Derm Coding Consult

[ Volume 16 | Number 1 | Spring 2012 ]

IMPORTANT Please Route to:

___ Dermatologist ___ Office Mgr ___ Coding Staff ___ Billing Staff

CPT only © 2013 American Medical Association. All Rights Reserved. Derm Coding Consult: Fall 2014 1

Derm Coding ConsultPublished by the American Academy of Dermatology Association

PQRS Changes Proposed for 2015The Centers for Medicare and Medicaid Services (CMS) Proposed 2015 Medicare Physician Fee Schedule features several potential changes for the Physician Quality Report-ing System (PQRS) in 2015. In 2015, CMS proposes that eligible professionals (EPs) can avoid a 2 percent payment reduction in 2017 by reporting 2015 PQRS measures. However, unlike PQRS in 2014, there will no longer be an incentive payment available. EPs will be required to report at least nine quality measures that cover at least three of the National Quality Strategy Domains. Each measure must be reported for at least 50 percent of the EP’s Medicare Part B, fee-for-service patients seen Jan. 1, 2015 through Dec. 31, 2015 to which the measure applies.

CMS is also proposing a new requirement that at least two of the reported measures must be from a set of cross-cutting measures. All five of the current dermatol-ogy-specific measures (measures #137, #138, #224, #265, and #337) are likely to remain in 2015 PQRS. CMS has also proposed adding a melanoma pathology measure that will ask the EP if he or she has pathology reports for primary malignant cutaneous melanoma that include the pT cate-gory and a statement on thickness and ulceration and for pTI, mitotic rate. The proposed cross-cutting measures are:

1. Measure #TBD: Tobacco Use and Help with Quitting Among Adolescents

2. Measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

3. Measure 240: Childhood Immunization Status

4. Measure 134: Preventive Care and Screening: Screen-ing for Clinical Depression and Follow-Up Plan

5. Measure 130: Documentation of Current Medications in the Medical Record

6. Measure 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up

7. Measure 374: Closing the Referral Loop: Receipt of Specialist Report

8. Measure 46: Medication Reconciliation

9. Measure 110: Preventive Care and Screening: Influ-enza Immunization

IMPORTANT Please Route to:

___ Dermatologist ___ Office Mgr ___ Coding Staff ___ Billing Staff

PQRS Changes Proposed for 2015 . . . . . . . . . . . . . . . . . 1

Coding Clarification: Mohs Surgery (17311-17315) . . . 2

Narrowing Networks: How to Respond . . . . . . . . . . . . 2-3

Routine Foot Care: Coding & Reimbursement Guidelines . . . . . . . . . . . . . 3-4

New ICD-10 Implementation Date allows for Additional Prep Time . . . . . . . . . . . . . . . . . . . . . . . . . 5

FAQ’S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-6

Adding a Non-Physician Clinician to Your Practice . . . . . . . . . . . . . . . . . . . . . . . . . . .6-7

Correction to pg . 5, Spring 2014 DCC: FAQs on Wound Repairs . . . . . . . . . . . . . . . . . . . . . . 7

In the Know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Contents

[ Volume 18 | Number 3 | Fall 2014 ]

10. Measure 111: Pneumonia vaccination Status for Older Adults

11. Measure 317: Preventive Care and Screening: screen-ing for High Blood Pressure and Follow-Up Documented

12. Measure 318: Falls: Screening for Fall Risk

13. Measure 47: Care Plan

14. Measure 131: Pain Assessment and Follow-Up

15. Measure 182: Functional Outcome Assessment

16. Measure 321: CAHPS for PQRS Clinician/Group Survey

17. Measure 236: Controlling High Blood pressure

18. Measure #TBD: Screening for Hepatitis C Virus (HCV) for Patients at High Risk

More information on which measures are most appropriate for dermatology practices will be available upon publication of the final rule in November 2014. v

CPT only © 2013 American Medical Association. All Rights Reserved.2 Derm Coding Consult: Fall 2014

