Murad Alam, MD, MSCI

In 2013, the Centers for Medicare and Medicaid Services (CMS) issued a guidance to reduce reimbursement issues for Mohs micrographic surgery (MMS).¹ One crucial question that remains is when and if these documentation guidelines will be formally implemented. The guidelines outlined by the CMS currently are regarded as suggestions until Medicare contractors adopt them into the local coverage determinations (LCDs).

Key Documentation Guidelines

To reduce MMS reimbursement issues, documentation in the patient’s medical record should support the medical necessity of the procedure and reflect the number and anatomic locations of specimens taken and the reason for the procedure should be clearly communicated. The specific tumor type also should be approved for treatment with MMS in the respective LCD.

Nonphysician providers are not authorized by Medicare to perform MMS. To ensure proper coding, both surgery and pathology must be performed by a single physician and should be supported by documentation in the patient’s medical record (eg, relevant chart notes should be made under the provider’s signature). These documentation guidelines are not new but are included in the CMS guidance to reiterate their importance in reducing MMS reimbursement issues.

Per customary clinical practice, the CMS guidance specifies that MMS documentation should include gross description of the tissue removed, including the location, number, and size of the lesions, as well as how many specimens were removed for each stage. However, the guidance diverges from routine MMS documentation requirements in its emphasis on providing a histologic description of the tissue removed. The guidance suggests that the depth of tumor invasion, pathologic pattern, cell morphology (which is not typically specified for skin cancers), and, if present, the existence of perineural invasion or scar tissue should be documented. If these features are constant across stages, they only need to be noted for the first stage.

Adapting Guidelines for Clinical Practice

The CMS guidance may create some conundrums for physicians regarding MMS documentation; for instance, if a tumor is cleared in one stage, as is often the case, no tumor will be seen on glass slides prepared to assess tissue margins during the procedure and therefore documentation of characteristics like depth and pattern will be impossible. Similarly, cell morphology is not a feature that usually is relevant for most squamous and basal cell carcinomas, although it may be useful in certain unusual instances, such as in cases of rare tumors with particular histologic features that may influence management and/or prognosis. When in doubt regarding the appropriate documentation method for MMS, the surgeon should use his or her best judgment based on clinical experience rather than simply following guidelines that may not be applicable.

Final Thoughts

The CMS guidance serves as a reminder of the documentation requirements for MMS and extends current practice by suggesting a detailed microscopic description of the removed tissue. The American Academy of Dermatology has developed a guide to help Mohs surgeons provide the necessary documentation without creating cumbersome chart notes.² Mohs surgeons should consult the most recent version of the LCD that applies to their geographic area to determine if the new documentation guidelines have been adopted.

In 2013, the Centers for Medicare and Medicaid Services (CMS) issued a guidance to reduce reimbursement issues for Mohs micrographic surgery (MMS).¹ One crucial question that remains is when and if these documentation guidelines will be formally implemented. The guidelines outlined by the CMS currently are regarded as suggestions until Medicare contractors adopt them into the local coverage determinations (LCDs).

Key Documentation Guidelines

To reduce MMS reimbursement issues, documentation in the patient’s medical record should support the medical necessity of the procedure and reflect the number and anatomic locations of specimens taken and the reason for the procedure should be clearly communicated. The specific tumor type also should be approved for treatment with MMS in the respective LCD.

Nonphysician providers are not authorized by Medicare to perform MMS. To ensure proper coding, both surgery and pathology must be performed by a single physician and should be supported by documentation in the patient’s medical record (eg, relevant chart notes should be made under the provider’s signature). These documentation guidelines are not new but are included in the CMS guidance to reiterate their importance in reducing MMS reimbursement issues.

Per customary clinical practice, the CMS guidance specifies that MMS documentation should include gross description of the tissue removed, including the location, number, and size of the lesions, as well as how many specimens were removed for each stage. However, the guidance diverges from routine MMS documentation requirements in its emphasis on providing a histologic description of the tissue removed. The guidance suggests that the depth of tumor invasion, pathologic pattern, cell morphology (which is not typically specified for skin cancers), and, if present, the existence of perineural invasion or scar tissue should be documented. If these features are constant across stages, they only need to be noted for the first stage.

Adapting Guidelines for Clinical Practice

The CMS guidance may create some conundrums for physicians regarding MMS documentation; for instance, if a tumor is cleared in one stage, as is often the case, no tumor will be seen on glass slides prepared to assess tissue margins during the procedure and therefore documentation of characteristics like depth and pattern will be impossible. Similarly, cell morphology is not a feature that usually is relevant for most squamous and basal cell carcinomas, although it may be useful in certain unusual instances, such as in cases of rare tumors with particular histologic features that may influence management and/or prognosis. When in doubt regarding the appropriate documentation method for MMS, the surgeon should use his or her best judgment based on clinical experience rather than simply following guidelines that may not be applicable.

Final Thoughts

The CMS guidance serves as a reminder of the documentation requirements for MMS and extends current practice by suggesting a detailed microscopic description of the removed tissue. The American Academy of Dermatology has developed a guide to help Mohs surgeons provide the necessary documentation without creating cumbersome chart notes.² Mohs surgeons should consult the most recent version of the LCD that applies to their geographic area to determine if the new documentation guidelines have been adopted.

In 2013, the Centers for Medicare and Medicaid Services (CMS) issued a guidance to reduce reimbursement issues for Mohs micrographic surgery (MMS).¹ One crucial question that remains is when and if these documentation guidelines will be formally implemented. The guidelines outlined by the CMS currently are regarded as suggestions until Medicare contractors adopt them into the local coverage determinations (LCDs).

Key Documentation Guidelines

To reduce MMS reimbursement issues, documentation in the patient’s medical record should support the medical necessity of the procedure and reflect the number and anatomic locations of specimens taken and the reason for the procedure should be clearly communicated. The specific tumor type also should be approved for treatment with MMS in the respective LCD.

Nonphysician providers are not authorized by Medicare to perform MMS. To ensure proper coding, both surgery and pathology must be performed by a single physician and should be supported by documentation in the patient’s medical record (eg, relevant chart notes should be made under the provider’s signature). These documentation guidelines are not new but are included in the CMS guidance to reiterate their importance in reducing MMS reimbursement issues.

Per customary clinical practice, the CMS guidance specifies that MMS documentation should include gross description of the tissue removed, including the location, number, and size of the lesions, as well as how many specimens were removed for each stage. However, the guidance diverges from routine MMS documentation requirements in its emphasis on providing a histologic description of the tissue removed. The guidance suggests that the depth of tumor invasion, pathologic pattern, cell morphology (which is not typically specified for skin cancers), and, if present, the existence of perineural invasion or scar tissue should be documented. If these features are constant across stages, they only need to be noted for the first stage.

Adapting Guidelines for Clinical Practice

The CMS guidance may create some conundrums for physicians regarding MMS documentation; for instance, if a tumor is cleared in one stage, as is often the case, no tumor will be seen on glass slides prepared to assess tissue margins during the procedure and therefore documentation of characteristics like depth and pattern will be impossible. Similarly, cell morphology is not a feature that usually is relevant for most squamous and basal cell carcinomas, although it may be useful in certain unusual instances, such as in cases of rare tumors with particular histologic features that may influence management and/or prognosis. When in doubt regarding the appropriate documentation method for MMS, the surgeon should use his or her best judgment based on clinical experience rather than simply following guidelines that may not be applicable.

Final Thoughts

The CMS guidance serves as a reminder of the documentation requirements for MMS and extends current practice by suggesting a detailed microscopic description of the removed tissue. The American Academy of Dermatology has developed a guide to help Mohs surgeons provide the necessary documentation without creating cumbersome chart notes.² Mohs surgeons should consult the most recent version of the LCD that applies to their geographic area to determine if the new documentation guidelines have been adopted.

