The following statements reflect the current interpretation by the AMA and AADA of correct coding and appropriate claims processing and payment. They are offered as a basis for discussion with medical directors to clarify these important issues and facilitate agreement.
General E/M bundling issues
- When an E/M service is provided and represents a separately identifiable service, it is reasonable for physicians to expect payment, assuming that the physician has documented a separate E/M service in the medical record.
- It is generally more convenient for the patient and more cost effective if multiple separate services can be provided on the same date rather than requiring multiple return visits.
- The -25 modifier is the most straightforward way for physicians to indicate a separate E/M service to carriers, and the CPT descriptor of modifier -25 is clear enough that it should not be misconstrued by carriers. Carriers are expected to recognize modifiers.
- The CPT definition of modifier -25 states that an E/M service may be prompted by the system or condition for which a separate procedure or service is needed, and as such, different diagnoses are not required for the E/M service and other separate procedure.
- The -57 modifier is also reasonable to indicate a separately identifiable E/M service that results in a decision for surgery that might be performed on the same day.
Dermatology E/M bundling issues
- A shave removal procedure, e.g. code 11311, does not include an E/M service in the physician work, and a separate E/M service submitted with a -25 modifier on the same date should not be bundled with the shave removal.
- The intralesional injection codes (11900 and 11901) do not include an E/M service in their physician work and a separate E/M service submitted with a -25 modifier on the same date should not be bundled with the intralesional injection.
- A destruction procedure, e.g. code 17000, or an acne surgery, e.g. code 10040, are not components of an E/M service, and if an unrelated E/M service indicated by a -25 modifier is provided on the same date as the other service, the separate E/M service should also be paid on the initial claim with the other services.
Dermatologic surgery bundling issues
- A destruction procedure, e.g. code (17000) is not a component of a shave removal procedure, e.g. code (11301), and they should not be bundled together for payment.
- The destruction a benign or premalignant lesion, e.g. code (17000) is not a component of the destruction of a malignant lesion (codes 17260 through 17286), and by definition must be separate lesions and should not be bundled together for payment.
- The destruction procedure for benign or premalignant lesions, e.g. code (17000) is not a component of excision procedures for benign lesions (11400 series) or of excision of malignant lesions (11600 series) and since each is a distinct and separate service, they should not be bundled together for payment.
- A layered intermediate or complex repair is not included in the excision of benign or malignant skin lesions which by CPT definition only includes simple repair.
- Mohs surgery code 17311 is to be reported for first stage performed on head, neck, hands, feet, genitalia, or any location with surgery involving muscle, cartilage, bone, tendon, major nerves or vessels, up to five tissue blocks. Each additional stage, up to 5 tissue blocks, is to be reported with 17312, and not bundled with Mohs code 17311.
Mohs code 17313 to be reported for first stage performed on trunk, arms or legs, up to five tissue blocks. Each additional block, up to five tissue blocks is to be reported with Mohs code 17314. Mohs code 17315 is to be reported as an add-on code in conjunction with Mohs codes 17311-17314.
Please note that Mohs codes are no longer modifier 51 exempt.
Dermatopathology bundling issues
- Pathology codes 88304 or 88305 are never "incidental" to a surgical procedure and should never be bundled with the surgery.
- Biopsy (11100) and frozen section pathology interpretation of tissue from that biopsy (88331), prior to a decision for Mohs surgery is appropriate in cases where no prior biopsy was performed to establish the diagnosis. Such services are appropriately coded with a -59 modifier and should not be bundled with subsequent separate Mohs surgery procedures.
Multiple surgery rule
- The Multiple Surgery Rule as described in the Federal Register, June 24, 1994, p. 32767-32768, is the current standard for multiple procedure payment. This rule bases payment on the lesser of the actual charge or 100 percent of the fee schedule amount for the primary procedure and 50 percent for the second through fifth procedures. This relative value for additional procedures was established by the Harvard (Hsiao) study in 1993 and accepted by CMS and other third-party payers. The reduction by insurance carriers for a third and additional procedures to 25 percent is outdated, unfair and unreasonable.
- Codes designated in CPT as add-on codes are already valued as secondary procedures and are exempt from the multiple surgery rule.