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2011 CDM Updates Day 1
 

2011 CDM Updates Day 1

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Part 1 of 2 day workshop presented to the Western New York chapter of HFMA.

Part 1 of 2 day workshop presented to the Western New York chapter of HFMA.

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    2011 CDM Updates Day 1 2011 CDM Updates Day 1 Presentation Transcript

    • HFMA Western NY Chapter January 25, 2011 – Day 12011 OPPS UPDATES, CODING CHANGES AND CHARGE MASTER APPROACHES
    • INTRODUCTIONS Caroline Rader, Associate Director – Ms. Rader has approximately 15 years combined of industry and professional consulting experience related to charge integrity services; including but not limited to, charge description master maintenance, charge capture strategies, outpatient clinical documentation improvement, and billing compliance. She serves many of the top hospitals in the nation on related topics including Johns Hopkins Health System, Novant Health, University of Maryland Medical System, Caritas Christi and MedStar Health. Ms. Rader is also recognized as a state and national speaker for HCCA, HFMA, ACDIS and AHIMA. Deborah Zarick, Associate Director – Ms. Zarick has both a clinical and coding compliance background. She has many credentials including R.N, B.S.N, CPC, CCS-P, CEMC, CPC-I, and CPMA. She leads NCI’s physician coding services, providing consulting to such clients as University of Maryland Medical System, Lifebridge Health, Loyola and Stanford Medical Clinics. 2
    • OBJECTIVES OF THE WORKSHOP2011 includes 400 CPT® revisions, deletions, and additions. In order toavoid claim denials and coding errors as well as capture revenue foraccurately documented services, it is critical that you keep current onrelevant and significant updates to CPT as well as HCPCS codes.The workshop will address specific code changes, the rationale behind thechange, and the impact these changes will have on your charge descriptionmaster. The work shop will cover the items below by clinical department: 2011 CPT and HCPCS update Charge Capture Strategies Tips for Auditing and Monitoring Regulatory Update and Considerations CPT® is registered trademark of the American Medical Association. All rights reserved. 3
    • OBJECTIVES OF THE WORKSHOPAfter attending this meeting, participants should be able to: Implement the new OPPS rules into day to day operations; Cite important HCPCS/CPT coding changes for 2011; Describe the use of new codes; Identify target areas for investigation; Analyze current use of the charge description master to identify opportunities for improvement in charge capture, and Implement office policies and procedures to ensure compliance with fraud and abuse regulations and statutes. 4
    • CHARGE DESCRIPTION MASTER The charge description master (CDM) is a file that contains a list of a provider’s chargeable services. Hospital facilities can assess a patient charge for visits, procedures, medications and supplies. A current and accurate CDM is vital to any healthcare provider seeking proper reimbursement. Among the potential negative impacts that may result from an inaccurate charge master are overpayments, underpayments, claim rejections, civil monetary fines and penalties. 5
    • CHARGE DESCRIPTION MASTER In addition to the list of services, the CDM electronic file includes the following: unique reference identifier the procedure or service description the appropriate HCPCS/CPT code (if available) the UB-04 revenue code number unit of service and/or multiplier corresponding charge dollar amount. CDM HCPCS/ UB04 Rev Charge CDM Service Description UOS Number CPT Code Amount 4500100 ED VISIT LEVEL I 99281 450 1 $200.00 6
    • CHARGE DESCRIPTION MASTER Unique Reference Identifier - An internally assigned unique number that identifies each specific procedure or service listed on the charge master. Procedure or Service Description - This designation describes the procedure or service to be performed. HCPCS/CPT Code - The corresponding HCPCS/CPT code that identifies the specific line item service or procedure. Level I Category I - CPT Codes Level I Category II – Quality Measurements Level I Category III – New Technology Level II – HCPCS National Codes 7
    • CHARGE DESCRIPTION MASTER UB-04 Revenue Code - A three-digit code number representing a specific accommodation, ancillary service, or billing calculation required for facility billing. Unit of Service/Multiplier – In most cases the service unit of service will default to a unit of “1” and the line item is charged per each service. However, some instances will occur where the line item service or item is provided or dispensed in multiple units. Charge Dollar Amount - The specific amount charged by the facility for each procedure or service. This is not the actual amount that the facility will be reimbursed by a third party payer. Instead, the charge dollar amount represents the standard charge for that item. 8
    • CHARGE DESCRIPTION MASTER Services and/or items found in the CDM can either be hard- coded or soft-coded. To “hard-code” a service or item is to include the HCPCS/CPT in the CDM. The service or item is coded automatically and no human intervention is required. Hard-coding should be used only for the services that lack variability in their approach, performance, or situation such as EKGs, ED and clinic visits, radiology and laboratory services. To “soft-code” a service or item is to not include the HCPCS/CPT in the CDM. The service or item requires coding to be done manually by HIM or other means. Soft-coding is suitable for procedures that are variable in nature; such as surgical procedures (e.g. CPT codes 10000-69999). 9
    • CHARGE DESCRIPTION MASTERCurrent Procedural Terminology or CPT Codes (Level I/Category I CPT)) Maintained and updated annually by the American Medical Association. New updated code manuals provided in November of each year, with January 1 effective dates for changes. Focus on Appendix B of the CPT Coding Manual — Summary of Additions, Deletions, and Revisions — when evaluating the necessary changes to the charge master. CPT Code Categories: Evaluation and Management CPT Codes 99201 – 99499 Anesthesia CPT Codes 00100 – 01999 Surgery CPT Codes 10021 – 69990 Radiology CPT Codes 70010 – 79999 Pathology & Laboratory CPT Codes 80048 – 89399 Medicine CPT Codes 90281 – 99199 10
    • CHARGE DESCRIPTION MASTERHealthcare Common Procedure Coding System or HCPCS Codes (Level II) Maintained and revised throughout the year by CMS. New HCPCS codes are effective January 1 of each year, with quarterly updates. HCPCS Code Categories: A Codes Transportation services K Codes DME Regional Carriers B Codes Enteral and Parental Therapy L Codes Orthotic and Prosthetic Procedures C Codes Temporary codes for use with OPPS M Codes Other Medical Services D Codes Dental procedures P Codes Pathology and Laboratory Services E Codes Durable Medical Equipment Q Codes Temporary G Codes Procedures and Professional Services R Codes Diagnostic Radiology Services H Codes Alcohol & Drug Abuse Treatment Services S Codes Nat’l Codes (Non-Medicare) J Codes Drugs Administered Other Than Oral T Codes Nat’l Codes for State Medicaid Agencies V Codes Vision and Hearing Services 11
    • CHARGE DESCRIPTION MASTERCPT Category III Codes Maintained and updated semiannually by the AMA. Temporary codes for emerging technologies, services, and procedures. Use Category III Code if available in lieu of Category I unlisted CPT Code. Codes have a alpha character as the fifth digit. Category Code III assignment does not imply coverage. 12
    • CHARGE DESCRIPTION MASTERCPT and HCPCS Level II Modifiers Modifiers provide a means by which a service can be altered without changing the procedure code. Required by CMS to be reported for outpatient services. The CPT modifiers currently approved for hospital reporting include: 25, 27, 50, 52, 58, 59, 73, 74, 76, 77, 78, 79 and 91. The HCPCS modifiers that are currently approved for hospital reporting are: CA, E1 through E4, FA through F9, BL, GN, GO, GP, GA, GY, GZ, GG, GH, LC, LD, RC, LT, RT, and TA through T9. 13
    • CHARGE DESCRIPTION MASTERCPT and HCPCS Level II Modifiers Varying methods of modifier assignment: Hard coded in the charge master Assigned by HIM Assigned during charge entry process Assigned through automated edits Assigned during pre-bill by PFS Assignment of correct modifiers can be critical to reimbursement Modifier 25 Modifier 50 Modifier 59 Modifier CA 14
    • CHARGE DESCRIPTION MASTERCPT and HCPCS Level II Modifiers Most common modifiers: 25 – Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. 27 – Multiple outpatient hospital E/M encounters on the same date 50 – Bilateral procedure 52 – Reduced services 59 – Distinct procedure 91 – Repeat clinical diagnostic laboratory test LT – Left side RT - Right side 15
    • CHARGE DESCRIPTION MASTER Hospital facilities also incorporate standard business rules around how their CDM is structured. Considerations can include the following: inclusion or use of statistical or other zero dollar line items Example: patient visit counters for productivity measures the determination of allowable items for charging Example: charging thresholds, routine supplies duplicate CPT codes across clinical departments Example: EKGs in the emergency department, clinics and diagnostic cardiology use of charge explosions use of miscellaneous CDMs decisions to standardize the CDM across a health system 16
    • CHARGE DESCRIPTION MASTER The CDM is one of the most complex master files within any hospital facility and is subject to continuous updates. Proper maintenance is essential to ensure proper charging for services and supplies within financial and regulatory parameters. Poor maintenance of the CDM can put the hospital at financial risk and may introduce risk of regulatory non-compliance. Because the Healthcare Common Procedure Coding System (HCPCS) codes and APCs are updated regularly, hospitals should pay particular attention to the task of updating the CDM to ensure the assignment of correct codes to outpatient claims. This should include timely updates, proper use of modifiers, and correct associations between procedure codes and revenue codes. - OIG Compliance Guidance for Hospitals 17
    • CHARGE DESCRIPTION MASTER Scenario Hospital bills and is reimbursed for services performed outside of the hospital. The staff performing the services did not indicate the patient location or type of service to charge entry staff. Similar services are provided within the hospital therefore billing staff do not question claims. The services are billed as if they were performed within the hospital walls. The hospital is reimbursed at a higher rate and benefit than would have been if the services were billed appropriately. Cause De-centralized CDM maintenance processes. Lack of charge capture knowledge within clinical department. Lack of participation of CDM Team in creation of new service line. Lack of regular CDM audit process. Consequences The hospital is fined over $1 million and is placed under a corporate integrity agreement with the OIG for 5 years. Required training and annual external review cost the hospital hundreds of thousands of dollars that are exempt from cost reporting. New positions are created and better controls in place as required under agreement. 18
    • CHARGE DESCRIPTION MASTER Hospitals can benefit from a formal process that routinely seeks to improve the maintenance and management of the CDM. Management of the CDM requires a coordinated team effort led by a senior manager (“CDM Coordinator”). CDM Coordinators create the need for a specific skill set: knowledge of the clinical terminology understanding of the various procedures performed in a given specialty area a solid understanding of coding and billing functions ability to work with stakeholders of the front, middle and back end of the revenue cycle 19
    • CHARGE DESCRIPTION MASTER Effective and efficient operation of the CDM requires close coordination and participation by various departments. Patient Financial Services Financial Reimbursement and Contract Management Patient Care Departments Compliance and Revenue Integrity Health Information Management Information Systems = CDM TEAM 20
    • CHARGE DESCRIPTION MASTER The primary purpose of the CDM team is to review the CDM policies and procedures and to improve the management and understanding of the CDM across the hospital users. The team should review all the new items and services it intends to add to the CDM. The team should be able to suggest changes to existing CDM items. CDM additions, revisions and deletions should be inventoried through the use of a change request form. The purpose of the form is to help the team evaluate the change request. 21