In these instances, the submitted specimen may origi-nate from the same operative site or from a different operative site, but is not the same tissue that was processed during the Mohs surgery. In such a situation, codes 88302-88309, describing the pathology performed on the separate tissue, may be reported in addition to the Mohs surgery codes (17311-17315). v

Narrowing Networks: How to RespondNarrowing of Medicare Advantage (MA) networks has been a hot topic of discussion for several months at the Academy. Since January, Academy leadership has met with members of Congress and the White House to discuss its concerns. Most recently, leadership met with the Centers for Medicare & Medicaid Services (CMS) where Academy leaders discussed the impact that UnitedHealthcare (UHC) and Humana MA networks are having on patients’ continuity and access to care by haphazardly terminating physicians from their networks of providers. Academy leaders urged CMS to reevaluate if the current criteria used by UHC and Humana to termi-nate physicians disproportionately impact the frail and elderly. Additionally, leadership asked CMS to re-evaluate the appeals process implemented by UHC & Humana as both appear to breach MA regulations.

Dermatologists are receiving termination letters in the mail notifying them that they are no longer participating providers within the MA network. There is no real basis or explanation for the termination and it appears that termina-tion notices are being sent to physicians that specialize in treatments that are of both higher risk and cost. The payers cite a need to develop a high quality and high performance network, but it appears, the effort is to control costs by restricting access to highly specialized physicians. In most cases evaluated by the Academy, physicians have

Coding Clarification: Mohs Surgery (17311-17315)As published in AMA CPT Assistant of February 2014/Volume 24 Issue 2, Pg. 10

Published with permission from American Medical Asso-ciation CPT Assistant Editorial Panel

In the January 2007 issue of CPT® Assistant (page 29), the following question was posed: Is it appropriate to report codes 88302-88309 for the same specimen used in a Mohs surgery procedure?

The article stated:

For CPT 2007, concurrent with the revisions to the Mohs micrographic surgery section, instructional notes have been developed prior to code 88302 and after code 88309. The instructions direct the surgeon not to report codes 88302-88309 on a specimen(s) derived from a Mohs surgery procedure.

The pathologic examination of the specimen is an inclusive component of Mohs micrographic surgery to be performed by the surgeon and should not be reported separately by him. If the Mohs surgeon submits a specimen(s) derived from the procedure for pathologic examination to another physician (ie, a pathologist) for either frozen (88329-88334) or permanent section (88305), the pathologist is enti-tled to report his or her services, but the procedure no longer qualifies as Mohs surgery. The surgeon should report for excision and repair using the appro-priate codes.

Thus as noted above, it is inappropriate to report both Mohs Micrographic Surgery codes 17311-17315 and Surgical Pathology codes 88302-88309 on the same tissue used for margin evaluation during Mohs surgery. However, there are legitimate instances in which tissue separate from the tissue examined during the Mohs surgery is submitted for subsequent formalin-fixed processing and histopathologic examination.

Editorial Advisory BoardEditor’s Notes:The material presented herein is, to the best of our knowledge accurate and factual to date. The information and suggestions are provided as guidelines for coding and reimbursement and should not be construed as organiza-tional policy. The American Academy of Dermatology/Association disclaims any responsibility for the consequences of actions taken, based on the infor-mation presented in this newsletter.

Mission Statement:Derm Cod ing Consult is published quar ter ly (March, June, September and December) to pro vide up–to–date information on coding and re im burse ment is sues per ti nent to dermatology practice.

