Billing and Coding Update

1 Billing and Coding Update Alexander Miller, AAD Representative to the AMA CPT. Advisory Committee New Skin Biopsy CPT Codes It's all about the Technique! SPEAKER: Alexander Miller, AAD Representative to the AMA-CPT Advisory Committee Chair AAD Health Care Finance Committee Arriving on January 1, 2019. New and Restructured Biopsy Codes Tangential biopsy Punch Biopsy Incisional Biopsy How Did We Get Here? CMS CY 2016. Biopsy codes (11100, 11101 identified as potentially mis-valued; high expenditure RUC Survey sent to AAD Members Specialty survey results are the only tool available to support code values Challenging survey results Survey revealed bimodal data distribution; CPT Codes 11100, 11101 referred to CPT for respondents were valuing different procedures restructuring Rationale for New Codes 11100; 11101. Previous skin biopsy codes did not distinguish between the different biopsy techniques that were being used CPT Recommended technique specification in new biopsy codes Will also provide for reimbursement commensurate with the technique used How Did We Get Here?)

2 CPT Editorial Panel deleted 11100; 11101. February 2017 6 New codes created based on technique utilized Each technique: primary code and add-on code March 2017 RUC survey sent to AAD members April 2017 Survey results presented to the RUC. Biopsy Codes Effective Jan., 1, 2019. Biopsy of nail unit (plate, bed, matrix, hyponychium, Integumentary biopsy codes 11755. proximal and lateral nail folds 11100, 11101 have been deleted 30100 Biopsy, intranasal New Skin Biopsy codes: 11102 - 40490 Biopsy of lip mucosa 11107 skin 40808 Biopsy, vestibule of mouth only, does not include mucosa41100 Biopsy of tongue; anterior two-thirds 41105 Biopsy of tongue; posterior one-third Site-specific biopsy codes still 41108 Biopsy of floor of mouth applicable 54100 Biopsy of penis 56605 Biopsy of vulva or perineum; 1 lesion 56606 Biopsy of vulva or perineum, each separate additional lesion All remain unchanged 67810 Incisional biopsy of eyelid skin including lid margin 69100 Biopsy external ear Definition: Procedure to obtain tissue solely for histopathologic examination Sampling of a lesion You want to know what it is on histopathology, so you biopsy it Stratum corneum sampling by any method (scraping, tape stripping) is not a biopsy Skin Biopsy codes can be reported to indicate: During excisions, destructions, or shave removals, that the procedure was tissue submitted performed independently, or for histopathology that the procedure to obtain was unrelated or distinct is a routine tissue was solely for from other component of such diagnostic histopathologic procedures/services procedure(s) and is examination.)

3 Provided during the same not reported encounter separately biopsies performed on a different lesion or different site(s) on the same date of service may be reported separately as they are not considered components of other procedures Code Criterion is Based on Technique Optimal tissue Three distinct Biopsy sampling: consider techniques: technique type of neoplastic, three primary is selected inflammatory or other biopsy codes;. based on: lesion requiring tissue three add-on diagnosis codes 2019 Skin Biopsy Codes 11102 11104 11106. Incisional Tangential biopsy Punch biopsy of biopsy of skin of skin, (eg, shave, skin, (including (eg, wedge), scoop, saucerize, simple closure (including simple curette), single when performed), closure when lesion single lesion performed), single lesion 11103 11105 11107. each separate/ each separate/ each separate/. additional lesion additional lesion additional lesion Tangential biopsy Vs. Shave removal Tangential biopsy Tangential biopsy Shave removal Intent: obtain tissue sample for Intent: therapeutic removal of diagnostic pathologic examination epidermal or epidermal-dermal lesion Instrument: removal with a sharp Instrument: sharp blade, such as scalpel, blade, such as scalpel, flexible blade flexible blade, curette Depth: not through dermis Depth: may include epidermis only, or No suturing required epidermis and dermis Histopathologic tissue evaluation: may Histopathologic tissue evaluation: always be done done Code selection: determined by site and lesion size Two codes only: primary and add-on Tangential biopsy vs.

