T his month, learn the answers to a wide variety of questions regarding coding for certain conditions treated with a laser, billing for services in an assisted-living facility, and what to bill Medicare for when you read your own slides.

Q: Can I use CPT codes 17106, 17107 and 17108 when I treat acne rosacea and actinic keratosis using a laser?
A: No. Let’s investigate why not. The first step is to review the CPT definition for these three codes:

17106 — Destruction cutaneous vascular proliferative lesions (e.g., laser technique): less than 10 square centimeters.
17107 — Destruction cutaneous vascular proliferative lesions (e.g., laser technique): 10.0 to 50.0 square centimeters.
17108 — Destruction cutaneous vascular proliferative lesions (e.g., laser technique): over 50.0 square centimeters.
The operative words in the definitions are “vascular” and “proliferative.” The codes were designed for providers that treat port wine stains, large strawberry hemangiomas and other large vascular formations.
These types of lesions commonly take up a large surface area of the patient’s skin and therefore, are measured in square centimeters versus lesions that are measured in straight linear fashion. It’s pretty difficult (if not entirely impossible) to measure an acne lesion or an actinic keratosis in square centimeters.
Acne rosacea is not a “lesion,” rather it is a condition. Easily said, it’s a form of acne, not a vascular proliferative lesion(s). Actinic keratosis also doesn’t fit into this category because these lesions already have their own set of codes, CPT codes 17000-17004 and 96567. Billing the destruction of actinic keratosis using the 17106-17108 codes would be inappropriate.

Q: I saw several patients in an assisted living facility. I billed CPT code 99321 with a POS (place of service) designator 32. Medicare denied the service stating that the place of service was inconsistent with the E/M visit billed. What did I do wrong?
A: The assisted living facility is in the same category as rest home, boarding home or custodial care services facility. These type of facilities have no full-time medical component as do the nursing facilities — formerly called skilled nursing facilities (SNFs), intermediate care facilities (ICFs) or long-term care facilities (LTCFs).
SNFs, ICFs and LTCFs provide convalescent, rehabilitative or long-term care and are must conduct comprehensive, accurate, standardized and reproducible assessments of each resident’s functional capacity using a resident assessment instrument (RAI).
All RAIs include the minimum data set, resident assessment protocols and utilization guidelines. The minimum data set is the primary screening and assessment tool. The resident assessment protocols trigger the identification of potential problems and provide guidelines for follow-up assessments.
Physicians have a central role in assuring that all residents receive thorough assessments and that medical plans of care are instituted or revised to enhance or maintain the residents’ physical and psychosocial functioning.
These facilities have round-the-clock professional nursing care as well as a physician who serves as medical director. The CPT codes appropriate for use in these facilities include 99251-99255, 99261-99263, 99301-99303 and 99311-99313.
Physicians may use the consultation codes and can see patients once per day, if necessary. The place of service for SNFs, ICFs and LTCFs is 31 or 32.
The assisted living centers or boarding/custodial care residences provide room, board and other personal assistance services, generally on a long-term basis. The facilities generally have no organized, full-time medical component. For these facilities the POS is 33 and CPT codes 99321-99323 and 99331-99333 are appropriate. No consultation services can be billed for these facilities and patient visits can only be billed one visit per month per patient.

Q: I read my own slides. I was told that I’m allowed to bill Medicare globally (88305 with no modifiers) if I pay the laboratory that makes the slides directly. Because Medicare is receiving only one bill from me for both the technical and the professional component (no other entity bills Medicare), then I can bill globally. Is this correct? The reason I’m asking is that I get paid a lot more money if I bill 88305 globally than if I separate the technical component (e.g. 88305-TC) from the professional component (e.g., 88305-26). Also, it seems much easier because many times I get denials for the technical component billings. Please comment.
A: For Medicare, the answer is “no.” You cannot bill globally if you’re purchasing the technical component (e.g., the slide) from an outside source. In 1996, Medicare implemented the purchased service regulations that allow physicians to
purchase the technical component from an outside source and bill for both components.
The catch is that the technical and professional components must be billed for separately. Plus, you can only bill the charge for the technical component based on the exact charge assessed to you by the outside laboratory.
Here’s an example: If the outside laboratory charges your office $6.50 for the slide prep, then on the claim to Medicare you must bill $6.50 (not one penny more or less) even though Medicare allows $52.85 for the technical component. The purchased services regulations prohibit purchased service mark-ups and make it illegal for the “middle man” to make a profit by purchasing a service. You can only bill Medicare globally if you make the slide in your own office (or laboratory) as well as read the slide.

Q: How do you bill for a biopsy and destruction of the same lesion on the same date of service? During a patient examination, I find a lesion that I suspect could be a skin cancer, I take a sample of the lesion (the biopsy) and then I destroy the base of the lesion by curettage and electrodessication. That way, if the lesion is benign, the lesion is considered treated; if not I can call the patient back for further treatment. Can I bill 11100 and 17000? Do I need a modifier on either one of the two codes?
A: No, you can’t bill for both services; that’s unbundling. You must decide which is the most comprehensive, extensive service and bill that code. Based on the scenario you describe, I’d bill the biopsy.