Medicare audits have revealed recurring errors in billing for pulmonary procedures and Mohs surgery. Here are some guidelines for correct billing.
Pulmonary Procedures and E&M Services: Medicare recovery auditors have identified overpayments associated with evaluation and management (E&M) services (CPT codes 99211-99213) for pulmonary diagnostic procedures. These overpayments occurred due to claims billed without modifier 25 on the same date of service as a pulmonary diagnostic, therapeutic, or monitoring procedure (94010-94799).
All practices should be familiar with the definitions of CPT 99211-99213 and the correct use of modifier 25. For practices providing procedures, remember:
- If a physician in attendance for a pulmonary function study obtains a history and performs a physical exam related to the pulmonary function testing, separate reporting of an E&M service is not appropriate.
- If the physician performs a significant, separately identifiable E&M service unrelated to the performance of the pulmonary function test, the physician may report an E&M service with modifier 25.
- If the E&M was not separately identifiable, then the physician should not bill the E&M service.
Example: A physician billed CPT code 94060 (Evaluation of Wheezing) with no modifier for date of service Feb.12, 2011. The same physician also billed CPT code 99212 for the same patient on the same date of service without a modifier. CPT code 99212 should not be billed if the E&M service was related to the code 94060 (e.g., see first bullet point above). If the E/M service was not related to the 94060, then 99211 can be billed with modifier 25.
For more information, see the Centers for Medicare & Medicaid Services’ (CMS’) MLN Matters No. SE1315 (PDF).
Mohs Surgery: During an audit of the CPT codes associated with Mohs micrographic surgery (MMS) across several states in a region, Medicare recovery auditors found instances in which someone other than the surgeon (or his/ her employee) prepared and/or interpreted the slides of tissue removed during the procedures.
Medicare will pay for MMS, an advanced skin cancer treatment, only when the Mohs surgeon acts as both surgeon and pathologist. Practices may not bill Medicare for this procedure if a physician other than the Mohs surgeon prepares or interprets the pathology slides.
Example: A physician billed CPT code 17313 (Mohs Micrographic Surgery), while on the same date of service a different practitioner separately billed CPT code 88305 (Surgical Pathology, gross and microscopic examination), without a modifier, for the preparation and interpretation of the slides taken during the procedure. CPT code 17313 was, therefore, an overpaid claim.
For more information, see MLN Matters No. SE1318 (PDF).
Also, be sure to check the Novitas local coverage determinations applicable to for these services. In addition, refer to Novitas’ Evaluation and Management Center and Coding Guidelines: Modifiers page.
Having a problem with a Medicare claim? Use TMA’s Hassle Factor Log program, which helps TMA members resolve insurance-related problems. Turn to TMA Practice Consulting if you need help with coding and documentation in your practice. TMA’s consultants offer audits, check-ups, and training.
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Published Sept. 12, 2013
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