In the November 2015 issue of The Dermatologist, dermatologic procedures with a 90-day global period as well as miscellaneous other procedures were discussed. This article (Part 6 in the series) will discuss the important concept and appropriate use of modifiers with regards to proper billing and coding. Modifiers are codes that can be applied to either Evaluation/Management (E/M) codes or Current Procedural Terminology (CPT) codes to communicate specific information to the insurance carriers. Understanding the role of modifiers in dermatology is critical due to the number and variety of procedures performed. Without the use of modifiers, many procedures will not be properly reimbursed and will result in lost revenue for the physician. There are many existing modifiers, but the most frequently used modifiers will be discussed in this article.
E/M and CPT Modifiers
One of the most frequently used and poorly understood modifiers is the “25” modifier. According to the Centers for Medicare & Medicaid Services (CMS), the definition of the “25” modifier is: a significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service. What does this truly mean? Physicians will often attach a “25” modifier to any E/M code if a procedure is performed in the same visit. This is incorrect use of the “25” modifier and can result in an audit.
The first thing to know is the “25” modifier can only be applied to E/M codes. It is not appropriate to attach it to a procedure code. The best way to conceptualize the “25” modifier is to subtract a procedure from a visit, and then see what documentation remains. Physicians often forget that included in procedure codes are the pertinent history and physical exam, discussion of treatment options, consent, performing the procedure, and follow-up care and instructions.
For example, a patient comes for evaluation of a new lesion on the arm. The physician examines the lesion, discusses possible diagnoses and treatment options, and decides to biopsy the lesion. All of this care is included in the CPT code 11100 for skin biopsy. It would be inappropriate for the physician to bill an office visit with code such as 99213 in addition to the 11100 CPT code. However, if the same patient also mentions they have scalp itching, and the physician examines the scalp and diagnoses the patient with seborrheic dermatitis, a “25” modifier would be used to indicate that the patient had additional dermatologic issues addressed during the office visit outside of the condition that required a procedure.
Use of the “25” modifier requires intimate knowledge of what care is included within certain CPT codes. The Table provides some examples of included care in commonly used dermatology procedure codes. Medicare policy specifies that a “25” modifier should not be appended to new patient visits, as these codes are excluded from restrictions based on the global surgical package. In such instances, when billing Medicare, bill the procedure code and an appropriate new patient visit code (99201-99205) without any modifier.
The “24” modifier is another modifier that can only be applied to an E/M service code. The “24” modifier is used to indicate a separate E/M encounter during a postoperative period of a prior performed procedure. For example, a patient who underwent Mohs with graft repair develops a rash 2 weeks later. The physician would need to use a “24” modifier to the office visit for the rash to indicate to insurance that this is a new and separate issue from the previous surgical procedure. If that same patient required a skin biopsy of the rash, the provider would need to use both “24” and “79” modifiers to indicate a separate office visit with a separate procedure from the graft repair (the “79” modifier is discussed later this article). Proper use of the “24” modifier requires knowledge of the global periods associated with different dermatology procedures, as discussed in the previous articles in this series.
Article continues on page 2
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The “57” modifier indicates a separately identifiable E/M service related to the decision to perform surgery. Medicare further defines surgery as a procedure with a 90-day global period. This modifier would be used in the situation where a surgeon meets with a patient for the first time, interviews patient and performs an exam, and then decides to perform Mohs surgery on the same day (as long as the Mohs repair is a 90-day global repair type such as flap or graft). This allows for E/M code, Mohs surgery code, and repair codes to all be submitted and reimbursed on the same day. The “57” modifier should not be used because the decision to perform surgery is included in 10-day or zero-day global periods.
The “59” modifier is attached to CPT codes to indicate a procedure or service was distinct or separate from other services performed on the same day. This modifier is used to unbundle 2 procedures so reimbursement for 2 distinct procedures is possible. For example, if a patient undergoes cryosurgery of 4 actinic keratoses and a shave biopsy of a mole, the biopsy CPT code 11100 would require a “59” modifier. If 3 procedures are performed in a single office visit, the “59” modifier would need to be applied to the second and third procedures listed. Overuse or inappropriate use of this modifier can often lead to an audit.
Due to perceived overuse of the “59” modifier, CMS developed 4 new modifiers which took effect January 1, 2015. These modifiers include: XS, XP, XU, and XE, and can all potentially be used in place of the “59” modifier. CMS states anytime 1 of these 4 modifiers can be used, it should be used over the “59” modifier. The “XS” modifier is used to represent 2 procedures performed in the same encounter, but on different organs or structures. For dermatologists, this would mainly be used to indicate different anatomic locations on the skin.