Medically Unlikely Edits (MUEs) are benchmarks recognized by the Centers for Medicare & Medicaid Services (CMS) that are designed to prevent incorrect or excessive coding. Specifically, an MUE is an edit that tests medical claims for services billed in excess of the maximum number of units of service permitted for a single beneficiary on the same date of service from the same provider (eg, multiples of the same Healthcare Common Procedure Coding System [HCPCS] code listed on different claim lines).¹

The MUE System

If the number of units of service billed by the same physician for the same patient on the same day exceeds the maximum number permitted by the CMS, the Medicare Administrative Contractor (MAC) will deny the code or return the claim to the provider for correction (return to provider [RTP]). Units of service billed in excess of the MUE will not be paid, but other services billed on the same claim form may still be paid. In the case of an MUE-associated RTP, the provider should resubmit a corrected claim, not an appeal; however, an appeal is possible in the case of an MUE-associated denial. An MUE-associated denial is a coding denial, not a medical necessity denial; therefore, the provider cannot use an Advance Beneficiary Notice to transfer liability for claim payment to the patient.

MUE Adjudication Indicators

In 2013, the CMS modified the MUE process to include 3 different MUE adjudication indicators (MAIs) with a value of 1, 2, or 3 so that some MUE values would be date of service edits rather than claim line edits.² Medically Unlikely Edits for HCPCS codes with an MAI of 1 are identical to the prior claim line edits. If a provider needs to report excess units of service with an MAI of 1, appropriate modifiers should be used to report them on separate lines of a claim. Current Procedural Terminology (CPT) modifiers such as -76 (repeat procedure or service by the same physician) and -91 (repeat clinical diagnostic laboratory test) as well as anatomic modifiers (eg, RT, LT, F1, F2) may be used, with modifier -59 (distinct procedural service) used only if no other modifier suffices. An example of an 
MUE with an MAI of 1 is CPT code 17264 (destruction, malignant lesion [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], trunk, arms or legs; lesion 
diameter 3.1–4.0 cm), for which the MUE threshold is 3, meaning no more than 3 destructions can be submitted per claim line without triggering an 
edit-based rejection or RTP.

An MAI of 2 denotes absolute date of service edits, or so-called “per day edits based on policy.” Such edits are in place because units of service billed in excess of the MUE value on the same date of service are considered to be impossible by the CMS based on regulatory guidance or anatomic considerations.² For instance, although the same physician may destroy multiple actinic keratoses in a single patient on the same date of service, it would not be possible to code more than one unit of service as 
CPT code 17000, which specifically and exclusively 
refers to the first lesion destroyed. Similarly, 
CPT code 13101 (repair, complex, trunk; lesion diameter 2.6–7.5 cm) could only be reported once that day, as all complex repairs at that anatomic site must be summed and smaller or larger totals would be reported with another code.

Anatomic limitations are sometimes obvious and do not require specific coding rules. For example, only 1 gallbladder can be removed per patient. Although Qualified Independent Contractors and Administrative Law Judges are not bound by MAIs, they do give particular deference to an MAI of 
2 given its definitive nature.² Because ambulatory surgical center providers (Medicare specialty code 49) cannot report modifier -50 for bilateral 
procedures, the MUE value used for editing is doubled for HCPCS codes with an MAI of 2 or 3 if the bilateral surgery indicator for the HCPCS code is 1.³

An MAI of 3 describes less strict date of service edits, so-called “per day edits based on clinical benchmarks.”² Similar to MAIs of 1, MUEs for MAIs of 3 are based on medically likely daily frequencies of services provided in most settings. To determine if an MUE with an MAI of 3 has been reached, the MAC sums the units of service billed on all claim lines of the current claim as well as all prior paid claims for the same patient billed by the same provider on the same date of service. If the total units of service obtained in this manner exceeds the MUE value, then all claim lines with the relevant code for the current claim will be denied, but prior paid claims will not be adjusted. Denials based on MUEs for codes with an MAI of 3 can be appealed to the local MAC. Successful appeals require documentation that the units of service in excess of the MUE value were actually delivered and demonstration of medical necessity.² An example of a CPT code with an MAI of 3 is 40490 (biopsy of lip) for which the MUE value is 3.

Complications With MUE and MAI

Because MUEs are based on current coding guidelines as well as current clinical practice, they are only applicable for the time period in which they are in effect. A change made to an MUE value for a particular code is not retroactive; however, in exceptional circumstances when a retroactive effective date is applied, MACs are not directed to examine prior claims but only “claims that are brought to their attention.”²

It also is important to realize that not all 
MUEs are publicly available and many are confidential. When claim denials occur, particularly in the context of multiple units of a particular code, 
automated MUE edits should be among the issues that are suspected. Physicians may resubmit RTP claims on separate lines if a claim line edit 
(MAI of 1) is operative. An MAI of 2 suggests a coding error that needs to be corrected, as these coding approaches are generally impossible based on definitional issues or anatomy. If an MUE with an 
MAI of 3 is the reason for denial, an appeal is possible, provided there is documentation to show that the service was actually provided and that it was medically necessary.

Final Thoughts

Dermatologists should be vigilant for unexpected payment denials, which may coincide with the implementation of new MUE values. When such denials occur and MUE values are publicly available, dermatologists should consider filing an appeal if the relevant MUEs were associated with an MAI of 
1 or 3. Overall, dermatologists should be aware that many MUEs that were formerly claim line edits 
(MAI of 1) have been recently transitioned to date of service edits (MAI of 3), which are more restrictive.

Medically Unlikely Edits (MUEs) are benchmarks recognized by the Centers for Medicare & Medicaid Services (CMS) that are designed to prevent incorrect or excessive coding. Specifically, an MUE is an edit that tests medical claims for services billed in excess of the maximum number of units of service permitted for a single beneficiary on the same date of service from the same provider (eg, multiples of the same Healthcare Common Procedure Coding System [HCPCS] code listed on different claim lines).¹

The MUE System

If the number of units of service billed by the same physician for the same patient on the same day exceeds the maximum number permitted by the CMS, the Medicare Administrative Contractor (MAC) will deny the code or return the claim to the provider for correction (return to provider [RTP]). Units of service billed in excess of the MUE will not be paid, but other services billed on the same claim form may still be paid. In the case of an MUE-associated RTP, the provider should resubmit a corrected claim, not an appeal; however, an appeal is possible in the case of an MUE-associated denial. An MUE-associated denial is a coding denial, not a medical necessity denial; therefore, the provider cannot use an Advance Beneficiary Notice to transfer liability for claim payment to the patient.

MUE Adjudication Indicators

In 2013, the CMS modified the MUE process to include 3 different MUE adjudication indicators (MAIs) with a value of 1, 2, or 3 so that some MUE values would be date of service edits rather than claim line edits.² Medically Unlikely Edits for HCPCS codes with an MAI of 1 are identical to the prior claim line edits. If a provider needs to report excess units of service with an MAI of 1, appropriate modifiers should be used to report them on separate lines of a claim. Current Procedural Terminology (CPT) modifiers such as -76 (repeat procedure or service by the same physician) and -91 (repeat clinical diagnostic laboratory test) as well as anatomic modifiers (eg, RT, LT, F1, F2) may be used, with modifier -59 (distinct procedural service) used only if no other modifier suffices. An example of an 
MUE with an MAI of 1 is CPT code 17264 (destruction, malignant lesion [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], trunk, arms or legs; lesion 
diameter 3.1–4.0 cm), for which the MUE threshold is 3, meaning no more than 3 destructions can be submitted per claim line without triggering an 
edit-based rejection or RTP.