    • CHARGE DESCRIPTION MASTER 22
    • CHARGE DESCRIPTION MASTER The CDM team should establish a “charge-audit” process to ensure that all new charges and planned changes to existing charges are properly captured, reported, and documented. The focus of this audit is to examine not only the accuracy of the billing statement but also the supporting medical record documentation to prevent the charge from being denied. The CDM policies and procedures should also include a schedule for performing routine audits of the CDM. Limited reviews are recommended at least annually, with comprehensive reviews at a three-year interval. 23
    • CHARGE DESCRIPTION MASTER Limited CDM Comprehensive Review Step Review CDM Review Review CDM for Deleted Codes √ √ Review CDM for Accurate Assignment in HCPCS/CPT, based on CDM Procedure or Service Description √ √ Review CDM for Accuracy in UB04 Revenue Code Assignment √ √ Review CDM for Accuracy in Unit of Service/Multiplier Assignment √ √ Review CDM for Missing HCPCS/CPT √ Review CDM for Zero Usage Line Items √ Review CDM Pricing √ Review CDM for Duplicate HCPCS/CPTs √ Review CDM Line Item Usage Against Expected Usage Patterns √ Review Departmental CDM, Charge Capture and Documentation Practices – including review of charge capture tools and medical record documentation √ to charge capture Review Clinical Subsystem to CDM Linkage (aka Order Entry Mapping) √ 24
    • CHARGE DESCRIPTION MASTER The CDM is a critical piece of effective revenue management. Hospital organizations of all sizes and capabilities are using tools to support daily CDM maintenance. NOTE: this is a tool and not a complete solution Optimal software packages include the following: online reference tools have a complete and active code book feature include a browser-based, cross-reference toolkit have the ability to analyze prospective and retrospective claims for potential charge capture and/or compliance issues 25
    • OUTPATIENT REIMBURSEMENT With the implementation of APCs in 2000, the CDM has had a more important role in the charge capture, coding and billing processes of services rendered. Payment is defined by the HCPCS/CPT codes reported, which in many cases is hard-coded in the CDM. The importance of capturing and reporting the correct HCPCS/CPTs continues as Medicaid contractors, such as New York State Medicaid, adopt other reimbursement methodologies such as Ambulatory Payment Groups (APGs) and as health care reform moves to bundled payment methodologies. 26
    • OUTPATIENT REIMBURSEMENT APC system was implemented by Medicare in 2000. Annual and quarterly update process. Payment for services is calculated based on APC grouping logic. Services within an APC are similar clinically and require similar resources. APC payments include certain packaged items, such as anesthesia, supplies, certain drugs, and the use of recovery rooms. Packaged services are considered to be included in the primary APC payment and can also include ancillary services Payment logic is further defined by the use of NCCI edits, MUEs and status indicators. 27
    • OUTPATIENT REIMBURSEMENT National Correct Coding Initiative (NCCI) CMS developed the NCCI to promote national correct coding methodologies. The NCCI was developed by the Centers for Medicare and Medicare Services (CMS) to: Prevent payments from being made due to inappropriate CPT and HCPCS code assignment; Eliminate unbundling of services; Detect incorrect or inappropriate reporting of combinations of CPT and HCPCS codes; and Curtail improper coding practices that lead to inappropriate increased payment. NCCI edits are reviewed for every possible pairing of CPT and HCPCS codes. They continue to be enhanced utilizing the following: Coding conventions defined in the American Medical Associations CPT code manual; National and local policies and edits; Coding guidelines developed by national societies; Analysis of standard medical and surgical practice; and Review of current coding practice. 28
    • OUTPATIENT REIMBURSEMENT Medically Unlikely Edits (MUEs) CMS developed (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Payment for Part B services is limited by HCPCS/CPT as defined by the MUEs. Not all HCPCS/CPT codes have an MUE. Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors use only. Those that have been published are available online on CMS’ website.http://www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage 29
    • OUTPATIENT REIMBURSEMENTCMS Status IndicatorsIndicator Definition Explanation A Indicates services that are paid under some other method: Not paid under OPPS. Paid by Medicare • Durable medical equipment, prosthetics and orthotics are paid under contractors under the appropriate fee schedule or the DMEPOS fee schedule another payment system. • Physical, occupational, and speech therapy are paid under the physician fee schedule • Ambulance services are paid under the ambulance fee schedule • Erythropoietin (EPO) for end-stage renal disease (ESRD) is paid under a national rate • Physician services for ESRD patients are billed to the Medicare carrier • Clinical diagnostic laboratory services are paid under the laboratory fee schedule • Screening mammography is paid by either the lower charge or national rate structure B Codes not recognized by OPPS when submitted on an Should not be used for OPPS billing since they are Outpatient Hospital Part B bill type (12x,13x, and 14x) not payable under OPPS. Services may be payable when submitted on a different bill type (e.g., 075X CORF). Some codes may have an alternate code that should be used for OPPS billing. C Inpatient only Not paid under OPPS unless specific circumstances have been met. Admit patient; bill as inpatient. 30
    • OUTPATIENT REIMBURSEMENTIndicator Definition Explanation D Deleted Code or Discontinued Code Codes deleted or discontinued effective January 1, 2011. E Items, codes, and services that meet one of the following Not paid under OPPS or any other Medicare conditions: payment system. • Are not covered by Medicare based on statutory exclusion • Are not covered by Medicare for reasons other than statutory exclusion • Are not recognized by Medicare but for which an alternate code for the same item or service may be available • Separate payment is not provided by Medicare F Corneal Tissue Acquisition Cost; Certain CRNA Services Not paid under OPPS. Paid at reasonable cost. G Drug/Biological Pass-Through Paid under OPPS. Separate APC payment made. H Device Category Pass-Through, Therapeutic Paid under OPPS. Separate cost-based pass- Radiophamaceuticals through payment made. 31
    • OUTPATIENT REIMBURSEMENTIndicator Definition Explanation K Non Pass-through Drug/Biological; Separate APC Payment Paid under OPPS. Separate APC payment. L Influenza Vaccine; Pneumumoccal Pneumonia Vaccine Not paid under OPPS. Paid at reasonable cost and not subject to deductible or coinsurance. M Service not billable to FI and not payable under OPPS Not paid under OPPS. N Service Is Packaged into APC Rate Paid under OPPS. However, payment is packaged into payment for other services. No separate APC payment made. P Partial Hospitalization Paid under OPPS; per diem APC payment. Q1 STVX Packaged Paid under OPPS. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator “S,” “T,” “V,” or “X.” (2) In all other circumstances, payment is made through the separate APC as listed in the table. 32
    • OUTPATIENT REIMBURSEMENTIndicator Definition Explanation Q2 T Packaged Paid under OPPS. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator “T.” (2) In all other circumstances, payment is made through the separate APC as listed in the table. Q3 Composite Paid under OPPS. (1) Composite APC payment based on OPPS composite-specific payment criteria. Payment is packaged into a single payment for specific combinations of service. (2) In all other circumstances, payment is made through a separate APC payment or packaged into payment for other services. 33
    • OUTPATIENT REIMBURSEMENTIndicator Definition Explanation R Blood and Blood Products Paid under OPPS; separate APC payment. S Significant Procedure, Not Discounted When Multiple Paid under OPPS; separate APC payment. T Procedure, Discounted When Multiple “T” Procedures Paid under OPPS; separate APC payment. Performed U Brachytherapy Sources Paid under OPPS; separate APC payment. V Visit to Clinic or Emergency department Paid under OPPS; separate APC payment. X Ancillary Service; Separate APC Payment Paid under OPPS; separate APC payment. Y Non-Implantable Durable Medical Equipment:; Not paid Not paid under OPPS. All institutional providers under OPPS other than home health agencies bill to durable medical equipment regional carrier. 34
    • OUTPATIENT REIMBURSEMENT Payment is driven at an encounter level and requires the use of HCPCS/CPT codes. All items and services should be captured per encounter to collect valuable cost and clinical information for future rate setting. Fifty percent of the full OPPS amount is paid if a procedure for which anesthesia is planned is discontinued. Multiple surgical procedures furnished during the same operative session are discounted. Other items/services may qualify as pass-through items and receive an additional payment. These items/services are identified by status indicators “G” and “H”. 35
    • OUTPATIENT REIMBURSEMENT Composite APCs are reimbursed for services that can span an episode of care and package services into a single payment for services such as the following: Outpatient Observation Services Low Dose Radiation Prostate Brachytherapy Electrophysiology Studies Mental Health Services Multiple Imaging Studies 36
    • OUTPATIENT REIMBURSEMENT Composite APC Composite APC Title Criteria for Composite Payment8000 Cardiac Electrophysiologic At least one unit of CPT code 93619 or Evaluation and Ablation 93620 and at least one unit of CPT code Composite 93650, 93651 or 93652 on the same date of service.8001 Low Dose Rate Prostate One or more units of CPT codes 55875 Brachytherapy Composite and 77778 on the same date of service.8002 Level I Extended Assessment and 1) Eight or more units of HCPCS code Management Composite G0378 are billed-- • On the same day as HCPCS code G0379*; or • On the same day or the day after CPT codes 99205 or 99215; and 2) There is no service with SI=T on the claim on the same date of service or 1 day earlier 37
    • OUTPATIENT REIMBURSEMENT Ambulatory Payment Groups (APGs) were created in the mid- 1990’s as a methodology to reimburse outpatient services. The APGs were designed to clearly describe and define each ambulatory visit for both clinical and financial purposes. The overriding goals of APGs are to create a medical home for patients, promote and ensure continuity of care, and promote efficiencies in a payment model. Several state Medicaid programs and third-party payers continue to operate under an OPPS developed using APGs as the classification system. 38
    • OUTPATIENT REIMBURSEMENT Many similarities still exist between APGs and APCs, including the use of HCPCS/CPT codes to assign payment groups, and packaging logic to bundle ancillaries into final payment. The methodology is further defined by the consideration of ICD-9-CM diagnoses and significant procedure consolidation. As with APCs, HCPCS/CPTs are grouped to APGs. From the grouping additional factors, such as weights and packaging discounts, are considered before final payment is determined. 39
    • OUTPATIENT REIMBURSEMENT There are three primary types of APGs: Significant Procedure - A procedure which constitutes the reason for the visit and dominates the time and resources expended during the visit. Examples include: excision of skin lesion, stress test, treating fractured limb. Medical Visit – A visit during which a patient receives medical treatment (normally denoted by an E&M code), but did not have a significant procedure performed. E&M codes are assigned to one of the 181 medical visit APGs based on the diagnoses shown on the claim (usually the primary diagnosis). Ancillary Tests and Procedures - Ordered by the primary physician to assist in patient diagnosis or treatment. Examples include: immunizations, plain films, laboratory tests. 40
    • OUTPATIENT REIMBURSEMENTSource: New York State Office of Health Insurance Programs, “APG Implementation Ambulatory Patient Groups (APGs) andAncillary Lab/Radiology Services”, September 2009. 41