With the transition to International Classification of Diseases, Tenth Revision (ICD-10), we now have the ability to use more specific anatomic location ICD-10 codes compared with previous International Classification of Diseases, Ninth Revision (ICD-9) codes. Despite the increase in site specificity, CMS still recommends using the “XS” modifier when appropriate. The “XP” modifier is used to specify a distinct service which is performed by a different provider. The “XU” modifier indicates use of a service that is distinct because it does not overlap usual components of the main service. The “XE” modifier indicates a service that is distinct because it occurred during a separate encounter.
The “50” modifier denotes the bilateral nature of a procedure within 1 encounter. One common scenario for a dermatologist to use this modifier would be application of bilateral Unna boots which would be reported as 29580 + 50. Inappropriate use of this modifier would be when removing a lesion on the right arm and 1 on the left arm, or on the right and left leg. The provider should use the “RT” and “LT” modifiers, or the “XS” instead of the “50” modifier.
The “79” modifier is used to indicate the performance of a separate and unrelated procedure during a postoperative global period. This modifier is analogous to the “59” E/M modifier but indicates a new/separate procedure occurring during the global period rather than on the same date of service as the original procedure.
The “58” modifier indicates 1 of 2 things: either a staged procedure during a postoperative period such as the takedown of an interpolation flap, or a re-excision of a lesion which had a positive margin on previous treatment, if the re-excision occurs during the previous procedure’s global period. For example, the provider excises a squamous cell carcinoma on the leg with intermediate linear closure and the margin is reported as positive. A week later, the provider removes additional tissue and uses modifier “58” to the second excision code.
The “GC” modifier is typically used in teaching environments to indicate the office visit or procedure has been completed at least in part by a resident under the direct supervision of an attending physician, in accordance with Medicare teaching guidelines. For minor procedures, considered to be those with global periods of 10 days or less, the attending physician must be present for the entire procedure in order to bill for those procedures. This includes cryotherapy and skin biopsies. Teaching centers may also use internal modifiers to signify to their respective coding departments patient visits and procedures that were solely conducted by a nonattending physician.
Teledermatology is becoming increasingly utilized as a method of treating patients in underserved populations. The 2 main types of telemedicine are store and forward or live interactive. Currently CMS only reimburses for interactive telemedicine, defined as “2-way, real-time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.” The modifier “GT” is used by the physician providing the telemedicine service, and is attached to a normal E/M level of service code. The modifier “GQ” is used alongside E/M codes for “store and forward” telemedicine which is not a live physician–patient encounter. Currently CMS only reimburses for “store and forward” visits in Hawaii and Alaska, though some private insurers may reimburse for this service in other areas.
V codes were used with ICD-9 to help justify certain types of office visits and procedures. With the transition to ICD-10, V codes have been replaced with similar Z codes. Medicare does not pay for most preventive dermatology services. Routine or preventive skin checks are not typically covered by Medicare without a presenting complaint, unless the provider indicates a history of skin cancer. Z85.820 indicates a personal history of malignant melanoma, and Z85.828 indicates a personal history of other malignant neoplasm of skin. These, along with several other analogous “Z” codes, can be used as primary diagnosis codes for skin check visits, and can also help justify more frequent skin checks. For any associated long-term, high-risk drug use, Z79.899 (monitoring of long-term risky medication) or Z51.81 (encounter for therapeutic drug monitoring) can be added as they communicate the medical necessity of a visit or ordering tests to evaluate drug efficacy or monitor for toxicity. These Z codes can help justify a higher level of complexity in the medical decision-making portion of documentation, as well as more frequent office visits and coverage of laboratory tests. Z48.02 can be used for postoperative visits to indicate an encounter for suture or staple removal, while Z09 indicates an encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm.
The final article in this series will discuss proper coding and documentation of inpatient dermatology and emergency department consultations.
Article continues on page 3
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Coding Intricacies
The business of coding can be tricky. A reader, Howard Rogers, MD, PhD, in practice in Norwich, CT, wrote in with several concerns regarding the October 2015 article, on Understanding Global Periods:
1. Under shave removal, the intent to completely remove a lesion through at the dermal level is what defines the code—not whether the margins are clear histologically.
