Diagnosis Coding Excludes 1 Codes

Question:

Our physicians list their diagnosis codes in the Assessment section of their notes. They link the diagnosis codes to the charges in our EHR. We receive a claims submission edit stating the two diagnosis codes may not be reported together. We review the rules and find the codes have an “Excludes 1” relationship. Our question is, should we remove the diagnosis code that is listed as the “Excludes 1” from the Assessment section of the note when correcting the claim based on the guidelines.

Answer:

No don’t do that but it is great news to hear you are reviewing your claims edit reports in a timely manner. The “Excludes 1” is an ICD-10-CM coding guideline or a coding rule. Think of this like an NCCI edit; when CMS has an edit between 2 CPT codes, we do not change the documentation in the operative note. Rather, we report the most comprehensive of the 2 CPT codes. The “Excludes 1” guideline is a similar concept—we do not change the documentation; rather, we report the most comprehensive diagnosis code.

*This response is based on the best information available as of 11/2/23.

E&M Coding Based on Time

Question:

Our physicians’ defaults to time for almost every office encounter. We are working with them on documentation and what work contributes to total time and what does not. They perform their own procedures such as skin lesion removal and biopsies in the office. They are counting the total time spent with the patient, including these activities and we do not believe that is correct. Can you help?

Answer:

Thank you for your inquiry. We will not address the default to time for almost every encounter other than to say medical necessity must be present for time spent. That said, the activities you identify are billable services represented by other CPT codes (aka are separately reported) and may not contribute to the total time in the billed Evaluation and Management (E/M). In other words, the procedure time must be deducted from the total time, assuming the E/M service is reportable.

*This response is based on the best information available as of 10/19/23.

Modifier Order on CMS Claim Form

Question:

We are submitting a hospital claim form with the modifier 25 and FS modifier. We are unsure which modifier to list first. What is your recommendation?

Answer:

Thanks for contacting KZA and remembering to use the FS modifier for shared services provided in the hospital. KZA recommends placing the modifier 25 first, as this is considered a reimbursement modifier followed by the FS modifier, which is an informational modifier.

*This response is based on the best information available as of 10/5/23.

Coding for a Laceration Repair

Question:

I repaired a 12 cm jagged laceration of the midabdomen by undermining 1cm to release the skin edges. Due to the length of the laceration and potential wound tension concerns, I closed the laceration in layers and retention sutures are used. What procedure code should I report?

Answer:

Good question. Because Undermining of tissue under skin, retention sutures constitute a complex repair. Since the defect is 12 cm you would report CPT code 13101 for the first first 2.6 to 7.5 cm with 13102 for each additional 5 cm or less.

*This response is based on the best information available as of 08/03/23.

Shared Visits in the Hospital for Medicare

Question:

I have a question regarding 2023 shared visit rules. I am reviewing an E&M note where I will select the level of E&M based on the MDM being the substantive part and not time. My question: does each provider have to document their individual time if not a factor in the level of E&M I recommend?

Answer:

No, the documentation of time is not required if Time will not be a determining factor in E&M code selection.

CMS has delayed the implementation of Time as driver for defining the substantive part of the shared encounter until January 2024.

The following excerpt is from the Final Rule published in November 2022.

Page 212:
“After consideration of public feedback, we proposed to delay implementation of our definition of the substantive portion as more than half of the total time until January 1, 2024. We continued to believe it is appropriate to define the substantive portion of a split (or shared) service as more than half of the total time, and proposed that this policy will be effective beginning January 1, 2024….”

You may consider working with your providers to start documenting time should CMS move forward with a final implementation of Time as the driver of substantive time in 2024. This would allow them to become familiar with including this in their notes, while informational at this time, if the code is to be selected on the MDM and not time.

*This response is based on the best information available as of 07/06/23.

History of Skin Cancer

Question:

If the patient is coming in for a skin examination and they have a history of skin cancer, is the complexity of the problem addressed low or moderate. We are having a debate in our office about this. The coders feel it is low when this is the only problem addressed but the doctors tell us the complexity is moderate since this is a chronic condition.

Answer:

Yes, a history of skin cancer is considered a chronic condition, but if there are not other problems addressed and the patient currently is doing well with no reoccurrence of skin cancer the complexity of the problem addressed is low. Based on the medical decision-making table for 2021, a chronic stable problem is low, but a chronic problem inadequately controlled, not at treatment goal, etc. is moderate. The coders are correct if this is the only problem addressed during the encounter the complexity of the problem is low. But keep in mind that this one of three elements. The amount and/or complexity of data to be reviewed/analyzed and risk are the other two elements to consider. Code selection is determined by two of three elements on the MDM table which must be met. This table can be found on: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf.

*This response is based on the best information available as of 06/08/23.