    • OUTPATIENT REIMBURSEMENT Other payers may reimburse based on a fee-for-service system or a prepaid system. The prepaid system includes managed care plans or capitation plans that pay in advance of any services for each of its members. Usually, the medical provider receives a fixed dollar amount each month for each member in return for medical services when they are needed. The focus of the chargemaster changes from one of charges to that of resource management and costs in order to determine the actual cost of services versus the reimbursement. 42
    • OUTPATIENT REIMBURSEMENT The future methodology for outpatient reimbursement will focus on bundled payments. Seen as a measure to control health care costs and provide higher quality of care. Under bundled care models, the payment model highly incentivizes providers to care for complicated patients with high severity of illness. Any reduction of cost based on expected complications will be pure profit potential. “Evidence driven medicine” 43
    • REGULATORY CONSIDERATIONS Maintaining a CDM to stay current on ever changing regulations, payer expectations and clinical practice can be daunting. Lack of controls and an effective maintenance process can lead to regulator scrutiny. Regulators are beginning to focus more and more on outpatient services in their auditing and monitoring of payment compliance. With the CDM as the backbone of the HCPCS/CPT coding and charge capture of outpatient services, the maintenance of the CDM should be at the forefront of any hospital revenue integrity program. 44
    • REGULATORY CONSIDERATIONS Why the shift in focus to outpatient services? Outpatient services are : provided in greater quantity, in a short span of time can occur simultaneously with other services involve different coding guidelines and different coding systems rely heavily on documentation from non-physician staff utilize a higher degree of computerization for documentation utilize automated processes for code selection that may not involve certified and/or experienced coding professionals 45
    • REGULATORY CONSIDERATIONS There are many regulatory contractors and initiatives to be aware of in today’s outpatient environment: Comprehensive Error Rate Testing (CERT) Medicare Administrative Contractors (MACs) Medicaid Fraud Control Unit (MFCU) Medicaid Integrity Contractors (MIC) Payment Error Rate Measurement (PERM) Recovery Audit Contractor (RAC) Zone Program Integrity Contractors (ZPIC) The approach to reviews and issues targeted are very similar, if not the same. 46
    • REGULATORY CONSIDERATIONS Target Areas/Identified Issues Medical Necessity Infusion Therapy ICDs and Pacers Coronary Artery Stents Frequency Limitations Screening and Preventive Services Presence of Complete Provider Orders Laboratory and Radiology Complete and Legible Documentation Accuracy in Units of Service Reporting Pharmaceuticals Time-Based Codes 47
    • REGULATORY CONSIDERATIONS How are hospitals reacting? Revenue Integrity Programs Primary objective is to prevent recurrence of issues that can cause revenue leakage and/or compliance risk Activities under Revenue Integrity are expected to focus more on process improvement Taking a holistic approach 48
    • REGULATORY CONSIDERATIONS Revenue Integrity Programs A successful revenue integrity program will provide for a holistic view of the revenue cycle, with support from leadership and technology. Ultimately the program will provide for the following: Identification and correction to the processes and systems that lead to lost revenue opportunities through the creation of processes to ensure the accurate capture and reporting of data, translation of data into useful information and use of data to support strategic initiatives; Assurance that every chargeable procedure, item or service is coded, documented, captured, billed and paid according to the terms of government guidelines and payer contracts, and Serve as a resource for other staff members on questions or issues related to documentation, coding, charge capture and billing to create, or better foster, an organization-wide understanding of the importance of revenue integrity. 49
    • REGULATORY CONSIDERATIONS The Holistic View of Revenue IntegrityMedAssets. (n.d.). Securing Revenue with Improved Data Use. Retrieved December 2010, from Healthcare FinancialManagement Association: www.hfma.org 50
    • CY2011 HCPCS/CPT AND OPPS UPDATES CPT Updates 109 deleted codes 213 new codes 365 revised codes Revisions can include those that did not change the intent of the service, but rather included a grammatical or formatting change HCPCS Updates 287 deleted codes 140 new codes 43 revised codes OPPS Updates Published Federal Register Final Rule, November 24, 2010 51
    • CY2011 HCPCS/CPT AND OPPS UPDATES Outline for remainder of work shop: Laboratory (inc. Blood Bank)D Radiology (inc. Nuclear Medicine) Pain ManagementA Interventional RadiologyY Cardiac Catheterization Electrophysiology1 Medical and Surgical Supplies Outpatient Facility E/M Services; Clinic and Emergency ServicesD Outpatient Observation Services Infusions and InjectionsA PharmaceuticalsY Diagnostic Cardiology Respiratory/Pulmonary2 Cardiac and Pulmonary Rehabilitation Radiation Oncology 52
    • CY2011 HCPCS/CPT AND OPPS UPDATES Hospital Facility Chargemaster Reference Guide Includes additional detail for topics discussed today HCPCS/CPT Code to UB04 crosswalk Modifier definitions Greater narrative detail The companion guide provides for quick access to important payment tables and references UB04 claim form UB04 revenue code descriptions CMS Medically Unlikely Edits (MUEs) CY2011 CPT Code Changes CMS OPPS status indicator definitions CMS OPPS comment indicator definitions CY2011 CMS OPPS Final Rule Addendum B 53
    • LABORATORY Laboratory services are included in CPT code 80,000 range and include HCPCS for screening services (G-codes) and blood products (P-codes). The laboratory section of the CPT code manual includes subheadings and subsections that separate types of testing. UB04 revenue codes are specific to the type of testing being performed. CDM service or procedure descriptions often do not mirror the CPT manual description. Units of service in the CDM will default as “1” but it is common for a multiplier to be utilized due to the nature of the test to be resulted per specimen, analyte or other means. 54
    • LABORATORY CMS does not pay for laboratory services as part of APCs. Laboratory services are reimbursed from the laboratory fee schedule. There are essential coding guidelines to consider when capturing laboratory services: Diagnosis Coding Code Selection Modifier Use Date of Service Reporting Reference Laboratory Testing 55
    • LABORATORY Diagnosis Coding The diagnosis documented by the pathologist is the condition representing the highest degree of certainty for that visit. When the physician interpretation of a test performed in the outpatient setting establishes a definitive diagnosis, this definitive diagnosis should be coded. Any presenting symptoms that are integral to this diagnosis should not be coded. Any documented symptoms or conditions not routinely associated with the definitive diagnosis should be assigned additional codes. Abnormal findings in test results not interpreted by a physician, such as CBC or urinalysis, should not be coded unless confirmation of a definitive diagnosis is obtained from the physician. In these cases, the presenting symptoms, conditions, or other reasons for the test should be coded. 56
    • LABORATORY Code Selection Only those services ordered by a qualified provider should be provided and billed. Providers may not perform additional laboratory services based on internal standard or implied protocols. The following sample protocols are not covered Medicare services and may be subject to a regulatory contractor for corrective action. Physician’s written order for a hemoglobin and hematocrit prompts the lab to perform a CBC Physician’s written order for a CBC prompts the lab to perform a CBC with differential White cells or bacteria discovered in a physician ordered urine test prompts the lab to perform a urine culture without a physicians order 57
    • LABORATORY Modifier Use Modifier 91 should be appended to laboratory procedure(s) or service(s) to indicate a repeat test or procedure on the same day. This modifier should not be used to report repeat laboratory testing due to laboratory errors, quality control, or confirmation of results. Modifier 59 should be used to report procedures that are distinct or independent, such as performing the same procedure (which uses the same procedure code) for a different specimen. Modifier BL must be reported with blood products (P-codes) and blood processing HCPCS/CPT codes by OPPS providers that purchase blood or blood products from a community blood bank or assesses a charge for blood or blood products collected in its own blood bank. 58
    • LABORATORY Date of Service Reporting As a general rule the date the specimen was collected is the date of service to be reported. In the case where the specimen collection spans over two days, the date the collection ended is the reported date of service. Where a specimen is an archived specimen (stored >30 days), the date of service should reflect the date of the test. Reference Laboratory Testing Only one laboratory may bill for a referred laboratory service. It is the responsibility of the referring laboratory to ensure that the reference laboratory does not bill for the referred service when the referring laboratory does so (or intends to do so). In the event the reference laboratory bills or intends to bill, the referring laboratory may not do so. 59
    • LABORATORY Common Errors in Laboratory Billing per Comprehensive Error Rate Testing (CERT) Results Physician order for billed labs not submitted. Report date and date of order do not match. General coding errors Venipuncture Panels Urinalysis Blood Counts 60
    • LABORATORY Venipuncture CPT 36415 A specimen must be extracted in order to be paid. Only one collection fee is allowed for each type of specimen. If a series of specimens is required to complete a single test; treated as a single encounter. If the test resulted is deemed not medically necessary, the venipuncture to obtain the specimen is also considered to not be medically necessary. 61
    • LABORATORY Panels CPTs 80048, 80053 and 80061 (cited specifically) Individual tests that duplicate a test in a panel and should not be ordered. All of the tests in the definition of the panel should be documented as performed. Urinalysis with Microscope CPT 81001 Documentation must support the use of a microscope. Microscopic testing performed as part of a reflex test should be documented. “Unable to read dipstick reactions due to color/chemical interference. The microscopic testing will be performed.” 62
    • LABORATORY Blood Counts CPTs 85025 and 85027 The physician order must indicate “CBC with differential” to bill for 85025; otherwise CPT 85027 should be billed. Submit CPT code 85027 to report a CBC to measure hemoglobin, hematocrit, red blood cell, white blood cell and platelet levels Submit CPT code 85025 to report a CBC and differential white blood cell (WBC) count to measure the percentages of white blood cell types If the provider orders an automated hemogram (CPT 85027) and a manual differential WBC (CPT 85007), both codes can be reported. CPT 85007 cannot be reported with CPT 85025, as the WBC would be considered duplicative. 63
    • LABORATORY CMS Special Coverage and Billing Considerations Blood and Blood Products The act of transfusing blood or blood products is paid once per day, per CMS guidelines. The transfusion CPT should correspond to the type of product transfused Laboratory testing including blood typing, screening or matching should also be captured. Testing is reported separately whether the hospital received the product from a community blood bank or its own blood bank. Blood products must be reported with the transfusion service, and vice versa. If either is missing the claim may be returned to the provider. Report the unit(s) of blood transfused, applicable HCPCS with modifier BL, and UB04 revenue code 0380 – 0389 Albumin is reported with UB04 revenue code 0636 64
