Coding Category

Understanding the Multiple Procedure Rule

When providers report more than a single (non-evaluation and management) procedure during a single encounter, payers typically will reimburse only the highest-valued procedure at full fee schedule value, and will reduce payment for the second and subsequent procedures. This occurs because payers reason that many of the component services that comprise the physician’s work (such as surgical approach and closure) should be paid only one time, per session. Chapter 1 of the National Correct Coding Initiative (NCCI) Policy Manual explains:

Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. When multiple procedures are performed at the same patient encounter, there is often overlap of the pre-procedure and post-procedure work. Payment methodologies for surgical procedures account for the overlap of the pre-procedure and post-procedure work.

This is the basis for the “multiple procedure rule,” under which Medicare pays a reduced amount for the second and subsequent procedures performed during the same session. The amount of the reduction (if any) is determined by the indicator within the “Multiple Procedure” column of the Physician Fee Scheduled Relative Value file:

0=No payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure, base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount for the procedure.

1=Standard payment adjustment rules in effect before January 1, 1995 for multiple procedures apply. In the 1995 file, this indicator only applies to codes with a status code of “D”. If procedure is reported on the same day as another procedure that has an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 25%, 25%, 25%, and by report). Base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage.

2=Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50% and by report). Base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage.

3=Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in the Endobase field of this file. Apply the multiple endoscopy rules to a family before ranking the family with the other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure. Payment for the base procedure is included in the payment for the other endoscopy.

4=Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging procedure in the same family (per the diagnostic imaging family indicator, below). If procedure is reported in the same session on the same day as another procedure with the same family indicator, rank the procedures by fee schedule amount for the TC. Pay 100% for the highest priced procedure, and 75% for each subsequent procedure. Base the payment for subsequent procedures on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage. The professional component (PC) is paid at 100% for all procedures.

9=Concept does not apply.

Multiple procedure rule does not apply to all CPT® codes. Payers should never reduce payment for:

• Significant, separately identifiable E/M services provided on the same day as other procedures/services and properly appended with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service

• Any designated “add-on” CPT® code (listed with a “+” next to the descriptor)

• Any procedure designated by CPT as “Modifier 51 exempt,” which may be identified in the CPT codebook by a “circle with a slash” next to the code.

You can find a full list of “add-on” and “modifier 51” exempt procedures in Appendices D and E of the CPT® codebook. The relative values assigned to these codes factor in the “additional” nature of the procedure/services; therefore, there is no justification to reduce reimbursement when these codes are reported in addition to other procedures.

August 21st, 2014

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Surgery Arthroscopy Includes Debridement (with an Important Exception)

In most cases, per CMS rules, surgical arthroscopy will include arthroscopic debridement of the same joint; therefore, you may not report the debridement separately.

For example, you should not separately report 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) and 29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)with other knee arthroscopy codes (29866- 29889), for Medicare payers.

There is an exception to this general rule: You may report G0289 Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chrondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee with other knee arthroscopy codes, for Medicare payers, but only if the removal or debridement occurs in a different compartment of the knee from the primary surgical service. Per Chapter 4 of the National Correct Coding Initiative (NCCI) Policy Manual:

Since CPT codes 29880 and 29881 (Surgical knee arthroscopy with meniscectomy including debridement/shaving of articular cartilage of same or separate compartment(s)) include debridement/shaving of articular cartilage of any compartment, HCPCS code G0289 may be reported with CPT codes 29880 or 29881 only if reported for removal of a loose body or foreign body from a different compartment of the same knee. HCPCS code G0289 should not be reported for removal of a loose body or foreign body or debridement/shaving of articular cartilage from the same compartment as another knee arthroscopic procedure.

When removal of a loose body or foreign body occurs in the same compartment of the same knee as another procedure, you may not report the procedure separately.

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Two New “K” Codes in Effect Oct. 1

Durable medical equipment (DME) suppliers will soon have two new “K” codes (K0901 and K0902) for reporting off-the-shelf (OTS) prefabricated single and double upright knee orthoses to Medicare.

To identify prefabricated single and double upright knee orthoses that are furnished in a variety of standard sizes and do not require the skills of an expert to measure and fit to the individual, the following OTS codes will be added to the HCPCS Level II code set, effective October 1, 2014:

K0901 - Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

K0902 - Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

The Centers for Medicare & Medicaid Services (CMS) defines the term “minimal self-adjustment” to mean an adjustment that the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist or an individual who has specialized training.

You can download the complete list of OTS orthotics HCPCS Level II codes from the CMS website.

Sources: MLN Matters® Number: MM8839; CMS Transmittal  3016, CR8839

August 13th, 2014

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CMS Proposes Coverage of Colorectal Cancer DNA Test

An easier colorectal screening method may be reimbursed by Centers for Medicare & Medicaid Services (CMS) related programs if support for a proposed decision memo succeeds. CMS is proposing coverage of the Cologuard™ DNA stool test once every three years for beneficiaries who meet particular criteria.

Cologuard was recently approved by the Food and Drug Administration (FDA). Research supports the test, which detects molecular markers of the altered DNA contained in cells shed by colorectal cancer and pre-malignant colorectal epithelial neoplasia. The test identifies three specific markers, the first being epigenetic changes, the second detecting specific point mutations, and the third identifying human fecal hemoglobin.

The test will be a relief for most adults between ages 50 and 85 years. Additional criteria beyond age include:

  • Asymptomatic (No signs or symptoms of colorectal disease including gastrointestinal pain, blood in stool, positive guaiac fecal occult blot test or fecal immunochemical test.)
  • Average risk (No history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease (IBD), Crohn’s disease, ulcerative colitis. No family history of colorectal cancer or adnomatous polyp, familial adenomatous polyposis, or hereditary nopolyposis colorectal cancer).

CMS seeks comments on the proposed decision by September 11.

August 11th, 2014

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What To Do When Your Patient Is a “Poor Historian”

Clear and comprehensive documentation is a critical element in getting claims paid. You hear that advice day in and day out. So what do you do when the provider is unable to obtain a critical component of documentation from a patient? The answer isn’t as tricky as you might think.

When a provider is unable to obtain certain medical information, he or she should clearly document in the record:

  • The components that were unobtainable (for example, the history of present illness (HPI); and
  • Circumstances that precluded obtaining the specific documentation. For example, “The patient was unconscious.” Or, “The patient was a ‘poor historian’ due to advanced dementia.”

Before giving up the ship, however, the provider should attempt to obtain the information from another source, such as a family member, spouse, medical record, etc. If these sources were unable to supply the missing information, the attempt should be documented as well. For example:

  • “A family member was contacted, but unable to provide additional information.” Or,
  • “The medical record did not contain the needed information.”

If, at a later time, the patient or some other source is able to supply the missing information, the provider may add an addendum to the record to fill in the missing blanks that support medical necessity for the provided services.

Resource: The Centers for Medicare & Medicaid Services 1995 and 1997 Documentation Guidelines for Evaluation and Management Services

August 8th, 2014

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