2. Benign lesions can be removed by shave removal—this is not reserved for malignant lesions.
3. Intralesional injections 11900 have a zero-day global period.
Dr. Strowd responds:
The CPT coding series for shave removals (11300…) is one that has historically generated some controversy among providers and billing specialists, as there can be significant overlap between this CPT series and excision CPT codes and cutaneous biopsy CPT codes. The main distinguishing factor between shave removal codes and excision codes are the depth of the defect created. If the defect extends to the subcutaneous fat, such as in a saucerization procedure, the appropriate CPT code would be an excision code regardless of whether a closure is performed.
There is slightly more ambiguity when it comes to differentiating between 11300 CPT series and 11100 CPT series. In both series, the lesion in question can be benign or malignant and tissue can be submitted for pathologic examination. The main difference lies in the intent of the physician. If the intent is to remove a lesion for therapeutic reasons, then the shave removal series may be more appropriate. If the intent of the provider is to provide a tissue sample for diagnostic purposes, the 11100 series is more appropriate.
In clinical practice, most physicians will submit tissue for histopathologic examination if there is any remote possibility of tissue atypia or malignancy. The controversy of margins then comes into play. In the October 2015 article, I made an error in stating that a margin of free tissue is needed for the 11300 series—in the CPT manual published by the American Medical Association, margin of normal skin is not a requirement to use this coding series. But, it is important to remember that the term is shave removal. This implies the physician is removing the entire lesion in question. Inga Ellzey published an article in The Dermatologist in June 2008 regarding this as well. The Derm Coding Consult published by American Academy of Dermatology also addresses this issue, and states that “if the entire lesion is removed without full thickness, and is documented as such, then the appropriate code would be selected from the shave removal [series].” If the 2 coding series reimbursed the same amount, this may be a moot point; however, the fact is that there are 12 shave removal codes compared to 2 biopsy codes and the majority of the shave removal codes reimburse more than the biopsy codes, especially if more than 1 lesion is removed during a visit or if the lesions are removed from the face. If a physician submits a lesion for pathology and it is a nevus or cutaneous malignancy and margins are clear histologically, the physician could choose to code for a shave removal of this lesion, which typically results in a higher compensation.
Another issue with shave removals comes into play when the physician is removing a known benign lesion. Unless there is clear documentation of significant inflammation, pain, or bleeding to justify removal of a benign lesion, insurance companies may consider the removal to be cosmetic and will deny payment. This is similar to benign lesion destruction codes and skin tag removals. Medicare local coverage determination publishes rules regarding documentation necessary to justify benign shave removal reimbursement. Insurance carriers can vary on their degree of coverage. The difference in reimbursement between benign shave removals and benign lesion destruction (17110 CPT series) can be quite significant. Benign shave removals can be billed separately for individual lesions compared to benign lesion destruction where the reimbursement is the same for destruction of up to 14 lesions at a time. Finally, intralesional injections CPT 1900 have a zero-day global period.
The complex repair CPT coding series 13XXX has a global surgical period of 10 days, not 90 as was discussed in the November issue.
Dr. Strowd is assistant professor of dermatology at Wake Forest School of Medicine in Winston-Salem, NC.
Disclosure: The author reports no relevant financial relationships.
In the November 2015 issue of The Dermatologist, dermatologic procedures with a 90-day global period as well as miscellaneous other procedures were discussed. This article (Part 6 in the series) will discuss the important concept and appropriate use of modifiers with regards to proper billing and coding. Modifiers are codes that can be applied to either Evaluation/Management (E/M) codes or Current Procedural Terminology (CPT) codes to communicate specific information to the insurance carriers. Understanding the role of modifiers in dermatology is critical due to the number and variety of procedures performed. Without the use of modifiers, many procedures will not be properly reimbursed and will result in lost revenue for the physician. There are many existing modifiers, but the most frequently used modifiers will be discussed in this article.
E/M and CPT Modifiers
One of the most frequently used and poorly understood modifiers is the “25” modifier. According to the Centers for Medicare & Medicaid Services (CMS), the definition of the “25” modifier is: a significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service. What does this truly mean? Physicians will often attach a “25” modifier to any E/M code if a procedure is performed in the same visit. This is incorrect use of the “25” modifier and can result in an audit.
The first thing to know is the “25” modifier can only be applied to E/M codes. It is not appropriate to attach it to a procedure code. The best way to conceptualize the “25” modifier is to subtract a procedure from a visit, and then see what documentation remains. Physicians often forget that included in procedure codes are the pertinent history and physical exam, discussion of treatment options, consent, performing the procedure, and follow-up care and instructions.
