Coding and Reimbursement Primer - Ameriburn

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Coding and

Reimbursement Primer

2018 EDITION

American Burn Association

311 South Wacker Drive, Suite 4150

Chicago, IL 60606

(312) 642-9260



American Burn Association

311 N. Wacker Dr., Suite 4150

Chicago, IL 60606

(312) 642-9260

Copyright ? American Burn Association 2001, 2002, 2003, 2004, 2005, 2006,

2007, 2008, 2009, 2017, 2018 All Rights Reserved.

CPT codes, descriptions and material only are copyright 2000-2017American

Medical Association. All Rights Reserved. No fee schedules, basic units, relative

values or related listings are included in CPT. The AMA assumes no liability for

the data contained herein.

Disclaimer: Although the American Burn Association has taken reasonable steps

to ensure the accuracy of the information presented in this Primer, this

publication should not be construed as providing professional advice or

consultation. Readers are encouraged to consult with knowledgeable coding

consultants on specific issues affecting them. The American Burn Association

assumes no legal liability for the information contained herein.

This publication was made possible in part through an

unrestricted educational grant from the Integra Foundation.

CPT codes, descriptions and material only ? 2017 American Medical Association. All Rights Reserved

CPT? is a registered trademark of the American Medical Association

ABA Coding and Reimbursement Primer ¨C 2018 Edition 3

Burn surgeons are involved in exciting and truly changing times. The advent of tissue

engineering, coupled with the expanding role of government in health care, including the

Centers for Medicare and Medicaid Services (CMS), third party payers, HMOs, ACO¡¯s, and

case management agencies, poses challenges involving not only the physician¡¯s

responsibility to the burn patient but also how to address the socioeconomic issues of

burn care. Case management and payers in general have introduced their own models of

quality assurance. In addition, CMS has developed active programs to detect potential

fraud and abuse in the delivery of health care for its Medicare and Medicaid programs.

It is evident that the clinical and surgical knowledge and skills of a burn surgeon are not

enough to ensure success. It is also necessary to learn to properly code burn diagnoses

and to appropriately code medical services and procedures performed on the burn

patient. The burn surgeon cannot be content allocating this task to coding personnel.

Correct coding is the responsibility of the burn physician. It is dependent upon

appropriate documentation and a daily reporting mechanism for the medical and surgical

services rendered to the burn patient.

To address this challenge, burn surgeons must become familiar with a group of

acronyms: ICD-10-CM, ICD-10-PCS, CPT, E/M, MS-DRGs, RBRVS, HCPCS and others.

This manual is designed to address the most important coding and reimbursement

issues affecting burn surgeons and to provide relevant information to help avoid liability

for fraud or abuse.

The content of this coding manual is based on current (as of this publication) CPT and

Medicare/CMS coding and reporting guidelines, where applicable. In cases where the

two sources diverge significantly (e.g., designation of burn wound excision as global vs.

minor surgery), the policy distinction is explained.

CPT and Medicare/CMS are generally recognized as setting the national standard for

coding and reporting. However, coding and reporting guidelines can and often do vary from

community to community and state to state. Any non-Medicare payer may elect to adopt

some or all of the national standards or deviate from them in whole or in part. Therefore,

this manual does not attempt to address coding and reporting that is unique to a specific

geographic region or given payer. Burn surgeons and coding staff are encouraged to utilize

the manual as a standard coding reference while following any local payer coding and

reporting guidelines that may vary from the national standard.

CPT codes, descriptions and material only ? 2017 American Medical Association. All Rights Reserved

ABA Coding and Reimbursement Primer ¨C 2018 Edition

ACKNOWLEDGMENTS

The 2018 ABA Coding Primer represents the Association¡¯s

continued commitment to providing burn centers and ABA

members with pertinent information to enhance documentation

and coding for the care of patients treated in burn center

hospitals. It would not have been possible without the ongoing

contributions of a number of dedicated and knowledgeable

individuals: William Hickerson, MD, FACS (Chair of the ABA

Coding Committee) and the following staff in the ABA Central

Office: Kimberly A. Hoarle, MBA, CAE, Executive Director and

Maureen T. Kiley, BA, Senior Program Director. The Association

thanks Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA,

for serving as project consultant and, in that capacity, sharing

her dedication, enthusiasm and extensive coding expertise.

Special thanks and appreciation are also extended to the

Foundation of Integra Lifesciences Corporation for their

support of the Primer.

CPT codes, descriptions and material only ? 2017 American Medical Association. All Rights Reserved

4

ABA Coding and Reimbursement Primer ¨C 2018 Edition 5

Table of Contents

Introduction & Purpose of Manual .........................................................3

Acknowledgments .................................................................................4

CODING FOR PHYSICIAN SERVICES

Key Concepts ......................................................................................11

What is Coding? ..................................................................................... 11

Coding Systems for Physician Claims ..................................................... 11

Procedures, Services and Supplies Furnished by Physicians ?

Diseases, Conditions Evaluated /Treated by Physician ? Coding

Systems¡ªEffective Dates of Annual Updates ? Recent CPT Changes

Affecting Burn Surgery for 2018

Relative Value Update Process (RUC) ...................................................... 16

Claim Forms for Physician Services ........................................................ 16

What Makes a Claim Payable? ................................................................ 17

Defensible Documentation ...................................................................... 17

Establishing Medical Necessity ...............................................................19

Unbundling and Bundling ...................................................................... 20

MUEs¡ªMedically Unlikely Edits (Medicare) ............................................ 22

Global Periods ........................................................................................ 28

Global Surgery Package, CPT Surgical Package ? Medicare Global

Surgery Package ? Medicare Coding Case Studies (1.0 & 2.0) for

Single or Multiple Physicians, Same Group, Caring for Same Patient ?

CPT ¡°Add-on¡± Codes

Modifiers ................................................................................................ 53

Modifier Essentials ? Modifiers Most Commonly Used by Burn

Surgeons ? Surgical Modifiers Frequently Used by Burn Surgeons ?

Evaluation and Management Modifiers Used Frequently by Burn

Surgeons

Multiple Surgical Procedures .................................................................. 63

Reduced Payment ? What is a Secondary Procedure? ? Reduced

Payment Not Applicable to Add-on Codes & Modifier 51 Exempt

Codes ? Ranking Procedures on the Claim

Assistant at Surgery: Medicare ............................................................... 66

CPT codes, descriptions and material only ? 2017 American Medical Association. All Rights Reserved

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