An MAI of 2 denotes absolute date of service edits, or so-called “per day edits based on policy.” Such edits are in place because units of service billed in excess of the MUE value on the same date of service are considered to be impossible by the CMS based on regulatory guidance or anatomic considerations.² For instance, although the same physician may destroy multiple actinic keratoses in a single patient on the same date of service, it would not be possible to code more than one unit of service as 
CPT code 17000, which specifically and exclusively 
refers to the first lesion destroyed. Similarly, 
CPT code 13101 (repair, complex, trunk; lesion diameter 2.6–7.5 cm) could only be reported once that day, as all complex repairs at that anatomic site must be summed and smaller or larger totals would be reported with another code.

Anatomic limitations are sometimes obvious and do not require specific coding rules. For example, only 1 gallbladder can be removed per patient. Although Qualified Independent Contractors and Administrative Law Judges are not bound by MAIs, they do give particular deference to an MAI of 
2 given its definitive nature.² Because ambulatory surgical center providers (Medicare specialty code 49) cannot report modifier -50 for bilateral 
procedures, the MUE value used for editing is doubled for HCPCS codes with an MAI of 2 or 3 if the bilateral surgery indicator for the HCPCS code is 1.³

An MAI of 3 describes less strict date of service edits, so-called “per day edits based on clinical benchmarks.”² Similar to MAIs of 1, MUEs for MAIs of 3 are based on medically likely daily frequencies of services provided in most settings. To determine if an MUE with an MAI of 3 has been reached, the MAC sums the units of service billed on all claim lines of the current claim as well as all prior paid claims for the same patient billed by the same provider on the same date of service. If the total units of service obtained in this manner exceeds the MUE value, then all claim lines with the relevant code for the current claim will be denied, but prior paid claims will not be adjusted. Denials based on MUEs for codes with an MAI of 3 can be appealed to the local MAC. Successful appeals require documentation that the units of service in excess of the MUE value were actually delivered and demonstration of medical necessity.² An example of a CPT code with an MAI of 3 is 40490 (biopsy of lip) for which the MUE value is 3.

Complications With MUE and MAI

Because MUEs are based on current coding guidelines as well as current clinical practice, they are only applicable for the time period in which they are in effect. A change made to an MUE value for a particular code is not retroactive; however, in exceptional circumstances when a retroactive effective date is applied, MACs are not directed to examine prior claims but only “claims that are brought to their attention.”²

It also is important to realize that not all 
MUEs are publicly available and many are confidential. When claim denials occur, particularly in the context of multiple units of a particular code, 
automated MUE edits should be among the issues that are suspected. Physicians may resubmit RTP claims on separate lines if a claim line edit 
(MAI of 1) is operative. An MAI of 2 suggests a coding error that needs to be corrected, as these coding approaches are generally impossible based on definitional issues or anatomy. If an MUE with an 
MAI of 3 is the reason for denial, an appeal is possible, provided there is documentation to show that the service was actually provided and that it was medically necessary.

Final Thoughts

Dermatologists should be vigilant for unexpected payment denials, which may coincide with the implementation of new MUE values. When such denials occur and MUE values are publicly available, dermatologists should consider filing an appeal if the relevant MUEs were associated with an MAI of 
1 or 3. Overall, dermatologists should be aware that many MUEs that were formerly claim line edits 
(MAI of 1) have been recently transitioned to date of service edits (MAI of 3), which are more restrictive.

Medically Unlikely Edits (MUEs) are benchmarks recognized by the Centers for Medicare & Medicaid Services (CMS) that are designed to prevent incorrect or excessive coding. Specifically, an MUE is an edit that tests medical claims for services billed in excess of the maximum number of units of service permitted for a single beneficiary on the same date of service from the same provider (eg, multiples of the same Healthcare Common Procedure Coding System [HCPCS] code listed on different claim lines).¹

The MUE System

If the number of units of service billed by the same physician for the same patient on the same day exceeds the maximum number permitted by the CMS, the Medicare Administrative Contractor (MAC) will deny the code or return the claim to the provider for correction (return to provider [RTP]). Units of service billed in excess of the MUE will not be paid, but other services billed on the same claim form may still be paid. In the case of an MUE-associated RTP, the provider should resubmit a corrected claim, not an appeal; however, an appeal is possible in the case of an MUE-associated denial. An MUE-associated denial is a coding denial, not a medical necessity denial; therefore, the provider cannot use an Advance Beneficiary Notice to transfer liability for claim payment to the patient.

MUE Adjudication Indicators

In 2013, the CMS modified the MUE process to include 3 different MUE adjudication indicators (MAIs) with a value of 1, 2, or 3 so that some MUE values would be date of service edits rather than claim line edits.² Medically Unlikely Edits for HCPCS codes with an MAI of 1 are identical to the prior claim line edits. If a provider needs to report excess units of service with an MAI of 1, appropriate modifiers should be used to report them on separate lines of a claim. Current Procedural Terminology (CPT) modifiers such as -76 (repeat procedure or service by the same physician) and -91 (repeat clinical diagnostic laboratory test) as well as anatomic modifiers (eg, RT, LT, F1, F2) may be used, with modifier -59 (distinct procedural service) used only if no other modifier suffices. An example of an 
MUE with an MAI of 1 is CPT code 17264 (destruction, malignant lesion [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], trunk, arms or legs; lesion 
diameter 3.1–4.0 cm), for which the MUE threshold is 3, meaning no more than 3 destructions can be submitted per claim line without triggering an 
edit-based rejection or RTP.

An MAI of 2 denotes absolute date of service edits, or so-called “per day edits based on policy.” Such edits are in place because units of service billed in excess of the MUE value on the same date of service are considered to be impossible by the CMS based on regulatory guidance or anatomic considerations.² For instance, although the same physician may destroy multiple actinic keratoses in a single patient on the same date of service, it would not be possible to code more than one unit of service as 
CPT code 17000, which specifically and exclusively 
refers to the first lesion destroyed. Similarly, 
CPT code 13101 (repair, complex, trunk; lesion diameter 2.6–7.5 cm) could only be reported once that day, as all complex repairs at that anatomic site must be summed and smaller or larger totals would be reported with another code.

Anatomic limitations are sometimes obvious and do not require specific coding rules. For example, only 1 gallbladder can be removed per patient. Although Qualified Independent Contractors and Administrative Law Judges are not bound by MAIs, they do give particular deference to an MAI of 
2 given its definitive nature.² Because ambulatory surgical center providers (Medicare specialty code 49) cannot report modifier -50 for bilateral 
procedures, the MUE value used for editing is doubled for HCPCS codes with an MAI of 2 or 3 if the bilateral surgery indicator for the HCPCS code is 1.³

An MAI of 3 describes less strict date of service edits, so-called “per day edits based on clinical benchmarks.”² Similar to MAIs of 1, MUEs for MAIs of 3 are based on medically likely daily frequencies of services provided in most settings. To determine if an MUE with an MAI of 3 has been reached, the MAC sums the units of service billed on all claim lines of the current claim as well as all prior paid claims for the same patient billed by the same provider on the same date of service. If the total units of service obtained in this manner exceeds the MUE value, then all claim lines with the relevant code for the current claim will be denied, but prior paid claims will not be adjusted. Denials based on MUEs for codes with an MAI of 3 can be appealed to the local MAC. Successful appeals require documentation that the units of service in excess of the MUE value were actually delivered and demonstration of medical necessity.² An example of a CPT code with an MAI of 3 is 40490 (biopsy of lip) for which the MUE value is 3.