For example, a patient comes for evaluation of a new lesion on the arm. The physician examines the lesion, discusses possible diagnoses and treatment options, and decides to biopsy the lesion. All of this care is included in the CPT code 11100 for skin biopsy. It would be inappropriate for the physician to bill an office visit with code such as 99213 in addition to the 11100 CPT code. However, if the same patient also mentions they have scalp itching, and the physician examines the scalp and diagnoses the patient with seborrheic dermatitis, a “25” modifier would be used to indicate that the patient had additional dermatologic issues addressed during the office visit outside of the condition that required a procedure.
Use of the “25” modifier requires intimate knowledge of what care is included within certain CPT codes. The Table provides some examples of included care in commonly used dermatology procedure codes. Medicare policy specifies that a “25” modifier should not be appended to new patient visits, as these codes are excluded from restrictions based on the global surgical package. In such instances, when billing Medicare, bill the procedure code and an appropriate new patient visit code (99201-99205) without any modifier.
The “24” modifier is another modifier that can only be applied to an E/M service code. The “24” modifier is used to indicate a separate E/M encounter during a postoperative period of a prior performed procedure. For example, a patient who underwent Mohs with graft repair develops a rash 2 weeks later. The physician would need to use a “24” modifier to the office visit for the rash to indicate to insurance that this is a new and separate issue from the previous surgical procedure. If that same patient required a skin biopsy of the rash, the provider would need to use both “24” and “79” modifiers to indicate a separate office visit with a separate procedure from the graft repair (the “79” modifier is discussed later this article). Proper use of the “24” modifier requires knowledge of the global periods associated with different dermatology procedures, as discussed in the previous articles in this series.
Article continues on page 2
{{pagebreak}}
The “57” modifier indicates a separately identifiable E/M service related to the decision to perform surgery. Medicare further defines surgery as a procedure with a 90-day global period. This modifier would be used in the situation where a surgeon meets with a patient for the first time, interviews patient and performs an exam, and then decides to perform Mohs surgery on the same day (as long as the Mohs repair is a 90-day global repair type such as flap or graft). This allows for E/M code, Mohs surgery code, and repair codes to all be submitted and reimbursed on the same day. The “57” modifier should not be used because the decision to perform surgery is included in 10-day or zero-day global periods.
The “59” modifier is attached to CPT codes to indicate a procedure or service was distinct or separate from other services performed on the same day. This modifier is used to unbundle 2 procedures so reimbursement for 2 distinct procedures is possible. For example, if a patient undergoes cryosurgery of 4 actinic keratoses and a shave biopsy of a mole, the biopsy CPT code 11100 would require a “59” modifier. If 3 procedures are performed in a single office visit, the “59” modifier would need to be applied to the second and third procedures listed. Overuse or inappropriate use of this modifier can often lead to an audit.
Due to perceived overuse of the “59” modifier, CMS developed 4 new modifiers which took effect January 1, 2015. These modifiers include: XS, XP, XU, and XE, and can all potentially be used in place of the “59” modifier. CMS states anytime 1 of these 4 modifiers can be used, it should be used over the “59” modifier. The “XS” modifier is used to represent 2 procedures performed in the same encounter, but on different organs or structures. For dermatologists, this would mainly be used to indicate different anatomic locations on the skin.
With the transition to International Classification of Diseases, Tenth Revision (ICD-10), we now have the ability to use more specific anatomic location ICD-10 codes compared with previous International Classification of Diseases, Ninth Revision (ICD-9) codes. Despite the increase in site specificity, CMS still recommends using the “XS” modifier when appropriate. The “XP” modifier is used to specify a distinct service which is performed by a different provider. The “XU” modifier indicates use of a service that is distinct because it does not overlap usual components of the main service. The “XE” modifier indicates a service that is distinct because it occurred during a separate encounter.
The “50” modifier denotes the bilateral nature of a procedure within 1 encounter. One common scenario for a dermatologist to use this modifier would be application of bilateral Unna boots which would be reported as 29580 + 50. Inappropriate use of this modifier would be when removing a lesion on the right arm and 1 on the left arm, or on the right and left leg. The provider should use the “RT” and “LT” modifiers, or the “XS” instead of the “50” modifier.
The “79” modifier is used to indicate the performance of a separate and unrelated procedure during a postoperative global period. This modifier is analogous to the “59” E/M modifier but indicates a new/separate procedure occurring during the global period rather than on the same date of service as the original procedure.