    • LABORATORY CMS Special Coverage and Billing Considerations PSA Screening Screening prostate antigen testing is covered once every 12 months for men age 50 years and older. Eleven months must elapse between exams. Specific coding requirements exist for payment consideration HCPCS code G0103 PSA screening, is payable by the Medicare laboratory fee schedule. Non-Medicare payers may not recognize the G-code and prefer a CPT code from range 84152-84154. Submit diagnosis code V76.44, “ Special screening for malignant neoplasm—prostate”, when billing for screening prostate specific antigen blood tests. 65
    • LABORATORY CMS Special Coverage and Billing Considerations Pap Smear Screening Screening Pap smears are covered once every two years for patients who are not at high risk. Screening Pap smears are covered annually, 11 months must elapse, for high-risk patients. Specific coding requirements exist for payment consideration HCPCS P3000 is payable under the Medicare Laboratory Fee Schedule Submit diagnosis code V76.2, “routine cervical PAP” 66
    • LABORATORY CMS Special Coverage and Billing Considerations Fecal Occult Blood Fecal occult blood and fecal immunoassays tests are covered annually by CMS, 11 months must elapse for patients age 50 years and older. Diagnosis codes appropriate to the risk factor should be submitted on the claim. Specific coding requirements exist for payment consideration HCPCS G0103 is payable under the Medicare Laboratory Fee Schedule - error CORRECTION: HCPCS G0328 (iFOBT, or immunoassay-based). CPT 82270 non-Medicare 67
    • LABORATORY CMS Special Coverage and Billing Considerations Diabetic Disease Screening Medicare covers diabetes screening tests for patients at risk for diabetes once every six months for patients who have been diagnosed with prediabetes, and once a year for those patient who have not received prediabetes diagnosis, or who have never been tested A fasting glucose (CPT code 82947) A post glucose challenge test (82950), or A glucose tolerance test (82951) is covered once every six months for patients who have been diagnosed with prediabetes and once a year for those patients who have not received a prediabetes diagnosis or who have never been tested. Report ICD-9-CM diagnosis code V77.1, “ Special screening for diabetes mellitus” 68
    • LABORATORY CMS Special Coverage and Billing Considerations Cardiovascular Disease Screening Medicare covers cardiovascular disease screening. These are screening laboratory tests for cholesterol and triglyceride levels that can indicate the presence or risk of cardiovascular conditions. A lipid panel (CPT code 80061) is covered once every 60 months. Note that if the individual tests (82465, 83718, 84478) included in the panel are individually billed, the benefit limit will still apply. When billing for cardiovascular screening, one of the following ICD-9- CM diagnosis codes should be reported: V81.0, “Special screening for ischemic heart disease” V81.1, “Special screening for hypertension” V81.2, “Special screening for other and unspecified cardiovascular conditions” 69
    • LABORATORY Charge Capture Tips for Laboratory Services Understand the relationship between the clinical subsystem and the CDM. If charge explosions are utilized, review the parent to children relationships annually for in-house tests and quarterly for reference laboratory testing. When pricing individual CDM line items, be sure to compare the per test charge to the Medicare Laboratory Fee Schedule. The fee schedule pays at the fee schedule amount or lesser of charges for most tests. Ensure there is a formal process for verifying that a complete physician order is present before drawing a specimen and or performing a laboratory test. Front office staff should have the ability to question orders, contact providers or obtain additional information from the patient in the absence of contact with the ordering physician (i.e. signs/symptoms). Understand the relationship of HCPCS/CPT codes to clinical practice to understand how to analyze usage statistics. 70
    • LABORATORY Analyzing the laboratory CDM line item usage can identify potential areas of financial and/or compliance risk. Examples Urinalysis with Microscope It is not expected that the volume of urinalysis with microscopy (81000 – 81001) be at the same volume level or exceed the number of total urinalyses. If this is found, further review including a review of charge capture practice and the review of actual encounters should be performed. CBC and Manual Differential It is not expected that the volume of manual differentials (85007) will be at the same volume level or exceed the number of total complete blood count (CBC) (85025/7). If this is found, further review including a review of charge capture practice and the review of actual encounters should be performed. 71
    • LABORATORY Examples (continued) Crossmatch It is not expected that the volume of crossmatch CPT Codes (86920 – 86923) will exceed the total volume units of blood captured. It is expected that the volumes would be equal, or close to equal. A crossmatch is expected for each unit of blood. Antibody Screen The volume for antibody screen CPT Code 86850 should not exceed the total volume of crossmatch CPT codes (86920-86923). It is expected that one antibody screen will be captured with each crossmatch. 72
    • LABORATORY CY2011 CPT Updates Drug Testing New CPT Code 80104 80104, “Multiple drug classes other than chromatographic method, each procedure.” Created to report a specific drug screen, qualitative analysis by multiplexed method for 2 – 15 drugs or drug classes (eg, multidrug screening kit) and to eliminate confusion created by the HCPCS level II codes for drug testing. 73
    • LABORATORY CY2011 CPT Updates Chemistry Replaced CPT Codes 82926 and 82928 The gastric acid codes had low-volume utilization and were deleted and replaced by a simplified CPT code 82930. Deleted CPT Codes: 82926, “Gastric acid, free and total, each specimen” 82928, “Gastric acid, free or total, each specimen” New CPT Code 82930, “Gastric acid analysis, includes pH if performed, each specimen” 74
    • LABORATORY CY2011 CPT Updates Chemistry Revised CPT Code 82952 82952, “Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure)” Revised to add-on status New CPT Code 83861 83861, ” Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity” Created to report tear analysis by direct microfluidic specimen collection and tear film osmolarity Use code 83861 twice for tear analysis of both eyes 75
    • LABORATORY CY2011 CPT Updates Chemistry New CPT Code 84112 84112, ” Placental alpha microglobulin-1 (PAMG-1), cervicovaginal secretion, qualitative” PAMG-1 is an immunoassay that represents a new approach as a chemical marker specific for detecting amniotic fluid from vaginal discharge. This biochemical marker can accurately and sensitively indicate fetal membrane rupture. Revised CPT Code 85597 85597, ” Phosphoid neutralization; platelet” CPT Code 85597 has been updated to include phospholipid neutralization and platelet phospholipid neutralization. 76
    • LABORATORY CY2011 CPT Updates Chemistry New CPT Code 85598 85598, ” Phospholipid neutralization; hexagonal phospholipid” New CPT Code 85598 was created to report hexagonal phospholipid neutralization CPT Code 85598 is a child code to 85597 77
    • LABORATORY CY2011 CPT Updates Immunology Revised CPT Codes 86480 86480, “Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon” CPT Code 86480 was revised to report TB testing by cell mediated immunity antigen response measurement New CPT Code 86481 86481, “Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T-cells in cell suspension” CPT Code 86481 was created to report TB testing by enumeration of gamma interferon-producing T cells. 78
    • LABORATORY CY2011 CPT Updates Transfusion New CPT Code 86902 86902, “Blood typing; antigen testing of donor blood using reagent serum, each antigen test” Deleted Codes 86903, “Blood typing; antigen screening for compatible blood unit using reagent serum, per unit screened” Use CPT Code 86902 79
    • LABORATORY CY2011 CPT Updates Microbiology New CPT Codes 87501, 87502 and 87503 Due to the volume of influenza molecular testing, more specific codes for detection of influenza virus were required. 87501, “Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, reverse transcription and amplified probe technique, each type or subtype” 87502, “Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, reverse transcription and amplified probe technique, first 2 types or sub-types” 87503, “Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, multiplex reverse transcription and amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to primary procedure)” 80
    • LABORATORY CY2011 CPT Updates Microbiology Revised CPT Code 87901 87901, “Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase and protease regions” HIV clinicians use resistance testing to select the appropriate drugs to optimize a patient’s treatment regimen. The DHHS recommends resistance testing be utilized. CPT Code 87901 was revised to provide clarity and terminology consistency. CPT Code 87906 was also created. New CPT Code 87906 87906, “Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (eg, integrase, fusion)” 81
    • LABORATORY CY2011 CPT Updates Cytopathology New CPT Codes 88120 and 88121 Created to allow more specific reporting for multiple probe kits 88120, “Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual” 88121, “Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computer-assisted technology” Revised CPT Code 88172 88172, “Cytopathology, evaluation of fine needle aspirate; immediate cytohistiologic study to determine adequacy for diagnosis, first evaluation episode, each site” Revised to specify the units of service 82
    • LABORATORY CY2011 CPT Updates Cytopathology New CPT Code 88177 88177, “Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure)” Created to report each additional evaluation of a fine needle aspiration at the same site 83
    • LABORATORY CY2011 CPT Updates Surgical Pathology Revised CPT Codes 88332 and 88334 88332, “Pathology consultation during surgery; each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure)” 88334, “Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site (List separately in addition to code for primary procedure)” Revised to add-on code status New CPT Code 88363 88363, “Examination and selection of retrieved archival (i.e., previously diagnosed) tissue(s) for molecular analysis (eg, KRAS mutational analysis)” Created to report the pathologist’s identification and selection of appropriate tumor tissue from a surgical specimen 84
    • LABORATORY CY2011 CPT Updates Lab Procedures New CPT Code 88749 88749, “Unlisted in vivo (eg, transcutaneous) laboratory service” Created to report unlisted in vivo tests because no unlisted service code was available Deleted CPT Codes With the creation of CPT Codes 43754-43755 (gastric intubation and aspiration) and to reflect current clinical practice, codes below have been deleted. 89100, “Duodenal intubation and aspiration; single specimen (eg, simple bile study or afferent loop culture) plus appropriate test procedure” 85
    • LABORATORY CY2011 CPT Updates Lab Procedures Deleted CPT Codes 89105, “Duodenal intubation and aspiration; collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube” 89130, “Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology;” 89132, “Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology; after stimulation” 89135, “Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 1 hour” 89136, “Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 2 hours” 86
    • LABORATORY CY2011 CPT Updates Lab Procedures Deleted CPT Codes 89140, “Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 2 hours including gastric stimulation (eg, histalog, pentagastrin)” 89141, “Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 3 hours, including gastric stimulation” 89225, “Starch granules, feces” 89235, “Water load test” 87
    • RADIOLOGY Radiology services are included in CPT code 70,000 range The radiology section of the CPT code manual includes subheadings and subsections that separate types of examinations UB04 revenue codes are specific to the type of testing being performed. There are essential coding guidelines to consider when capturing radiology services Packaging of Imaging Services under APCs Code Selection Diagnosis Coding Modifiers Contrast and Radiopharmaceuticals Multiple Day Studies 88
    • RADIOLOGY Packaging of Imaging Services under APCs Many imaging procedures are considered packaged with the procedure with which it is performed. Packaged imaging services include the following: Guidance Image Processing Imaging Supervision and Interpretation Contrast and Diagnostic Pharmaceuticals Special Packaging Multiple Imaging Procedures 89
