2011 CDM Updates Day 2

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Part 2 of 2 of a workshop presented to the Western New York chapter of HFMA

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2011 CDM Updates Day 2

  1. 1. HFMA Western NY Chapter January 26, 2011 – Day 22011 OPPS UPDATES, CODING CHANGES AND CHARGE MASTER APPROACHES
  2. 2. 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 2
  3. 3. 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 3
  4. 4. CLINIC AND EMERGENCY SERVICES Separate HCPCS/CPT codes have yet to be established to describe E/M services provided within a facility. Hospitals are permitted to utilize “physician” E/M to capture charges for services provided. Physicians – expertise Hospitals – overhead To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or already established. New vs. Established Pertains to whether or not the patient already has a medical record number If patient had use of that medical record number within the past 3 years, the patient is considered an established patient to the hospital The same patient could be “new” to a physician or department, but “established” to the hospital 4
  5. 5. CLINIC AND EMERGENCY SERVICES CMS Standards for E/M Guidelines for Facilities1. The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources2. The coding guidelines should be based on hospital facility resources, not physician3. The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits4. The coding guidelines should meet the HIPAA requirements5. The coding guidelines should only require documentation that is clinically necessary for patient care6. The coding guidelines should not facilitate upcoding or gaming7. The coding guidelines should be written or recorded, well-documented, and provide the basis for selection of a specific code.8. The coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply.9. The coding guidelines should not change with great frequency.10. The coding guidelines should be readily available for fiscal intermediary (or if applicable MAC) review.11. The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.2008, Federal Register Vol. 72, p. 66805 5
  6. 6. EMERGENCY SERVICES CY2009 New York State ED Facility Levels 40.00% 35.00% 30.00% 25.00% % Distribution 20.00% 15.00% 10.00% 5.00% 0.00% 1 2 3 4 5 6 New York 3.69% 13.12% 35.69% 34.59% 12.91% 1.00% National 3.40% 12.52% 33.22% 33.00% 17.87% 2.00%
  7. 7. CLINIC AND EMERGENCY SERVICES A visit should be charged only when the patient is being seen for such services as to: be diagnosed; obtain a referral; obtain or renew prescriptions; discuss plans for therapy; have a dressing changed; check vital signs, and/or obtain services where the reason for the visit is not for the sole purposes of having a diagnostic test/procedure, injection, surgical procedure or other service that is further defined by a CPT/HCPCS Code. 7
  8. 8. CLINIC AND EMERGENCY SERVICES VISIT CHARGE WITH PROCEDURE When the patient meets the visit criteria defined on the previous page, but during the same visit the patient does have a diagnostic test/procedure, injection, surgical procedure or other service, the visit level may still be charged. A modifier -25 must be appended to the visit charge to indicate to the payers that there were separate and distinct procedures performed. Visit with -25 modifier and Procedure Charge Scenario Mrs. Smith is being seen by the pain management specialist at the hospital for her back pain. She is unsure of the origin of her pain and her treatment options. She would like further evaluation. She is greeted in the pain management clinic with a history taken by the hospital nurse before being seen by the physician. The physician reviews her symptoms and history and recommends an epidural injection. The physician performs the epidural injection while the patient is still in the office. 8
  9. 9. CLINIC AND EMERGENCY SERVICES PROCEDURE ONLY When the patient’s reason for coming to the hospital is for a scheduled diagnostic test/procedure, injection, surgical procedure or other service it is not appropriate to also charge for a visit unless the patient presents a new problem or there is some degree of medical decision. Time spent preparing the patient, including any related evaluation prior, is included in the procedure charge. Procedure Charge Only Scenario Mrs. Smith is being seen by the pain management specialist at the hospital for her back pain. She has been scheduled for an epidural injection. The physician performs the epidural injection in the clinic. 9
  10. 10. CLINIC AND EMERGENCY SERVICES PROCEDURE ONLY When the patient’s reason for coming to the hospital is for a scheduled diagnostic test/procedure, injection, surgical procedure or other service it is not appropriate to also charge for a visit unless the patient presents a new problem or there is some degree of medical decision. Time spent preparing the patient, including any related evaluation prior, is included in the procedure charge. Procedure Charge Only Scenario Mrs. Smith is being seen by the pain management specialist at the hospital for her back pain. She has been scheduled for an epidural injection. The physician performs the epidural injection in the clinic. 10