The “58” modifier indicates 1 of 2 things: either a staged procedure during a postoperative period such as the takedown of an interpolation flap, or a re-excision of a lesion which had a positive margin on previous treatment, if the re-excision occurs during the previous procedure’s global period. For example, the provider excises a squamous cell carcinoma on the leg with intermediate linear closure and the margin is reported as positive. A week later, the provider removes additional tissue and uses modifier “58” to the second excision code.
The “GC” modifier is typically used in teaching environments to indicate the office visit or procedure has been completed at least in part by a resident under the direct supervision of an attending physician, in accordance with Medicare teaching guidelines. For minor procedures, considered to be those with global periods of 10 days or less, the attending physician must be present for the entire procedure in order to bill for those procedures. This includes cryotherapy and skin biopsies. Teaching centers may also use internal modifiers to signify to their respective coding departments patient visits and procedures that were solely conducted by a nonattending physician.
Teledermatology is becoming increasingly utilized as a method of treating patients in underserved populations. The 2 main types of telemedicine are store and forward or live interactive. Currently CMS only reimburses for interactive telemedicine, defined as “2-way, real-time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.” The modifier “GT” is used by the physician providing the telemedicine service, and is attached to a normal E/M level of service code. The modifier “GQ” is used alongside E/M codes for “store and forward” telemedicine which is not a live physician–patient encounter. Currently CMS only reimburses for “store and forward” visits in Hawaii and Alaska, though some private insurers may reimburse for this service in other areas.
V codes were used with ICD-9 to help justify certain types of office visits and procedures. With the transition to ICD-10, V codes have been replaced with similar Z codes. Medicare does not pay for most preventive dermatology services. Routine or preventive skin checks are not typically covered by Medicare without a presenting complaint, unless the provider indicates a history of skin cancer. Z85.820 indicates a personal history of malignant melanoma, and Z85.828 indicates a personal history of other malignant neoplasm of skin. These, along with several other analogous “Z” codes, can be used as primary diagnosis codes for skin check visits, and can also help justify more frequent skin checks. For any associated long-term, high-risk drug use, Z79.899 (monitoring of long-term risky medication) or Z51.81 (encounter for therapeutic drug monitoring) can be added as they communicate the medical necessity of a visit or ordering tests to evaluate drug efficacy or monitor for toxicity. These Z codes can help justify a higher level of complexity in the medical decision-making portion of documentation, as well as more frequent office visits and coverage of laboratory tests. Z48.02 can be used for postoperative visits to indicate an encounter for suture or staple removal, while Z09 indicates an encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm.
The final article in this series will discuss proper coding and documentation of inpatient dermatology and emergency department consultations.
Article continues on page 3
{{pagebreak}}
Coding Intricacies
The business of coding can be tricky. A reader, Howard Rogers, MD, PhD, in practice in Norwich, CT, wrote in with several concerns regarding the October 2015 article, on Understanding Global Periods:
1. Under shave removal, the intent to completely remove a lesion through at the dermal level is what defines the code—not whether the margins are clear histologically.
2. Benign lesions can be removed by shave removal—this is not reserved for malignant lesions.
3. Intralesional injections 11900 have a zero-day global period.
Dr. Strowd responds:
The CPT coding series for shave removals (11300…) is one that has historically generated some controversy among providers and billing specialists, as there can be significant overlap between this CPT series and excision CPT codes and cutaneous biopsy CPT codes. The main distinguishing factor between shave removal codes and excision codes are the depth of the defect created. If the defect extends to the subcutaneous fat, such as in a saucerization procedure, the appropriate CPT code would be an excision code regardless of whether a closure is performed.
There is slightly more ambiguity when it comes to differentiating between 11300 CPT series and 11100 CPT series. In both series, the lesion in question can be benign or malignant and tissue can be submitted for pathologic examination. The main difference lies in the intent of the physician. If the intent is to remove a lesion for therapeutic reasons, then the shave removal series may be more appropriate. If the intent of the provider is to provide a tissue sample for diagnostic purposes, the 11100 series is more appropriate.
In clinical practice, most physicians will submit tissue for histopathologic examination if there is any remote possibility of tissue atypia or malignancy. The controversy of margins then comes into play. In the October 2015 article, I made an error in stating that a margin of free tissue is needed for the 11300 series—in the CPT manual published by the American Medical Association, margin of normal skin is not a requirement to use this coding series. But, it is important to remember that the term is shave removal. This implies the physician is removing the entire lesion in question. Inga Ellzey published an article in The Dermatologist in June 2008 regarding this as well. The Derm Coding Consult published by American Academy of Dermatology also addresses this issue, and states that “if the entire lesion is removed without full thickness, and is documented as such, then the appropriate code would be selected from the shave removal [series].” If the 2 coding series reimbursed the same amount, this may be a moot point; however, the fact is that there are 12 shave removal codes compared to 2 biopsy codes and the majority of the shave removal codes reimburse more than the biopsy codes, especially if more than 1 lesion is removed during a visit or if the lesions are removed from the face. If a physician submits a lesion for pathology and it is a nevus or cutaneous malignancy and margins are clear histologically, the physician could choose to code for a shave removal of this lesion, which typically results in a higher compensation.