Address Correspondence to: David E. Geist, MD, FAAD Editorial Board Derm Coding Consult American Academy of Dermatology Association P.O. Box 4014 Schaumburg, IL 60168–4014

Coding & Reimbursement Task Force MembersMaryam Mandana Asgari, MDMay J. Chow, MD, FAADDavid E. Geist, MD, FAAD, ChairCarl Martin Leichter, MD, FAADDavid Kouba, MD, FAADDavid Michel Pariser, MD, FAADBen M. Treen, MD, FAADKavita Mariwalla, MD, FAADBrent Goedjen, MDGlenn D. Goldstein, MD, FAADMollie A. MacCormack, MD, FAADPhilip M. Williford, MD, FAADTodd Cartee, MD, FAADScott M. Dinehart, MD, FAAD

Rachna Chaudhari, MPHEditor, Derm Coding Consult

Ana Maria BustosAssistant Editor, Derm Coding Consult

Peggy Eiden, CPC, CCS–P, CPCDContributing Writer

Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDCContributing Writer

Scott WeinbergContributing Writer

William BradyContributing Writer

Alexander Miller, MD, FAADAAD Rep. to AMA CPT Advisory Committee

Ann F . Haas, MDAAD Alternate to AMA CPT Advisory CommitteeMurad Alam, MD, FAADASDS Rep. to AMA/CPT Advisory CommitteeStephen P . Stone, MD, FAADSID Rep. to AMA/CPT Advisory Committee

Jeremy Bordeaux, MD, FAAD ASDS Alternate Rep to AMA CPT Advisory Committee

David Pharis, MD, FAAD ACMS Rep to AMA CPT Advisory Committee

Ed Wantuch, Design Manager

Nicole Torling, Lead Designer

Theresa Oloier, Editorial Designer

— see NARROWING on page 3


Medicare generally does not cover routine foot care which includes:

• cutting or removal of corns and calluses;

• clipping, trimming, or debridement of nails;

• shaving, paring, cutting or removal of keratoma;

• any services performed in the absence of localized illness, injury, or symptoms involving the foot and other hygienic and preventive maintenance care in the realm of self-care, such as cleaning and soaking the feet and the use of skin creams to maintain skin tone of both ambulatory and bedridden patients;

• and non-definitive simple, palliative treatments like shaving or paring of plantar warts which do not require thermal or chemical cautery and curettage.

Although Medicare generally excludes routine foot care, there are a few specific conditions for coverage:

• for a patient with a systemic disease such as: metabolic, neurologic, or peripheral vascular disease of sufficient severity, that performance of such services by a nonpro-fessional person would put the patient at risk;

• treatment of warts on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body;

• services normally considered routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections;

• and treatment of mycotic nails may be covered under the exceptions to the routine foot care exclusion. The class findings, outlined below, or the presence of qualify-ing systemic illnesses causing a peripheral neuropathy must be present.

The following physical and clinical findings must be docu-mented and maintained in the patient record, in order for routine foot care services to be reimbursable. The presump-tion of coverage is applied when the physician performing the routine foot care has identified the Class A finding (Q7); two of the Class B findings (Q8); or one Class B and two Class C findings, in addition to a primary condition (Q9).

Class A findings (Q7):

• Non-traumatic amputation of foot or integral skeletal portion thereof

Class B findings (Q8):

• Absent posterior tibial pulse• Advanced trophic changes as evidenced by any three of

the following:

o hair growth (decrease or increase)o nail changes (thickening)o pigmentary changes (discoloring)o skin texture (thin, shiny)o skin color (rubor or redness)

• Absent dorsalis pedis pulse

been unsuccessful in appealing their termination notices. In some cases, it has been noted that patients have not received notice that their physicians are no longer partici-pating in their insurance plans and only find out when they try to schedule appointments with their physicians.

To date, the Academy has determined that there are approximately 20 states struggling with narrow networks. Given the high volume of states impacted, it is safe to assume that there are tens of thousands of patients whose medical needs are not being met, many of whom are in vulnerable healthcare situations. In early 2014, the Academy took an overall look at four UHC MA networks (Boca Raton, FL; Cincinnati, OH; Hartford, CT; and Provi-dence, RI) to determine network adequacy based on the parameters outlined by CMS. The Academy’s findings concluded that UHC MA’s networks have an inadequate number of dermatology specialists and subspecialists and that the current network rosters are full of errors, making the identification of dermatologists in such cities very difficult. Additionally, referring a patient within a limited network has become increasingly challenging for physicians as a follow up study showed some of these networks with wait time of over 10 weeks.

