codes are used for all adjacent tissue transfers and split- and full-thickness grafts. In documents listing global periods for CPT codes,¹ you also may see “XXX” when the global period concept does not apply to a particular code, “YYY” when the payer decides on whether a global period applies and what it will be, and “ZZZ” when a certain code is an add-on to another service and is therefore included in the global period for that service.

The contents of a service are defined by the global period. Although the procedure itself is an obvious component, CPT codes with a global period of 000 (eg, biopsy of a skin lesion, simple repairs) have no preoperative or postoperative periods, and an evaluation and management (E&M) service usually is not payable if it was done in relation to the procedure. If the patient returns the following day for any reason, including concerns about the procedure itself, these visits may be reported separately.

For CPT codes with global periods of 010 (eg, excisions, intermediate and complex repairs, destructions), there also is no preoperative period and a visit on the day of the procedure generally is not payable as a separate service. The day of the procedure and the 10 days after are included in the global period, and any visits relating to the procedure on that day and the 10 days following the procedure are not payable separately. Typically, the value of one 99212 or 99213 E&M visit is included in the payment for the procedure.

For CPT codes with global periods of 090, the day before the procedure, the day of the procedure, and 90 days following the procedure are all included. Typically, more than one established patient visit along with hospital management and discharge planning where deemed necessary by the Centers for Medicare & Medicaid Services (CMS) are included, which seems straightforward, but there is a sort of paradox here. An initial evaluation by the surgeon who determines the need for the 090 code (by definition, 090 means major surgery and major surgery means 090) can be separately reported for E&M using modifier -57 (decision for surgery), which means the surgeon seeing the hot abdomen in the emergency department can report an E&M code in addition to the procedure, as can the surgeon who decides to repair a defect after removal of a skin tumor with a flap or graft. The same is not applicable if one performs a simple repair (included with benign or malignant excisions) following Mohs micrographic surgery or an intermediate or complex repair after any form of skin cancer removal. In any event, you are making a decision about what repair is best for the patient and sharing that with him/her while obtaining patient consent, but only 090 codes allow the capture of the decision to perform the procedure.

Which modifiers can you use on the same day as a procedure during the global period?

All is not lost if you perform other activities on the same day as the procedure or during the global period if those other activities are unrelated, which means complications of the procedure cannot be separately reported. If the unrelated cognitive work is reported on the day of a procedure with an E&M code, it should be accompanied by modifier -25 (significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service). If you have an E&M visit unrelated to the procedure within the global period, report it using modifier -24 (unrelated E&M service by the same physician or other qualified health care professional during a postoperative period).

If you perform another procedure on the same day as the primary one, you can use modifier -51 (multiple procedures) to let the payer know you provided other services that are separately reportable. If you do multiples of the same procedure, use modifier -59 (distinct procedural service) to let the payer know that you indeed did multiple procedures and did not submit a typographical error. Modifier -59 also is used when you perform a pair of procedures on separate and distinct lesions that would be disallowed by Mutually Exclusive Edits if done on a single lesion. For example, if you perform a biopsy of a lesion and immediately curette it, you should wait for the pathology report; if the lesion is malignant, only the destruction should be reported, and if it is benign, the only medically necessary service was the biopsy. When biopsy and curettage are performed on 2 separate lesions on the same date of service, payer software will disallow the biopsy charge unless a -59 modifier is attached to indicate that the biopsy was performed on a separate lesion. Medicare has introduced the -XS modifier, which is planned to be phased in to replace the -59 modifier for Medicare patients,² if and when the CMS sets up their systems to accept the modifier.

If you repeat a procedure during the global period (eg, reexcision for a positive margin), it is appropriate to use modifier -58 (staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period). If an unrelated procedure is performed during the global period, such as removing another lesion at a different site, modifier -79 (unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) lets you report it.

There are 2 available modifiers that you might think twice before using. Modifier -76 (repeat procedure or service by same physician or other qualified health care professional) may be used if, for example, a wound opens and you have to sew it up again. The more common usage is more pedestrian; a second electrocardiogram reading on the same day is a common use.³ Modifier -78 (unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) is used when something goes awry, such as an aneurysm repair that is bleeding postoperatively, necessitating a trip back to the operating room.⁴

How might these modifiers be used in dermatology? One example may be if a wound dehisces or needs to be seen for a bleeding issue that might necessitate opening and exploring the wound; if a patient has one of these problems after fixing the plumbing and hits himself with a wrench, use of these modifiers is reasonable. On the other hand, if the patient is waiting in your office to be picked up and the problem happens, using these modifiers may not be the wisest thing to do. Let common sense prevail!