Complications With MUE and MAI

Because MUEs are based on current coding guidelines as well as current clinical practice, they are only applicable for the time period in which they are in effect. A change made to an MUE value for a particular code is not retroactive; however, in exceptional circumstances when a retroactive effective date is applied, MACs are not directed to examine prior claims but only “claims that are brought to their attention.”²

It also is important to realize that not all 
MUEs are publicly available and many are confidential. When claim denials occur, particularly in the context of multiple units of a particular code, 
automated MUE edits should be among the issues that are suspected. Physicians may resubmit RTP claims on separate lines if a claim line edit 
(MAI of 1) is operative. An MAI of 2 suggests a coding error that needs to be corrected, as these coding approaches are generally impossible based on definitional issues or anatomy. If an MUE with an 
MAI of 3 is the reason for denial, an appeal is possible, provided there is documentation to show that the service was actually provided and that it was medically necessary.

Final Thoughts

Dermatologists should be vigilant for unexpected payment denials, which may coincide with the implementation of new MUE values. When such denials occur and MUE values are publicly available, dermatologists should consider filing an appeal if the relevant MUEs were associated with an MAI of 
1 or 3. Overall, dermatologists should be aware that many MUEs that were formerly claim line edits 
(MAI of 1) have been recently transitioned to date of service edits (MAI of 3), which are more restrictive.

Services that physicians bill to Medicare but do not perform themselves are called “incident-to” services. These services usually are performed by nonphysician medical providers under close physician supervision. The authorization to bill for these incident-to services derives from the Social Security Act,¹ which provides for Medicare coverage of services and supplies offered incident to the professional services of a physician. The underlying logic is that incident-to services are delivered as a necessary but incidental part of the physician’s professional services during diagnosis or treatment.

Eligibility Criteria

One key qualification for incident-to services is direct supervision of a nonphysician provider by a physician. When services are delivered in an office setting (place of service 11), the physician must be present in the office and immediately available to offer direction to nonphysician providers. Some states do include telecommunication in their definition of direct supervision, wherein the physician is accessible by telephone or some similar medium.

Another element necessary in the criteria for incident-to services is that initial care must be personally provided by the physician who also writes orders for ongoing care. In general, incident-to services include ongoing physician involvement in the provision of care. Importantly, the physician who first saw a patient, initiated service, or ordered a test is not the only one who can supervise subsequent incident-to visits with a nonphysician provider. In office settings where several physicians are responsible for overseeing a nonphysician provider, any of these physicians who are in clinic at the time can act as the supervising physician. In such cases, each of the other physicians should be listed in appropriate documentation as substitute physicians for the nonphysician provider.

The Centers for Medicare & Medicaid Services recognize a variety of nonphysician providers, but in dermatology these providers typically include physician assistants, certified registered nurse practitioners, or clinical nurse specialists. When services offered by these nonphysician providers are reported as incident-to services, Medicare reimburses them at 100% of the physician fee schedule; conversely, a non–incident-to service reported under a nonphysician provider’s National Provider Identifier (NPI) number is reimbursed at 85%. Only approved mid-level nonphysician providers may bill evaluation and management services with codes above 99211 under incident-to guidelines. Even then, the services delivered must be appropriate for the given nonphysician provider based on training and licensure.

Not every type of visit is eligible for coding as an incident-to service. For instance, it is not appropriate to code new patient visits or new services provided to existing patients as incident-to services. Similarly, visits with established patients that address new diagnoses or problems cannot be considered incident-to services. The only visits or services that may potentially be classified as incident to are those that address existing problems in established patients with an established care plan.

When an established patient presents with a new problem, there are at least 2 coding approaches that may be appropriate. First, the physician could choose to see the patient and code the visit as a standard physician visit under the physician’s own NPI number. Alternatively, if the supervising physician in the practice is not available to see the patient, the nonphysician provider could code the entire service, including new and old problems, under his/her own NPI number as a non–incident-to service.

Regulations by State and Payer

State regulations and rules promulgated by specific payers also must be considered to ensure incident-to coding is proper. Each state may have guidelines that define the scope of practice of particular nonphysician providers, including what services can or cannot be coded as incident-to services. Additionally, states typically regulate the number of nonphysician providers that a physician can supervise; by extension, no more than this number of nonphysician providers could bill incident-to services under a given physician’s NPI number. Private payers may have comparable rules, and specific Medicare guidelines apply to Medicare patients. When there is ambiguity regarding incident-to coding, it may be prudent to check with major payers regarding relevant guidelines. It also may be helpful to confirm when supervision via telecommunication is acceptable.

Billing Tips

Common sense also can guide appropriate use of incident-to coding. Although occasional coding errors are likely unavoidable, periodic review of billing patterns will keep these errors to a minimum. For instance, if a nonphysician provider is the only provider of any type seeing patients in the office during particular days of the week, then incident-to coding would be unlikely. In another example, the number of nonphysician providers working with a given dermatologist and billing incident-to services should not exceed the number of nonphysician providers allowed per physician in that state. An interesting twist is the case in which a dermatologist is working in an ambulatory surgery center while a nonphysician provider is seeing patients in an adjacent office suite. Even when the 2 sites of service are physically contiguous, the physician in the surgery center generally is not deemed to be in office and is not able to supervise the nonphysician provider, unless telecommunication is allowed.

Final Thoughts

Attention to correct coding for incident-to services is particularly salient, as the Office of Inspector General (OIG) for the US Department of Health & Human Services has expressed concern that these services may be routinely coded incorrectly. Specifically, the OIG work plan for the 2013 fiscal year stated, “We will review physician billing for ‘incident-to’ services to determine whether payment for such services had a higher error rate than that for non–incident-to services.” The same report also cited a 2009 OIG review that found that “unqualified nonphysicians performed 21 percent of the services that physicians did not personally perform.”² In short, coding for incident-to services is under scrutiny, and it may be useful for dermatologists to review their internal policies regarding incident-to services.

Services that physicians bill to Medicare but do not perform themselves are called “incident-to” services. These services usually are performed by nonphysician medical providers under close physician supervision. The authorization to bill for these incident-to services derives from the Social Security Act,¹ which provides for Medicare coverage of services and supplies offered incident to the professional services of a physician. The underlying logic is that incident-to services are delivered as a necessary but incidental part of the physician’s professional services during diagnosis or treatment.

Eligibility Criteria

One key qualification for incident-to services is direct supervision of a nonphysician provider by a physician. When services are delivered in an office setting (place of service 11), the physician must be present in the office and immediately available to offer direction to nonphysician providers. Some states do include telecommunication in their definition of direct supervision, wherein the physician is accessible by telephone or some similar medium.

Another element necessary in the criteria for incident-to services is that initial care must be personally provided by the physician who also writes orders for ongoing care. In general, incident-to services include ongoing physician involvement in the provision of care. Importantly, the physician who first saw a patient, initiated service, or ordered a test is not the only one who can supervise subsequent incident-to visits with a nonphysician provider. In office settings where several physicians are responsible for overseeing a nonphysician provider, any of these physicians who are in clinic at the time can act as the supervising physician. In such cases, each of the other physicians should be listed in appropriate documentation as substitute physicians for the nonphysician provider.

The Centers for Medicare & Medicaid Services recognize a variety of nonphysician providers, but in dermatology these providers typically include physician assistants, certified registered nurse practitioners, or clinical nurse specialists. When services offered by these nonphysician providers are reported as incident-to services, Medicare reimburses them at 100% of the physician fee schedule; conversely, a non–incident-to service reported under a nonphysician provider’s National Provider Identifier (NPI) number is reimbursed at 85%. Only approved mid-level nonphysician providers may bill evaluation and management services with codes above 99211 under incident-to guidelines. Even then, the services delivered must be appropriate for the given nonphysician provider based on training and licensure.

