Make Sure to Comply With Existing Rules Before the 2024 Final Rules Are Released

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Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.

When 2023 began, wound/ulcer management physicians, other qualified healthcare professionals (QHPs), and hospital-owned outpatient provider-based departments (PBDs) were still dealing with the COVID-19 public health emergency (PHE). Then on May 11, 2023, the PHE ended, many of the waivers ended, and all wound/ulcer management stakeholders were challenged to reverse-engineer their businesses back to the pre-PHE regulations. After the payer audits resumed, many professionals reported that they incurred Medicare claim denials and/or repayments because, during the PHE, they had not been conducting self-audits and did not have adequate time to keep up with coding, coverage, and payment regulations.

This article reviews some errors that caused claim denials and repayments this year. These errors and subsequent denials/repayments are easily avoided. Simply share the information with your team and agree to tighten up your coding and documentation processes before the 2024 regulations are released!

Evaluation & Management (E/M) and PBD Clinic Visit Codes and Modifier 25 Reported with Minor Procedures

Although the coding rules for E/M changed significantly over the past 2 years, the coding rule, for reporting E/M and PBD clinic visits with Modifier 25 during the same encounter when a minor procedure is performed, has not changed. Most of the wound/ulcer management procedures are considered minor procedures, (0- or 10-day global days). Therefore, when a minor procedure is performed, E/M and PBD clinic visit codes with Modifier 25 should only be reported when a significant, separately identifiable E/M service is also managed at the same encounter.

Your individual Medicare Administrative Contractors (MACs) have provided very clear guidelines that pertain to the correct use of Modifier 25. Visit your MAC’s website to view their resources such as Local Coverage Determination, Local Coverage Articles, newsletters, and webinars. In addition, the American Medical Association, recently published guidelines entitled Reporting CPT Modifier 25, and the Centers for Medicare & Medicaid Services (CMS) recently published an Evaluation and Management Guide.

Despite all the available educational material, many professionals continue to inappropriately report E/M and PBD clinic visit codes with Modifier 25. When they receive payment for the E/M or PBD clinic visit code reported with Modifier 25 and the minor procedure, they have a false sense of security that they should always bill for both. However, they fail to realize that Modifier 25 forces payment of a claim, but the payment will be repaid upon a post-payment audit if a significant, separately identifiable E/M or PBD clinic visit service was not managed. For example: Wound/ulcer management assessments are included in commonly performed procedures such as surgical and selective debridement, hyperbaric oxygen therapy (HBOT), application of cellular and/or tissue-based products (CTPs) for skin wounds, and negative pressure wound therapy (NPWT). Yet many professionals incorrectly report a separate E/M or PBD clinic visit code with Modifier 25, along with one of these minor procedure codes.

Now that the payer audits have resumed, many professionals are learning that their documentation rarely supports a significant, separately identifiable managed E/M or PBD clinic visit service at the same encounter when they performed a minor procedure. When this author asks them, “Why did you report an E/M or clinic visit when you performed a minor procedure?” the professionals often say 1) “because we always get paid,” or 2) “because it takes a long time to assess the ulcer,” or 3) “because the finance office told me to report it.” Unfortunately, none of these responses align with the correct coding guidelines for Modifier 25.

Therefore, this author recommends that physicians, QHPs, and PBDs review the Modifier 25 guidelines and immediately stop reporting it if you did not manage and document a significant, separately identifiable problem during the same encounter when you performed a minor procedure.

National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits

Every quarter CMS updates the NCCI PTP edits for both physicians, QHPs and PBDs. As exciting innovative technologies are released, the first two questions that wound/ulcer management professionals typically ask to their sales representatives are: 1) “Does it have a code?”, and 2) “What is the Medicare allowable rate?” If the professionals like the answers to those two questions, they begin to incorporate the innovative technologies into their businesses. However, they rarely consider if any NCCI PTP edits exist when the innovative technology procedure is performed at the same encounter with another procedure, such as debridement.

If the innovative technology code has an NCCI PTP edit when performed with another procedure, only one of the codes will receive payment. When that happens, the professionals immediately think the innovative technology was to blame. In fact, the professionals failed to research if the innovative technology code was paired with another procedure code in the NCCI PTP edit file. CAUTION: Because CMS releases quarterly updates of the NCCI PTP edit files for both physicians/QHPs and PBDs, wound/ulcer management stakeholders should review the typical code pairs that they perform to see if their status changed on the NCCI PTP edit files. This review should be conducted several weeks before January 1, April 1, July 1, and October 1.