What is CPT code 99024?

Likely a code you have never used in your private office, the descriptor for 99024 states “postoperative follow-up visit, normally included in the surgical package, to indicate that an E&M service was performed during a postoperative period for a reason(s) related to the original procedure,” which translates to “here for an included visit so why am I billing this and having the cost of a claim with no reimbursement?” Why indeed. You may be using it as a space holder—one more check and balance so no patient leaves the office without a superbill or its electronic equivalent being submitted to your billing staff—or you may simply never use it. The CMS is interested in it as a way to see if the visits embedded in global periods actually take place. This is especially important as CMS is legally mandated under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)⁵ to see if these visits actually take place.⁶ There are billions of dollars paid out for visits that are part of the global package and this code is one way the government may track them. If you are not using this code at all, you might consider it, even if you do not submit a claim. Your staff will know you did not forget to report a service and the reporting of the code by you internally and it lets you document for the billing side of the practice that they were there and a code report has been performed and not simply forgotten.

Final Thoughts

Following this discussion of global periods and CPT code 99024, you may be wondering why you get paid what you do and how the visits all link together. The buzzword is intensity, and we will explore that concept and IWPUT (intraservice work per unit of time), which I have coined as meaning “I Will Persevere Until Then,” in the next column.

How does the global period affect dermatologists?

Global period is a term used to describe what is included in the payment for performance of a procedure using Current Procedural Terminology (CPT) codes. These global periods can either be 0 (000), 10 (010), or 90 (090) days. In dermatology, we have all three. Most codes used by dermatologists fall under global periods of 0 and 10 days, while 90-day codes are used for all adjacent tissue transfers and split- and full-thickness grafts. In documents listing global periods for CPT codes,¹ you also may see “XXX” when the global period concept does not apply to a particular code, “YYY” when the payer decides on whether a global period applies and what it will be, and “ZZZ” when a certain code is an add-on to another service and is therefore included in the global period for that service.

The contents of a service are defined by the global period. Although the procedure itself is an obvious component, CPT codes with a global period of 000 (eg, biopsy of a skin lesion, simple repairs) have no preoperative or postoperative periods, and an evaluation and management (E&M) service usually is not payable if it was done in relation to the procedure. If the patient returns the following day for any reason, including concerns about the procedure itself, these visits may be reported separately.

For CPT codes with global periods of 010 (eg, excisions, intermediate and complex repairs, destructions), there also is no preoperative period and a visit on the day of the procedure generally is not payable as a separate service. The day of the procedure and the 10 days after are included in the global period, and any visits relating to the procedure on that day and the 10 days following the procedure are not payable separately. Typically, the value of one 99212 or 99213 E&M visit is included in the payment for the procedure.

For CPT codes with global periods of 090, the day before the procedure, the day of the procedure, and 90 days following the procedure are all included. Typically, more than one established patient visit along with hospital management and discharge planning where deemed necessary by the Centers for Medicare & Medicaid Services (CMS) are included, which seems straightforward, but there is a sort of paradox here. An initial evaluation by the surgeon who determines the need for the 090 code (by definition, 090 means major surgery and major surgery means 090) can be separately reported for E&M using modifier -57 (decision for surgery), which means the surgeon seeing the hot abdomen in the emergency department can report an E&M code in addition to the procedure, as can the surgeon who decides to repair a defect after removal of a skin tumor with a flap or graft. The same is not applicable if one performs a simple repair (included with benign or malignant excisions) following Mohs micrographic surgery or an intermediate or complex repair after any form of skin cancer removal. In any event, you are making a decision about what repair is best for the patient and sharing that with him/her while obtaining patient consent, but only 090 codes allow the capture of the decision to perform the procedure.

Which modifiers can you use on the same day as a procedure during the global period?

All is not lost if you perform other activities on the same day as the procedure or during the global period if those other activities are unrelated, which means complications of the procedure cannot be separately reported. If the unrelated cognitive work is reported on the day of a procedure with an E&M code, it should be accompanied by modifier -25 (significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service). If you have an E&M visit unrelated to the procedure within the global period, report it using modifier -24 (unrelated E&M service by the same physician or other qualified health care professional during a postoperative period).