    • RADIOLOGY Code Selection The HCPCS/CPT code selected should be representative of the services ordered, rendered and documented. In radiology it is often found that the HCPCS/CPT code is determined based on a series of events beginning with the scheduling of the examination, the intake by the technologist and the examination selected in the clinical subsystem. Changes to the original order must be reflected within this process to ensure the proper HCPCS/CPT is billed on the final claim for reimbursement. 90
    • RADIOLOGY Code Selection The diagnosis documented by the radiologist is the condition representing the highest degree of certainty for that visit. When the physician interpretation of a test performed in the outpatient setting establishes a definitive diagnosis, this definitive diagnosis should be coded Any presenting symptoms that are integral to this diagnosis should not be coded. Any documented symptoms or conditions that are not routinely associated with the definitive diagnosis should be assigned additional codes. It is not necessary to code incidental findings documented in physician interpretations of tests. 91
    • RADIOLOGY Modifiers Modifier use is common in radiology procedures and can include both anatomic modifiers (-LT, -RT) as well as benefit modifiers (-GG, -GH). When a radiology procedure is reduced, the correct reporting is to code to the extent of the procedure performed. If no code exists for what has been done, report the intended code with modifier 52 attached. Modifiers are often found to be hard-coded in the radiology CDM, or automated through the use of the clinical subsystem. Certain modifiers are not appropriate for use in radiology (-73, -74) 92
    • RADIOLOGY Contrast Hospitals are strongly encouraged to report charges for all drugs, biologicals, and radiopharmaceuticals using the correct HCPCS codes for the items used, including the items that have packaged status. This includes contrast. Contrast should be reported with the appropriate HCPCS/CPT code, if available, and revenue code 636. In the absence of a HCPCS/CPT, the charge should be captured with revenue code 255 only. 93
    • RADIOLOGY Radiopharmaceuticals The majority, if not all, nuclear medicine procedures are performed with the assistance of the radiopharmaceutical or radioisotope drugs. Each nuclear medicine procedure is coded independently, with the isotope coded as a separate entry. Radiopharmaceuticals should be captured with units of service consistent with the HCPCS/CPT definition. Most radiopharmaceuticals are paid as a packaged item under the nuclear medicine procedure, however, some do exist that receive separate APC reimbursement. Radiopharmaceutical to Study Edits are in place to ensure that an isotope is billed with a study. Note the edits do not review for appropriate dosage units. 94
    • RADIOLOGY HCPCS/ Per HCPCS/CPT Description Quantity CPT Study A9500 Technetium Tc-99M Sestamibi, Diagnostic, Per Study Dose √ A9501 Technetium Tc-99M Teboroxime, Diagnostic, Per Study Dose √ A9502 Technetium Tc-99M Tetrofosmin, Diagnostic, Per Study Dose √ A9503 Technetium Tc-99M Medronate, Diagnostic, Per Study Dose, Up To 30 √ √ Millicuries A9504 Technetium Tc-99M Apcitide, Diagnostic, Per Study Dose, Up To 20 √ √ Millicuries A9505 Thallium Tl-201 Thallous Chloride, Diagnostic, Per Millicurie √ A9507 Indium In-111 Capromab Pendetide, Diagnostic, Per Study Dose, Up To 10 √ √ Millicuries A9508 Iodine I-131 Iobenguane Sulfate, Diagnostic, Per 0.5 Millicurie √ A9509 Iodine I-123 Sodium Iodide, Diagnostic, Per Millicurie √ 95
    • RADIOLOGY Multiple Day Studies When a study is performed over a span of two or more days, the hospital should submit the study HCPCS/CPT with the date the study was initiated. Most likely this would occur in nuclear medicine and would involve the use of a radiopharmaceutical. The radiopharmaceutical should also be captured with the date of service reflecting the date of the administration. Hospitals are required to submit the HCPCS code for the radiolabeled product on the same claim as the HCPCS code for the nuclear medicine procedure. Hospitals are also instructed to submit the claim so that the services on the claim each reflect the date the particular service was provided. Therefore, if the nuclear medicine procedure is provided on a different date of service from the radiolabeled product, the claim will contain more than one date of service. Medicare Claims Processing Manual, Chapter 17 Drugs and Biologicals, Section 90.2 (last updated 1/5/2009) 96
    • RADIOLOGY Charge Capture Tips for Radiology Services Understand the relationship between the clinical subsystem and the CDM. Understand the relationship of HCPCS/CPT codes to clinical practice to understand how to analyze usage statistics. Radiopharmaceuticals Reconcile the radiopharmaceuticals to the nuclear medicine volumes reported. Use average dosage amounts for those radiopharmaceuticals are reported in quantities. Adjust the quantities of the radiopharmaceuticals to “1” so a relationship to the number of procedures can be calculated. Component Coding Understand for radiologic guidance and other services that another HCPCS/CPT may also be captured. 97
    • RADIOLOGY CY2011 CPT Updates New CPT Codes 74176, 74177 and 74178 74176, “Computed tomography, abdomen and pelvis; without contrast material” 74177, “Computed tomography, abdomen and pelvis; with contrast material(s)” 74178, “Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions” The new codes were created to report combination CT of the abdomen and pelvis; the table below identifies the combination code to be utilized – do not report more than one CT abdomen or CT pelvis for any session 98
    • RADIOLOGY CY2011 CPT Updates Deleted CPT Codes Examinations considered to be obsolete 76150, “Xeroradiography” 76350, “Subtraction in conjunction with contrast studies” Replaced CPT Code 76880 Deleted CPT Code 76880, “Ultrasound, extremity, nonvascular, real time with image documentation” Through analysis, it was determined that code 76880 had a significant increase in utilization. It was determined that the increase was due to focused anatomic-specific ultrasound exams. CPT Code 76880 was deleted and replaced by 2 new codes (76881 and 76882). 99
    • RADIOLOGY CY2011 CPT Updates New CPT Codes 76881, “Ultrasound, extremity, nonvascular, real-time with image documentation; complete” 76882, “Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific” Revised CPT Code 77003 77003, “Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction” Deletion of language “ transforaminal epidural” 100
    • RADIOLOGY CY2011 OPPS Update Supervision of Hospital Outpatient Diagnostic Services For services furnished on a hospital’s main campus (i.e., in the hospital or in an on-campus outpatient department), the supervising physician or non-physician practitioner may be located anywhere on the hospital campus, including a physician’s office or other nonhospital space, so long as he/she is on the same campus and immediately available to furnish assistance and direction throughout the procedure. For services furnished in off-campus provider based departments of hospitals, the physician or non-physician practitioner must be physically present in the off-campus provider-based department (versus the previous requirement to be “present and on the premises of the location”) and be immediately available to furnish assistance and direction throughout the procedure. 101
    • RADIOLOGY CY2011 OPPS Update Payment Offset Policy for Diagnostic Radiopharmaceuticals Modifier FB Hospitals are instructed to report no cost/full credit cases using the ‘‘FB’’ modifier on the line with the procedure code in which the no cost/full credit device is used. In cases in which the device is furnished without cost or with full credit, the hospital is instructed to report a token device charge of less than $1.01. For CY 2011, OPPS payments for implantation procedures to which the ‘‘FB’’ modifier is appended are reduced by 100 percent of the device offset for no cost/full credit cases 102
    • RADIOLOGY CY2011 OPPS Update Pass-Through Payment for Radiopharmaceuticals Separately payable drugs and biologicals without pass-through status (including pharmacy overhead) are finalized to be paid at 105 percent of the ASP in place of the current rate of 104 percent of ASP and changed from the proposed 106 percent of ASP. Transitional pass-through (new), drugs, biologicals, diagnostic (Dx) RPs and contrast agents for 2011 include: A9582 Iobenguane, I-123, dx, per study dose, up to 15 millicuries, A9583 Injection, Gadofosveset trisodium, per ml. CMS did not propose any changes to transitional pass-through policies for 2011. 103
    • RADIOLOGY CY2011 OPPS Update Continued Policies CMS continues to package payments for ALL diagnostic (Dx) radiopharmaceuticals (RP) and contrast agents in with the major procedure payment, regardless of their per-day costs. CMS will continue the policy for separately payable therapeutic (Tx) radiopharmaceuticals in 2011. 104
    • PAIN MANAGEMENT Pain management services are described by in CPT codes in the surgical CPT and medicine CPT code sections, and also include Category III codes. Pain management services can include the following: Epidural injections Trigger point injections Facet injections Kyphoplasty Implantable Infusion Pumps Neurostimulators Vertebroplasty UB04 revenue codes are specific to the type of testing being performed. 105
    • PAIN MANAGEMENT There are essential coding and billing guidelines to consider when capturing pain management services Diagnosis Coding Modifier Use Radiologic Guidance Frequency Limitations Documentation Requirements 106
    • PAIN MANAGEMENT Diagnosis Coding Documentation of reasons for selecting this therapeutic option must be documented Diagnoses of general symptoms (e.g. back pain) will not provide for coverage or support medical necessity Modifier Use Modifier 50 for “Bilateral Procedure” Physicians perform many pain management procedures bilaterally, which means they treat both sides of the affected area during the procedure. The most common scenarios for modifier 50 use include: Arthrography, with anesthesia Selective nerve root blocks Facet injections Transforaminal injections Nerve destruction by neurolytic agent 107
    • PAIN MANAGEMENT Radiologic Guidance Radiologic guidance is included as part of the surgical CPT code in the following procedures: Paravertebral facet injection Transforaminal injections Radiologic guidance is not included as part of the surgical CPT code in the following procedures: Nerve destruction by neurolytic agent Epidural injection Vertebroplasty Kyphoplasty Percutaneous Neurostimulator (see exceptions) 108
    • PAIN MANAGEMENT Frequency Limitations Provision of a transforaminal epidural injection and/or paravertebral facet join injection on the same day as an interlaminar or caudal (lumbar, sacral) epidural/intrathecal injection sacroiliac joint injection, lumbar sympathetic block or other nerve block is considered to not be medically reasonable and necessary. If more than one procedure is provided on the same day, the facility must bill for only one procedure. Therapeutic transforaminal epidural or paravertebral facet joint nerve blocks exceeding two levels (bilaterally) on the same day will be denied as medically unnecessary. A maximum of three levels PER REGION may be considered for reimbursement when either of the above blocks is performed and billed unilaterally. (indicated with an LT or RT modifier) 109
    • PAIN MANAGEMENT Documentation Requirements The patients record should document an appropriate history and physical examination by the anesthesiologist/anesthetist specifying the medical indications requiring his/her presence when applicable. The indications should be recorded by both the anesthesiologist/ anesthetist and the provider performing the injection in their respective notes. The medical record must support medical necessity of the services billed for each date of service and frequency. Encounters should be able to stand on their own. The medical record must clearly indicate the patient’s history including failed conservative measure and extenuating circumstances (e.g. level of pain, interruption of daily activities) 110