Another issue with shave removals comes into play when the physician is removing a known benign lesion. Unless there is clear documentation of significant inflammation, pain, or bleeding to justify removal of a benign lesion, insurance companies may consider the removal to be cosmetic and will deny payment. This is similar to benign lesion destruction codes and skin tag removals. Medicare local coverage determination publishes rules regarding documentation necessary to justify benign shave removal reimbursement. Insurance carriers can vary on their degree of coverage. The difference in reimbursement between benign shave removals and benign lesion destruction (17110 CPT series) can be quite significant. Benign shave removals can be billed separately for individual lesions compared to benign lesion destruction where the reimbursement is the same for destruction of up to 14 lesions at a time. Finally, intralesional injections CPT 1900 have a zero-day global period.
The complex repair CPT coding series 13XXX has a global surgical period of 10 days, not 90 as was discussed in the November issue.
Dr. Strowd is assistant professor of dermatology at Wake Forest School of Medicine in Winston-Salem, NC.
Disclosure: The author reports no relevant financial relationships.
In the November 2015 issue of The Dermatologist, dermatologic procedures with a 90-day global period as well as miscellaneous other procedures were discussed. This article (Part 6 in the series) will discuss the important concept and appropriate use of modifiers with regards to proper billing and coding. Modifiers are codes that can be applied to either Evaluation/Management (E/M) codes or Current Procedural Terminology (CPT) codes to communicate specific information to the insurance carriers. Understanding the role of modifiers in dermatology is critical due to the number and variety of procedures performed. Without the use of modifiers, many procedures will not be properly reimbursed and will result in lost revenue for the physician. There are many existing modifiers, but the most frequently used modifiers will be discussed in this article.
E/M and CPT Modifiers
One of the most frequently used and poorly understood modifiers is the “25” modifier. According to the Centers for Medicare & Medicaid Services (CMS), the definition of the “25” modifier is: a significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service. What does this truly mean? Physicians will often attach a “25” modifier to any E/M code if a procedure is performed in the same visit. This is incorrect use of the “25” modifier and can result in an audit.
The first thing to know is the “25” modifier can only be applied to E/M codes. It is not appropriate to attach it to a procedure code. The best way to conceptualize the “25” modifier is to subtract a procedure from a visit, and then see what documentation remains. Physicians often forget that included in procedure codes are the pertinent history and physical exam, discussion of treatment options, consent, performing the procedure, and follow-up care and instructions.
For example, a patient comes for evaluation of a new lesion on the arm. The physician examines the lesion, discusses possible diagnoses and treatment options, and decides to biopsy the lesion. All of this care is included in the CPT code 11100 for skin biopsy. It would be inappropriate for the physician to bill an office visit with code such as 99213 in addition to the 11100 CPT code. However, if the same patient also mentions they have scalp itching, and the physician examines the scalp and diagnoses the patient with seborrheic dermatitis, a “25” modifier would be used to indicate that the patient had additional dermatologic issues addressed during the office visit outside of the condition that required a procedure.
Use of the “25” modifier requires intimate knowledge of what care is included within certain CPT codes. The Table provides some examples of included care in commonly used dermatology procedure codes. Medicare policy specifies that a “25” modifier should not be appended to new patient visits, as these codes are excluded from restrictions based on the global surgical package. In such instances, when billing Medicare, bill the procedure code and an appropriate new patient visit code (99201-99205) without any modifier.
The “24” modifier is another modifier that can only be applied to an E/M service code. The “24” modifier is used to indicate a separate E/M encounter during a postoperative period of a prior performed procedure. For example, a patient who underwent Mohs with graft repair develops a rash 2 weeks later. The physician would need to use a “24” modifier to the office visit for the rash to indicate to insurance that this is a new and separate issue from the previous surgical procedure. If that same patient required a skin biopsy of the rash, the provider would need to use both “24” and “79” modifiers to indicate a separate office visit with a separate procedure from the graft repair (the “79” modifier is discussed later this article). Proper use of the “24” modifier requires knowledge of the global periods associated with different dermatology procedures, as discussed in the previous articles in this series.
