Q: I understand that the Jul. 1, 2007, changes for the Correct Coding Initiative Version 13.2 had some huge changes for dermatology. What are they and how do they affect my billing?
A: Very few changes occurred to the third-quarter version 13.2 changes for dermatology with respect to Medicare’s Correct Coding Initiative. However, the coding edit changes that did occur are going to affect your payments for actinic keratosis and benign lesion destruction when performed on the same date of service — unless the services are properly appended with modifier 59.
I will show you the new edit bundles first and then show you how the bundles looked prior to Jul. 1, 2007.
It is very important that billing staff understand that if modifier 59 is appended to the incorrect CPT code or is appended when no bundling modifier is required, then the CPT code that has the 59 incorrectly attached will be denied. It is therefore extremely important that your staff have access to the current version of the bundling tables to avoid any denials in the coming months. Staff should also keep at least four old versions, in the event they must do a review. They need to know what the bundles were during the quarter the service was rendered.
Below are the new bundles. The examples show instances when both services are billed on the same date of service and assume that no other modifiers are required such as postoperative modifier 79.
New Bundles — Effective Jul. 1, 2007
Example 1: 17000 -59, 17110
Example 2: 17000 -59, 17111
Example 3: 17004, 17110 -59
Example 4: 17004, 17111 -59
Old Bundles — Valid Prior to Jul. 1, 2007
Example 1: 17000, 17110
Example 2: 17000, 17111 -59
Example 3: 17004, 17110
Example 4: 17004 -59, 17111
(For information for ordering the dermatology-specific CCI tables, contact the Inga Ellzey Practice Group [contact information at the end of this column].)
Q: I am having problems with Aetna’s not paying for repairs in conjunction with excisions. I do reviews with notes, but they still deny as medically not necessary. Are other practices having the same problem? What can I do to get paid?
A: In 2002, Aetna, which had not previously paid for repairs in conjunction with excisions, decided to pay for certain types of repairs with certain types of excisions. Aetna agreed to pay for both excisions and repairs based on the following guidelines:
Excision Codes Affected by the Rule:
Excision Benign Lesions:
CPT codes 11400 to 11446
Excision Malignant Lesions:
CPT codes 11600 to 11646
Intermediate Repair: 12031 to 12057
Complex Repair: 13100 to 13153
Benign skin lesions
(CPT codes 11400 to 11446)
1. Documentation for intermediate or complex repair would not routinely be required for the removal of lesions greater than 1.0 cm in diameter. This means the total measurement of the lesion and normal conservative margins (e.g., excised diameter) must be greater than 1.0 cm/d.
2. Lesions (e.g., excised diameter) less than 1.0 centimeter will typically be denied. This means that no repairs will be paid when billed with CPT codes 11400, 11401, 11420, 11421, 11400, and 11441.
Providers should not attempt to bill any repairs with the CPT codes listed in number two. If a denial is received, the denied service should be written off.
Malignant Skin Lesions
(CPT Codes 11600 to 11646)
1. Aetna agrees that many skin cancer excisions may require an intermediate or complex repair and are willing to pay for both if the documentation supports the medical necessity of the repair and describes the procedure as outlined below.
2. Aetna will not routinely review the documentation associated with the removal and repair of malignant lesions, but may ask for operative notes on a routine audit basis.
Intermediate Repairs
(CPT Codes 12031 to 12057)
1. In order to bill for an intermediate repair, one or more of the deeper layers of the subcutaneous tissue and superficial non-muscle fascia must be repaired, and this must be noted in the operative report.
2. The use of multiple layers of sutures that do not involve fascia does not constitute an intermediate closure.
Complex Repairs
(CPT codes 13100 to 13153)
1. In order to bill a complex repair, “extensive undermining” must be included in the operative note as well as what factor constituted extensive undermining for the lesion removed.
2. Aetna states in its guidelines that the reviewers at Aetna would consider the following as criteria in establishing medical necessity for complex repairs:
a. size of defect
b. type of lesion
c. location (site)
d. description of the procedure.
Documentation
Operative notes should always include:
1. the procedure that was performed (e.g., intermediate versus complex).
2. what indications made the use of the procedure medically necessary?
3. the size of the excised diameter and the size of the defect.
4. repair of superficial fascia for intermediate repairs.
5. extensive undermining for complex repairs.
Q: I have some questions regarding incident-to guidelines. I have both a physician assistant (PA) as well as a nurse practitioner (NP) working for me.
