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ICD-10-CM Implementation
Delay: Dermatology Practices
Receive a Lifeline
The AAD learned in early April that the implementation date
had been postponed for another full year. This new delay
came as part of H.R. 4302, the Protecting Access to Medicare Act of 2014 which was signed into law by President
Obama. Section 212 of the Act includes language stipulating
that The Secretary of Health and Human Services may not,
prior to Oct. 1, 2015, adopt ICD-10 codes as the standard for
code sets.
At the time the bill was signed into law, there were six
months remaining in the original anticipated implementation timeline date of October 1, 2014. Many dermatologists
and other specialty physicians had been working diligently
in learning the ins and outs of the new ICD-10-CM code
sets, in order to meet all the necessary requirements to
successfully implement ICD-10-CM by the initial implementation date.
This delay will allow those who were behind in the preparation phases to ramp up their efforts and assess areas
that need to be improved upon. Those who were on target
should look at this time as a time to continue efforts and
enhance their ICD-10-CM coding dexterity skills.
Stay Focused and Continue Preparing
While this delay was unexpected, it is very important to
stay the course and continue to anticipate the arrival of ICD10-CM implementation and to be prepared with continued
education.
The additional time delay should be used wisely and
constructively to allow dermatology practices time to take
another look at their implementation timeline (and budget)
to reevaluate how they are approaching this change in their
day to day activities. For example, a quick assessment of billing forms, superbills, patient encounters, progress notes and
electronic health care record template readiness are all good
places to start working on creating efficiencies for the future.
Doing these simple exercises will allow physicians and staff
members to stay focused and find motivation for improvement in specific areas during this additional timeframe.
Below are helpful tips your practice should follow during
this new additional time delay:
Continue to work with the original implementation timeline in mind if you were on track for October 1, 2014.
CPT only 2013 American Medical Association. All Rights Reserved.
Volume 16
[ Volume
|
Number
18 | Number
1 | 2 |Spring
Summer
2012
2014 ]
Contents
ICD-10-CM Implementation Delay:
Dermatology Practices Receive a Lifeline . . . . . . . . . . . . 1
Letter from the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Wound Debridement: Clarifying Common
Terminology & Coding Questions . . . . . . . . . . . . . . . . . 2-4
FAQs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
Dangers of Upcoding Using an EHR . . . . . . . . . . . . . . . . 5
Wound Debridement:
Clarifying Common Terminology
& Coding Questions
In the last few years, the American Medical Association
(AMA) has been actively clarifying and revising the coding
information in the CPT coding manual. New guidelines
have been established for wound debridement and are
listed in the Integumentary section of the manual.. There
are new aspects regarding the wound surface size and
depth that need to be kept in mind when reporting these
codes.
Below is a quick synopsis of how the documentation
needs to be reflective of the procedure performed
Surgical debridement is the excision or wide resection of all dead or devitalized tissue, possibly including
excision of the viable wound margin. This is usually
carried out in the operating theatre under anesthesia
by a surgeon. It is frequently used for deep tissue
infection, drainage of abscess or involved tendon
sheath, or debridement of bone.
Sharp debridement is the removal of dead or foreign
material just above the level of viable tissue, and is
performed in an office setting or at the patients
bedside with or without the use of local anesthesia.
Sharp debridement is less aggressive than surgical
debridement but has the advantage of rapidly improving the healing conditions in the ulcer. These typically
are the services of recurrent, superficial or repeated
wound care.
Blunt debridement is the removal of necrotic tissue
by cleansing, scraping, chemical application or wet to
dry dressing technique. It may also involve the cleaning
and dressing of small or superficial lesions. Generally,
this is not a skilled service and does not require the
skills of a therapist, nurse, or enterostomal nurse.
see DEBRIDEMENT on page 3
Editors Notes:
The material presented herein is, to the best of our knowledge accurate and
factual to date. The information and suggestions are provided as guidelines
for coding and reimbursement and should not be construed as organizational policy. The American Academy of Dermatology/Association disclaims
any responsibility for the consequences of actions taken, based on the information presented in this newsletter.
Mission Statement:
Derm Coding Consult is published quarterly (March, June, September and
December) to provide uptodate information on coding and reimbursement
issues pertinent to dermatology practice.
Address Correspondence to:
David E. Geist, MD, FAAD Editorial Board Derm Coding Consult
American Academy of Dermatology Association
P.O. Box 4014 Schaumburg, IL 601684014
Richard Martin
Contributing Writer
Wound Debridement:
Clarifying Common Terminology
& Coding Questions
continued from page 2
Wound Debridement:
Clarifying Common Terminology
& Coding Questions
continued from page 3
As with all procedures, there are certain documentation expectations that must be met. The operative or
procedure note should include the anatomical site
treated which may include a photograph or drawing,
surgical method performed, if anesthesia was required,
tissue type removed with its severity, odor and depth
and surface area of the wound with the post-operative
instructions.
Other important facts such as: was pathology performed,
was the patient compromised, and status and timing
of the treatment expectation for healing should all be
detailed in the documentation.