The Academy sent out a call for action to all members in early June asking them to inform the Academy of terminations and to inform their own patients of these narrowing networks. Additionally, the Academy sent out a supplementary alert to members in states with docu-mented terminations. Physicians should also encourage their patients to contact CMS and file complaints regard-ing the narrowing of networks and if possible, to also contact their senators and member of Congress to inform them of the impact the termination could have on their access to care through MA. Resources are avail-able to assist in your appeal on the AADA Payer Advocacy website at http://www.aad.org/members/practice-and-advocacy-resource-center/payment-and-reimbursement/private-payer-advocacy. For additional information, please contact David Brewster, Assistant Director of Practice Advocacy, at [email protected]

Routine Foot Care: Coding & Reimbursement GuidelinesMedical coverage for routine foot care and surgical treatment of nails is something dermatologists need to understand in order to get paid appropriately by either the carrier or the patient. Not everything is covered. This is an area Medicare monitors through post payment reviews and subsequent medical review audits.

— see FOOT CARE on page 4

Narrowing Networks: How to Respond — continued from page 2


Code Descriptor11055 Trim skin lesion11056 Trim skin lesions 2 to 411057 Trim skin lesions over 411719 Trim nail(s) any number11720 Debride nail 1-511721 Debride nail 6 or moreG0127 Trim nail(s)

The Routine Foot care documentation requirements are similar to other local coverage determinations in that they need to be in the patient’s chart and available upon Medi-care’s request. Each record must identify the patient by name with a date of service and the provider. The proce-dure must be supported by the documentation. There is a frequency of service of no more than every 60 days otherwise the claim will be denied. Payment is allowed if documentation can prove the medical necessity of such an acute or severe nature that requires more frequent services.

The covered systemic disease marked with or without an asterisk requires sufficient clinical documentation to support the evidence that non-professional performance of the service is hazardous to the patient. Just listing the above class findings is insufficient. Note that Medicare does not require the repeating of this clinical documenta-tion. The reference to an earlier date of service of routine foot care, if described accurately, will suffice and should be included upon Medicare’s request.

Medicare requires the location of each lesion treated, identification (by number or name) and description of all nails treated. They also request a description of the procedure beyond the simple term of “nail debrided.” The record needs to reflect the necessity of each service.

Documentation of foot-care services to residents of nursing homes must include an order from the patient’s supervising physician. A request from the patient or patient’s family/conservator is not sufficient to cover the necessity of routine foot care. This order requirement must meet the following:

• The supervising physician must sign and date it prior to the services being rendered.

• The supervising physician’s telephone or verbal orders must be authenticated by the dated physician’s signature within a reasonable period of time following the order.

• The order must be consistent with the overall plan of care and medically necessary services for the patient’s physical finding.

• Routine or “standing” facility orders are insufficient.

• Whoever requested the service (physician, patient, family etc) needs to be identified in the record.

The documentation must demonstrate the need for routine foot care services as outlined.

The “Medicare Benefit Policy Manual,” Publication 100-2, Chapter 15, is available at http://www.cms.hhs.gov/manu-als/Downloads/bp102c15.pdf on the CMS website. v

Class C findings (Q9):

• Claudication• Temperature changes (e.g., cold feet)• Edema• Paresthesias (abnormal spontaneous sensations

in the feet)• Burning

Note: Information on the potential coverage and billing for those diabetic patients with severe peripheral neuropathy involving the feet, but without vascular impairment, may be found at: Medicare National Coverage Determinations Manual-Pub. 100-03, Chapter 1, Section 70.2.1 and Medi-care Claims Processing Manual-Pub. 100-04, Chapter 32, Sections 80-80.8.