I have issues regarding what constitutes an established problem and also how long a PA or NP can see a patient without my involvement as incident to in order to consider it an incident-to event?
My specific questions include the following:
1. If I, the dermatologist, saw the patient several years ago for actinic keratosis or skin cancer and the patient now presents to the PA for a routine skin cancer follow-up after several years of missed appointments, could this still be billed as incident-to or is there a time limit (like the 3-year new patient definition in CPT)?
2. I have many Medicare patients whom I see regularly and have surgically removed some skin cancers in the past. If my PA sees the patient for a 6-month follow-up visit and finds a new skin cancer, which he biopsies, or discovers some newly developed actinic keratosis, can the PA diagnose and treat these under incident-to?
A: I have received this question many times before and have searched and searched for some formal guidelines by CMS. The only guidelines are those in Section 2050 of the Medicare Part B Claims Processing Manual.
I want to first state that my answer is in no way meant to be construed as any type of formal verification. My goal in even attempting to answer these two questions is prompted only by my wish to have providers be aware of any types of limitations or restrictions that may regulate incident-to guidelines by the carriers they bill and by the state laws that regulate the licenses of these non-physician providers (NPs and PAs).
Answer to question #1
Incident-to guidelines, which can be found under section 2050.1 of the Medicare Part B Claims Processing Manual, state that an incident-to service means “that the services are furnished as an integral part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”
Under section 2050.2, it clarifies the issue further:
“In order to have a service covered as incident-to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician’s personal in-office service. This does not mean that each occasion of an incident service performed by a non-physician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to:
a. Initiate the course of treatment of which the service being performed is an incidental part and
b. There must be subsequent services by the physician of a frequency that reflects his or her continuing active participation in and management of the course of treatment.
c. The physician must be physically present in the same office site and be immediately available to render assistance if that becomes necessary. Based on the aforementioned, I do not believe that if your provider saw the patient several years ago, the criteria for frequency and continuing active participation would be met.
Answer to question #2
I believe that question number two does show the active participation of the physician in the continued care of the patient. The fact that a new lesion was diagnosed or several new actinic keratoses had to be treated should not mitigate the incident-to guidelines since the PA knows how the physician routinely treats these conditions, the physician has already established a protocol for the treatment of these types of lesions, and the physician actively sees the patient at regular intervals.
A similar scenario would be a patient who has acne or psoriasis, for example. The patient, during the course of treatment, may need to have some medications increased or discontinued or new medications prescribed. The changes, if routine and do not represent any significant risk to the patient, could be considered an integral part of the provider’s care and should be allowed under incident-to. The incident-to provision, again, requires the active participation of the provider with the patient’s care and subsequent involvement that, without a doubt, reflects the physician’s active and continuing participation in the management of the course of treatment.
If your practice has any concerns about how your practice is utilizing its PAs and NPs under the incident-to guidelines, verify your supervision processes with a healthcare attorney or the medical director of your contracted plans for formal comment and guidance.
Q: I understand that the Jul. 1, 2007, changes for the Correct Coding Initiative Version 13.2 had some huge changes for dermatology. What are they and how do they affect my billing?
A: Very few changes occurred to the third-quarter version 13.2 changes for dermatology with respect to Medicare’s Correct Coding Initiative. However, the coding edit changes that did occur are going to affect your payments for actinic keratosis and benign lesion destruction when performed on the same date of service — unless the services are properly appended with modifier 59.
I will show you the new edit bundles first and then show you how the bundles looked prior to Jul. 1, 2007.
It is very important that billing staff understand that if modifier 59 is appended to the incorrect CPT code or is appended when no bundling modifier is required, then the CPT code that has the 59 incorrectly attached will be denied. It is therefore extremely important that your staff have access to the current version of the bundling tables to avoid any denials in the coming months. Staff should also keep at least four old versions, in the event they must do a review. They need to know what the bundles were during the quarter the service was rendered.
Below are the new bundles. The examples show instances when both services are billed on the same date of service and assume that no other modifiers are required such as postoperative modifier 79.
New Bundles — Effective Jul. 1, 2007
Example 1: 17000 -59, 17110
Example 2: 17000 -59, 17111
Example 3: 17004, 17110 -59
Example 4: 17004, 17111 -59
Old Bundles — Valid Prior to Jul. 1, 2007
Example 1: 17000, 17110
Example 2: 17000, 17111 -59
Example 3: 17004, 17110
Example 4: 17004 -59, 17111
(For information for ordering the dermatology-specific CCI tables, contact the Inga Ellzey Practice Group [contact information at the end of this column].)
