Multiple Procedure Payment Reductions; Error with Code 764.95

Multiple Procedure Payment Reductions

Q:  I keep being told that a doctor can only remove (shave or excise) up to six lesions on one person per visit, but I can't find any guidance referencing this limit.

A: The unit of reporting for the shaving or excision of a lesion is the lesion. There are no limitations or unit issues specified by CPT, so any such direction would come from the payer. You may wish to check with your Medicare contractor as to any payment reductions based on units made to a given code.

Over time, multiple surgical procedure payment reductions have taken many forms. We have seen the first procedure paid at 100 percent, the second at 50 percent, and historically, subsequent procedures paid at 25 percent. After the sixth or seventh procedure, the payment rate has been known to drop to zero. As above, this may just be anecdotal from times past, or a payer may be applying reductions in this manner.

New Transitional Care Management Codes

Q: Are the new CPT codes for transitional care management (TCM) only for a patient's primary-care provider? We have trauma surgeons and cardiologists asking if they can use these codes to represent their patients' follow-up care after a hospital stay.

A: In the 2013 Physician Fee Schedule Final Rule, CMS mentions that its version of the TCM codes is part of "a strategy to recognize and support primary care and care management."

Although the CPT manual does not specify which providers should use the codes (99495 and 99496), the final rule states, "The post-discharge transitional care services HCPCS G code we propose would be used by the community physician or qualified nonphysician practitioner to report the services furnished in the community to ensure the coordination and continuity of care for patients discharged from a hospital (inpatient stay, outpatient observation, or outpatient partial hospitalization), SNF stay, or CMHC. Given the elements of the service and the short window of time following a discharge during which a physician or qualifying nonphysician practitioner will need to perform several tasks on behalf of a beneficiary, we stated our belief that it would be unlikely that two or more physicians or practitioners would have had a face-to-face E/M contact with the beneficiary in the specified window of 30 days prior or 14 days post discharge and have furnished the proposed post-discharge TCM services. Therefore, we did not believe it necessary to take further steps to identify a beneficiary's community physician or qualified nonphysician practitioner who furnished the post-discharge TCM services. We propose to pay only one claim for the post-discharge transitional care GXXX1 billed per beneficiary at the conclusion of the 30-day post-discharge period."

So it is clear Medicare envisioned that the primary-care physician or practitioner would use these codes. That said, CMS is not prohibiting other specialties from billing the new codes because it believes "there will be circumstances in which cardiologists, oncologists, or other specialists will be in the best position to furnish transitional care coordination."

Error with Code 764.95

Q: One of our doctors is getting ICD-9 error messages when she enters code 764.95 on a pregnant patient. Is there something wrong with this code?

A: The code in question, 764.95, describes the fetus, not the mom. Your system is simply warning you that this could result in a denial because the code applies to the baby, not the mom. The code is valid.

If it is the only diagnosis code on the claim form it is more likely to be denied on the first pass. If there is a denial, resubmit it with the visit notes to support the claim.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the March 2013 issue of Physicians Practice.