Medicaid Alert - Attention: All Providers Implementation of Additional Correct Coding Edits: Global Surgery and Evaluation and Management Codes

As previously announced in the May bulletin, DMA will begin implementing additional correct coding guidelines. These new correct coding guidelines and edits will be nationally sourced by organizations such as the Centers for Medicare and Medicaid Services (CMS) and The American Medical Association (AMA). These edits will identify any inconsistencies with CPT, HCPCS, AMA, CMS and/or DMA policies and will deny the claim line. Additional correct coding edits for Global Surgery Package (GSP) and Evaluation and Management (E&M) codes will be implemented on August 1, 2011 for dates of service on or after August 1, 2011.Global Surgery Package (GSP)

GSP edits are defined by CMS as the specific time periods during which certain services related to a surgical procedure, furnished by the physician who performed the surgery, are to be included in the payment of the surgical procedure code. The GSP has two main subcategories:Evaluation and Management services billed on the same day as the surgical procedure or during the defined global period for the surgical procedure will be denied by the GSP Surgery/E&M editing if not submitted with an appropriate modifier to indicate a separate unrelated service. The following are examples of Global Surgery E & M Edits:Procedure Code DescriptionGlobalAnalysis

45385Colonoscopy with polypectomy0 DaysDeny E&M day of surgery
36571Peripheral insertion of central VAD with port10 DaysDeny E&M day of surgery and 10 days after
44970Appendectomy90 DaysDeny E&M day before, day of surgery and 90 days after

The GSP edits also contain logic that detects additional surgeries or procedures billed within the global period of a previously billed surgery. These edits will deny the subsequent surgery according to DMA Clinical Policy. The use of an appropriate modifier for a separate unrelated surgical service can be appended to the surgery code and will override a GSP Surgery/Surgery edit when appropriate. The following are examples of GSP Surgery/Surgery Edits: Procedure DescriptionDate of Service Analysis

33510Coronary artery bypass, vein only, single vessel01/30/2011Allow (has 90 day global period)
93510Left heart catheterization03/01/2011Deny
27275Manipulation hip joint requiring general anesthesia02/01/2011Allow (has 10 day global period)
27025Fasciotomy, hip or thigh, any type02/07/2011Deny

Evaluation and Management (E&M)

Evaluation and Management (E&M) codes are used to describe the intensity and work associated with a medical encounter as measured by the risks and complexities associated with the history, physical examination, and medical decision-making. The more detailed these components are the higher the level of the E&M service. Correct coding of E&M services stipulates only one E&M code may be reported per day for the same patient/provider. The appropriate use of modifiers complying with DMA policies will allow for appropriate reimbursement. The E & M edits ensure proper coding of these services.For more information about each group of edits, see “Descriptions of Planned Additional Correct Coding Edits” link on DMA's Correct Coding web page (http://www.ncdhhs.gov/dma/provider/ncci.htm). Providers are encouraged to frequently visit DMA’s Correct Coding web page and to review published bulletin articles for information on the project status. HP Enterprise Services
1-800-688-6696 or 919-851-8888

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.

To learn more about Atlantic Financial Consulting you may visit their website at

http://atlanticfinancial.us  or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.