Routine foot care is payable when the patient has a systemic condition resulting in severe circulatory impair-ments or areas of desensitization in the legs or feet. Report Class Findings on the CMS 1500 Claim form modifier field with the procedure performed. The diagnoses listed below represent systemic conditions that may result in the need for routine foot care:

• Amyotrophic Lateral Sclerosis (ALS)

• Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)

• Arteritis of the feet

• Buerger’s disease (thromboangiitis obliterans)

• Chronic indurated cellulitis

• Chronic thrombophlebitis*

• Chronic venous insufficiency

• Diabetes mellitus*

• Intractable edema-secondary to a specific disease (e.g., congestive heart failure, kidney disease, hypothyroidism)

• Lymphedema-secondary to a specific disease (e.g., Milroy’s disease, malignancy)

• Peripheral neuropathies involving the feet: Associated with malnutrition and vitamin deficiency; carcinoma; diabetes mellitus; multiple sclerosis; chronic kidney disease; traumatic injury; leprosy or neurosyphilis; hereditary disorders or sensory radicular neuropathy; Fabry’s; and Amyloid neuropathy

• Peripheral vascular disease

• Raynaud’s disease

*Designates those code ranges that allow coverage only if the patient is under active medical care.

Routine Foot Care: Coding & Reimbursement Guidelines — continued from page 3


Use the extended timeline to improve ICD-10-CM accuracy with introduction of clinical documentation improvement (CDI) to assist with ICD-10-CM coding accuracy. Additional practice with ICD-10-CM will improve your coding efficiency and confidence for increased productivity.

Identify any gaps in documentation that lead to report-ing nonspecific codes and work to remedy these gaps prior to the implementation deadline.

Use the extended timeline to review your current ICD-9-CM super bill and crosswalk these codes to ICD-10-CM at the highest specificity to ensure a seamless transition. v

FAQ’SQ . I need some guidance on a phototherapy billing

issue . For the first visit, the patient sees our nurse for consultation, information, forms, and showing them the appropriate use of the unit . They also have a treatment that day . Can we charge for a nurse visit in addition to the procedure on that first visit?

A. Just to clarify, the patient must be seen prior to this first photochemotherapy treatment visit by a physician or non-physician clinician, who will order the proce-dure. On this follow up visit for treatment, the nurse is updating the medical record, explaining and providing the procedure.

There is a Medicare National Correct Coding Edit (NCCI) for 99211, nurse visit. No modifier will allow payment for 99211 when reported with the 96910-96912 series codes. Check with you carrier for their edits which may vary.

The AAD’s Coding and Reimbursement Task Force recom-mends that rather than a nurse visit, it would be appropriate for the physician over a two to three week period of treat-ment to see the patient and report a low level E/M on the patient’s status or a change to the treatment.

Q . How do you decide which diagnosis should be attached to CPT code 88304 and 88305 . Is there a list somewhere we can reference?

A. 88304 and 88305 are different levels of surgical pathol-ogy service.

88304 is a level III pathology service code which includes examination of tissue from an induced abor-tion to a varicose vein. For dermatology, this level would cover: anus tag; bursa/synovial cyst; foreskin, other than newborn; ganglion cyst; hematoma; skin tags, cysts, debridement; soft tissue or lipoma debride-ment; and a vein varicosity.

88305 is a level IV. It too has numerous uses. In dermatol-ogy, this is used widely for biopsies of: gingiva/mucosa; lip; lymph node; muscle; nasal mucosa; skin, other than cyst/tag/debridement/plastic repair; soft tissue other than tumor/mass/lipoma/debridement; and tongue.

For the full listing, please see the AMA CPT Code Book.

New ICD-10 Implementation Date Allows for Additional Prep Time After repeatedly claiming that ICD-10 would be imple-mented on October 1st, 2014, we learned in early April that the implementation date had once again been postponed for another full year. This new delay came as part of H.R. 4302, the Protecting Access to Medicare Act of 2014 which was signed into law by President Obama. Section 212 of the Act includes language stipulating that “The Secretary of Health and Human Services may not, prior to Oct. 1, 2015, adopt ICD-10 codes as the standard for code sets.”

