Fall Risk Prevention Program: Part 1

Question:

We want to institute a Fall Risk Prevention Program in our practice to take advantage of CMS's Merit-based Incentive Payment System (MIPS). Based on CMS’s 2024 Quality Measures List, what codes should we report, and can our practice's medical assistant (MA) capture this work? 

Answer:

It is great that your practice will institute a Fall Risk Prevention Program to capture MIPS. According to CMS’s 2024 Quality Measures list, are 2 measures reportable in this category. 

Quality measure number 155 - Falls: Plan of Care.  This measure is designed to capture the percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months. 

Quality measure number 318 – Falls: Screening for Future Fall Risk.  This measure is designed to capture the percentage of patients 65 years of age and older screened for future fall risk during the measurement period. 

Per CPT, these quality measures should be reported with Category II tracking codes, which are used for performance measurement. 

The applicable category II CPT codes for these MIPS measures are as follows: 

1100F: Patient screened for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the past year (GER). 

1101F: Patient screened for future fall risk; documentation of no falls in the past year or only 1 fall without injury in the past year (GER). 

An MA can capture the work to assist the clinician when reporting these Category II CPT codes. 

*This response is based on the best information available as of 9/5/24.

Neck Dissection

Question:

My physician did a total thyroidectomy with a modified radical neck dissection.  Can I report the radical neck dissection with the thyroidectomy?

Answer:

If your physician performed the total thyroidectomy using CPT code 60240 and modified radical neck dissection (38724), both procedures may be reported during the same operative session.  The first listed code on the claim should be CPT 38724. Modifier 59 should be appended to CPT code 60240 (lower RVU) since it is bundled under the National Correct Coding Initiative.

*This response is based on the best information available as of 9/5/24.

Moderate Sedation

Question:

Can our vascular surgeon bill for moderate sedation if an RN was present to observe and monitor the patient?

Answer:

Yes; an RN has the knowledge and experience to observe and monitor the patients vital signs, including BP, oxygen levels, heart rate and level of consciousness under the direct supervision of the physician.

*This response is based on the best information available as of 7/11/24.

Evaluation and Management (E/M)

Question:

We had a new patient who came in for evaluation for itchy skin eruptions that had never been treated. He documented a complete history and full skin examination and diagnosed the patient with psoriasis, which was inadequately controlled, and performed an intralesional injection (11900) in the patient’s hand, which was the area of concern.  He found psoriasis on the scalp, hand, and chest and wrote the patient a prescription for Clobetasol ointment and spray.  My question is, can we bill an E/M service with Modifier 25 since he did a complete history and skin exam? 

Answer:

The E/M services require a clinically relevant history and examination. This will not determine whether Modifier 25 is supported. What does support a significant separate E/M service is that in addition to the intralesional injection, the physician developed a plan of care that not only included the injection but also prescribed medication to treat the areas. An E/M service based on medical decision-making or time 99203-99205 (new patient) can be reported with modifier 25 in addition to CPT code 11900.

*This response is based on the best information available as of 7/11/24.

Documentation for Modifier 22

Question:

What documentation is needed to report modifier 22?

Answer:

To be able to append modifier 22 which represents an increased procedural service, the provider needs to demonstrate that the work required was substantially greater than normally expected. To support this, the documentation must provide more than a blanket statement and include details as to why the work was greater. For example: “extensive lysis of adhesions took greater than 90 mins prior to reaching (the intended site)”.  The “what made it more work” is less crucial than the “details that explain why” it was more difficult so that payors will allow increased reimbursement. 

*This response is based on the best information available as of 7/11/24.

Microtia Surgery

Question:

What CPT code is appropriate for creating a cutaneous pocket fashioned for the framework for stage 1 of a microtia surgery? 

Answer:

The appropriate code for creating a cutaneous pocket in the context of stage 1 microtia surgery is CPT 14061 (adjacent tissue transfer).  This code corresponds to the procedure involving creating a cutaneous pocket in the right ear and transferring. The cutaneous pocket is essential for accommodating the framework created during reconstruction.  Since the code is selected based on anatomic location and sq centimeter size be sure to document this information in the operative report. 

*This response is based on the best information available as of 7/11/24.