Article continues on page 2
{{pagebreak}}
The “57” modifier indicates a separately identifiable E/M service related to the decision to perform surgery. Medicare further defines surgery as a procedure with a 90-day global period. This modifier would be used in the situation where a surgeon meets with a patient for the first time, interviews patient and performs an exam, and then decides to perform Mohs surgery on the same day (as long as the Mohs repair is a 90-day global repair type such as flap or graft). This allows for E/M code, Mohs surgery code, and repair codes to all be submitted and reimbursed on the same day. The “57” modifier should not be used because the decision to perform surgery is included in 10-day or zero-day global periods.
The “59” modifier is attached to CPT codes to indicate a procedure or service was distinct or separate from other services performed on the same day. This modifier is used to unbundle 2 procedures so reimbursement for 2 distinct procedures is possible. For example, if a patient undergoes cryosurgery of 4 actinic keratoses and a shave biopsy of a mole, the biopsy CPT code 11100 would require a “59” modifier. If 3 procedures are performed in a single office visit, the “59” modifier would need to be applied to the second and third procedures listed. Overuse or inappropriate use of this modifier can often lead to an audit.
Due to perceived overuse of the “59” modifier, CMS developed 4 new modifiers which took effect January 1, 2015. These modifiers include: XS, XP, XU, and XE, and can all potentially be used in place of the “59” modifier. CMS states anytime 1 of these 4 modifiers can be used, it should be used over the “59” modifier. The “XS” modifier is used to represent 2 procedures performed in the same encounter, but on different organs or structures. For dermatologists, this would mainly be used to indicate different anatomic locations on the skin.
With the transition to International Classification of Diseases, Tenth Revision (ICD-10), we now have the ability to use more specific anatomic location ICD-10 codes compared with previous International Classification of Diseases, Ninth Revision (ICD-9) codes. Despite the increase in site specificity, CMS still recommends using the “XS” modifier when appropriate. The “XP” modifier is used to specify a distinct service which is performed by a different provider. The “XU” modifier indicates use of a service that is distinct because it does not overlap usual components of the main service. The “XE” modifier indicates a service that is distinct because it occurred during a separate encounter.
The “50” modifier denotes the bilateral nature of a procedure within 1 encounter. One common scenario for a dermatologist to use this modifier would be application of bilateral Unna boots which would be reported as 29580 + 50. Inappropriate use of this modifier would be when removing a lesion on the right arm and 1 on the left arm, or on the right and left leg. The provider should use the “RT” and “LT” modifiers, or the “XS” instead of the “50” modifier.
The “79” modifier is used to indicate the performance of a separate and unrelated procedure during a postoperative global period. This modifier is analogous to the “59” E/M modifier but indicates a new/separate procedure occurring during the global period rather than on the same date of service as the original procedure.
The “58” modifier indicates 1 of 2 things: either a staged procedure during a postoperative period such as the takedown of an interpolation flap, or a re-excision of a lesion which had a positive margin on previous treatment, if the re-excision occurs during the previous procedure’s global period. For example, the provider excises a squamous cell carcinoma on the leg with intermediate linear closure and the margin is reported as positive. A week later, the provider removes additional tissue and uses modifier “58” to the second excision code.
The “GC” modifier is typically used in teaching environments to indicate the office visit or procedure has been completed at least in part by a resident under the direct supervision of an attending physician, in accordance with Medicare teaching guidelines. For minor procedures, considered to be those with global periods of 10 days or less, the attending physician must be present for the entire procedure in order to bill for those procedures. This includes cryotherapy and skin biopsies. Teaching centers may also use internal modifiers to signify to their respective coding departments patient visits and procedures that were solely conducted by a nonattending physician.
Teledermatology is becoming increasingly utilized as a method of treating patients in underserved populations. The 2 main types of telemedicine are store and forward or live interactive. Currently CMS only reimburses for interactive telemedicine, defined as “2-way, real-time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.” The modifier “GT” is used by the physician providing the telemedicine service, and is attached to a normal E/M level of service code. The modifier “GQ” is used alongside E/M codes for “store and forward” telemedicine which is not a live physician–patient encounter. Currently CMS only reimburses for “store and forward” visits in Hawaii and Alaska, though some private insurers may reimburse for this service in other areas.