At the time the bill was signed into law, there were still six months remaining in the anticipated implementation timeline date of Oct. 1, 2014. Many dermatologists and other specialty physicians had been working diligently in learning the ins and outs of the new ICD-10 code sets in order to meet all the necessary requirements to success-fully implement ICD-10 by the implementation date. In all, it is safe to assume that this new delay will allow those who were a bit behind in the preparation phases to ramp up their efforts and assess areas that need to be improved upon. Those who were on target should look at this time, as a time to continue efforts and enhance their ICD-10 coding dexterity skills.

Stay Focused and Continue Preparing

While this delay was unexpected, it is very important to stay the course and continue to anticipate the arrival of ICD-10 implementation and to be prepared with contin-ued education.

In fact, this additional time delay should be used construc-tively because it will allow many dermatology practices to take another look at their implementation timeline (and budget) and to reevaluate how they are approaching this change in their day to day processes. For example, a quick assessment of superbills, progress notes and elec-tronic health record templates are all good places to start working on creating efficiencies for the future. Doing this simple exercise will allow physicians and staff members to stay focused and find motivation for improvement in specific areas during this additional timeframe.

To ensure successful ICD-10 implementation, below are some helpful tips and ideas for your practice to stay on track during this new additional time delay:

Continue to work with the original implemen-tation timeline in mind if you were on track for October 1st, 2014. View an example of the imple-mentation timeline at http://www.aad.org/members/practice-and-advocacy-resource-center/payment-and-reimbursement/coding-resource-center/icd-10.

Use the extended timeline to practice dual diagno-sis coding to your practice. Take a few of your charts and review the medical record documentation. Code some of these encounters in both ICD-9-CM (submit these for payer payment) and ICD-10-CM (to estab-lish your ICD-10-CM accuracy level). — see FAQ’S on page 6


Q . I am currently using an electronic health record (EHR) . My office medical assistant (MA) takes a chief complaint prior to my entering the room . I perform the exam and document it and the assess-ment/plan . Many times I use the MA as a scribe . Once the documentation is complete, it’s signed by me as the primary physician and biller but not the staff . It’s been suggested by the EHR vendor that the staff also needs to sign the document with their complete name . The staff doesn’t want their names made available . For Medicare and auditing purposes, as well as Meaningful Use purposes, does staff need to sign the chart for any of these reasons? If so, can they simply put Joe A . or J . Smith as my assistant’s name instead of their full identifying information?

A. Since the medical record is a legal document, anyone who documents in the chart should sign their name. There is no difference if the chart is paper or elec-tronic. The Comprehensive Error Rate Testing (CERT) Signature Guidelines for Medical Review explain the signature requirements. Any notation made in the record should be signed or initialed. A suggestion is to use a signature log for the staff showing their name in print with their full initials or how they sign a chart and their signature. This log should be updated each year with additions for new employees. If anyone acts as a scribe, they especially need to sign the chart stating the documentation was scribed by them word for word with the provider’s signature.

Also, the Chief Complaint and the History of Present Illness, E/M History elements are to be documented by the provider. According to CMS’s Evaluation and Management (E/M) guidelines, unless scribed, the only element of the E/M that can be documented by ancil-lary staff or the patient is the Review of Systems (ROS) and the Past Family Social History (PFSH).

For general signature requirements see MedLearn SE1419: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se1419.pdf

And MM6698, “Signature Guidelines for Medical Review Purposes,” visit http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6698.pdf on the CMS website.

Q . If we are performing multiple biopsies on several separate sites, what is the correct modifier to use for the pathology billing on the 88305/TC and 88305/26? We have been getting denials using the -59 modifier . Should we use the -91 modifier?

A. To avoid Medicare’s duplicate claim denial, add a -91 modifier to pathology and lab codes. Since each Medi-care carrier processes these a little differently, your practice may have to try reporting multiples a couple of different ways. Check with your carrier but here are some suggestions.

1. The first method is to report everything on one claim line – 88305/26 with 91 or 88305/TC & 91 times the unit amounts performed.