Not every type of visit is eligible for coding as an incident-to service. For instance, it is not appropriate to code new patient visits or new services provided to existing patients as incident-to services. Similarly, visits with established patients that address new diagnoses or problems cannot be considered incident-to services. The only visits or services that may potentially be classified as incident to are those that address existing problems in established patients with an established care plan.

When an established patient presents with a new problem, there are at least 2 coding approaches that may be appropriate. First, the physician could choose to see the patient and code the visit as a standard physician visit under the physician’s own NPI number. Alternatively, if the supervising physician in the practice is not available to see the patient, the nonphysician provider could code the entire service, including new and old problems, under his/her own NPI number as a non–incident-to service.

Regulations by State and Payer

State regulations and rules promulgated by specific payers also must be considered to ensure incident-to coding is proper. Each state may have guidelines that define the scope of practice of particular nonphysician providers, including what services can or cannot be coded as incident-to services. Additionally, states typically regulate the number of nonphysician providers that a physician can supervise; by extension, no more than this number of nonphysician providers could bill incident-to services under a given physician’s NPI number. Private payers may have comparable rules, and specific Medicare guidelines apply to Medicare patients. When there is ambiguity regarding incident-to coding, it may be prudent to check with major payers regarding relevant guidelines. It also may be helpful to confirm when supervision via telecommunication is acceptable.

Billing Tips

Common sense also can guide appropriate use of incident-to coding. Although occasional coding errors are likely unavoidable, periodic review of billing patterns will keep these errors to a minimum. For instance, if a nonphysician provider is the only provider of any type seeing patients in the office during particular days of the week, then incident-to coding would be unlikely. In another example, the number of nonphysician providers working with a given dermatologist and billing incident-to services should not exceed the number of nonphysician providers allowed per physician in that state. An interesting twist is the case in which a dermatologist is working in an ambulatory surgery center while a nonphysician provider is seeing patients in an adjacent office suite. Even when the 2 sites of service are physically contiguous, the physician in the surgery center generally is not deemed to be in office and is not able to supervise the nonphysician provider, unless telecommunication is allowed.

Final Thoughts

Attention to correct coding for incident-to services is particularly salient, as the Office of Inspector General (OIG) for the US Department of Health & Human Services has expressed concern that these services may be routinely coded incorrectly. Specifically, the OIG work plan for the 2013 fiscal year stated, “We will review physician billing for ‘incident-to’ services to determine whether payment for such services had a higher error rate than that for non–incident-to services.” The same report also cited a 2009 OIG review that found that “unqualified nonphysicians performed 21 percent of the services that physicians did not personally perform.”² In short, coding for incident-to services is under scrutiny, and it may be useful for dermatologists to review their internal policies regarding incident-to services.

Services that physicians bill to Medicare but do not perform themselves are called “incident-to” services. These services usually are performed by nonphysician medical providers under close physician supervision. The authorization to bill for these incident-to services derives from the Social Security Act,¹ which provides for Medicare coverage of services and supplies offered incident to the professional services of a physician. The underlying logic is that incident-to services are delivered as a necessary but incidental part of the physician’s professional services during diagnosis or treatment.

Eligibility Criteria

One key qualification for incident-to services is direct supervision of a nonphysician provider by a physician. When services are delivered in an office setting (place of service 11), the physician must be present in the office and immediately available to offer direction to nonphysician providers. Some states do include telecommunication in their definition of direct supervision, wherein the physician is accessible by telephone or some similar medium.

Another element necessary in the criteria for incident-to services is that initial care must be personally provided by the physician who also writes orders for ongoing care. In general, incident-to services include ongoing physician involvement in the provision of care. Importantly, the physician who first saw a patient, initiated service, or ordered a test is not the only one who can supervise subsequent incident-to visits with a nonphysician provider. In office settings where several physicians are responsible for overseeing a nonphysician provider, any of these physicians who are in clinic at the time can act as the supervising physician. In such cases, each of the other physicians should be listed in appropriate documentation as substitute physicians for the nonphysician provider.

The Centers for Medicare & Medicaid Services recognize a variety of nonphysician providers, but in dermatology these providers typically include physician assistants, certified registered nurse practitioners, or clinical nurse specialists. When services offered by these nonphysician providers are reported as incident-to services, Medicare reimburses them at 100% of the physician fee schedule; conversely, a non–incident-to service reported under a nonphysician provider’s National Provider Identifier (NPI) number is reimbursed at 85%. Only approved mid-level nonphysician providers may bill evaluation and management services with codes above 99211 under incident-to guidelines. Even then, the services delivered must be appropriate for the given nonphysician provider based on training and licensure.

Not every type of visit is eligible for coding as an incident-to service. For instance, it is not appropriate to code new patient visits or new services provided to existing patients as incident-to services. Similarly, visits with established patients that address new diagnoses or problems cannot be considered incident-to services. The only visits or services that may potentially be classified as incident to are those that address existing problems in established patients with an established care plan.

When an established patient presents with a new problem, there are at least 2 coding approaches that may be appropriate. First, the physician could choose to see the patient and code the visit as a standard physician visit under the physician’s own NPI number. Alternatively, if the supervising physician in the practice is not available to see the patient, the nonphysician provider could code the entire service, including new and old problems, under his/her own NPI number as a non–incident-to service.

Regulations by State and Payer

State regulations and rules promulgated by specific payers also must be considered to ensure incident-to coding is proper. Each state may have guidelines that define the scope of practice of particular nonphysician providers, including what services can or cannot be coded as incident-to services. Additionally, states typically regulate the number of nonphysician providers that a physician can supervise; by extension, no more than this number of nonphysician providers could bill incident-to services under a given physician’s NPI number. Private payers may have comparable rules, and specific Medicare guidelines apply to Medicare patients. When there is ambiguity regarding incident-to coding, it may be prudent to check with major payers regarding relevant guidelines. It also may be helpful to confirm when supervision via telecommunication is acceptable.

Billing Tips

Common sense also can guide appropriate use of incident-to coding. Although occasional coding errors are likely unavoidable, periodic review of billing patterns will keep these errors to a minimum. For instance, if a nonphysician provider is the only provider of any type seeing patients in the office during particular days of the week, then incident-to coding would be unlikely. In another example, the number of nonphysician providers working with a given dermatologist and billing incident-to services should not exceed the number of nonphysician providers allowed per physician in that state. An interesting twist is the case in which a dermatologist is working in an ambulatory surgery center while a nonphysician provider is seeing patients in an adjacent office suite. Even when the 2 sites of service are physically contiguous, the physician in the surgery center generally is not deemed to be in office and is not able to supervise the nonphysician provider, unless telecommunication is allowed.

Final Thoughts

Attention to correct coding for incident-to services is particularly salient, as the Office of Inspector General (OIG) for the US Department of Health & Human Services has expressed concern that these services may be routinely coded incorrectly. Specifically, the OIG work plan for the 2013 fiscal year stated, “We will review physician billing for ‘incident-to’ services to determine whether payment for such services had a higher error rate than that for non–incident-to services.” The same report also cited a 2009 OIG review that found that “unqualified nonphysicians performed 21 percent of the services that physicians did not personally perform.”² In short, coding for incident-to services is under scrutiny, and it may be useful for dermatologists to review their internal policies regarding incident-to services.