If you perform another procedure on the same day as the primary one, you can use modifier -51 (multiple procedures) to let the payer know you provided other services that are separately reportable. If you do multiples of the same procedure, use modifier -59 (distinct procedural service) to let the payer know that you indeed did multiple procedures and did not submit a typographical error. Modifier -59 also is used when you perform a pair of procedures on separate and distinct lesions that would be disallowed by Mutually Exclusive Edits if done on a single lesion. For example, if you perform a biopsy of a lesion and immediately curette it, you should wait for the pathology report; if the lesion is malignant, only the destruction should be reported, and if it is benign, the only medically necessary service was the biopsy. When biopsy and curettage are performed on 2 separate lesions on the same date of service, payer software will disallow the biopsy charge unless a -59 modifier is attached to indicate that the biopsy was performed on a separate lesion. Medicare has introduced the -XS modifier, which is planned to be phased in to replace the -59 modifier for Medicare patients,² if and when the CMS sets up their systems to accept the modifier.

If you repeat a procedure during the global period (eg, reexcision for a positive margin), it is appropriate to use modifier -58 (staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period). If an unrelated procedure is performed during the global period, such as removing another lesion at a different site, modifier -79 (unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) lets you report it.

There are 2 available modifiers that you might think twice before using. Modifier -76 (repeat procedure or service by same physician or other qualified health care professional) may be used if, for example, a wound opens and you have to sew it up again. The more common usage is more pedestrian; a second electrocardiogram reading on the same day is a common use.³ Modifier -78 (unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) is used when something goes awry, such as an aneurysm repair that is bleeding postoperatively, necessitating a trip back to the operating room.⁴

How might these modifiers be used in dermatology? One example may be if a wound dehisces or needs to be seen for a bleeding issue that might necessitate opening and exploring the wound; if a patient has one of these problems after fixing the plumbing and hits himself with a wrench, use of these modifiers is reasonable. On the other hand, if the patient is waiting in your office to be picked up and the problem happens, using these modifiers may not be the wisest thing to do. Let common sense prevail!

What is CPT code 99024?

Likely a code you have never used in your private office, the descriptor for 99024 states “postoperative follow-up visit, normally included in the surgical package, to indicate that an E&M service was performed during a postoperative period for a reason(s) related to the original procedure,” which translates to “here for an included visit so why am I billing this and having the cost of a claim with no reimbursement?” Why indeed. You may be using it as a space holder—one more check and balance so no patient leaves the office without a superbill or its electronic equivalent being submitted to your billing staff—or you may simply never use it. The CMS is interested in it as a way to see if the visits embedded in global periods actually take place. This is especially important as CMS is legally mandated under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)⁵ to see if these visits actually take place.⁶ There are billions of dollars paid out for visits that are part of the global package and this code is one way the government may track them. If you are not using this code at all, you might consider it, even if you do not submit a claim. Your staff will know you did not forget to report a service and the reporting of the code by you internally and it lets you document for the billing side of the practice that they were there and a code report has been performed and not simply forgotten.

Final Thoughts

Following this discussion of global periods and CPT code 99024, you may be wondering why you get paid what you do and how the visits all link together. The buzzword is intensity, and we will explore that concept and IWPUT (intraservice work per unit of time), which I have coined as meaning “I Will Persevere Until Then,” in the next column.

Sheep are thought of as nervous animals, a good target for predators. You do not want to be a sheep. Unfortunately, many electronic health record (EHR) programs make you a target for audits and requests for the return of payments for a variety of reasons. Although you likely are aware of the uses of modifier -25, it is the abuses—either intentional or accidental—that can bring an audit your way. The use of modifier -25 was previously reviewed in Cutis.¹ Despite the availability of this excellent review, I have found that there is still great confusion about both the use of modifier -25 and the selection of the correct evaluation and management (E&M) code when used.

