Providing salient examples and insights from their experience, the expert panelists discuss proper documentation, coding for E&M services and appropriate use of modifiers.
As Harry Goldsmith, DPM, emphasizes, proper documentation allows the wound care specialist and others treating the patient to evaluate the patient’s status continuously, and plan for and execute the appropriate treatments.
“While serious wound care specialists are committed to excellence in wound care, they also need to understand and appreciate that quality documentation goes hand in hand with quality care,” says Dr. Goldsmith, adding that such thoroughness takes time.
As the “captain of the ship” when it comes to submitting claims for reimbursement, the wound care specialist is ultimately accountable for accurate coding and billing for the services and procedures he or she performs.
Kazu Suzuki, DPM, CWS, concurs, saying “you should code (and bill for) what you did, nothing more or nothing less.” He has heard that many physicians actually “under-code” their procedures because they have an unfounded belief that they are “over-billing” for their services and are afraid of being audited. On the other hand, he notes that “up-coding” or billing for more than what your service has provided is “a cardinal sin,” and can lead to severe penalties or prosecution.
Dr. Suzuki strives for the best documentation possible with the assumption that every chart will be audited. He also takes multiple digital pictures (before, during and after) of surgical procedures as well as the specimens he removed to “tell the story” of what he performed.
Anthony Poggio, DPM, says one must list the basics such as drainage, odor and cellulitis/abscess. He says it is also key to measure the wound before and after debridement, and describe the wound base. Dr. Poggio says there must be clear documentation as to what type of tissue one actually removed and cautions that simply stating “wound debrided” is not enough. Barbara Aung, DPM, CWS, also documents the wound size pre- and post-debridement. She also notes the tissues she removed and the instrument she used. Dr. Aung cites the importance of describing the wound’s surrounding tissue and exudate, along with any offloading and/or compression therapy that one uses. She says the last two items show the clinician is addressing the underlying medical condition that contributed to the development of the wound.
When treating multiple ulcers, Dr. Poggio says one should remember that coding is per aggregate size of all similar (type of tissue debrided) ulcers after debridement regardless of where they are on the body. Therefore, he says billing each lesion with a right/left -51 modifier is no longer appropriate.
Wound care specialists must have more than just a passing familiarity with the codes they commonly bill, according to Dr. Goldsmith. He says they should have a good understanding of coding definitions, guidelines and payer policies. Dr. Goldsmith suggests owning or having access to CPT, HCPCS and ICD-9-CM manuals. In addition, he says the American Podiatric Medical Association Coding Resource Center has those manuals online and Medicare contractor information is also online at http://www.apmacodingrc.org  . Dr. Goldsmith also suggests attending coding seminars and workshops hosted or presented by reputable organizations, companies and/or individuals.
Generally, Dr. Aung suggests documenting using either paper history and physical exam forms, or an electronic health record (EHR) configured to collect the data required to document the services performed. One should avoid using EHR templates that just copy the same information from visit to visit. Dr. Aung says rote EHR template notes invite targeting by auditors and “would not support the level of services actually performed or provide justification to meet medical necessity.”
Prior to the introduction of E&M coding over 20 years ago, Dr. Goldsmith notes there were no hard and fast guidelines as to what qualified the level of outpatient or inpatient “visit” coding. Evaluation and management service coding changed all that. He offers the following tips for E&M billing.
• The volume (pertinent versus “fluff”) of medical record documentation presented may have nothing to do with the ultimate level of E&M service warranted.
• Not all patient encounters qualify as reimbursable E&M services.
• Each patient encounter is unique in terms of E&M qualification or level of service.
• One determines E&M service levels not only by the documentation but by medically relevant circumstances, comorbidities, age, activity, medical necessity and standard of care.
• When performing minor procedures, one must clearly document E&M as “significant, separately identifiable” from the inherent E&M within the procedure coding allowance.
• Know your E&M service modifiers. Access the National Correct Coding Initiative edits to determine whether the E&M and procedure are bundled, and if one can have them unbundled.
• For established patients returning for follow-up of a specific condition, only interval changes to history, examination and/or medical decision making define the level (if any) of E&M service billable.
As Dr. Suzuki explains, modifier -24 allows physicians to perform office services for unrelated diagnoses during the post-op global period. Dr. Aung says an example of this would be reporting an ingrown toenail (either on the same foot as surgery or the contralateral limb) for a patient who presents for a post-op visit five days after a bunionectomy.
Modifier -57 (decision for surgery) may be more important and more frequently used in wound care practice, according to Dr. Suzuki. He explains that usually physicians are not allowed to charge for E&M for the same day of procedure as it falls on the global period, unless one adds this “decision for surgery” modifier to indicate that one spent extra time of E&M to work up the patient. Dr. Poggio adds that the -57 modifier covers a 90-day global period.