Health care providers select Current Procedural Terminology codes based on the service provided and then document to support the level of service reported.¹ According to the Office of Inspector General (OIG) for the US Department of Health and Human Services, “Medicare contractors have noted an increased frequency of medical records with identical documentation across services,” which may under certain circumstances be considered inappropriate.² Regarding this practice, the OIG work plan for the 2014 fiscal year stated: "We will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. We will also review multiple E/M services associated with the same providers and beneficiaries to determine the extent to which electronic or paper medical records had documentation vulnerabilities."²The OIG’s annual work plan reflects areas of concern that will be investigated in the coming years. These investigations may result in audits of specific Medicare and Medicaid providers, including physicians.

Concerns about physicians providing identical documentation across services has evinced an ongoing focus on the so-called cloning of medical records. Cloning is not well defined but generally refers to inappropriate use of the same exact documentation, perhaps via cutting and pasting, in different patient encounters. This type of cloning could occur in office visits with the same patient or different patients. The advent of electronic health records has made such duplication easier, and the concern is that duplicated notes in a medical record for a particular encounter may not accurately reflect the services that were provided in another encounter; in some cases, services may be overdocumented, with this creating a risk that that they may also be overcoded.

How can dermatologists minimize the risk for being flagged for cloning records? If you use templates for procedures, you may consider reviewing the completed template before filing the record to ensure that the details are consistent with the procedure that was performed. If you use abbreviations or other unique documentation that may not be easily understandable to an outside authority, you may want to keep a manual somewhere in your office that defines or describes such abbreviations and notations. Also, be aware that scribing is different than cloning, and scribing is not under scrutiny by OIG. A scribe writes word for word as a physician dictates and cannot act independently to alter or embellish the notes; once scribing is complete, both the scribe and the physician should sign the notes.

The American Academy of Dermatology has been concerned that an imprecise definition of so-called cloning can unfairly marginalize appropriate coding practices. In particular, when similar procedures or E/M services are performed by the same physician, the documentation may be very similar, even identical, while still being accurate and appropriately descriptive of the services provided. To help explain when similar notes are an acceptable practice in dermatology and when notes should be different, the American Academy of Dermatology has developed a guidance document that has been approved by its board of directors.³

Current Procedural Terminology coding guidelines clearly indicate that documentation cannot drive the level of coding and that excessive documentation cannot be used to justify a higher-level code, such as a higher-level E/M code. Instead, the level of service delivered should be appropriate for the patient’s condition and should be documented accordingly.⁴

It is important for dermatologists to document patient encounters as accurately and completely as is necessary for good patient care. Documentation will often vary substantially from patient to patient and encounter to encounter, but sometimes routine procedures or E/M visits may be coded similarly. For instance, a shave biopsy on the cheek to rule out nonmelanoma skin cancer may be performed by a particular practitioner with a standard instrument and after standard preparation and infiltration of local anesthetic; postoperative care may also be the same. To minimize regulatory scrutiny when similar descriptions are used, review the documentation for accuracy and to confirm that important specific information has not been inadvertently omitted or that wrong information has not been appended.

Unfortunately, there are dermatologists who have been audited for cloning during the last year. As with any audit, it is important to be vigilant regarding deadlines and to file appeals in a timely manner. Keep all the notifications you receive safely and explain to your staff that any communications should be promptly forwarded to you. If you are audited for suspected cloning, you may wish to contact the coding staff of professional dermatology societies for general guidance.

Health care providers select Current Procedural Terminology codes based on the service provided and then document to support the level of service reported.¹ According to the Office of Inspector General (OIG) for the US Department of Health and Human Services, “Medicare contractors have noted an increased frequency of medical records with identical documentation across services,” which may under certain circumstances be considered inappropriate.² Regarding this practice, the OIG work plan for the 2014 fiscal year stated: "We will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. We will also review multiple E/M services associated with the same providers and beneficiaries to determine the extent to which electronic or paper medical records had documentation vulnerabilities."²The OIG’s annual work plan reflects areas of concern that will be investigated in the coming years. These investigations may result in audits of specific Medicare and Medicaid providers, including physicians.

Concerns about physicians providing identical documentation across services has evinced an ongoing focus on the so-called cloning of medical records. Cloning is not well defined but generally refers to inappropriate use of the same exact documentation, perhaps via cutting and pasting, in different patient encounters. This type of cloning could occur in office visits with the same patient or different patients. The advent of electronic health records has made such duplication easier, and the concern is that duplicated notes in a medical record for a particular encounter may not accurately reflect the services that were provided in another encounter; in some cases, services may be overdocumented, with this creating a risk that that they may also be overcoded.

How can dermatologists minimize the risk for being flagged for cloning records? If you use templates for procedures, you may consider reviewing the completed template before filing the record to ensure that the details are consistent with the procedure that was performed. If you use abbreviations or other unique documentation that may not be easily understandable to an outside authority, you may want to keep a manual somewhere in your office that defines or describes such abbreviations and notations. Also, be aware that scribing is different than cloning, and scribing is not under scrutiny by OIG. A scribe writes word for word as a physician dictates and cannot act independently to alter or embellish the notes; once scribing is complete, both the scribe and the physician should sign the notes.

The American Academy of Dermatology has been concerned that an imprecise definition of so-called cloning can unfairly marginalize appropriate coding practices. In particular, when similar procedures or E/M services are performed by the same physician, the documentation may be very similar, even identical, while still being accurate and appropriately descriptive of the services provided. To help explain when similar notes are an acceptable practice in dermatology and when notes should be different, the American Academy of Dermatology has developed a guidance document that has been approved by its board of directors.³

Current Procedural Terminology coding guidelines clearly indicate that documentation cannot drive the level of coding and that excessive documentation cannot be used to justify a higher-level code, such as a higher-level E/M code. Instead, the level of service delivered should be appropriate for the patient’s condition and should be documented accordingly.⁴

It is important for dermatologists to document patient encounters as accurately and completely as is necessary for good patient care. Documentation will often vary substantially from patient to patient and encounter to encounter, but sometimes routine procedures or E/M visits may be coded similarly. For instance, a shave biopsy on the cheek to rule out nonmelanoma skin cancer may be performed by a particular practitioner with a standard instrument and after standard preparation and infiltration of local anesthetic; postoperative care may also be the same. To minimize regulatory scrutiny when similar descriptions are used, review the documentation for accuracy and to confirm that important specific information has not been inadvertently omitted or that wrong information has not been appended.

Unfortunately, there are dermatologists who have been audited for cloning during the last year. As with any audit, it is important to be vigilant regarding deadlines and to file appeals in a timely manner. Keep all the notifications you receive safely and explain to your staff that any communications should be promptly forwarded to you. If you are audited for suspected cloning, you may wish to contact the coding staff of professional dermatology societies for general guidance.

Health care providers select Current Procedural Terminology codes based on the service provided and then document to support the level of service reported.¹ According to the Office of Inspector General (OIG) for the US Department of Health and Human Services, “Medicare contractors have noted an increased frequency of medical records with identical documentation across services,” which may under certain circumstances be considered inappropriate.² Regarding this practice, the OIG work plan for the 2014 fiscal year stated: "We will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. We will also review multiple E/M services associated with the same providers and beneficiaries to determine the extent to which electronic or paper medical records had documentation vulnerabilities."²The OIG’s annual work plan reflects areas of concern that will be investigated in the coming years. These investigations may result in audits of specific Medicare and Medicaid providers, including physicians.

Concerns about physicians providing identical documentation across services has evinced an ongoing focus on the so-called cloning of medical records. Cloning is not well defined but generally refers to inappropriate use of the same exact documentation, perhaps via cutting and pasting, in different patient encounters. This type of cloning could occur in office visits with the same patient or different patients. The advent of electronic health records has made such duplication easier, and the concern is that duplicated notes in a medical record for a particular encounter may not accurately reflect the services that were provided in another encounter; in some cases, services may be overdocumented, with this creating a risk that that they may also be overcoded.