  11. 11. CLINIC AND EMERGENCY SERVICES CY2011 OPPS UPDATE CMS has not made revisions regarding the guidelines for clinic and emergency services E/Ms. Continue to utilize internal guidelines. Critical Care in the Facility Setting CMS clarified in the final rule that, consistent with the 2011 CPT guidelines, hospitals may begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care. However, hospitals will not receive separate payment for these ancillary services. If code 99291 is present on the claim with any of the specified ancillary procedure codes, the IOCE will change the status indicator of the ancillary procedure code from Q[#] to N for packaging. There is an exception to the packaged payment status of ancillary services when they are not provided in conjunction with critical care services. Hospitals may use modifier -59 to indicate when an ancillary procedure or service is distinct or independent from critical care when performed on the same day but in a different encounter. Payment for such services will not be packaged into the payment for critical care. 11
  12. 12. CLINIC AND EMERGENCY SERVICES CY2011 OPPS UPDATE Physician Supervision of Therapeutic Services CMS clarified in the final rule that therapeutic services performed in hospitals must be done under direct physician supervision. The definition only requires that the supervising physician or NPP be “immediately available to furnish assistance and direction throughout the performance of the procedure.” Examples of Outpatient Therapeutic Services: Clinic/emergency department visits Observation services Drug infusions and blood transfusions Outpatient psychiatric services Wound debridement Cardiac and pulmonary rehabilitation 12
  13. 13. CLINIC AND EMERGENCY SERVICES CY2011 OPPS UPDATE Tobacco Cessation Counseling Starting January 1, 2011, hospitals will have two new HCPCS codes for reporting covered tobacco cessation counseling services. HCPCS codes C9801 and C9802 will be deleted December 31, 2010, and replaced with HCPCS codes G0436 and G0437. G0436 - Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes G0437 - Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes Specific coverage and coding guidelines http://www.cms.gov/manuals/downloads/clm104c18.pdf 13
  14. 14. OUTPATIENT OBSERVATION SERVICES “Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. “ – Medicare Claims Processing Manual Specific coding and billing requirements exist for payment: Physician Order Documentation HCPCS/CPT requirements Calculation of Hours 14
  15. 15. OUTPATIENT OBSERVATION SERVICES Physician Order The physician documentation should clearly differentiate an order for outpatient observation from an order for inpatient admission. The reason for observation must be stated in the orders for observation. Physicians should not use the term “admit” when placing the patient in observation. This term could confuse staff responsible for indicating the appropriate status in the bed tracking systems, request for documentation requirements, internal flags for processing of laboratory and pharmacy orders, etc. Inadequate Documentation: “Place in observation due to a large amount of alcohol ingestion”. Adequate Documentation: “Place in observation due to large amount of alcohol ingestion and the risk of hypoxia and aspiration”. 15
  16. 16. OUTPATIENT OBSERVATION SERVICES Documentation Medical records will be expected to demonstrate the consistency between the physician order (physician intent), the services actually provided (inpatient or outpatient) and the medical necessity of those services, including the medical appropriateness of the inpatient or observation stay. The medical record must clearly support the medical necessity for observation and should include a timed order to observe which will support the number of hours billed. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient. 16
  17. 17. OUTPATIENT OBSERVATION SERVICES Calculation of Hours Observation time begins at the clock time documented in the patient’s medical record, which coincides with the time that observation care is initiated in accordance with a physician’s order. Observation time ends when all medically necessary services related to observation care are completed. For example, this could be before discharge when the need for observation has ended, but other medically necessary services not meeting the definition of observation care are provided (in which case, the additional medically necessary services would be billed separately or included as part of the emergency department or clinic visit) Hospitals should round to the nearest hour. 17
  18. 18. OUTPATIENT OBSERVATION SERVICES Calculation of Hours Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure (e.g., colonoscopy, chemotherapy). In situations where such a procedure interrupts observation services, hospitals would record for each period of observation services the beginning and ending times during the hospital outpatient encounter and add the length of time for the periods of observation services together to reach the total number of units reported on the claim for the hourly observation services HCPCS code G0378 (Hospital observation service, per hour). – Medicare Claims Processing Manual 18