V codes were used with ICD-9 to help justify certain types of office visits and procedures. With the transition to ICD-10, V codes have been replaced with similar Z codes. Medicare does not pay for most preventive dermatology services. Routine or preventive skin checks are not typically covered by Medicare without a presenting complaint, unless the provider indicates a history of skin cancer. Z85.820 indicates a personal history of malignant melanoma, and Z85.828 indicates a personal history of other malignant neoplasm of skin. These, along with several other analogous “Z” codes, can be used as primary diagnosis codes for skin check visits, and can also help justify more frequent skin checks. For any associated long-term, high-risk drug use, Z79.899 (monitoring of long-term risky medication) or Z51.81 (encounter for therapeutic drug monitoring) can be added as they communicate the medical necessity of a visit or ordering tests to evaluate drug efficacy or monitor for toxicity. These Z codes can help justify a higher level of complexity in the medical decision-making portion of documentation, as well as more frequent office visits and coverage of laboratory tests. Z48.02 can be used for postoperative visits to indicate an encounter for suture or staple removal, while Z09 indicates an encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm.
The final article in this series will discuss proper coding and documentation of inpatient dermatology and emergency department consultations.
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Coding Intricacies
The business of coding can be tricky. A reader, Howard Rogers, MD, PhD, in practice in Norwich, CT, wrote in with several concerns regarding the October 2015 article, on Understanding Global Periods:
1. Under shave removal, the intent to completely remove a lesion through at the dermal level is what defines the code—not whether the margins are clear histologically.
2. Benign lesions can be removed by shave removal—this is not reserved for malignant lesions.
3. Intralesional injections 11900 have a zero-day global period.
Dr. Strowd responds:
The CPT coding series for shave removals (11300…) is one that has historically generated some controversy among providers and billing specialists, as there can be significant overlap between this CPT series and excision CPT codes and cutaneous biopsy CPT codes. The main distinguishing factor between shave removal codes and excision codes are the depth of the defect created. If the defect extends to the subcutaneous fat, such as in a saucerization procedure, the appropriate CPT code would be an excision code regardless of whether a closure is performed.
There is slightly more ambiguity when it comes to differentiating between 11300 CPT series and 11100 CPT series. In both series, the lesion in question can be benign or malignant and tissue can be submitted for pathologic examination. The main difference lies in the intent of the physician. If the intent is to remove a lesion for therapeutic reasons, then the shave removal series may be more appropriate. If the intent of the provider is to provide a tissue sample for diagnostic purposes, the 11100 series is more appropriate.
In clinical practice, most physicians will submit tissue for histopathologic examination if there is any remote possibility of tissue atypia or malignancy. The controversy of margins then comes into play. In the October 2015 article, I made an error in stating that a margin of free tissue is needed for the 11300 series—in the CPT manual published by the American Medical Association, margin of normal skin is not a requirement to use this coding series. But, it is important to remember that the term is shave removal. This implies the physician is removing the entire lesion in question. Inga Ellzey published an article in The Dermatologist in June 2008 regarding this as well. The Derm Coding Consult published by American Academy of Dermatology also addresses this issue, and states that “if the entire lesion is removed without full thickness, and is documented as such, then the appropriate code would be selected from the shave removal [series].” If the 2 coding series reimbursed the same amount, this may be a moot point; however, the fact is that there are 12 shave removal codes compared to 2 biopsy codes and the majority of the shave removal codes reimburse more than the biopsy codes, especially if more than 1 lesion is removed during a visit or if the lesions are removed from the face. If a physician submits a lesion for pathology and it is a nevus or cutaneous malignancy and margins are clear histologically, the physician could choose to code for a shave removal of this lesion, which typically results in a higher compensation.
Another issue with shave removals comes into play when the physician is removing a known benign lesion. Unless there is clear documentation of significant inflammation, pain, or bleeding to justify removal of a benign lesion, insurance companies may consider the removal to be cosmetic and will deny payment. This is similar to benign lesion destruction codes and skin tag removals. Medicare local coverage determination publishes rules regarding documentation necessary to justify benign shave removal reimbursement. Insurance carriers can vary on their degree of coverage. The difference in reimbursement between benign shave removals and benign lesion destruction (17110 CPT series) can be quite significant. Benign shave removals can be billed separately for individual lesions compared to benign lesion destruction where the reimbursement is the same for destruction of up to 14 lesions at a time. Finally, intralesional injections CPT 1900 have a zero-day global period.
The complex repair CPT coding series 13XXX has a global surgical period of 10 days, not 90 as was discussed in the November issue.
Dr. Strowd is assistant professor of dermatology at Wake Forest School of Medicine in Winston-Salem, NC.
Disclosure: The author reports no relevant financial relationships.