How can dermatologists minimize the risk for being flagged for cloning records? If you use templates for procedures, you may consider reviewing the completed template before filing the record to ensure that the details are consistent with the procedure that was performed. If you use abbreviations or other unique documentation that may not be easily understandable to an outside authority, you may want to keep a manual somewhere in your office that defines or describes such abbreviations and notations. Also, be aware that scribing is different than cloning, and scribing is not under scrutiny by OIG. A scribe writes word for word as a physician dictates and cannot act independently to alter or embellish the notes; once scribing is complete, both the scribe and the physician should sign the notes.

The American Academy of Dermatology has been concerned that an imprecise definition of so-called cloning can unfairly marginalize appropriate coding practices. In particular, when similar procedures or E/M services are performed by the same physician, the documentation may be very similar, even identical, while still being accurate and appropriately descriptive of the services provided. To help explain when similar notes are an acceptable practice in dermatology and when notes should be different, the American Academy of Dermatology has developed a guidance document that has been approved by its board of directors.³

Current Procedural Terminology coding guidelines clearly indicate that documentation cannot drive the level of coding and that excessive documentation cannot be used to justify a higher-level code, such as a higher-level E/M code. Instead, the level of service delivered should be appropriate for the patient’s condition and should be documented accordingly.⁴

It is important for dermatologists to document patient encounters as accurately and completely as is necessary for good patient care. Documentation will often vary substantially from patient to patient and encounter to encounter, but sometimes routine procedures or E/M visits may be coded similarly. For instance, a shave biopsy on the cheek to rule out nonmelanoma skin cancer may be performed by a particular practitioner with a standard instrument and after standard preparation and infiltration of local anesthetic; postoperative care may also be the same. To minimize regulatory scrutiny when similar descriptions are used, review the documentation for accuracy and to confirm that important specific information has not been inadvertently omitted or that wrong information has not been appended.

Unfortunately, there are dermatologists who have been audited for cloning during the last year. As with any audit, it is important to be vigilant regarding deadlines and to file appeals in a timely manner. Keep all the notifications you receive safely and explain to your staff that any communications should be promptly forwarded to you. If you are audited for suspected cloning, you may wish to contact the coding staff of professional dermatology societies for general guidance.

According to Current Procedural Terminology (CPT), modifier -25 is to be used to identify “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”¹ Modifier -25 frequently is integral to the description of patient visits in dermatology. Dermatologists use modifier -25 more than physicians of any other specialty, and in recent years, more than 50% of dermatology evaluation and management (E/M) visits have been appended with this modifier.

When patients present for assessment and management of various skin findings, a dermatologist may deem it appropriate to proceed with a diagnostic or therapeutic procedure at the same visit after obtaining the patient’s medical history, completing a review of systems, and conducting a clinical examination. Most commonly, a skin biopsy or destruction of a benign or malignant lesion may be performed, but other simple procedures also may be appropriate. The ability to assess and intervene during the same visit is optimal for patients who subsequently may require fewer follow-up visits and experience more immediate relief from their symptoms.

When E/M Cannot Be Billed Separately

Regulatory guidance from the National Correct Coding Initiative (NCCI) dated January 2013 indicates that procedures with a global period of 90 days are major surgical procedures, and if an E/M service is performed on the same day as such a procedure to decide whether or not to perform that procedure, then the E/M service should be reported with modifier -57.² On the other hand, CPT defines procedures with a 0- or 10-day global period as minor surgical procedures, and E/M services provided on the same day of service as these procedures are included in the procedure code and cannot be billed separately. For review, common dermatologic procedures with 0-day global periods include biopsies (CPT code 11000), shave removals (11300–11313), debridements (11000, 11011–11042), and Mohs micrographic surgery (17311–17315); procedures with 10-day global periods include destructions (17000–17286), excisions (11400–11646), and repairs (12001–13153). If an E/M service is performed on the same day as one of these procedures to decide whether to proceed with the minor surgical procedure, this E/M service cannot be reported separately. Additionally, the fact that the patient is new to the physician is not sufficient to allow reporting of an E/M with such a minor procedure.

When E/M Can Be Billed Separately

However, a “significant and separately identifiable E/M service unrelated to the decision to perform the minor procedure” is separately reportable with modifier -25. According to the NCCI, the minor procedure and the E/M do not require different diagnoses, but the E/M service must be above and beyond what is usually required for the minor surgical procedure.² Because a certain amount of so-called preservice time is built into minor procedure codes, the implication is that substantially more E/M was needed than envisioned in this preservice time, necessitating inclusion of an E/M in addition to a minor procedure when there is a single diagnosis.

When there is a single diagnosis, the physician has to decide when such a significant and separately identifiable service exists. If the physician determines that it is appropriate to code for E/M in addition to the minor procedure, clear documentation of the additional E/M service provided will reduce the likelihood of this choice being questioned. Specifically, it may be helpful to describe the additional history, examination results, medical knowledge, professional skill, and work time above and beyond what is usually required for the minor surgical procedure.

When there are many diagnosis codes for a single visit and only a subset of them are associated with the minor procedure, as is common in dermatology, then the decision to include an E/M service is simpler. In this case, if E/M services were provided that pertained to a diagnosis or diagnoses other than the one(s) associated with the minor procedure(s), then these additional E/M services will clearly not be included in the preservice time for the procedure and an E/M can virtually always be coded separately. For instance, if a patient presents with a growing scaly bump (clinically apparent squamous cell carcinoma) on the leg that the dermatologist deems is appropriate for biopsy but concurrently notices nummular dermatitis of the legs, which the patient describes as itchy and uncomfortable, then the diagnosis and management of the dermatitis would clearly be a separate E/M service and would not be included in the workup for the biopsy. The E/M code that is applied should, of course, reflect the services provided exclusive of those integral to the minor procedure. To make it easier for regulators and auditors, it may be helpful to clearly itemize the additional diagnoses unrelated to the minor procedure and describe the specific E/M services provided for these diagnoses. Although it is certainly not necessary or required, it also may be helpful to physically separate the documentation for the minor procedure from the E/M services for the additional diagnoses within the medical chart.

Final Thoughts

It is clear that frequent use of modifier -25 is appropriate in routine, high-quality dermatologic practice. Simultaneous provision of E/M services and minor procedures often is in the patient’s best interest, as it minimizes unnecessary office visits and expedites treatment. When modifier -25 is appropriately appended, careful documentation by the dermatologist can help to clarify the precise basis for its use. Recent NCCI edits provide guidelines for use of this modifier that can be adapted by individual dermatologists for particular patient circumstances.²

According to Current Procedural Terminology (CPT), modifier -25 is to be used to identify “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”¹ Modifier -25 frequently is integral to the description of patient visits in dermatology. Dermatologists use modifier -25 more than physicians of any other specialty, and in recent years, more than 50% of dermatology evaluation and management (E/M) visits have been appended with this modifier.

When patients present for assessment and management of various skin findings, a dermatologist may deem it appropriate to proceed with a diagnostic or therapeutic procedure at the same visit after obtaining the patient’s medical history, completing a review of systems, and conducting a clinical examination. Most commonly, a skin biopsy or destruction of a benign or malignant lesion may be performed, but other simple procedures also may be appropriate. The ability to assess and intervene during the same visit is optimal for patients who subsequently may require fewer follow-up visits and experience more immediate relief from their symptoms.