    • PAIN MANAGEMENT Charge Capture Tips for Pain Management Services Discography Discography is the radiographic demonstration of intervertebral disk by injection of contrast media into the nucleus pulposus. Reporting discography includes the injection of contrast and the radiologic supervision and interpretation. The number of units for both the injection and radiology components should equal. If two levels are injected, report 2 units for both the surgical and radiology component. Add modifier 50 to the surgical CPT code if the injection is performed bilaterally at a single level, and report 2 units for the radiology component. 111
    • PAIN MANAGEMENT Charge Capture Tips for Pain Management Services Facet Injections A local anesthetic or corticosteroid is injected into the facet joint. Facet joints are the gliding joints between the vertebrae. The injections are reported per each level of the spinal region of interest. When multiple levels in the same regions are injected, two CPT Codes should be reported. Fluoroscopic or CT guidance is often used to aid in locating the joint to be injected. The guidance is included. If ultrasound is used, refer to Category III codes. Facet injections can be performed as bilateral procedures. When this occurs, only one unit of service should be reported and modifier 50 should be appended to the surgical CPT Code. 112
    • PAIN MANAGEMENT Charge Capture Tips for Pain Management Services Nerve Blocks Selective nerve root blocks can be performed for diagnostic and/or therapeutic purposes. For example, nerve root blocks can be performed to isolate and identify the source of a symptomatic root by reproducing the pain, injecting anesthetic and/or steroidal substances, and evaluating radicular (nerve root) pain relief. Nerve block injections are unilateral procedures, bilateral procedures should be indicated with the use of modifier 50. Radiologic guidance can be captured separately. Fluoroscopy CPT Code 77003 CT CPT Code 77012 113
    • PAIN MANAGEMENT Charge Capture Tips for Pain Management Services Trigger Point Injections Trigger points refer pain to adjacent and distant areas in a reproducible pattern characteristic of each muscle. CPT Codes indicate the number of muscles; 1 or 2, >3. Modifier 50 would not be appropriate if bilateral muscles were injected. Count each injection. Radiologic guidance can be captured separately. Fluoroscopy CPT Code 77002 CT CPT Code 77012 MR CPT Code 77021 114
    • PAIN MANAGEMENT Charge Capture Tips for Pain Management Services Epidurals The epidural injection of a non-neurolytic substance is performed when analgesia is desired mainly in a nerve or nerve root. Fluoroscopic guidance is often used to aid in locating the area to be injected. The guidance should be reported separately with CPT Code 77003. Capture multiple units for the fluoroscopic guidance if more than one spinal region is injected and fluoroscopic guidance is used for each region (e.g. cervical, lumbar, etc). Epidurography vs. Epidural Guidance 115
    • PAIN MANAGEMENT Charge Capture Tips for Pain Management Services Vertebroplasty Vertebroplasty is a minimally invasive procedure designed to relieve back pain caused by compression fractures of the thoracic and lumbar spine that have failed to normally heal. By injecting bone cement into the compressed vertebral body, the fracture is stabilized, significantly improving or alleviating the patient’s back pain. The CPT Codes are reported per vertebral body (thoracic or lumbar) and include bilateral injections, therefore modifier 50 is not applicable. Fluoroscopic or CT guidance is often used during the procedure and is separately reportable per vertebral body. Fluoroscopy CPT Code 72291 CT CPT Code 72292 116
    • PAIN MANAGEMENT Charge Capture Tips for Pain Management Services Kyphoplasty Kyphoplasty is a procedure designed to relieve back pain caused by compression fractures of the thoracic and lumbar spine that have failed to heal normally. It is possible to treat more than one fractured vertebra at the same operation, if necessary. The CPT Codes are reported per vertebral body (thoracic or lumbar) and include bilateral injections, therefore modifier 50 is not applicable. Fluoroscopic or CT guidance is often used during the procedure and is separately reportable per vertebral body. Fluoroscopy CPT Code 72291 CT CPT Code 72292 117
    • PAIN MANAGEMENT Charge Capture Tips for Pain Management Services Implantable Infusion Pumps The services for implantation of monitoring, refilling and maintenance of implantable infusion pumps for intractable pain and spasticity are covered in CMS National Coverage Determination. When seeing patients for monitoring, programming, maintenance and refilling of pumps and/or reservoirs, it is appropriate to bill both services at the same encounter, if both services are performed. Maintenance and refilling CPT code should NOT be billed if the only reason for the encounter is flushing of a port-a-cath or irrigation and anticoagulant flushing of an implantable venous access port. 118
    • PAIN MANAGEMENT Charge Capture Tips for Pain Management Services Percutaneous Implant Neurostimulator Neurostimulators are implantable, pacemaker-sized devices that send electrical stimulation through a lead to electrodes implanted near the spinal cord or an affected peripheral nerve. Fluoroscopic guidance can be used for the initial implant, revision or removal. Report CPT Code 77002, only for insertion or removal involving the insertion of percutaneous arrays and/or pulse generator. Fluoroscopic guidance is included in the non-percutaneous removal and revision procedures. For initial or subsequent electronic analysis and programming of neurostimulator pulse generators, refer to CPT codes 95970 - 95975. 119
    • PAIN MANAGEMENT Charge Capture Tips for Pain Management Services Pharmacologic Challenge or Trial During a challenge or trial test, drugs are administered by intravenous infusion and the patients are monitored and observed for side effects, signs of toxicity, and levels of pain control. After the pharmacologic challenge for pain is completed, the results are reviewed and a decision of further treatment or therapy is made. To code this service, follow the coding guidelines for infusion therapy services. This is addressed in more detail in a separate section. In general, the test is coded using the intravenous infusion CPT codes for therapeutic, prophylactic, and diagnostic injections and infusions (CPT Codes 96365 – 96368). The pharmaceutical is captured and reported separately. 120
    • PAIN MANAGEMENT Analyzing the pain management CDM line item usage can identify potential areas of financial and/or compliance risk. Examples Injection Procedures and Imaging It is expected for those injection procedures where imaging can be captured separately that the volumes for the procedures should be relatively equal. Considerations will need to be made for bilateral procedures. Example: Bilateral Discography Neurostimulator Implant and Analysis It is expected that for each implant of a neurostimulator, an analysis will be performed at the time of implant. The analysis volume should be at least that of the implant procedures. 121
    • PAIN MANAGEMENT CY2011 CPT Code Updates New Codes 0213T, “Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves) innervating that joint) with ultrasound guidance, cervical or thoracic; single level” 0214T – second level 0215T – third and any additional level(s) 0216T, “Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves) innervating that joint) with ultrasound guidance, lumbar or sacral; single level” 0217T – second level 0218T - third level Added in 2010, but not published until 2011. Allow for reporting of procedure under ultrasound guidance. 122
    • PAIN MANAGEMENT CY2011 CPT Code Updates Revised Codes 64479, “Injection(s), anesthetic agent &/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level” 64480 – cervical or thoracic, each additional level 64483 – lumbar or sacral, single level 64484 – lumbar or sacral, each additional level Revised to include fluoroscopic and CT guidance with transforaminal epidural injection services 123
    • INTERVENTIONAL RADIOLOGY Interventional Radiology is a subspecialty of radiology in which minimally invasive procedures are performed using image guidance. Procedures can include the following: Percutaneous Transluminal Coronary Angioplasty (PTCA) Percutaneous Transluminal Angioplasty (PTA) Angiography Interventional Radiology services are included in CPT code 70,000 range for the radiology component and the CPT code range for surgical services for the surgical component. UB04 revenue codes are specific to the radiologic and surgical components. 124
    • INTERVENTIONAL RADIOLOGY There are essential coding guidelines to consider when capturing interventional radiology services: Component Coding In general, more than one HCPCS/CPT is used to describe the complete procedure. Exception lies with lower extremity revascularization (NEW!) Coding is performed in components and can include the following: Introduction of needle Surgical intervention(s) Radiological guidance 125
    • INTERVENTIONAL RADIOLOGY Rules for Upper Extremity Revascularization Code separately for each component or step of the procedure (i.e. angiography, intervention, etc) Code each vascular family separately. Within a vascular family, code only the highest order catheterization. If multiple vessels within a vascular family are selected, an add-on code may be used to describe the additional selective effort and supervision & interpretation Catheter movement (retrograde and antegrade) and vascular families determine vessel ordering. Each vascular access site is coded separately. Code for each vessel treated, not each lesion treated. 126
    • INTERVENTIONAL RADIOLOGY Example - Bilateral renal artery balloon angioplasty 127
    • INTERVENTIONAL RADIOLOGY Rules for Lower Extremity Revascularization Provided by the American College of Radiology http://www.acr.org/Hidden/Economics/FeaturedCategories/Pubs/coding_source/archives/Sept Oct10/2011-CPT-Code-Update.aspx Report only one primary code for each vascular territory treated per limb. If multiple vascular territories are treated during the same session, it is appropriate to report the primary code for the initial vessel in each vascular territory. Add-on codes are used to report additional second or third vessels treated within the same vascular territory, such as in the iliac or tibial/peroneal territory. Since the iliac and tibial/peroneal territories include three vessels, a maximum of two add-on codes may be reported within each territory. Add-on codes are used when treatments are performed in different vessels within the same vascular territory, not for distinct lesions in the same vessel. 128
    • INTERVENTIONAL RADIOLOGY Rules for Lower Extremity Revascularization The femoral/popliteal territory is considered one vessel; therefore, add-on codes do not apply. The common peroneal trunk is considered part of the three vessels in the tibial/peroneal territory and is not treated as a separate, fourth vessel for CPT reporting of lower extremity endovascular revascularization procedures. Multiple stent placements in the same vessel are reported once. For a bilateral procedure, use modifier 59 if the same territory(ies) is treated (even if mode of therapy is different). For example, use modifier -59 when the right external iliac artery is treated with angioplasty (37220), and the left external iliac artery is treated with angioplasty and stent (37221-59). Lesions treated which cross vascular territories should only be coded once. 129
    • INTERVENTIONAL RADIOLOGY Rules for Lower Extremity Revascularization Diagnostic angiography performed at a separate session from an interventional procedure is reported separately. Diagnostic angiography supervision and interpretation codes are reportable when the criteria for the appropriate reporting of them at the same time as interventions are satisfied. Mechanical thrombectomy and/or thrombolysis, when used, is reported separately 130
    • INTERVENTIONAL RADIOLOGY Example - PTA, common iliac arteries, bilateral and intravascular stent(s) placement 131
    • INTERVENTIONAL RADIOLOGY Angiography If the catheter or needle is placed directly into an artery or vein and is not manipulated further, assign a nonselective code. Nonselective placement includes direct placement into the aorta or vena cava from any approach, and direct puncture of arteries, veins, or the vena cava without further manipulation. These CPT Codes include 36200 and 36010. If the catheter requires additional movement or manipulation beyond the initial placement, assign a selective code. This indicates that the catheter is guided into a position of the artery other than the aorta or where the artery is punctured. 132