Q: I am having problems with Aetna’s not paying for repairs in conjunction with excisions. I do reviews with notes, but they still deny as medically not necessary. Are other practices having the same problem? What can I do to get paid?
A: In 2002, Aetna, which had not previously paid for repairs in conjunction with excisions, decided to pay for certain types of repairs with certain types of excisions. Aetna agreed to pay for both excisions and repairs based on the following guidelines:
Excision Codes Affected by the Rule:
Excision Benign Lesions:
CPT codes 11400 to 11446
Excision Malignant Lesions:
CPT codes 11600 to 11646
Intermediate Repair: 12031 to 12057
Complex Repair: 13100 to 13153
Benign skin lesions
(CPT codes 11400 to 11446)
1. Documentation for intermediate or complex repair would not routinely be required for the removal of lesions greater than 1.0 cm in diameter. This means the total measurement of the lesion and normal conservative margins (e.g., excised diameter) must be greater than 1.0 cm/d.
2. Lesions (e.g., excised diameter) less than 1.0 centimeter will typically be denied. This means that no repairs will be paid when billed with CPT codes 11400, 11401, 11420, 11421, 11400, and 11441.
Providers should not attempt to bill any repairs with the CPT codes listed in number two. If a denial is received, the denied service should be written off.
Malignant Skin Lesions
(CPT Codes 11600 to 11646)
1. Aetna agrees that many skin cancer excisions may require an intermediate or complex repair and are willing to pay for both if the documentation supports the medical necessity of the repair and describes the procedure as outlined below.
2. Aetna will not routinely review the documentation associated with the removal and repair of malignant lesions, but may ask for operative notes on a routine audit basis.
Intermediate Repairs
(CPT Codes 12031 to 12057)
1. In order to bill for an intermediate repair, one or more of the deeper layers of the subcutaneous tissue and superficial non-muscle fascia must be repaired, and this must be noted in the operative report.
2. The use of multiple layers of sutures that do not involve fascia does not constitute an intermediate closure.
Complex Repairs
(CPT codes 13100 to 13153)
1. In order to bill a complex repair, “extensive undermining” must be included in the operative note as well as what factor constituted extensive undermining for the lesion removed.
2. Aetna states in its guidelines that the reviewers at Aetna would consider the following as criteria in establishing medical necessity for complex repairs:
a. size of defect
b. type of lesion
c. location (site)
d. description of the procedure.
Documentation
Operative notes should always include:
1. the procedure that was performed (e.g., intermediate versus complex).
2. what indications made the use of the procedure medically necessary?
3. the size of the excised diameter and the size of the defect.
4. repair of superficial fascia for intermediate repairs.
5. extensive undermining for complex repairs.
Q: I have some questions regarding incident-to guidelines. I have both a physician assistant (PA) as well as a nurse practitioner (NP) working for me.
I have issues regarding what constitutes an established problem and also how long a PA or NP can see a patient without my involvement as incident to in order to consider it an incident-to event?
My specific questions include the following:
1. If I, the dermatologist, saw the patient several years ago for actinic keratosis or skin cancer and the patient now presents to the PA for a routine skin cancer follow-up after several years of missed appointments, could this still be billed as incident-to or is there a time limit (like the 3-year new patient definition in CPT)?
2. I have many Medicare patients whom I see regularly and have surgically removed some skin cancers in the past. If my PA sees the patient for a 6-month follow-up visit and finds a new skin cancer, which he biopsies, or discovers some newly developed actinic keratosis, can the PA diagnose and treat these under incident-to?
A: I have received this question many times before and have searched and searched for some formal guidelines by CMS. The only guidelines are those in Section 2050 of the Medicare Part B Claims Processing Manual.
I want to first state that my answer is in no way meant to be construed as any type of formal verification. My goal in even attempting to answer these two questions is prompted only by my wish to have providers be aware of any types of limitations or restrictions that may regulate incident-to guidelines by the carriers they bill and by the state laws that regulate the licenses of these non-physician providers (NPs and PAs).