When to Bill for E&M

Based on recent discussions with colleagues in the New York area who have been audited, an easy way to bring on a request for medical records is to report an E&M 100% of the time with a procedure. In these instances, every single E&M was performed on the same visit as a dermatologic procedure, most commonly biopsies(Current Procedural Terminology [CPT] code 11100, 11101) and premalignant destructions (CPT code 17000, 17003, 17004), which is in contrast with typical practitioners who perform an E&M approximately 70% of the time (RUC rationale; American Medical Association RBRVS Data Manager; May 12, 2016). One circumstance involved the reporting of E&M services 100% of the time when performed during the same visit as Mohs micrographic surgery (CPT code 17311–17315), a surprising frequency considering that the typical same day use of a code for this procedure with an E&M in the Medicare population is less than 25%.

According to the National Correct Coding Initiative Policy Manual for Medicare Services, procedures with a global period of 90 days are defined as major surgical procedures,² which only include adjacent tissue transfers and grafts for dermatology. If an E&M is performed on the same date of service as one of these procedures to decide whether to perform the procedure, the E&M can be reported separately using modifier -57. Other preoperative E&M services provided on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not reported separately.²

All other procedures dermatologists perform generally are considered minor, which are defined as having a global period of 0 or 10 days. Because the decision to perform a minor procedure is included in the payment for the procedure, E&M services should not be reported separately from the minor procedure. 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. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.”²

Documentation Guidelines

These guidelines seem straightforward, but as with so much else where the government is involved, the devil is in the details. When making coding decisions, you may consult the documentation guidelines from either 1995³ or 1997,⁴ which are available for download on the Centers for Medicare & Medicaid Services (CMS) website (https://www.cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNedwebguide/emdoc.html). The 1995 guidelines are less empiric and offer more flexibility, while the 1997 guidelines rely on number of “bullets” as examination elements.

1995 Guidelines

According to the 1995 documentation guidelines, the levels of E&M services are based on 4 types of examination that are defined as follows: (1) problem focused, a limited examination of the affected body area or organ system; (2) expanded problem focused, a limited examination of the affected body area or organ system and other symptomatic or related organ system(s); (3) detailed, an extended examination of the affected body area(s) and other symptomatic or related organ system(s); and (4) comprehensive, a general multisystem examination or complete examination of a single organ system.³ Detailed history is the fuzziest part of the coding universe. Some insurers take an approach that you need to examine 2 to 7 organ systems and 4 distinct lesions in 4 body areas, which is discussed in audit tools available from some Medicare intermediaries (Advancing the Business of Healthcare forum; April 10, 2014). As a result, the 12-bullet examination from the 1997 documentation guidelines may be more suitable for a new level 3 or established level 4 visit. For a comprehensive examination, the 1995 criteria allow for a complete examination of a single organ system such as the full-body skin examination with the patient completely undressed, which is medically necessary in our melanoma patients.

For purposes of examination, 9 body areas are recognized in the 1995 guidelines,³ along with more than a dozen organ systems of which the skin is of most interest to dermatologists.

According to the 1995 guidelines,³ the extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s) and range from focused examinations of single body areas to general multisystem or complete single organ system examinations. Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. Although a notation of normal is sufficient, abnormal without elaboration is insufficient, and abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. The medical record for a general multisystem examination should include findings involving approximately 8 or more of the 12 organ systems.

An expanded problem focused examination under the 1995 guidelines could be as simple as “Scar on cancer excision site on left cheek soft and supple. No cervical adenopathy.” There is some confusion regarding detailed examinations, and one consultant went as far as calling the guidelines “vague,”5 while others such as a Medicare intermediary make a quantum leap that if a comprehensive general system examination includes 8 to 12 organ systems, one step below should include 2 to 7 organ systems.6 In essence, the payer makes the rules here.

1997 Guidelines

According to the 1997 documentation guidelines, count bullets that are examination elements, which can be either general or single organ system.⁴ (A table showing the bullets for the examination elements is available from the CMS.⁴) For each type of examination, apply the following: problem focused examination requires 1 to 5 elements identified by a bullet, expanded problem focused examination needs at least 6, detailed examination requires at least 12, and comprehensive examination requires all elements identified by a bullet with documentation of every element in each box with a shaded border and at least 1 element in each box with an unshaded border.⁴ Although you may do more writing when using the 1997 guidelines, you can easily count up bullets and these guidelines are amenable to template examinations on paper and obviously easily coded into EHR software that will do the bullet counting for you.

Unfortunately, this is where a ewe becomes a sheep, ripe for hunting for a number of reasons. First, just because you documented an E&M service does not mean it is medically necessary. Do you really need vital signs for every visit? If you are a meaningful EHR user working on penalty avoidance, you may capture examination data for meaningful use that is not medically necessary but cannot be parsed out by the autocoder in your EHR. As a result, simply do a quick manual audit of your notes to see if you are overcoding, which becomes second nature if you do it often.