Dr. Goldsmith poses a hypothetical example. A doctor is called to the emergency department of his hospital to consult on a patient who had a contusion and laceration of her right foot when she accidentally kicked the shower door. The examination of the foot reveals some simple and intermediate lacerations, and an open, displaced fracture of the distal fifth metatarsal. The surgeon scheduled the patient for surgical repair first thing in the morning. In order to avoid only being paid for the fracture and laceration repair, Dr. Goldsmith says one would append a -57 modifier to the outpatient E&M service code. He cautions that the use of the -57 modifier implies that the major surgical procedure(s) will occur within 24 hours of the decision for surgery.
Dr. Aung frequently uses modifier -57 when she decides to perform surgery for new or established patients who present with an acute abscess or a worsening abscess or ulceration. This modifier would also cover the attendant workup as well as the pre-op history and physical to schedule the procedure. Dr. Aung may either schedule the procedure for the same day or sometime in the next few days.
Modifier -25 covers a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service, according to Dr. Goldsmith. Dr. Poggio says one uses the -25 modifier when the procedure has a 0 or 10 day global period. Dr. Goldsmith says this modifier is applicable for an established patient who makes an appointment for an abscess on the tip of the fifth toe on the left foot with local erythema and swelling, not to mention pain. He says the doctor would bill CPT 10060 for the incision and drainage of the abscess, and an E&M service with a -25 modifier appended for the initial workup of the problem.
Dr. Poggio cautions that each procedure has a certain amount of E&M built into the procedure fee allowance. When the evaluation and management is beyond that time period, he says one can append the E&M with one of those modifiers. If one is only providing wound care, Dr. Poggio says the modifier may not be appropriate. On the other hand, he notes if one is prescribing or changing existing antibiotic prescriptions, ordering or reviewing labs or diagnostic studies, or instituting new wound care protocols, then an E&M service may be payable in addition to the wound care codes.
Modifier -59 indicates that one is operating on two or more separate locations, incisions or body parts, according to Dr. Suzuki. One example he cites is if one is applying skin substitutes to foot and ankle wounds simultaneously, the codes would be 15271 and 15275 (-59).
Dr. Goldsmith considers a hypothetical patient presenting to the office with two ingrown nails, one on the lateral border of the left hallux and the other on the medial border of the right hallux. Conservative treatment occurred previously for the left hallux ingrown nail and the physician decided to perform a matrixectomy. He notes the coding would be CPT 11750-TA and CPT 11730-59-T5. As Dr. Goldsmith explains, the -59 modifier tells the payer’s computers that the nail avulsion is distinct and not related to the matrixectomy.
“One would think that the ‘T’ anatomical modifiers would alone say the same thing but unfortunately, a number of payer software programs ignore ‘T’ modifiers,” explains Dr. Goldsmith.
As for other modifiers, Dr. Aung says -22 is for increased procedure service, covering substantial additional work along with the reason for added services.
If the procedure code description does not exclude its use, then Dr. Aung says one should use -50 (bilateral procedure) to document the same procedure performed during the same surgical session on the contralateral limb.
Dr. Aung notes that one would use modifiers -54, -55 and -56 to reflect that one physician provides only surgical care, postoperative management and/or pre-operative management services while another physician provides the other services that are bundled in the surgical case fee.
Dr. Aung says modifier -76 covers a repeat procedure by the same physician while modifier -77 is for a repeat procedure by another physician.
Dr. Goldsmith says modifier -78 concerns an unplanned return to the operating/procedure room by the same physician following the initial procedure for a related procedure during the postoperative period. Dr. Aung says an example would be a patient who develops an infection or hardware becomes unstable after the original procedure.
Modifier -79 is for an unrelated procedure or service by the same physician during the postoperative period, notes Dr. Goldsmith. Dr. Aung gives the hypothetical example of a patient who underwent a bunionectomy and fell, and presented with a metatarsal fracture, which requires surgery.
“When it comes to any modifier, make sure the use of each modifier is understood. Adding an inappropriate modifier or adding one when none is needed may in and of itself result in your claim being denied,” advises Dr. Poggio.
Dr. Aung currently serves as a PPOD (podiatry, pharmacy, optometry, dental) Workgroup Member for the CDC-NIH National Diabetes Education Program. She is also the principal investigator for the State of Arizona’s Department of Health Services Diabetes Control Program Amputation Risk Reduction Project. Dr. Aung is in private practice in Tuscon, Ariz., and is the Co-Director of the Wound Center at Carondelet St. Joseph’s Hospital in Tucson, Ariz.
Dr. Goldsmith is the CEO of Codingline. He is a consultant to the American Podiatric Medical Association’s Department of Health Policy and Practice. Dr. Goldsmith is a medical reviewer to a number of insurance companies. He is a certified Surgical Foot and Ankle coder (AAPC specialty coder certification).
Dr. Poggio is a California Podiatric Medicine Association Liaison to Palmetto GBA J1 MAC and a medical consultant to several national health insurance and review organizations. He is a member of the American College of Podiatric Medical Reviewers and is board certified by the American Board of Podiatric Medicine and the American Board of Podiatric Orthopedics.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo.
For further reading, see “A Guide To Coding For Outpatient And In-Hospital Debridement” in the August 2011 issue of Podiatry Today.