For more information see CMS Wound care and
Debridement LCDs: http://www.cms.gov/medicare-coverage-database/search/search-results.aspx?CoverageSelec
tion=Local&ArticleType=All&PolicyType=Final&s=All&CptH
cpcsCode=11042&bc=gAAAAAAAAAAAAA%3d%3d&=& v
FAQS
Wound repairs
In recent weeks there have been an increased number
of inquiries from dermatologists regarding denials for
providing multiple repairs with or without grafts. Normally,
when two or more repairs or grafts of the same anatomical classification are performed on the same day, they are
added together and reported as one code. For example,
two excisions on the arm, 11401 and 11403, are reported
separately but only one repair was performed the correct
code to report is 12032.
The AMA, through the CPT, has created new guidelines
for wound repairs when more than one classification of
wounds is performed. The complicated repair procedure is to be reported as the primary procedure first,
followed by the less complicated repair as the secondary
procedure. The less complicated repair from another classification is to be reported with a Modifier-59.
For example, a simple repair of a 2.6 cm wound on the
neck is performed during the same visit as an intermediate repair of a 2.7 cm wound on the scalp. The appropriate
codes to report are 12032 followed by 12002-59 plus the
excisions codes. These codes are subject to the multiple
surgical reduction but for most carriers, modifier -51 is
not a requirement. However; modifier -59 on the less
complicated procedure may be necessary. Check with
the most recent NCCI edits found on CMS website:
www.cms.gov/NCCI
Q. I have encountered some payment denials with
Novitas when billing repairs involving two graphs
A. CPT Code 15120 description is spilt skin graft, scalp,
face, eyelids, mouth, neck, ears, orbits, genitalia,
hands, feet and or multiple digits; first 100 sq. cm
or less
see FAQ on page 5
FAQS
continued from page 4
Dangers of Upcoding
Using an EHR
One of the dangers of using an EHR is the potential
to upcode evaluation and management (E&M) levels
through the use of auto-populated data fields, automated
coding application, and copy and paste functionality.
Another danger is repetitive, inconsistent, or identical
chart notes. Duplicative chart notes do not enhance
the care or treatment of patients over time. Physicians
tend to ignore standard entries that appear to be form
driven and lacking unique patient-specific observation.
This charting style may also lead to questions of medical
necessity. The documentation focused E&M level drives
physician reimbursement.
Duplicative and over-documented chart notes can trigger insurance denials or audits. When using automated
coding functionality features within the EHR system,
the E&M level will be based on all of the documentation
entered. It is important to remember that copy and paste
documentation, as well as newly charted documentation
are considered in the leveling of E&M visits when utilizing automated coding functionality.
The risks associated with automated coding functionality
are:
Immunohistochemistry or immunocytochemistry,
each separately identifiable antibody per block,
cytologic preparation, or hematologic smear;
first separately identifiable antibody per slide.
(List separately in addition to code for primary
procedure)
88342 X 4
G0461 X 1
see IHC on page 7
CPT only 2013 American Medical Association. All Rights Reserved.
88342 X4
Number
participating
Number
earning
incentive
Percent
earning
incentive
Dermatology
3,853
3,602
93.5%
$887
$1,532
Plastic Surgery
1,006
878
87.3%
$233
$323
Urology
5,351
4,438
82.9%
$852
$962
Ophthalmology
11,135
9,216
82.8%
$1,304
$1,728
Psychiatry
3,989
3,562
89.3%
$63
$139
88342 X 2
G0461 X 2
88342 X 2
Median
Mean
incentive incentive
earned
earned
Source: 2012 reporting experience, including trends (20092013): Physician Quality Reporting System and electronic
prescribing (eRx) incentive program. March 14, 2014. v
(Correction to page 1,
Spring 2014 DCC)
Example:
Patient presents with 5 mm diameter ill-defined, suspicious mole with irregular margins on arm. Mole has varying
shades of color, though mostly pink with flat and bumpy
components.
Diagnosis: Dysplastic Nevus
ICD-10-CM Code: D232.60 Melanocytic Nevus of unspecified upper limb, including shoulder.
Versus:
Patient presents with 5 mm diameter ill-defined, suspicious mole with irregular margins on right upper arm. Mole
has varying shades of color, though mostly pink with flat
and bumpy components.
Diagnosis: Dysplastic Nevi
ICD-10-CM Code: D232.61 Melanocytic nevi of right upper
limb, including shoulder. v
In The Know..
Some payers may not reimburse for closure by
intermediate repair when the defect size is less
than 1.0 cm.
For example, Aetna, under Other Payment Policies Services or supplies that have limited or no coverage
based on Aetnas Payment Policies, CPT 1203113160 Intermediate and Complex Repair: Aetna
does not allow separate payment for intermediate
or complex repairs with excision of benign lesions
that are 1.0 cm. or smaller. It is unlikely that this
type of repair would be done on lesions of this size.
However, if the operative report confirms that the
repair was actually performed on lesions of 1.0 cm
or smaller, an intermediate or complex repair will be
considered for payment.
In this policy, Aetna states that if the intermediate
closure was performed and has been documented,
providers can appeal the denial.