  19. 19. OUTPATIENT OBSERVATION SERVICES Calculation of Hours Observation time ends when all medically necessary services related to observation care are completed. For example, this could be before discharge when the need for observation has ended, but other medically necessary services not meeting the definition of observation care are provided (in which case, the additional medically necessary services would be billed separately or included as part of the emergency department or clinic visit). Alternatively, the end time of observation services may coincide with the time the patient is actually discharged from the hospital or admitted as an inpatient. – Medicare Claims Processing Manual 19
  20. 20. OUTPATIENT OBSERVATION SERVICES HCPCS/CPT requirements Hospitals should report G0378 when observation services are provided to patients receiving outpatient observation services. The numbers of units reported are equal to the number of hours in observation. If the period of observation spans more than 1 calendar day, all of the hours for the entire period of observation must be included on a single line and the date of service for that line is the date that observation care begins. Hospitals should report G0379 when observation services are the result of a direct admission into outpatient observation services without an associated emergency room visit, hospital outpatient clinic visit, or critical care service on the day of initiation of outpatient observation services. Revenue Codes 0760 or 0762 may be used on the UB0413X bill type to report observation services. 20
  21. 21. OUTPATIENT OBSERVATION SERVICES 21
  22. 22. INFUSIONS AND INJECTIONS Infusion therapy and injections can include both chemotherapeutic and non- chemotherapeutic pharmaceuticals. To report, refer to CPT Codes 96360 – 96549 UB-04 revenue codes are specific to the type of therapy (e.g. chemo – 0335) A hierarchy was created for facilities to report infusion therapy services. The initial code should be selected using a hierarchy whereby chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration services. Infusions are primary to pushes, which are primary to injections. Facilities are to follow this hierarchy and it supersedes parenthetical instructions for add-on codes that suggest an add-on of a higher hierarchical position may be reported in conjunction with a base code of a lower position. 22
  23. 23. INFUSIONS AND INJECTIONS Additional Coding Tips: If performed to facilitate the infusion or injection, the following services are included and are not reported separately: Use of local anesthesia IV start Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion Standard tubing, syringes, and supplies Preparation of chemotherapy agents When multiple drugs are administered, report the service(s) and the specific materials or drugs for each. Don’t report infusion for fluids used to administer a drug. This also includes the administration of fluid to maintain IV line patency during blood transfusions. 23
  24. 24. INFUSIONS AND INJECTIONS Additional Coding Tips: When administering multiple infusions, injections or combinations, only one “initial” service code should be reported, unless protocol requires that two separate IV sites must be used. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services then a subsequent or concurrent code from the appropriate section should be reported, e.g., the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code. It is important to remember that injections are coded per injection, not per medication. When reporting codes based on infusion time, use the actual time over which the infusion is administered. 24
  25. 25. INFUSIONS AND INJECTIONS Additional Coding Tips: Length of time, calculated by the start and stop times, determines whether a procedure is coded as an infusion or injection. To ensure accurate coding and billing, providers must understand the start and stop documentation requirement. Any infusion less than 15 minutes should be coded as an intravenous push injection. In the absence of start and stop time, providers may only request reimbursement at the IV push level. Fluid used to administer the drug(s) is considered incidental hydration and is not separately reportable. If documentation supports a clinical condition that warrants hydration, other than one brought about by the requirements of a procedure, the hydration can be separately billable. 25
  26. 26. INFUSIONS AND INJECTIONS Additional Coding Tips: Outpatient visits (E/M CPTs 99201- 99215) can be reported in the infusion center setting when identified as a separate and distinct service. The basic assessment and monitoring of the patient pre and post injection/infusion is inherent in the procedure and not considered to be separate and distinct. When patients receive therapeutic treatment in the outpatient setting, the first-listed code should represent the diagnosis, condition, problem or other reason for the encounter/visit that is chiefly responsible for the outpatient services provided. The only exception to this rule is that when the primary reason for the encounter is chemotherapy, radiation therapy or rehabilitation, the appropriate V-code for the service should be sequenced as the first-listed code and the diagnosis or problem for which the service is provided is coded in subsequent positions. - V58.11, “Encounter for antineoplastic chemotherapy”, or V58.12, “Encounter for antineoplastic immunotherapy” 26