To this author’s surprise, many professionals report that they never heard of, and never read, the NCCI Policy Manual, which is updated every year and posted on the CMS website. This is a big mistake because the manual explains the rationale for many of the PTP edits for pairs of wound/ulcer management procedures. Although the NCCI Policy Manual has many chapters, wound/ulcer management professionals only must read a few short chapters: the introduction, the general correct coding policies, and the chapters that discuss the codes for the services and procedures they perform.

Please note that CMS recently updated their website and relocated the NCCI PTP edit files. For your convenience, here are the links to the NCCI PTP files and to the NCCI Policy Manual.

CAUTION: This author has been receiving many calls from professionals who incurred repayments because they appended Modifier 59 to one of the codes for a procedure that the NCCI PTP edit file considers a component of another procedure. In general, the only time that wound/ulcer management professionals should use Modifier 59 is when 2 procedures that have an NCCI PTP edit are performed on different anatomic locations during the same encounter and when the documentation clearly supports the modifier use. In case you missed it, here is the link to the MLN Fact Sheet, entitled Proper Use of Modifiers 59, XE, XP, XS, and XU, that was updated in March 2023.

Codes for New Cellular and/or Tissue-Based Products (CTPs) for Skin Wounds

With the plethora of CTPs entering the marketplace, wound/ulcer management professionals and revenue cycle team members continue to question whether new products are assigned HCPCS codes that begin with “A” or “Q.” In fact, some coders change the “A” codes to “Q” codes, which always causes claim denials.

For your convenience, all the new CTPs that were assigned HCPCS codes in 2023 are listed in Table 1. If you use any of these new CTPs, load the correct codes into your electronic health record, your Charge Description Master, and your charging system. CAUTION: When CMS assigns an HCPCS code to a product, wound/ulcer management professionals should not assume that Medicare covers the product. The MACs determine 1) if a particular CTP meets all their program requirements for coverage, and 2) if the documentation supports the medical necessity for coverage.

Outpatient Prospective Payment System (OPPS) Assignment of CTP Codes to High-Cost and Low-Cost Groups in the OPPS

Each year the OPPS Final Rule includes a table that identifies which CTPs are assigned to the High-Cost and Low-Cost payment package. However, CMS updates those assignments on a quarterly basis throughout the year. Because the PBD is required to report the codes 15271–15278 when high-cost CTPs are applied and to report codes C5271–C5278 when low-cost CTPs are applied, PBDs should monitor the packaged payment assignments every quarter and should inform their physicians, QHPs, and entire revenue cycle team when changes occur.

For your convenience, Table 2 lists the CTP packaged payment assignments as of October 1, 2023. When the 2023 OPPS Final Rule is released in a few weeks, you should verify the CTP packaged payment assignments for 2024 and inform your team of any changes.

Wound/ulcer management physicians/QHPs should be mindful that Medicare only covers the application of CTPs that are in sheet form and that are secured with the physician’s choice of fixation. Therefore, Table 2 only includes CTPs that are sold in sheet form. CAUTION: Some physicians, QHPs, and PBDs have incurred claim denials and repayments when they applied CTPs that are not in sheet form and reported the CTP with a HCPCS code of another product that is in sheet form.

Physician/QHP Office Confusion Regarding Published Average Sales Prices (ASPs) of CTPs

For many years, CMS did not publish the ASP for most of the CTPs. Several years ago, CMS began requiring manufacturers of CTPs to report their ASPs every quarter. Since then, CMS has been including more CTPs on the ASP Drug Pricing File.¹ Despite requests by wound/ulcer management stakeholders and a recommendation by the Office of Inspector General, CMS has not yet reported the ASPs for all the CTPs submitted by the manufacturers. For example: none of the CTPs assigned HCPCS “A” codes have been added to the ASP Drug Pricing File. The lack of published ASPs creates more work for physician/QHP offices to submit their claims and more work for the MACs to process the claims.

For your convenience, Table 3 lists the CTPs that were in the ASP Drug Pricing File prior to 2023 and identifies those CTPs that were added to the ASP Drug Pricing File quarterly updates throughout 2023. If you compare the CTPs listed in Table 2 with the CTPs listed in Table 3, you will quickly see the CTPs that are currently missing from the ASP Drug Pricing File.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.   

Reference
1. Centers for Medicare and Medicaid Services. Average Sales Price Drug Pricing Files. Last accessed 10/8/2023.