The second trap, which brings us back to modifier -25, is when you perform a procedure the same day as your E&M or vice versa. Every procedure we do within the Resource-Based Relative Value Scale contains preservice time, which includes review of materials relevant to the procedure, examination of the area, and all preparation (eg, marking, time out, anesthesia, scrub and drape) before the surgery begins. The detailed vignettes are available to those involved in the Relative Value Scale Update Committee process and to the rest of the world in a subscription product called the RBRVS DataManager Online, which is produced by the American Medical Association. Unfortunately, the American Medical Association is not accepting new subscriptions to this product, as it has decided to outsource most of its coding resources to Optum360, one of the many arms of UnitedHealth Group, and will not have a replacement product until after June 30, 2016.⁷

In essence, if you (and your EHR) are counting bullets and then treating the body area in question, you are double-dipping, as the examination of the area is included in the procedure. So if you are heading toward a CPT 99213-25 with 6 bullets, one of which is on the left arm, and you perform a 0- or 10-day global procedure on that arm, you are down to 5 bullets, which drops your level of examination to problem focused. Remember, you need only 2 of 3—history, examination, and decision making—to be at or above that need for that particular level of reporting. If only one of your history or decision making is at or above the needed level for a 99213, the loss of a single bullet drops you down to a 99212! An audit where a handful of medical records are pulled and a request for money back on the universe of payments the insurer has paid is always unpleasant and you should, if you get a request for same, follow all the rules and timelines outlined by the payer. If you knowingly behaved in a risky fashion, consult a good attorney.

Of course, you may argue that the effort needed for the E&M work for the procedure was above and beyond what is typical for the service, which can be a hard standard to meet. Although the CMS requires a “significant and separately identifiable E&M service” as noted above and a separate diagnosis is not needed, the onus is on you to prove it. It is much easier to have a separate diagnosis that stands on its own, which will probably make an audit less common (unless you do it too often).

Final Thoughts

In summary, document what you do, do what you document, and report what is medically necessary. Keep watch over your EHR to be sure it is not overcoding for you. You do not want to be a ewe!

Sheep are thought of as nervous animals, a good target for predators. You do not want to be a sheep. Unfortunately, many electronic health record (EHR) programs make you a target for audits and requests for the return of payments for a variety of reasons. Although you likely are aware of the uses of modifier -25, it is the abuses—either intentional or accidental—that can bring an audit your way. The use of modifier -25 was previously reviewed in Cutis.¹ Despite the availability of this excellent review, I have found that there is still great confusion about both the use of modifier -25 and the selection of the correct evaluation and management (E&M) code when used.

When to Bill for E&M

Based on recent discussions with colleagues in the New York area who have been audited, an easy way to bring on a request for medical records is to report an E&M 100% of the time with a procedure. In these instances, every single E&M was performed on the same visit as a dermatologic procedure, most commonly biopsies(Current Procedural Terminology [CPT] code 11100, 11101) and premalignant destructions (CPT code 17000, 17003, 17004), which is in contrast with typical practitioners who perform an E&M approximately 70% of the time (RUC rationale; American Medical Association RBRVS Data Manager; May 12, 2016). One circumstance involved the reporting of E&M services 100% of the time when performed during the same visit as Mohs micrographic surgery (CPT code 17311–17315), a surprising frequency considering that the typical same day use of a code for this procedure with an E&M in the Medicare population is less than 25%.

According to the National Correct Coding Initiative Policy Manual for Medicare Services, procedures with a global period of 90 days are defined as major surgical procedures,² which only include adjacent tissue transfers and grafts for dermatology. If an E&M is performed on the same date of service as one of these procedures to decide whether to perform the procedure, the E&M can be reported separately using modifier -57. Other preoperative E&M services provided on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not reported separately.²

All other procedures dermatologists perform generally are considered minor, which are defined as having a global period of 0 or 10 days. Because the decision to perform a minor procedure is included in the payment for the procedure, E&M services should not be reported separately from the minor procedure. 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. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.”²

Documentation Guidelines

These guidelines seem straightforward, but as with so much else where the government is involved, the devil is in the details. When making coding decisions, you may consult the documentation guidelines from either 1995³ or 1997,⁴ which are available for download on the Centers for Medicare & Medicaid Services (CMS) website (https://www.cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNedwebguide/emdoc.html). The 1995 guidelines are less empiric and offer more flexibility, while the 1997 guidelines rely on number of “bullets” as examination elements.