2. Second method, report on the first claim line, 88305/26 and each subsequent lines as 88305/26 & 91 or 88305/TC/91 again times the unit amounts performed

3. The third suggestion is to line item each 88305/26/91 or 88305/TC/91 procedure on separate lines on the claim.

Modifier 76 is used in the same fashion for ‘Like” CPT surgical procedure codes (10040 -17999). Add on codes (11101, 17003, 11201, etc) are excluded as like codes and don’t require any modifiers. So if two 11401 were performed, they would be reported as 11401; 11401/76. If these codes were considered bundled into another service, the modifier 59 would be required. v

Adding a Non-Physician Clinician to Your Practice Dermatology practices interested in adding a non-physician clinician (NPC) to their practice should consider in advance a number of key factors before proceeding to ensure success. The practice will need to answer some basic questions to determine if adding an NPC is the best option.

Assessing Practice Need and Readiness

A busy practice is usually one of the first signs that another clinician may be needed to meet patient demand. Before hiring an NPC, it’s critical for the practice to develop a business case that accurately reflects current practice needs. This preliminary but critical step will help the prac-tice establish a clear need and purpose for a prospective NPC, as well as clarify their intended role and responsibili-ties. For example, is the practice contemplating adding an NPC to meet increasing patient demand, to extend the range of dermatologic services, or to be able to attract new patients? Consider profiling your patient demand in terms of wait time (number of weeks out for scheduling patients) and caseloads (types of visits).

Defining clear goals for a prospective NPC is another critical element to consider. Will adding an NPC allow the practice to meet patient demand, decrease appointment wait time, and/or lessen the clinical team’s workload? Will it aid in improving patient satisfaction, allowing the dermatologists to concentrate on more complex patient care? With clear goals, the practice can move forward with deciding whether a PA or NP best fits its needs. In addition, since it may take anywhere from three to six months to integrate an NPC into your workflow, the prac-tice should take this into account.

Compliance Requirements

Understanding the compliance requirements of your state’s applicable laws and the regulations governing the appropriate use of NPCs is another key factor as it

— see NON-PHYSICIAN on page 7

FAQ’S — continued from page 5


will help determine how to properly deploy the practice’s new NPC. Knowing what level of physician supervision and collaboration is required, will help you determine whether a PA or NP is the better choice for your needs and provide you with a clear understanding of what the practice will need to do to prepare and maintain full compliance with state laws.

Payer Requirements

Find out from your top payers what their billing and reim-bursement policies mean for NPCs. For Medicare, this means enrolling and credentialing your NPC, as well as understanding their “direct” vs. “incident-to” billing require-ments. Direct billing can bill directly for services provided under the PA’s or NP’s own name and NPI number and is paid at 85% of the Medicare fee schedule. “Incident-to” billing can bill as “Incident-to” a physician’s services, and under the supervising physician’s name and NPI and is paid at 100% of the Medicare fee schedule. “Incident-to” billing requires following specific rules, which are noted in the Academy’s new e-book Adding a Non-Physician Clinician to your Prac-tice (available at www.aad.org/store). This research should be undertaken before hiring the new NPC so the practice can determine a realistic revenue target for a new NPC.

While Medicare has clear and specific policies for billing when an NPC is involved in providing care, many private payers have differing rules. Create a table showing what each of your top private payers require and how they will process claims involving your NPC. For example, a compar-ative fact-finding chart can include clarification on billing policies, reimbursement rates, and payment guidelines addressing NPC billing. Consider including payer links or reference attachments to support the findings as well as the name and contact information from each payer. After collecting all the relevant information, use this chart to educate the billing staff so that they clearly understand all the billing and reimbursement requirements.

Educating Practice Staff, Physician Colleagues and Patients

Another important element in this process is preparing your current administrative and clinical practice staff for a poten-tial new hire. This will include educating auxiliary staff so they clearly understand what this professional will mean for the practice, and what they will need to do to welcome this person on board—both in terms of providing support with making sure all the prerequisite paperwork is in order, and helping the dermatologist educate the new NPC about the practice’s office culture and staff dynamic.