  27. 27. PHARMACEUTICALS Hospitals must report all appropriate HCPCS codes and charges for separately payable drugs, in addition to reporting the applicable drug administration codes. Hospitals should also report the HCPCS codes and charges for drugs that are packaged into payments for the corresponding drug administration or other separately payable services. Drugs are billed in multiples of the dosage specified in the HCPCS code long descriptor. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit based on the HCPCS long descriptor for the code in order to report the dose provided. If the full dosage provided is less than the dosage for the HCPCS code descriptor specifying the minimum dosage for the drug, the provider reports one unit of the HCPCS code for the minimum dosage amount. 27
  28. 28. PHARMACEUTICALS Several outpatient drugs are classified as self-administrable and are not covered by Medicare. The only ordinarily noncovered, self-administered outpatient drugs covered under Medicare are insulin administered in an emergency situation to a patient in a diabetic coma and antiemetics in limited situations. Oral radiopharmaceuticals can be captured and billed. Each line item billed as not covered or associated with an ABN must be identified with a HCPCS code and associated modifier. This includes all OPPS packaged items and those items traditionally not billed with HCPCS codes in the past. Report the most specific HCPCS code available to describe the item or service. If no specific HCPCS code exists, report HCPCS code A9270, “Non covered item/service” with revenue code 0637. Outpatient claims submitted with a revenue code 0637 without a HCPCS will be returned to the provider. 28
  29. 29. PHARMACEUTICALS CY2011 CMS OPPS Update Reporting Pharmaceuticals CMS continues to strongly urge hospitals to report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used. CMS also restates that “It is also of great importance that hospitals billing for these products make certain that the reported units of service of the reported HCPCS codes are consistent with the quantity of a drug, biological, or radiopharmaceutical that was used in the care of the patient.” 29
  30. 30. PHARMACEUTICALS CY2011 CMS OPPS Update Reporting Pharmaceuticals CMS reminded hospitals, “If two or more drugs or biologicals are mixed together to facilitate administration, the correct HCPCS codes should be reported separately for each product used in the care of the patient. The mixing together of two or more products does not constitute a “new” drug as regulated by the Food and Drug Administration (FDA) under the New Drug Application (NDA) process. In these situations, hospitals are reminded that it is not appropriate to bill HCPCS code C9399. HCPCS code C9399, Unclassified drug or biological, is for new drugs and biologicals that are approved by the FDA on or after January 1, 2004, for which a HCPCS code has not been assigned. Unless otherwise specified in the long description, HCPCS code descriptors refer to the non-compounded, FDA-approved final product. If a product is compounded and a specific HCPCS code does not exist for the compounded product, the hospital should report an appropriate unlisted code such as J9999 or J3490.” 30
  31. 31. PHARMACEUTICALS CY2011 CMS OPPS Update New Codes For 2011, fourteen new HCPCS codes that are eligible for separate payment have been created for reporting drugs and biologicals in the hospital outpatient setting: C9274 Crotalidae Polyvalent Immune Fab (Ovine), 1 vial C9275 Injection, hexaminolevulinate hydrochloride, 100 mg, per study dose C9276 Injection, cabazitaxel, 1 mg C9277 Injection, alglucosidase alfa (Lumizyme), 1 mg C9278 Injection, incobotulinumtoxin A, 1 unit C9279 Injection, ibuprofen, 100 mg J0638 Injection, canakinumab, 1 mg J1559 Injection, immune globulin (Hizentra), 100 mg 31
  32. 32. PHARMACEUTICALS CY2011 CMS OPPS Update New Codes J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg J2358 Injection, olanzapine, long-acting, 1 mg J7196 Injection, antithrombin recombinant, 50 IU J7309 Methyl aminolevulinate (mal) for topical administration, 16.8%, 10 mg Q4118 Matristem micromatrix, 1 mg Q4121 Theraskin, per square centimeter 32
  33. 33. PHARMACEUTICALS CY2011 CMS OPPS Update New Codes J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg J2358 Injection, olanzapine, long-acting, 1 mg J7196 Injection, antithrombin recombinant, 50 IU J7309 Methyl aminolevulinate (mal) for topical administration, 16.8%, 10 mg Q4118 Matristem micromatrix, 1 mg Q4121 Theraskin, per square centimeter 33
  34. 34. DIAGNOSTIC CARDIOLOGY Diagnostic cardiology includes diagnostic non-invasive testing; such as, electrocardiograms and echocardiograms. CPT Coding is fairly straightforward for each test. Report the technical service only, “without interpretation and report” The units of service are “1” per test. Routine electrocardiographic monitoring during surgery does not constitute a separate charge. A specific order must be present in documentation, along with a separate, signed, written, and retrievable report. Reviewing strips from a telemetry monitoring system is not enough – “I saw a blip!”, Nurse Sally The UB revenue code required for reporting comes from 48X. Most providers default to the general classification of 0480. 34