1995 Guidelines

According to the 1995 documentation guidelines, the levels of E&M services are based on 4 types of examination that are defined as follows: (1) problem focused, a limited examination of the affected body area or organ system; (2) expanded problem focused, a limited examination of the affected body area or organ system and other symptomatic or related organ system(s); (3) detailed, an extended examination of the affected body area(s) and other symptomatic or related organ system(s); and (4) comprehensive, a general multisystem examination or complete examination of a single organ system.³ Detailed history is the fuzziest part of the coding universe. Some insurers take an approach that you need to examine 2 to 7 organ systems and 4 distinct lesions in 4 body areas, which is discussed in audit tools available from some Medicare intermediaries (Advancing the Business of Healthcare forum; April 10, 2014). As a result, the 12-bullet examination from the 1997 documentation guidelines may be more suitable for a new level 3 or established level 4 visit. For a comprehensive examination, the 1995 criteria allow for a complete examination of a single organ system such as the full-body skin examination with the patient completely undressed, which is medically necessary in our melanoma patients.

For purposes of examination, 9 body areas are recognized in the 1995 guidelines,³ along with more than a dozen organ systems of which the skin is of most interest to dermatologists.

According to the 1995 guidelines,³ the extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s) and range from focused examinations of single body areas to general multisystem or complete single organ system examinations. Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. Although a notation of normal is sufficient, abnormal without elaboration is insufficient, and abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. The medical record for a general multisystem examination should include findings involving approximately 8 or more of the 12 organ systems.

An expanded problem focused examination under the 1995 guidelines could be as simple as “Scar on cancer excision site on left cheek soft and supple. No cervical adenopathy.” There is some confusion regarding detailed examinations, and one consultant went as far as calling the guidelines “vague,”5 while others such as a Medicare intermediary make a quantum leap that if a comprehensive general system examination includes 8 to 12 organ systems, one step below should include 2 to 7 organ systems.6 In essence, the payer makes the rules here.

1997 Guidelines

According to the 1997 documentation guidelines, count bullets that are examination elements, which can be either general or single organ system.⁴ (A table showing the bullets for the examination elements is available from the CMS.⁴) For each type of examination, apply the following: problem focused examination requires 1 to 5 elements identified by a bullet, expanded problem focused examination needs at least 6, detailed examination requires at least 12, and comprehensive examination requires all elements identified by a bullet with documentation of every element in each box with a shaded border and at least 1 element in each box with an unshaded border.⁴ Although you may do more writing when using the 1997 guidelines, you can easily count up bullets and these guidelines are amenable to template examinations on paper and obviously easily coded into EHR software that will do the bullet counting for you.

Unfortunately, this is where a ewe becomes a sheep, ripe for hunting for a number of reasons. First, just because you documented an E&M service does not mean it is medically necessary. Do you really need vital signs for every visit? If you are a meaningful EHR user working on penalty avoidance, you may capture examination data for meaningful use that is not medically necessary but cannot be parsed out by the autocoder in your EHR. As a result, simply do a quick manual audit of your notes to see if you are overcoding, which becomes second nature if you do it often.

The second trap, which brings us back to modifier -25, is when you perform a procedure the same day as your E&M or vice versa. Every procedure we do within the Resource-Based Relative Value Scale contains preservice time, which includes review of materials relevant to the procedure, examination of the area, and all preparation (eg, marking, time out, anesthesia, scrub and drape) before the surgery begins. The detailed vignettes are available to those involved in the Relative Value Scale Update Committee process and to the rest of the world in a subscription product called the RBRVS DataManager Online, which is produced by the American Medical Association. Unfortunately, the American Medical Association is not accepting new subscriptions to this product, as it has decided to outsource most of its coding resources to Optum360, one of the many arms of UnitedHealth Group, and will not have a replacement product until after June 30, 2016.⁷

In essence, if you (and your EHR) are counting bullets and then treating the body area in question, you are double-dipping, as the examination of the area is included in the procedure. So if you are heading toward a CPT 99213-25 with 6 bullets, one of which is on the left arm, and you perform a 0- or 10-day global procedure on that arm, you are down to 5 bullets, which drops your level of examination to problem focused. Remember, you need only 2 of 3—history, examination, and decision making—to be at or above that need for that particular level of reporting. If only one of your history or decision making is at or above the needed level for a 99213, the loss of a single bullet drops you down to a 99212! An audit where a handful of medical records are pulled and a request for money back on the universe of payments the insurer has paid is always unpleasant and you should, if you get a request for same, follow all the rules and timelines outlined by the payer. If you knowingly behaved in a risky fashion, consult a good attorney.

