How Will The New Coding Changes Affect Your Practice?

Pages: 22 - 25
By Billie C. Bradford, MBA

It happens every year. All healthcare professionals have learned to anticipate annual changes in Medicare regulations, coding and reimbursement. However, this year’s delays and payment uncertainties definitely qualify 2003 as one of the worst years yet for physicians trying to do some financial planning for their practices. For starters, the Centers for Medicare and Medicaid Services (CMS) released its 2003 Medicare Physician Fee Schedule and Final Rule on Dec. 31, 2002, two months behind schedule. As a result of that delay, the payment rates for 2003 were amended to take effect on March 1, and 2003 procedures provided prior to that date were to be reimbursed at last year’s rates. The flawed formula that was used to calculate the annual pay updates included a 4.4 percent reduction in the fee schedule conversion factor (CF) across the board. Under that Final Rule, the physician fee CF for 2003 ($34.5920), which adjusted the base calculation for all physician services, was not to become effective until March 1 because of the delay in its release. Services provided on or after Jan. 1 and before March 1 were paid under the 2002 Fee Schedule at the $36.1992 CF. Without congressional intervention, physicians could well have been facing an overall drop of 18 percent over a four-year period, with CY 2005 fee payments falling below the 1991 Medicare payment scale. In an attempt to halt the proposed reductions prior to implementation, congressional negotiators agreed in early February to increase Medicare payments to doctors by nearly $49 billion over the next 10 years. Doing so warded off the scheduled March 1 pay cut that many feared could drive thousands of physicians out of the program. Finally, the agreed-on remedy, beyond maintaining payments at current levels, provided an approximately 1.6 percent increase. This legislative change in Medicare payments was attached to the $395 billion annual appropriations bill that had been delayed for more than four months by partisan battling. The bill, applying to all government departments and program funding, cleared both the House of Representatives and the Senate on Feb. 14. Finally, after waiting for over two months into the year, the Medicare CF of $36.7856 became finalized for professional physician services provided during the period of March 1 through Dec. 31, 2003. As this issue went to press, CMS was revising its opinion on the effect of the legislation and estimating that Medicare payments to physicians will decline during the years 2004-2007, with a 4.2 percent cut in 2004. This change is due to the Sustainable Growth Rate (SGR), which cuts payments if growth in Medicare patients’ use of services exceeds the growth in the Gross Domestic Product (GDP) of the entire U.S. economy. Physicians are the only medical providers subject to the SGR. Be Aware Of These Coding Twists Now there are some answers to the inevitable question: What specific changes are in the wind this year? CMS finalized the relative value units (RVUs) for Healthcare Common Procedure Coding System (HCPCS) Codes G0245, G0246 and G0247 for the treatment of peripheral neuropathy that became effective on July 1, 2002. Specifically, CMS stated these services are provided to those diabetic beneficiaries who are “at risk” for foot care problems but do not have an injury or illness of the foot. You should use the appropriate CPT codes (for example, E/M service, debridement service) for any service you provide to a diabetic beneficiary who has an illness or injury to the foot (for example, foot pain, foot ulcer, foot infection). This year’s CMS changes contain both new codes and revisions to existing codes. CMS has confirmed its determination that CPT Code 97602 for active wound care is already included in the work and practice expenses of CPT Code 97601, and typically the patient has the dressing placed over the wound. It determined the services included in Code 97602 are contained in the work and practice expenses of CPT Code 97022 for whirlpool application. In essence, CMS finalized its decision that Code 97602 is a bundled service and should not be paid separately. New HCPCS Codes G0281-G0283 have been established to implement the coverage determination for electrical stimulation in wound care. Medicare does not presently cover G0282. Keep in mind that CMS has directed practitioners to avoid using the CPT Code 97032 for any wound care. Medicare also presently identifies electromagnetic stimulation to one or more areas (G0295) as a non-covered service. An Update On Coding For Shockwave Therapy In response to multiple requests from CMS contractors to establish a national payment amount, CMS had inaccurately considered CPT Category III Code 0020T for extracorporeal shock wave therapy (ESWT). CMS officials had said that ESWT was “similar to other physical therapy modalities” involving the plantar fascia and had designated it to be paid on the therapy fee schedule. The American College of Foot and Ankle Surgeons (ACFAS) and the American Podiatric Medical Association (APMA) both worked hard to successfully have that inappropriate determination withdrawn from the 2003 Medicare Fee Schedule and re-evaluated. CPT Codes: Key Changes You Need To Know In addition to dealing with the fluctuating dictates from CMS, podiatric practices also are challenged to ensure their adherence to the most current annual changes in CPT codes. Some of the more significant 2003 coding changes that your practice needs to be aware of are presented below. The American Medical Association CPT benign and malignant lesion excision codes guidelines have been changed significantly for CY 2003. Under the new guidelines, one should determine the code by measuring the greatest clinical diameter of the apparent lesion plus the margin required for complete excision. In other words, the lesion diameter plus the most narrow margins required equal the excised diameter. The excised diameter is the same whether you have repaired the surgical defect in a linear fashion or reconstructed it (e.g., with a skin graft). You should report each excised lesion separately. The 2003 malignant lesion guidelines also contain additional coding directives regarding frozen section pathology and any additional excision during the same operative session. Re-excision during the post-op period of the primary excision should include the “-58” modifier. A Heads-Up On Coding For Injections The intent behind the 2003 revisions to the descriptors for the CPT Code Series 20550-20553 was to have physicians report codes 20552 and 20553 one time per session, regardless of the number of injections or muscles they injected. You should report codes 20550 and 20551 one time when you have performed multiple or single injections to a single tendon sheath, ligament, tendon origin or tendon insertion. Report injections to multiple tendon sheaths, tendon origins, tendon insertions or ligaments one time for each injection. The CPT Code 20612 was created this year to separate the aspiration and/or injection of ganglion cyst(s) from Codes 20550, 20600 and 20605. Other Coding Essentials The CPT Code 27870 previously was used to report an ankle arthrodesis performed by any method. However, a code descriptor change in 2003 removed “any method” from the nomenclature to clarify that the code intent involves only an “open” surgical approach. CPT Code 29899 has been added in 2003 CPT to identify the arthroscopic ankle fusion procedure. The CPT Code 29540 for applying strapping has been clarified by a descriptor change that now says you can report the code for “strapping, ankle and/or foot.” The 2003 CPT has also deleted all language within the modifier descriptors referencing the use of five-digit modifier codes (e.g., 09959 can no longer be used as an alternative to modifier “-59”). Ms. Bradford is the Director of the Department of Socioeconomics and Practice Management for the American College of Foot and Ankle Surgeons. She is the author of two textbooks on ICD-9-CM coding for physician offices. For additional information, please contact Ms. Bradford at ACFAS headquarters, 847-292-2237, ext. 322, or via e-mail at or Editor’s Note: For a related article, see “Maximize Your Reimbursement: A Guide To Billing In Diabetic Care,” in the March issue of Podiatry Today or visit the archives at

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