Answer to question #1
Incident-to guidelines, which can be found under section 2050.1 of the Medicare Part B Claims Processing Manual, state that an incident-to service means “that the services are furnished as an integral part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”
Under section 2050.2, it clarifies the issue further:
“In order to have a service covered as incident-to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician’s personal in-office service. This does not mean that each occasion of an incident service performed by a non-physician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to:
a. Initiate the course of treatment of which the service being performed is an incidental part and
b. There must be subsequent services by the physician of a frequency that reflects his or her continuing active participation in and management of the course of treatment.
c. The physician must be physically present in the same office site and be immediately available to render assistance if that becomes necessary. Based on the aforementioned, I do not believe that if your provider saw the patient several years ago, the criteria for frequency and continuing active participation would be met.
Answer to question #2
I believe that question number two does show the active participation of the physician in the continued care of the patient. The fact that a new lesion was diagnosed or several new actinic keratoses had to be treated should not mitigate the incident-to guidelines since the PA knows how the physician routinely treats these conditions, the physician has already established a protocol for the treatment of these types of lesions, and the physician actively sees the patient at regular intervals.
A similar scenario would be a patient who has acne or psoriasis, for example. The patient, during the course of treatment, may need to have some medications increased or discontinued or new medications prescribed. The changes, if routine and do not represent any significant risk to the patient, could be considered an integral part of the provider’s care and should be allowed under incident-to. The incident-to provision, again, requires the active participation of the provider with the patient’s care and subsequent involvement that, without a doubt, reflects the physician’s active and continuing participation in the management of the course of treatment.
If your practice has any concerns about how your practice is utilizing its PAs and NPs under the incident-to guidelines, verify your supervision processes with a healthcare attorney or the medical director of your contracted plans for formal comment and guidance.
Q: I understand that the Jul. 1, 2007, changes for the Correct Coding Initiative Version 13.2 had some huge changes for dermatology. What are they and how do they affect my billing?
A: Very few changes occurred to the third-quarter version 13.2 changes for dermatology with respect to Medicare’s Correct Coding Initiative. However, the coding edit changes that did occur are going to affect your payments for actinic keratosis and benign lesion destruction when performed on the same date of service — unless the services are properly appended with modifier 59.
I will show you the new edit bundles first and then show you how the bundles looked prior to Jul. 1, 2007.
It is very important that billing staff understand that if modifier 59 is appended to the incorrect CPT code or is appended when no bundling modifier is required, then the CPT code that has the 59 incorrectly attached will be denied. It is therefore extremely important that your staff have access to the current version of the bundling tables to avoid any denials in the coming months. Staff should also keep at least four old versions, in the event they must do a review. They need to know what the bundles were during the quarter the service was rendered.
Below are the new bundles. The examples show instances when both services are billed on the same date of service and assume that no other modifiers are required such as postoperative modifier 79.
New Bundles — Effective Jul. 1, 2007
Example 1: 17000 -59, 17110
Example 2: 17000 -59, 17111
Example 3: 17004, 17110 -59
Example 4: 17004, 17111 -59
Old Bundles — Valid Prior to Jul. 1, 2007
Example 1: 17000, 17110
Example 2: 17000, 17111 -59
Example 3: 17004, 17110
Example 4: 17004 -59, 17111
(For information for ordering the dermatology-specific CCI tables, contact the Inga Ellzey Practice Group [contact information at the end of this column].)
Q: I am having problems with Aetna’s not paying for repairs in conjunction with excisions. I do reviews with notes, but they still deny as medically not necessary. Are other practices having the same problem? What can I do to get paid?
A: In 2002, Aetna, which had not previously paid for repairs in conjunction with excisions, decided to pay for certain types of repairs with certain types of excisions. Aetna agreed to pay for both excisions and repairs based on the following guidelines:
Excision Codes Affected by the Rule:
Excision Benign Lesions:
CPT codes 11400 to 11446
Excision Malignant Lesions:
CPT codes 11600 to 11646
Intermediate Repair: 12031 to 12057
Complex Repair: 13100 to 13153
Benign skin lesions
(CPT codes 11400 to 11446)
1. Documentation for intermediate or complex repair would not routinely be required for the removal of lesions greater than 1.0 cm in diameter. This means the total measurement of the lesion and normal conservative margins (e.g., excised diameter) must be greater than 1.0 cm/d.
2. Lesions (e.g., excised diameter) less than 1.0 centimeter will typically be denied. This means that no repairs will be paid when billed with CPT codes 11400, 11401, 11420, 11421, 11400, and 11441.
Providers should not attempt to bill any repairs with the CPT codes listed in number two. If a denial is received, the denied service should be written off.