Of course, you may argue that the effort needed for the E&M work for the procedure was above and beyond what is typical for the service, which can be a hard standard to meet. Although the CMS requires a “significant and separately identifiable E&M service” as noted above and a separate diagnosis is not needed, the onus is on you to prove it. It is much easier to have a separate diagnosis that stands on its own, which will probably make an audit less common (unless you do it too often).

Final Thoughts

In summary, document what you do, do what you document, and report what is medically necessary. Keep watch over your EHR to be sure it is not overcoding for you. You do not want to be a ewe!

Sheep are thought of as nervous animals, a good target for predators. You do not want to be a sheep. Unfortunately, many electronic health record (EHR) programs make you a target for audits and requests for the return of payments for a variety of reasons. Although you likely are aware of the uses of modifier -25, it is the abuses—either intentional or accidental—that can bring an audit your way. The use of modifier -25 was previously reviewed in Cutis.¹ Despite the availability of this excellent review, I have found that there is still great confusion about both the use of modifier -25 and the selection of the correct evaluation and management (E&M) code when used.

When to Bill for E&M

Based on recent discussions with colleagues in the New York area who have been audited, an easy way to bring on a request for medical records is to report an E&M 100% of the time with a procedure. In these instances, every single E&M was performed on the same visit as a dermatologic procedure, most commonly biopsies(Current Procedural Terminology [CPT] code 11100, 11101) and premalignant destructions (CPT code 17000, 17003, 17004), which is in contrast with typical practitioners who perform an E&M approximately 70% of the time (RUC rationale; American Medical Association RBRVS Data Manager; May 12, 2016). One circumstance involved the reporting of E&M services 100% of the time when performed during the same visit as Mohs micrographic surgery (CPT code 17311–17315), a surprising frequency considering that the typical same day use of a code for this procedure with an E&M in the Medicare population is less than 25%.

According to the National Correct Coding Initiative Policy Manual for Medicare Services, procedures with a global period of 90 days are defined as major surgical procedures,² which only include adjacent tissue transfers and grafts for dermatology. If an E&M is performed on the same date of service as one of these procedures to decide whether to perform the procedure, the E&M can be reported separately using modifier -57. Other preoperative E&M services provided on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not reported separately.²

All other procedures dermatologists perform generally are considered minor, which are defined as having a global period of 0 or 10 days. Because the decision to perform a minor procedure is included in the payment for the procedure, E&M services should not be reported separately from the minor procedure. 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. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.”²

Documentation Guidelines

These guidelines seem straightforward, but as with so much else where the government is involved, the devil is in the details. When making coding decisions, you may consult the documentation guidelines from either 1995³ or 1997,⁴ which are available for download on the Centers for Medicare & Medicaid Services (CMS) website (https://www.cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNedwebguide/emdoc.html). The 1995 guidelines are less empiric and offer more flexibility, while the 1997 guidelines rely on number of “bullets” as examination elements.

1995 Guidelines

According to the 1995 documentation guidelines, the levels of E&M services are based on 4 types of examination that are defined as follows: (1) problem focused, a limited examination of the affected body area or organ system; (2) expanded problem focused, a limited examination of the affected body area or organ system and other symptomatic or related organ system(s); (3) detailed, an extended examination of the affected body area(s) and other symptomatic or related organ system(s); and (4) comprehensive, a general multisystem examination or complete examination of a single organ system.³ Detailed history is the fuzziest part of the coding universe. Some insurers take an approach that you need to examine 2 to 7 organ systems and 4 distinct lesions in 4 body areas, which is discussed in audit tools available from some Medicare intermediaries (Advancing the Business of Healthcare forum; April 10, 2014). As a result, the 12-bullet examination from the 1997 documentation guidelines may be more suitable for a new level 3 or established level 4 visit. For a comprehensive examination, the 1995 criteria allow for a complete examination of a single organ system such as the full-body skin examination with the patient completely undressed, which is medically necessary in our melanoma patients.

