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Codes 99211-99215 Billed with Unna Boot Code 29580 (GEN)
Posted January 8, 2007
The Medical Review Department recently conducted a service-specific review (SSR) of evaluation and management (E/M) codes 99211-99215 billed along with Unna Boot code 29580. A complete description of codes 99211-99215 may be found in the Current Procedural Terminology (CPT) Manual and in the 1995/1997 Documentation Guidelines for Evaluation and Management Services.
This SSR (initiated in June 2006 and completed in October 2006) involved review of 100 claims (for dates of service October 1, 2005 – February 28, 2006) chosen at random by our computer system. Medicare contractors conduct these reviews to identify widespread problems by monitoring usage of procedure codes among the provider community.
The decisions that resulted from this SSR were based on the following resources:
- The Unna Boot local coverage determination (LCD), #SU002G03 (Database ID #L21510), and Coding Guidelines article (#A36517).
- The Debridement Services LCD, #SU013G04 (Database ID #L3808), and Coding Guidelines article (#A34613).
- 1995/1997 Documentation Guidelines for Evaluation and Management Services.
- Current Procedural Terminology (CPT) manual referencing modifier 25.
On completion of SSRs, a provider error rate is calculated. An explanation of how error rates are calculated may be accessed in Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.11.1.5.
The SSR resulted in an overall error rate of 78 percent, with a down-coded/denial change rate of 83 percent. Below is a summary of the major issues and billing problems that were identified:
- Documentation did not support medical necessity for payment of a separate E/M service when billed on the same day as an Unna Boot, since the sole reason for the visit consisted of Unna Boot application.
- Modifier 25 was appended incorrectly. The E/M service did not substantiate medical necessity.
- In some cases, documentation did not support an Unna Boot, but rather another type of dressing, such as ace wrap, Acticoat-7, Profore Dressing, or Aquacel AG.
In November 2005, the Office of Inspector General (OIG) published a report of an investigation conducted on E/M services billed to the Medicare program with a 25 modifier appended. Their study identified that 35 percent of claims with modifier 25 did not meet program requirements for payment.
The Unna Boot LCD describes an Unna Boot as a “bandage impregnated with a paste, made from gelatin, zinc oxide, and glycerin. This bandage is layered on the leg until the bandage becomes rigid. The resulting pressure and bacteriostatic properties assist in healing.”
The LCD states, “placing of an Unna Boot is covered for treatment of leg ulcers due to venous insufficiency or those instances where there are acquired or congenital microthromboses resulting in non-healing ulcers.”
The Coding Guidelines article addresses E/M services as follows:
- “An evaluation and management (E/M) code can be billed in addition, when the initial evaluation of the condition leading to a decision to apply the Unna Boot is done.” The 25 modifier should be appended for this.
- “A subsequent E/M code for an established patient should not be billed when repeat Unna Boot application is done, unless a separately identifiable E/M service is performed. In this case, modifier 25 must be used with the E/M code.”
When billing Unna Boot code 29580, providers are to follow guidelines in the Unna Boot LCD. In addition, modifier 25 should only be utilized on E/M services when supporting documentation identifies a significant, separately identifiable service. |
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