When E/M Cannot Be Billed Separately

Regulatory guidance from the National Correct Coding Initiative (NCCI) dated January 2013 indicates that procedures with a global period of 90 days are major surgical procedures, and if an E/M service is performed on the same day as such a procedure to decide whether or not to perform that procedure, then the E/M service should be reported with modifier -57.² On the other hand, CPT defines procedures with a 0- or 10-day global period as minor surgical procedures, and E/M services provided on the same day of service as these procedures are included in the procedure code and cannot be billed separately. For review, common dermatologic procedures with 0-day global periods include biopsies (CPT code 11000), shave removals (11300–11313), debridements (11000, 11011–11042), and Mohs micrographic surgery (17311–17315); procedures with 10-day global periods include destructions (17000–17286), excisions (11400–11646), and repairs (12001–13153). If an E/M service is performed on the same day as one of these procedures to decide whether to proceed with the minor surgical procedure, this E/M service cannot be reported separately. Additionally, the fact that the patient is new to the physician is not sufficient to allow reporting of an E/M with such a minor procedure.

When E/M Can Be Billed Separately

However, a “significant and separately identifiable E/M service unrelated to the decision to perform the minor procedure” is separately reportable with modifier -25. According to the NCCI, the minor procedure and the E/M do not require different diagnoses, but the E/M service must be above and beyond what is usually required for the minor surgical procedure.² Because a certain amount of so-called preservice time is built into minor procedure codes, the implication is that substantially more E/M was needed than envisioned in this preservice time, necessitating inclusion of an E/M in addition to a minor procedure when there is a single diagnosis.

When there is a single diagnosis, the physician has to decide when such a significant and separately identifiable service exists. If the physician determines that it is appropriate to code for E/M in addition to the minor procedure, clear documentation of the additional E/M service provided will reduce the likelihood of this choice being questioned. Specifically, it may be helpful to describe the additional history, examination results, medical knowledge, professional skill, and work time above and beyond what is usually required for the minor surgical procedure.

When there are many diagnosis codes for a single visit and only a subset of them are associated with the minor procedure, as is common in dermatology, then the decision to include an E/M service is simpler. In this case, if E/M services were provided that pertained to a diagnosis or diagnoses other than the one(s) associated with the minor procedure(s), then these additional E/M services will clearly not be included in the preservice time for the procedure and an E/M can virtually always be coded separately. For instance, if a patient presents with a growing scaly bump (clinically apparent squamous cell carcinoma) on the leg that the dermatologist deems is appropriate for biopsy but concurrently notices nummular dermatitis of the legs, which the patient describes as itchy and uncomfortable, then the diagnosis and management of the dermatitis would clearly be a separate E/M service and would not be included in the workup for the biopsy. The E/M code that is applied should, of course, reflect the services provided exclusive of those integral to the minor procedure. To make it easier for regulators and auditors, it may be helpful to clearly itemize the additional diagnoses unrelated to the minor procedure and describe the specific E/M services provided for these diagnoses. Although it is certainly not necessary or required, it also may be helpful to physically separate the documentation for the minor procedure from the E/M services for the additional diagnoses within the medical chart.

Final Thoughts

It is clear that frequent use of modifier -25 is appropriate in routine, high-quality dermatologic practice. Simultaneous provision of E/M services and minor procedures often is in the patient’s best interest, as it minimizes unnecessary office visits and expedites treatment. When modifier -25 is appropriately appended, careful documentation by the dermatologist can help to clarify the precise basis for its use. Recent NCCI edits provide guidelines for use of this modifier that can be adapted by individual dermatologists for particular patient circumstances.²

According to Current Procedural Terminology (CPT), modifier -25 is to be used to identify “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”¹ Modifier -25 frequently is integral to the description of patient visits in dermatology. Dermatologists use modifier -25 more than physicians of any other specialty, and in recent years, more than 50% of dermatology evaluation and management (E/M) visits have been appended with this modifier.

When patients present for assessment and management of various skin findings, a dermatologist may deem it appropriate to proceed with a diagnostic or therapeutic procedure at the same visit after obtaining the patient’s medical history, completing a review of systems, and conducting a clinical examination. Most commonly, a skin biopsy or destruction of a benign or malignant lesion may be performed, but other simple procedures also may be appropriate. The ability to assess and intervene during the same visit is optimal for patients who subsequently may require fewer follow-up visits and experience more immediate relief from their symptoms.

When E/M Cannot Be Billed Separately

Regulatory guidance from the National Correct Coding Initiative (NCCI) dated January 2013 indicates that procedures with a global period of 90 days are major surgical procedures, and if an E/M service is performed on the same day as such a procedure to decide whether or not to perform that procedure, then the E/M service should be reported with modifier -57.² On the other hand, CPT defines procedures with a 0- or 10-day global period as minor surgical procedures, and E/M services provided on the same day of service as these procedures are included in the procedure code and cannot be billed separately. For review, common dermatologic procedures with 0-day global periods include biopsies (CPT code 11000), shave removals (11300–11313), debridements (11000, 11011–11042), and Mohs micrographic surgery (17311–17315); procedures with 10-day global periods include destructions (17000–17286), excisions (11400–11646), and repairs (12001–13153). If an E/M service is performed on the same day as one of these procedures to decide whether to proceed with the minor surgical procedure, this E/M service cannot be reported separately. Additionally, the fact that the patient is new to the physician is not sufficient to allow reporting of an E/M with such a minor procedure.

When E/M Can Be Billed Separately

However, a “significant and separately identifiable E/M service unrelated to the decision to perform the minor procedure” is separately reportable with modifier -25. According to the NCCI, the minor procedure and the E/M do not require different diagnoses, but the E/M service must be above and beyond what is usually required for the minor surgical procedure.² Because a certain amount of so-called preservice time is built into minor procedure codes, the implication is that substantially more E/M was needed than envisioned in this preservice time, necessitating inclusion of an E/M in addition to a minor procedure when there is a single diagnosis.

When there is a single diagnosis, the physician has to decide when such a significant and separately identifiable service exists. If the physician determines that it is appropriate to code for E/M in addition to the minor procedure, clear documentation of the additional E/M service provided will reduce the likelihood of this choice being questioned. Specifically, it may be helpful to describe the additional history, examination results, medical knowledge, professional skill, and work time above and beyond what is usually required for the minor surgical procedure.

When there are many diagnosis codes for a single visit and only a subset of them are associated with the minor procedure, as is common in dermatology, then the decision to include an E/M service is simpler. In this case, if E/M services were provided that pertained to a diagnosis or diagnoses other than the one(s) associated with the minor procedure(s), then these additional E/M services will clearly not be included in the preservice time for the procedure and an E/M can virtually always be coded separately. For instance, if a patient presents with a growing scaly bump (clinically apparent squamous cell carcinoma) on the leg that the dermatologist deems is appropriate for biopsy but concurrently notices nummular dermatitis of the legs, which the patient describes as itchy and uncomfortable, then the diagnosis and management of the dermatitis would clearly be a separate E/M service and would not be included in the workup for the biopsy. The E/M code that is applied should, of course, reflect the services provided exclusive of those integral to the minor procedure. To make it easier for regulators and auditors, it may be helpful to clearly itemize the additional diagnoses unrelated to the minor procedure and describe the specific E/M services provided for these diagnoses. Although it is certainly not necessary or required, it also may be helpful to physically separate the documentation for the minor procedure from the E/M services for the additional diagnoses within the medical chart.

Final Thoughts

It is clear that frequent use of modifier -25 is appropriate in routine, high-quality dermatologic practice. Simultaneous provision of E/M services and minor procedures often is in the patient’s best interest, as it minimizes unnecessary office visits and expedites treatment. When modifier -25 is appropriately appended, careful documentation by the dermatologist can help to clarify the precise basis for its use. Recent NCCI edits provide guidelines for use of this modifier that can be adapted by individual dermatologists for particular patient circumstances.²