  35. 35. DIAGNOSTIC CARDIOLOGY CY2011 CPT Updates Deleted Codes 93012, “Telephonic transmission of post-symptom electrocardiogram rhythm strip(s), 24 hour attended monitoring, per 30 day period of time; tracing only” 93014 – physician review with interpretation and report only To report telephonic transmission of post-symptom electrocardiogram rhythm strips, see 93268-93272 35
  36. 36. DIAGNOSTIC CARDIOLOGY CY2011 CPT Updates Revised Codes 93224, “External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation” 93225 – recording (includes connection, recording and disconnection) 93226 – scanning analysis with report 93227 – physician review and interpretation Revised to describe external electrocardiographic recording for up to 48 hours The term “wearable” has been replaced with “external” for consistency with other codes. 36
  37. 37. DIAGNOSTIC CARDIOLOGY CY2011 CPT Updates Revised Codes 93228, “External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report” 93229 – technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports The term “wearable” has been replaced with “external” for consistency with other codes. 37
  38. 38. DIAGNOSTIC CARDIOLOGY CY2011 CPT Updates Deleted Codes 93230, “Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; includes recording, microprocessor-based analysis with report, physician review and interpretation” 93231 – recording (includes connection, recording, and disconnection) 93232 – microprocessor-based analysis with report 93233 – physician review and interpretation To report external electrocardiographic rhythm derived monitoring for up to 48 hours, see 93224-93227 38
  39. 39. DIAGNOSTIC CARDIOLOGY CY2011 CPT Updates Deleted Codes 93235, “Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous computerized monitoring and non-continuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient activated; includes monitoring and real-time data analysis with report, physician review and interpretation” 93236 – monitoring and real-time data analysis report 93237 – physician review and interpretation To report external electrocardiographic rhythm derived monitoring for up to 48 hours, see 93224-93227 39
  40. 40. DIAGNOSTIC CARDIOLOGY CY2011 CPT Updates Revised Codes 93268, “External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom- related memory loop with remote download capability up to 30 days, 24 hours attended monitoring; includes transmission, physician review and interpretation” 93270 – recording (includes connection, recording, and disconnection) 93271 – transmission download and analysis 93272 – physician review and interpretation The term “wearable” has been replaced with “external” for consistency with other codes. 40
  41. 41. RESPIRATORY/PULMONARY Respiratory and pulmonary services are found in CPT range 94010–94799. Services include laboratory procedure(s) and interpretation of test results. If a separate identifiable evaluation and management (E/M) service is performed, the appropriate E/M service code should be reported in addition these services. The respiratory therapy/pulmonary function chargemaster may include procedures, therapies and supplies. Services have great potential to be confusing and lend to errors in coding and charge capture. Common issues are found across facilities nationwide. 41
  42. 42. RESPIRATORY/PULMONARY General Coding Tips: Spirometry and flow loop should not be reported together. When spirometry is performed, this includes vital capacity and/or maximum voluntary ventilation. Spirometry with bronchodilator includes a pre and post spirometry. The demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device can only be reported once per day. 42
  43. 43. CARDIAC AND PULMONARY REHABILITATION Cardiac and pulmonary rehabilitation are covered services under CMS, with specific requirements for HCPCS/CPT coding,, diagnoses and frequency limitations. Element Cardiac Rehabilitation Pulmonary Rehabilitation HCPCS/CPT 93797, 93798 G0424 Diagnoses Acute MI, CABG, Stable Moderate to Severe COPD Angina, Heart Valve Repair/Replacement, PTCA, Heart or Heart/Lung Transplant Frequency 2-1 hour sessions/day 2-1 hour sessions/day 36 sessions up to 36 weeks 36 sessions Services are required to be provided under direct physician supervision. http://www.cms.gov/manuals/downloads/clm104c32.pdf 43
  44. 44. SURGICAL SERVICES Surgical services are found in the range of CPTs 10000 – 69990 some Category III G-codes HIM often will not “code per payer” Typically captured through use of time-based codes, but no standard methodology is found. Involves soft-coding processes Exception may exist with minor surgical procedures performed in ED, Clinic or Radiology procedures Examples: breast biopsies, wound care, intubation, gastric lavage Pricing includes routine costs ,equipment, overhead, etc. 44
  45. 45. SURGICAL SERVICES CY2011 CMS Updates Number of updates made including additions, revisions and deletions. Minimal number of the changes are found ton include procedures that can either be found hard-coded in the CDM All CPT updates can be provided in a separate presentation to the group. 45
  46. 46. SURGERY - INTEGUMENTARY Extensive revisions to the integumentary system by removing the term “excisional debridement” and replacing with only the term “debridement” Guidelines have been expanded to define wound debridement and surface area related to debridement of the subcutaneous tissue, biofilm, epidermis, dermis, muscle, &/or fascia.