The success of the new NPC will depend in part on the supporting role provided by other members of the practice staff. The staff will need to understand fully how and when an NPC’s scope of practice and incident-to requirements apply so that they know what types of patient visits can be scheduled, and when the supervising physicians may need to be involved. In addition, the physician and the NPC should jointly educate the practice staff by providing a list

Adding a Non-Physician Clinician to Your Practice — continued from page 6

of examples of types of visits, dermatologic conditions, and patient types that will be handled by either the derma-tologist, the NPC, or both. This educational effort should include reviewing this clinical protocol policy with each staff member—scheduling, reception, medical assistants, billing, etc.—so that they all have a chance to understand and can ask questions. As an added benefit, an educated staff can then readily answer patient inquiries and schedule appointments appropriately so that the practice continues to work efficiently and effectively.

Develop a marketing strategy and communication plan to showcase the new NPC and enhance professional relation-ship building with key outside groups. If your practice has hired new clinicians in the past, adopt a similar but modi-fied approach when announcing the new NPC. Identify your target audience—specifically, outside physicians who refer (note they may be apprehensive about referring to the new NPC, so work with them to address their concerns), and even other physicians in your neighborhood or enrolled with your private payers—so that announcements can be made to each. Some experts also advise scheduling a “meet and greet” so that patients can meet and talk with the new NPC and hiring dermatologist as well as sharing promo-tional materials with them. These educational resources should list the NPC’s education, training, clinical services and areas of personal interest. This information should also be provided on the practice’s website and while patients wait on the phone to schedule an appointment.

NPC Training

Training the NPC on coding and documentation require-ments is critical. Engage the practice manager and/or billing staff to work with the NPC. The hiring practice cannot afford to assume that the NPC knows what is billable or not since they may not be familiar with dermatology and are new to the practice. Providing the new NPC with complete, correct and accurate training and supporting resources related to billing and documentation is the responsibility of the hiring practice. v

Correction to pg. 5, Spring 2014 DCC: FAQs on Wound RepairsA simple repair is included in an excision. The original FAQ example was clarified to state that a simple lacera-tion repair was performed during the same encounter as a different excision and intermediate repair. Both services are appropriate.

For example, patient presents with a neck laceration and the physician performs a 2.6 cm simple repair as well as an excision with an intermediate repair of a 2.7 wound on the scalp. “The appropriate codes to report are 12032 followed by 12002-59 plus the excisions codes.” These codes are subject to the multiple surgical reduction but for most carri-ers Modifier 51 is not required. Modifier 59 on the less complicated procedure may be necessary. Check with the most recent NCCI edits found on CMS website: www.cms.gov/NCCI v


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In The Know…..Do you have the correct payer identification number (ID#) for timely claim reimbursement?

Payers have unique identification numbers to indi-cate where your clearinghouse should direct your claims. All claims dermatology practices submit electronically through a clearinghouse must be directed through the correct payer with the correct payer ID number. Some payers may have multiple ID numbers. To ensure that the claims are submitted to the correct location, check the patient’s insurance ID card for the correct payer ID number for their specific plan.

Utilizing the correct payer ID number improves the accuracy and efficiency for real-time eligibility and benefits verification and electronic claims submis-sion. It also improves efficiency and accuracy for your claim reimbursements, reducing write-offs and improving first-pass acceptance rates because your claims are submitted to the correct claim adjudicator.

For example, if your patient holds a policy plan from UnitedHealthcare of the River Valley (including Heri-tage), their payer ID # is 87726. Claims submitted with this payer ID# ensure that the claim will be sent to the correct mailing address and location.

If you need to locate your payer name and their correct ID, visit e-claims listing at Payer List Search – Commercial: https://www.eclaims.com/payerlist.asp?action=desc_results&displayresults=Y

Now you are In The Know!

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Documents

Derm Coding Consult