4 Shave removal, examples Tangential biopsy Shave removal Biopsy of an inflammatory Cosmetic shave removal of an dermatosis with the shave elevated nevus technique Shave removal of irritated Biopsy of a large atypical seborrheic keratosis, irritated pigmented lesion (saucerization or nevus scoop biopsy technique, into deep dermis) Intent: to completely remove the lesion; or to completely remove Intent: obtain an optimal tissue the noxious portion of lesion sample for histopathology Punch Biopsy (11104, 11105). Intent: Full-thickness removal of Manipulation of the a skin sample, including adjoining skin, such as obtain tissue sample for simple closure removal of adjacent diagnostic pathologic standing cones/Burow's Punch penetrates examination using through dermis into triangles/dog ears is punch instrument subdermal space included Two codes only: Histopathologic tissue primary and add-on evaluation always done 11104 11105. Punch Biopsy Example Punch defect: Excision of Simple through dermis standing cones suturing included included Incisional Biopsy Vs.

5 Excision Incisional Biopsy Excision, benign or malignant Intent: obtain tissue sample for diagnostic Intent: excision of entire lesion, with margins histopathologic examination Instrument: sharp blade Instrument: sharp blade (not a punch) Depth: full-thickness, through dermis Depth: full-thickness tissue sample: Includes: simple closure o penetrates into the subcutaneous space Histopathologic evaluation: usually done o May include large fat tissue sample, if Code selection determined by: required (eg, panniculitis) Benign vs. Malignant Includes: simple closure Location Histopathologic evaluation: always done Maximum excision diameter Two codes only: primary and add-on Incisional Biopsy Vs. Soft Tissue Biopsy Incisional Biopsy Biopsy, Soft Tissue Intent: obtain tissue sample for diagnostic Intent: sampling of tissues deep to skin: histopathologic examination subcutaneous, subfascial, intramuscular Instrument: sharp blade Instrument: sharp blade (not a punch).

6 Tissue sample: subcutaneous or subfascial or Tissue sample: full-thickness skin muscle o penetrates into the subcutaneous space o Skin may not be included o Contains skin Includes: simple or intermediate repair o May include large fat tissue sample, if Histopathologic evaluation: always done required Code selection determined by: o Location Includes: simple closure o Type of biopsy: superficial or deep Histopathologic evaluation: always done Two codes only: primary and add-on 2018 vs. 2019 Biopsy Coding 2018 2019. First biopsy: First biopsy: 11106: Incisional 11100 11104: Punch each additional: 11101 11102: Tangential each additional: 11107: Incisional 11105: Punch 11103: Tangential Biopsy Coding Hierarchies Incisional Punch Biopsy Tangential biopsy 11106 11104 Biopsy 11102. Additional Additional incisional: punch: Additional 11107 11105 tangential: 11103. Additional Additional Punch: 11105 tangential: Additional 11103. tangential: 11103. Single Technique Biopsy Coding Examples Tangential Punch Incisional Three tangential Bx: Three punch Bx: Two incisional Bx: 11102, 11103x2 11104, 11105x2 11106, 11107.

7 Multiple Biopsies, Different Lesions or Sites More than one biopsy List the highest value Additional biopsy add- with different base (primary) code on codes in order of techniques used for first highest to lowest value each additional lesion 11102. +11103. 3. 11104. +11105. 2. 11106. 1. +11107. Multiple Biopsies of Different Lesions or Sites Only one primary code is used, regardless if multiple biopsy techniques used When multiple biopsies are done, use one primary code and add- on code(s) appropriate to the additional biopsy techniques used Incisional biopsy (11106) is always primary to other biopsy techniques Punch biopsy (11104) is always primary when shave biopsy also performed Multiple Techniques Biopsy Coding Examples One incisional, Two punch, one One incisional, one punch, two tangential two tangential tangential 11106 11104 (punch) 11106. (incisional) (incisional). 11105 (punch). 11105 (punch) 11103. 11103. (tangential). 11103x2 (tangential). (tangential) 11103.