    • INTERVENTIONAL RADIOLOGY Angiography Only the most selective placement (highest order) in each vascular family may be coded in procedures involving both nonselective and selective placements. The exception is if more than one access is utilized. If a nonselective catheter placement (with the same access) is then converted to a selective catheter placement, only the selective catheter placement is reported. The work of the non-selective catheter placement is included in the selective placement, and has been taken into account when the fee schedule for selective levels was determined. 133
    • INTERVENTIONAL RADIOLOGY Angiography To assign the correct selective code, imagine the vascular system as a tree: The main trunk (aorta or vena cava) has several primary branches (first order) The aorta as the main trunk is considered non-selective. Secondary branches (second order) spring from each of the primary branches, also resulting in tertiary branches (third order). A single primary branch with all of its secondary and tertiary branches is a “vascular family”. 134
    • INTERVENTIONAL RADIOLOGY 135
    • INTERVENTIONAL RADIOLOGY Example - Abdominal Aortogram with Study of Pelvic Vessels and Proximal Lower Extremity Vessels. The catheter is placed via femoral approach and repositioned into the distal abdominal aorta. The catheter is exchanged over a guidewire for a selective catheter, which is first positioned in the common femoral artery and then repositioned in the external iliac artery. 136
    • INTERVENTIONAL RADIOLOGY “Drive-bys” Where the attending physician does not request, and where the medical condition (documented in the chart) does not warrant additional procedures, than the addition of other, unrelated procedures may be seen as medically unnecessary and may result in payment denials, refunds and more, if identified during an audit. In such cases, an investigation may be initiated to determine if other "schemes to defraud", have occurred. Hospitals should be very careful with what they consider to be "drive by" procedures. Remember, without regard to what the physician codes and bills, the hospital has a fiduciary responsibility to code and bill for only those procedures that meet medical necessity guidelines, have written orders, and have signed reports to document existence. 137
    • INTERVENTIONAL RADIOLOGY Charge Capture Tips for Interventional Radiology Services Understand the relationship of HCPCS/CPT codes to clinical practice to understand how to analyze usage statistics. Component Coding Understand for radiologic guidance and other services that another HCPCS/CPT may also be captured. Venous Access Procedures Angiography Upper Extremity Revascularization Assess the charge capture, coding and documentation practices to understand the best practice for your hospital Should the CDM be hard-coded or should HIM, or a departmental coder, assign all codes? 138
    • INTERVENTIONAL RADIOLOGY CY2011 CPT Code Updates Deleted Codes 6 codes have been deleted to accommodate the addition of the new lower extremity endovascular revascularization procedures (37220 – 37235) Transluminal balloon angioplasty, open; renal or other visceral artery 35454 – iliac 35456 – femoral-popliteal 35459 – tibioperoneal trunk and branche 35470 – Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel 35473 – iliac 35474 – femoral-popliteal 139
    • INTERVENTIONAL RADIOLOGY CY2011 CPT Code Updates Revised CPT Code 35471 35471, “Transluminal balloon angioplasty, percutaneous; renal or visceral artery” With the deletion of parent CPT Code 35470, 35471 was revised to become the parent code rather than a child code. New Codes Category III Codes 0234T – 0238T Describe atherectomy performed by any method in arteries above the inguinal ligaments. Includes radiologic guidance. 140
    • INTERVENTIONAL RADIOLOGY CY2011 CPT Code Updates Deleted codes 6 codes have been deleted to accommodate the addition of the new lower extremity endovascular revascularization procedures (37220 – 37235) and atherectomy procedures (0234T – 0238T) 35480 , “Transluminal peripheral atherectomy, open; renal or other visceral artery” – to report use 0234T, 0235Y 35481 , aortic – to report use 0236T 35482 - iliac – to report use 0238T 35483 – femoral-popliteal – to report use 37225, 37227 35484 – brachiocephalic trunk or branches, each vessel – to report use 0237T 35485 – tibioperoneal trunk or branches – to report use 37229, 37231, 37233, 37235 141
    • INTERVENTIONAL RADIOLOGY CY2011 CPT Code Updates Deleted codes 6 codes have been deleted to accommodate the addition of the new lower extremity endovascular revascularization procedures (37220 – 37235) and atherectomy procedures (0234T – 0238T) 35490 , “Transluminal peripheral atherectomy, percutaneous; renal or other visceral artery” – to report use 0234T, 0235T 35491 – aortic – to report use 0236T 35492 – iliac – to report use 0238T 35493 – femoral-popliteal – to report use 37225, 37227 35494 – brachiocephalic trunk or branches – to report use 0237T 35495 – tibioperoneal trunk and branches – to report use 37229, 37231, 37233, 37235 142
    • INTERVENTIONAL RADIOLOGY CY2011 CPT Code Updates Revised Codes In support of the new lower extremity endovascular revascularization procedures, revised for consistency purposes by adding “iliac and lower extremity arteries” to the parentheses 37205, “Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity arteries), percutaneous; initial vessel” 37206 – each additional vessel 37207, “Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity arteries), open; initial vessel” 37208 – each additional vessel 143
    • INTERVENTIONAL RADIOLOGY CY2011 CPT Code Updates New Codes New codes for reporting lower extremity endovascular revascularization services performed for occlusive disease 37220 – 37223 – iliac vascular territory 37224 – 37227 – femoral / popliteal territory 37228 – 37235 – tibial / peroneal territory CY2011 OPPS Updates The new endovascular revascularization CPTs map to a device dependent APC, and are assigned a status indicator “NI”. 144
    • CARDIAC CATHETERIZATION ALL NEW IN 2011! CPT Codes 93451 – 93568 New introductory section The primary cardiac catheterization procedures include all roadmapping angiography in order to place the catheters, including any injections and imaging supervision, interpretation, and report. The primary cardiac catheterization procedures DO NOT include contrast injection(s) and imaging supervision, interpretation, and report for imaging that is separately identified by specific procedure codes(s) (e.g. pulmonary angiography) 145
    • CARDIAC CATHETERIZATION There are essential coding guidelines to consider when capturing cardiac catheterization services: Injection and Imaging Procedures Reporting of Vascular Closure Device Administration of Pharmacologic Agent Angiography During Catheterization Swan Ganz Insertion Cardiac Catheterization and Other Procedures 146
    • CARDIAC CATHETERIZATION Injection and Imaging Procedures All injection CPT Codes include radiological supervision, interpretation, and report. Cardiac catheterization, other than that for congenital anomalies, includes the typical injection of contrast and imaging. Coronary angiography Left ventricular or Left atrial angiography Non typical injections can be captured separately when performed with any cardiac catheterization procedure. Right ventricular or Right atrial angiography Supravalvular aortography Pulmonary angiography 147
    • CARDIAC CATHETERIZATION Example – Left Heart Catheterization, Ventriculography and Coronary Angiography 2011 CPT 2010 CPT Component 93510 Insertion of Catheter 93543 Injection, Ventriculography 93458 93545 Injection, Coronary Angiography 93555 Imaging, Ventriculography 93556 Imaging, Coronary Angiography 148
    • CARDIAC CATHETERIZATION Reporting of Vascular Closure Device The contrast injection to place and the act of placing the vascular closure device are inherent to the cardiac catheterization procedure and should not be captured separately. The actual device (e.g. Angioseal, Star Close) can be captured and reported separately as an implant supply C1760, “Closure device, implantable (insertable)“ Administration of Pharmacologic Agent The administration of a pharmacologic agent (e.g. dobutamine) to repeat hemodynamic measurements for the purposes of evaluating hemodynamic measurement can be reported separately. When the administration is for the purposes of completing a coronary interventional or imaging procedure, it is not separately reportable. 149
    • CARDIAC CATHETERIZATION Angiography During Catheterization HCPCS Codes were created in 2003 for use by hospitals in describing renal and iliac angiography for non-selective angiography. G0275 - renal G0278 - iliac The Codes were not created for “drive bys” or for a guiding shot for closure. Reporting of G0275 and G0278 is expected to be low. Increased volumes could open the hospital and physicians to an audit and compliance risk. The G-codes will be considered reasonable if the patient has a clear indication of renal artery stenosis or the patient undergoes stenting at a later date should significant renal artery stenosis be discovered. 150
    • CARDIAC CATHETERIZATION Swan Ganz Insertion When a flow directed catheter is placed for hemodynamic monitoring, and not for diagnostic reasons, the insertion of the catheter should be coded as a stand alone procedure. The passage of a catheter into or through the chambers of the heart does not itself constitute a diagnostic cardiac catheterization. The insertion of a flow directed catheter during catheterization is not coded separately. Cardiac Catheterization with Other Procedures When cardiac catheterization is the approach for another procedure, and it is not being performed for specific evaluation (beyond the approach) it should not be coded separately. 151
    • CARDIAC CATHETERIZATION CY2011 CPT Code Updates Deleted codes: Cardiac Catheterization Procedures CPT Codes 93501, 93508-93529 have been deleted, to report see 93451-93461 Injection and Imaging CPT Codes 93539-93556 have been deleted and replaced by new codes 93563-93568. 152
    • CARDIAC CATHETERIZATION CY2011 CPT Code Updates New Codes 93451, “Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed” 93452, “Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed” 93453, “Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed” 153
    • CARDIAC CATHETERIZATION CY2011 CPT Code Updates New Codes 93454, “Catheter placement in coronary artery(s) for angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation” 93455 – with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography 93456 – with right heart catheterization 93457 – with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization 93458 – with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 154
    • CARDIAC CATHETERIZATION CY2011 CPT Code Updates New Codes 93459 - with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography 93460 – with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 93461 - with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography 155
    • CARDIAC CATHETERIZATION CY2011 CPT Code Updates New Codes 93462, “Left heart catheterization by transseptal puncture through intact septum or by transapical puncture “ 93463, “Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprussidee, dobutamine, milrinone or other agent) including assessing hemodynamic measurements before, during, after, and repeat pharmacologic agent administration, when performed” 93464, “Physiologic exercise study (eg, bicycle or arm ergometry) including assessing hemodynamic measurements before and after” 156
    • CARDIAC CATHETERIZATION CY2011 CPT Code Updates New Codes 93563, “Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective coronary angiography during congenital heart catheterization” 93564 – for selective opacification of aortocoronary venous or arterial bypass graft(s) (eg, aortocoronary saphenous vein, free radial artery, or free mammary artery graft) to one or more coronary arteries and in situ conduits (eg, internal mammary), whether native or used for bypass to one or more coronary arteries during congenital heart catheterization, when performed 93565 – for selective left ventricular or left arterial angiography 93566 – for selective right ventricular or right atrial angiography 93567 – for supravalvular aortography 93568 – for pulmonary angiography 157