For purposes of examination, 9 body areas are recognized in the 1995 guidelines,³ along with more than a dozen organ systems of which the skin is of most interest to dermatologists.

According to the 1995 guidelines,³ the extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s) and range from focused examinations of single body areas to general multisystem or complete single organ system examinations. Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. Although a notation of normal is sufficient, abnormal without elaboration is insufficient, and abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. The medical record for a general multisystem examination should include findings involving approximately 8 or more of the 12 organ systems.

An expanded problem focused examination under the 1995 guidelines could be as simple as “Scar on cancer excision site on left cheek soft and supple. No cervical adenopathy.” There is some confusion regarding detailed examinations, and one consultant went as far as calling the guidelines “vague,”5 while others such as a Medicare intermediary make a quantum leap that if a comprehensive general system examination includes 8 to 12 organ systems, one step below should include 2 to 7 organ systems.6 In essence, the payer makes the rules here.

1997 Guidelines

According to the 1997 documentation guidelines, count bullets that are examination elements, which can be either general or single organ system.⁴ (A table showing the bullets for the examination elements is available from the CMS.⁴) For each type of examination, apply the following: problem focused examination requires 1 to 5 elements identified by a bullet, expanded problem focused examination needs at least 6, detailed examination requires at least 12, and comprehensive examination requires all elements identified by a bullet with documentation of every element in each box with a shaded border and at least 1 element in each box with an unshaded border.⁴ Although you may do more writing when using the 1997 guidelines, you can easily count up bullets and these guidelines are amenable to template examinations on paper and obviously easily coded into EHR software that will do the bullet counting for you.

Unfortunately, this is where a ewe becomes a sheep, ripe for hunting for a number of reasons. First, just because you documented an E&M service does not mean it is medically necessary. Do you really need vital signs for every visit? If you are a meaningful EHR user working on penalty avoidance, you may capture examination data for meaningful use that is not medically necessary but cannot be parsed out by the autocoder in your EHR. As a result, simply do a quick manual audit of your notes to see if you are overcoding, which becomes second nature if you do it often.

The second trap, which brings us back to modifier -25, is when you perform a procedure the same day as your E&M or vice versa. Every procedure we do within the Resource-Based Relative Value Scale contains preservice time, which includes review of materials relevant to the procedure, examination of the area, and all preparation (eg, marking, time out, anesthesia, scrub and drape) before the surgery begins. The detailed vignettes are available to those involved in the Relative Value Scale Update Committee process and to the rest of the world in a subscription product called the RBRVS DataManager Online, which is produced by the American Medical Association. Unfortunately, the American Medical Association is not accepting new subscriptions to this product, as it has decided to outsource most of its coding resources to Optum360, one of the many arms of UnitedHealth Group, and will not have a replacement product until after June 30, 2016.⁷

In essence, if you (and your EHR) are counting bullets and then treating the body area in question, you are double-dipping, as the examination of the area is included in the procedure. So if you are heading toward a CPT 99213-25 with 6 bullets, one of which is on the left arm, and you perform a 0- or 10-day global procedure on that arm, you are down to 5 bullets, which drops your level of examination to problem focused. Remember, you need only 2 of 3—history, examination, and decision making—to be at or above that need for that particular level of reporting. If only one of your history or decision making is at or above the needed level for a 99213, the loss of a single bullet drops you down to a 99212! An audit where a handful of medical records are pulled and a request for money back on the universe of payments the insurer has paid is always unpleasant and you should, if you get a request for same, follow all the rules and timelines outlined by the payer. If you knowingly behaved in a risky fashion, consult a good attorney.

Of course, you may argue that the effort needed for the E&M work for the procedure was above and beyond what is typical for the service, which can be a hard standard to meet. Although the CMS requires a “significant and separately identifiable E&M service” as noted above and a separate diagnosis is not needed, the onus is on you to prove it. It is much easier to have a separate diagnosis that stands on its own, which will probably make an audit less common (unless you do it too often).

Final Thoughts

In summary, document what you do, do what you document, and report what is medically necessary. Keep watch over your EHR to be sure it is not overcoding for you. You do not want to be a ewe!