Malignant Skin Lesions
(CPT Codes 11600 to 11646)
1. Aetna agrees that many skin cancer excisions may require an intermediate or complex repair and are willing to pay for both if the documentation supports the medical necessity of the repair and describes the procedure as outlined below.
2. Aetna will not routinely review the documentation associated with the removal and repair of malignant lesions, but may ask for operative notes on a routine audit basis.
Intermediate Repairs
(CPT Codes 12031 to 12057)
1. In order to bill for an intermediate repair, one or more of the deeper layers of the subcutaneous tissue and superficial non-muscle fascia must be repaired, and this must be noted in the operative report.
2. The use of multiple layers of sutures that do not involve fascia does not constitute an intermediate closure.
Complex Repairs
(CPT codes 13100 to 13153)
1. In order to bill a complex repair, “extensive undermining” must be included in the operative note as well as what factor constituted extensive undermining for the lesion removed.
2. Aetna states in its guidelines that the reviewers at Aetna would consider the following as criteria in establishing medical necessity for complex repairs:
a. size of defect
b. type of lesion
c. location (site)
d. description of the procedure.
Documentation
Operative notes should always include:
1. the procedure that was performed (e.g., intermediate versus complex).
2. what indications made the use of the procedure medically necessary?
3. the size of the excised diameter and the size of the defect.
4. repair of superficial fascia for intermediate repairs.
5. extensive undermining for complex repairs.
Q: I have some questions regarding incident-to guidelines. I have both a physician assistant (PA) as well as a nurse practitioner (NP) working for me.
I have issues regarding what constitutes an established problem and also how long a PA or NP can see a patient without my involvement as incident to in order to consider it an incident-to event?
My specific questions include the following:
1. If I, the dermatologist, saw the patient several years ago for actinic keratosis or skin cancer and the patient now presents to the PA for a routine skin cancer follow-up after several years of missed appointments, could this still be billed as incident-to or is there a time limit (like the 3-year new patient definition in CPT)?
2. I have many Medicare patients whom I see regularly and have surgically removed some skin cancers in the past. If my PA sees the patient for a 6-month follow-up visit and finds a new skin cancer, which he biopsies, or discovers some newly developed actinic keratosis, can the PA diagnose and treat these under incident-to?
A: I have received this question many times before and have searched and searched for some formal guidelines by CMS. The only guidelines are those in Section 2050 of the Medicare Part B Claims Processing Manual.
I want to first state that my answer is in no way meant to be construed as any type of formal verification. My goal in even attempting to answer these two questions is prompted only by my wish to have providers be aware of any types of limitations or restrictions that may regulate incident-to guidelines by the carriers they bill and by the state laws that regulate the licenses of these non-physician providers (NPs and PAs).
Answer to question #1
Incident-to guidelines, which can be found under section 2050.1 of the Medicare Part B Claims Processing Manual, state that an incident-to service means “that the services are furnished as an integral part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”
Under section 2050.2, it clarifies the issue further:
“In order to have a service covered as incident-to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician’s personal in-office service. This does not mean that each occasion of an incident service performed by a non-physician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to:
a. Initiate the course of treatment of which the service being performed is an incidental part and
b. There must be subsequent services by the physician of a frequency that reflects his or her continuing active participation in and management of the course of treatment.
c. The physician must be physically present in the same office site and be immediately available to render assistance if that becomes necessary. Based on the aforementioned, I do not believe that if your provider saw the patient several years ago, the criteria for frequency and continuing active participation would be met.
Answer to question #2
I believe that question number two does show the active participation of the physician in the continued care of the patient. The fact that a new lesion was diagnosed or several new actinic keratoses had to be treated should not mitigate the incident-to guidelines since the PA knows how the physician routinely treats these conditions, the physician has already established a protocol for the treatment of these types of lesions, and the physician actively sees the patient at regular intervals.
A similar scenario would be a patient who has acne or psoriasis, for example. The patient, during the course of treatment, may need to have some medications increased or discontinued or new medications prescribed. The changes, if routine and do not represent any significant risk to the patient, could be considered an integral part of the provider’s care and should be allowed under incident-to. The incident-to provision, again, requires the active participation of the provider with the patient’s care and subsequent involvement that, without a doubt, reflects the physician’s active and continuing participation in the management of the course of treatment.
If your practice has any concerns about how your practice is utilizing its PAs and NPs under the incident-to guidelines, verify your supervision processes with a healthcare attorney or the medical director of your contracted plans for formal comment and guidance.