8 (tangential). CMS 2019 Proposed RVUs Code Descriptor RVU. 11102 Tangential .66. 11103 Tangential Add-On .29 (RUC recommended .38). 11104 Punch .83. 11105 Punch Add-On .45. 11106 Incisional 11107 Incisional Add-On .54. 11100 Deleted Biopsy .81. 11101 Deleted Biopsy Add-On .41. CMS Proposed Values for Skin Biopsy Codes - 2019. Medicare Medicare 2018 National National Total 2019 Total Average Average 2019 2018 2019 Non- Non- 2018 2019. CPT / Work Work Facility Facility Payment Payment HCPCS Description RVUs RVUs RVUs RVUs Amount $ Amount $. 11100 Biopsy of skin n/a NA $ NA. 11101 Biopsy of skin add-on n/a NA $ NA. 11102 Tangential bx skin single lesion NA NA NA $ 11103 Tangential bx skin ea sep/addl NA NA NA $ 11104 Punch bx skin single lesion NA NA NA $ 11105 Punch bx skin ea sep/addl NA NA NA $ 11106 Incisional bx skin single lesion NA NA NA $ 11107 Incisional bx skin ea sep/addl NA NA NA $ National Correct Coding Edits Medically Unlikely Edits (MUEs) for the new biopsy codes have been determined Multiple procedures on the same date of service are still likely to be reduced under the multiple surgical reduction rule (MSRR).

9 Add-on codes need not be further discounted However, payers can choose to discount payment for any reason in spite of CMS/NCCI guidelines 2019 NCCI Edits Examples Column1/Column 2 Edits Modifier Modifier 0=Not Allowed 0=Not Allowed Column 1 Column 2 1=Allowed Column 1 Column 2 1=Allowed 9=Not Applicable 9=Not Applicable 11442 11102 1 17004 11102 1. 11442 11104 1 17004 11104 1. 11442 11106 1 17004 11106 1. 11602 11102 1 17110 11102 1. 11602 11104 1 17110 11104 1. 11602 11106 1 17110 11106 1. 17000 11102 1 17262 11102 1. 17000 11104 1 17262 11104 1. 17000 11106 1 17262 11106 1. 2019 MUE Edits/MAI Indicators Practitioner MUE Adjudication HCPCS/CPT Code Services MUE MUE Rationale Indicator (MAI). Values 11102 1 2 Date of Service Edit Date of Service Edit +11103 6 3 Date of Service Edit Date of Service Edit 11104 1 2 Date of Service Edit Date of Service Edit +11105 3 3 Date of Service Edit Date of Service Edit 11106 1 2 Date of Service Edit Date of Service Edit +11107 2 3 Date of Service Edit Date of Service Edit MAI = 2 Based on policy; not appealable MAI = 3 Based on clinical benchmarks: ; appealable Impact on MAI Edit Rationale Claim These are claim line edits.

10 CLAIM LINE. 1 Based on CPT code descriptor and is not appealable EDIT. These are per day edits based on policy . Rigorously reviewed and vetted within CMS. MAI designation because UOS on the same date of service (DOS) in excess of the MUE value would be DATE OF considered impossible because it was contrary to statute, regulation or subregulatory guidance. SERVICE. 2 EDIT: This subregulatory guidance includes clear correct Coding policy that is binding on both providers and CMS. POLICY claims processing contractors. Limitations created by anatomical or Coding limitations are incorporated in correct Coding policy, both in the HIPAA mandated Coding descriptors and CMS approved Coding guidance as well as specific guidance in CMS and NCCI manuals.). These are per day edits based on clinical benchmarks . If claim denials based on these edits are appealed, contractors may pay UOS in excess of the MUE value if DATE OF there is adequate documentation of medical necessity of correctly reported units.