    • CARDIAC CATHETERIZATION CY2011 CPT Code Updates New Codes New codes for reporting cardiac catheterization New codes – 93451-93464 for diagnostic cardiac cath New codes – 93452 – 93461 include contrast injections CY2011 OPPS Updates The new cardiac catheterization CPTs are assigned a status indicator “NI”. 158
    • ELECTROPHYSIOLOGY Electrophysiology procedures treat heart rhythm disorders and can include the following types of procedures: Pacemaker Insertion ICD/AICD Insertion Studies/Procedures Procedures include the use of surgical intervention, radiologic guidance and involve high dollar supplies and implants. These procedures are costly and charge capture is critical to reimbursement. 159
    • ELECTROPHYSIOLOGY There are essential coding guidelines to consider when capturing electrophysiology services: Component Coding In general, more than one HCPCS/CPT is used to describe the complete procedure. Surgical Intervention Radiologic Guidance Analysis To best understand the components , an understanding of the individual procedures is essential. 160
    • ELECTROPHYSIOLOGY Pacemaker Procedures A pacemaker is a device that controls the rhythm of the heart and may also improve total cardiac output (the amount of blood pumped by the heart). Increased cardiac output improves blood perfusion to the vital organs and extremities. A pacemaker may be temporary or permanent. Pacemakers are also described as single or dual chamber. Pacemaker procedure CPT Codes are separated into categories: Insertion/Replacement Repair Subsequent Analysis 161
    • ELECTROPHYSIOLOGY Pacemaker Procedures Insertion/Replacement Fluoroscopic guidance can be captured separately (CPT 71090). The insertion/replacement of the pacemaker generator may or may not include electrodes. When replacing a previously implanted pacemaker, the insertion remains to be coded the same as if an initial implantation was performed To assign the appropriate CPT Code you should know the following: Method employed (e.g. transvenous, xiphoid, thoracotomy Area of the heart to be paced (i.e. atrium or ventricle) Type of pacemaker system (e.g. temporary, permanent, single or dual chamber) Analysis performed at the time of insertion is included in the CPT code and not separately reportable. 162
    • ELECTROPHYSIOLOGY Pacemaker Procedures Repair Permanent pacemakers may at times require repair. For example, an electrode may fracture or an insulation defect may occur. In both examples it may be possible to repair the pacemaker electrode and continue with its use. CPT Codes for repair of electrodes describe the repair of the electrode, single and dual chamber systems. The Codes include the removal and reinsertion of the pacemaker leads. If when the repair is performed and the pulse generator requires replacement, CPT Codes for the pacemaker generator only should also be captured. Radiologic guidance should be captured separately. Note CPT 71090 is for insertion of pacemaker only, and not reportable if procedure does not involve the insertion of a pacemaker generator. 163
    • ELECTROPHYSIOLOGY Pacemaker Procedures Subsequent Analysis Subsequent analysis of the pacemaker system may include the evaluation of the programmable parameters at rest and activity, electrocardiographic recording, event markers, and device response. Pacemaker analysis is only reportable when performed subsequent to the insertion of the pacemaker. The initial analysis is included in the CPT Code for the insertion/replacement. 164
    • ELECTROPHYSIOLOGY ICD/AICD Procedures An ICD, or implantable cardioverter-defibrillator, can also be referred to as an AICD or pacing cardioverter-defibrillator. An ICD includes a pulse generator and electrodes. Unlike a pacemaker, an ICD may require multiple electrodes, even if only one heart chamber is to be paced. ICDs systems can be single or dual chamber. The systems are utilized to treat ventricular tachycardia or fibrillation by low energy cardioversions or defibrillating shocks. ICD procedure CPT Codes are separated into categories: Insertion/Replacement Removal Repair Subsequent Analysis 165
    • ELECTROPHYSIOLOGY ICD/AICD Procedures Insertion/Replacement The insertion of implantable cardioverter defibrillators (ICD) can be accomplished by an open approach using either a sternotomy or a thoracotomy, or by a closed approach using a variety of electrode configurations. In the closed approach, one or more electrodes may be inserted in the heart, usually by cannulation of the subclavian vein. In some circumstances, a subcutaneous patch may also be required. ICDs are either inserted as a whole system (with electrodes and pulse generator) or as a pulse generator only. The Codes do not discriminate between a single or dual chamber pacing system. Fluoroscopic guidance can be captured separately (CPT 71090). Unlike the insertion of a pacemaker, the evaluation of the electrodes or pulse generator can be identified separately from the insertion (CPTs 93640 – 93641). 166
    • ELECTROPHYSIOLOGY ICD/AICD Procedures Removal When an ICD system is removed and not replaced CPT Codes for the removal of the generator AND electrodes should be captured. The ICD CPT Codes do not discriminate between a single or dual chamber pacing system. When an ICD system is removed and either reinserted (or another system is inserted) CPT Codes for the removal of the generator and electrodes, AND the insertion of the system should be captured. Radiologic guidance should be captured separately. 167
    • ELECTROPHYSIOLOGY ICD/AICD Procedures Repair CPT Codes 33218 and 33220 describe the repair of the electrode and include the removal and reinsertion of the leads. If when the repair is performed and the pulse generator requires replacement, CPT Codes 33240 and 33241 should be reported in addition to CPT Code 33218 or 33220. One of the following CPT Codes should be reported based on the number of electrodes/ Radiologic guidance should be captured separately. 168
    • ELECTROPHYSIOLOGY ICD/AICD Procedures Subsequent Analysis The ICD may require post-implantation evaluations, which are not performed on the same date as the implantation or replacement of the ICD. The evaluation may include defibrillation threshold evaluation, induced arrhythmia, and the evaluation of sensing and pacing. To report post-implantation evaluations CPT Code 93642 should be reported. To determine the effectiveness of the ICD, electronic analysis may also be necessary. Electronic analysis includes an evaluation at rest and during activity, using electrocardiographic recording, analysis of event markers and device response. CPT Codes 93741 – 93744 describe the electronic analysis of ICDs. The Codes are distinguished by the number of chambers involved and whether the ICD was reprogrammed. Electronic analysis can be reported with CPT Code 93642. 169
    • ELECTROPHYSIOLOGY Studies/Procedures EP Studies A comprehensive EP with induction includes six sub-component procedures each with their own CPT code. Bundle of His recording Intra-atrial pacing Intra-atrial recording Intraventricular pacing Right ventricular recording Induction of arrhythmia If fewer than the six sub-components of the comprehensive EP study are performed, look to the individual CPT codes for charge capture. If all components are present with exception of induction of arrhythmia, capture the comprehensive EP without induction. 170
    • ELECTROPHYSIOLOGY Studies/Procedures EP Studies A comprehensive EP without induction includes five sub- component procedures each with their own CPT code. Bundle of His recording Intra-atrial pacing Intra-atrial recording Intraventricular pacing Right ventricular recording If fewer than the five sub-components are documented, look to the individual CPT codes for charge capture. Ablations Ablation procedures can be performed independently or the same time as a diagnostic electrophysiology study. When a study, mapping and ablation are performed on the same day, all components are reported separately. 171
    • ELECTROPHYSIOLOGY Analyzing the electrophysiology CDM line item usage can identify potential areas of financial and/or compliance risk. Examples Generator Insertion and Supply It is expected that with each insertion of a pacemaker or ICD generator that a supply would also be captured. Review usage statistics for the insertion procedures against the C-codes for the devices. Look beyond Medicare! ICD Implant and Analysis It is expected that for each implant of an ICD an analysis will be performed at the time of the implant. The analysis can be captured separately. 172
    • MEDICAL AND SURGICAL SUPPLIES The vast majority of supplies used in a hospital do not require HCPCS codes. Supplies should be identified by HCPCS in the following situations: The device is classified as a pass-through item that generates additional reimbursement. The item is a prosthetic, orthotic, or implanted durable medical equipment (DME) (including pacemakers, slings, braces and trusses). The item is used with stoma care and is provided at the initial surgery creating the opening. The item qualifies as DME and the hospital is certified as a DME supplier and bills the DME MAC. The item qualifies as total parenteral nutrition (TPN) or enteral nutrition (EN) permanent nutritional therapy, and the hospital is registered as a provider and bills directly to the designated carrier. Other payers may require the hospital to identify different supplies using HCPCS codes or a payer-specific code. 173
    • MEDICAL AND SURGICAL SUPPLIES For the most part HCPCS codes are not required for supplies when billed under revenue codes 0270, 0271, 0272, 0273, 0277, and 0279. Hospitals must report all pass-through devices using HCPCS C codes under revenue code 0275, 0276, 0278, or 0624. Hospitals are encouraged to report all charges for a procedure even though some of the payment may be packaged. For determining whether supplies are separately billable determine the following: Is the supply directly identifiable to a specific patient? Is the supply furnished at the direction of a physician because of specified medical needs? Is the supply disposable? In determining how the supply CDM should be structured, a hospital must weigh pros and cons of different methodologies. 174
    • MEDICAL AND SURGICAL SUPPLIES 175
    • MEDICAL AND SURGICAL SUPPLIES Coding and Billing Considerations KITS Hospitals may buy kits that contain surgical supplies and devices. For kits that contain devices with a HCPCS code but the pass-through status has expired, the hospital may report the charge for the whole kit with the HCPCS code for the device. If the hospital wants to bill only the charge for the device, the rest of the kit should be billed under the appropriate supply revenue code. In either case the payment will be packaged into the payment for the procedure. For kits that contain devices with a pass-through status, hospitals should report the device separately, with the appropriate HCPCS codes. They should not bill other supplies billed in the kit with the pass- through device. However, the charges should be reported under the appropriate supply revenue code. 176
    • MEDICAL AND SURGICAL SUPPLIES Coding and Billing Considerations Device to Procedure Code Edits Current edits require a device code whenever certain procedures are billed. Device edits will require a procedure code whenever a device code is billed. The devices for which edits are to be implemented include such high dollar supplies as pacemaker and ICD generators and neurostimulator generators. Pass-Through Supplies Devices that qualify for transitional pass-through payments are those that fit in one of the established active device categories. Devices qualifying for pass-through status are indicated with status indicator “H”. 177
    • MEDICAL AND SURGICAL SUPPLIES Coding and Billing Considerations Vendor/Manufacturer Coding Guidance Medical device manufacturers are now recognized as an authoritative source of coverage information for devices receiving pass-through payments. CMS has stated that the information from a device company is “reasonable support for a coding decision.” Hospitals are advised to maintain a copy of any data from a manufacturer, should the need arise to prove their decision. 178
    • THANK YOU!
    • PRESENTER INFORMATIONCaroline Rader, MBA, MSHCA, CHCAssociate Director, Navigant Consultingcaroline.rader@navigantconsulting.com410-463-9867Deborah S. Zarick, R.N., BSN, CPC, CCS-P, CEMC, CPC-I, CPMAAssociate Director, Navigant Consultingdebbie.zarick@navigantconsulting.com484-764-6688