  47. 47. DEBRIDEMENT Revision Example – Integumentary: Editorially revised for standardization of the nomenclature describing debridement including removal of foreign material at the site of an open fracture &/or an open dislocation 11010 – Debridement including removal of foreign material at the site of an open fracture &/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues Old – Debridement including removal of foreign material associated with open fracture(s) &/or dislocation(s); skin and subcutaneous tissues 11011 – skin, subcutaneous tissue, muscle fascia, and muscle 11012 – skin, subcutaneous tissue, muscle fascia, muscle, and bone
  48. 48. DEBRIDEMENT Deleted codes: 11040 – Debridement; skin partial thickness 11041 skin, full thickness For debridement of skin, ie epidermis &/or dermis only, see 97597, 97598 Revised codes: 11042, 11043, 11044 - Revised by surface area and depth, and the depth was further split into 4 levels of wound surface. Also uniformly include a 20 sq cm with add-on codes for additional services. New codes: 11045, 11046, 11047 - Add-on codes to report each additional 20 sq cm, or part thereof
  49. 49. SURGERY-MUSCULOSKELETAL Deleted code: 20000 – incision of soft tissue abscess; superficial Deleted due to overlap and intent of the cutaneous/subcutaneous codes To report incision and drainage procedures, cutaneous/subcutaneous, see 10060, 10061 Revised code: 20005 – Incision and drainage of soft tissue abscess, subfascial (ie, involved the soft tissue below the deep fascia) Editorially revised to define the depth of the incision and drainage as “subfascial” instead of “deep”
  50. 50. RESPIRATORY New code: Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed, diagnostic, with cell washing, when performed 31634 – with balloon occlusion, with assessment of air leak, with administration of occlusive substance (eg, fibrin glue), if performed New code to describe a bronchoscopic technique that has been performed in the past as part of a last effort to resolve persistent broncho-pleural fistulas. It is becoming more common as an earlier therapy for the disease.
  51. 51. RESPIRATORY New codes: 31295 – Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa) 31296 – with dilation of frontal sinus ostium (eg, balloon dilation) 31297 – with dilation of sphenoid sinus ostium (eg, balloon dilation) Created to describe the dilation of sinus ostia by displacement of tissue utilizing any method
  52. 52. RADIATION ONCOLOGY The process of treating a patient with radiation involves five basic steps: Consult or new patient exam Treatment planning Simulation and Dosimetry Treatment delivery and management Follow up Documentation to support the medical necessity of all procedures and complementary services must be maintained in the patient’s medical record. Planned course of therapy Type and delivery of treatment Level of clinical management involved Ongoing documentation of any changes in the course of treatment. 52
  53. 53. RADIATION ONCOLOGY Examples of documentation include, but are not limited to: Treatment plan for course of therapy Type and method of delivery of therapy Clinical management notes Simulation – request, level, devices, medical necessity, and location performed Physics/Dosimetry – calculations and signatures, isodose plans, special dosimetry, special consults, etc. Treatments Procedure notes Treatment devices 53
  54. 54. RADIATION ONCOLOGY General Coding and Billing Tips Date of Service Since a number of services are considered to be components of major services performed for treatment planning and delivery, it is necessary that all services billed include the date of service documented in the medical record. Treatment Planning Treatment planning is generally only reported once for a given course of treatment since it is directly tied to the course of therapy and to the site(s) where the therapy will be provided. A different problem necessitating a new course of radiation therapy will justify the charge for another treatment planning code. If additional plans are done, the specific reason for the additional plan must be documented. 54
  55. 55. RADIATION ONCOLOGY General Coding and Billing Tips Simulation Documentation of simulation requires a written record of the procedure and hardcopy of electronic images and evidence of image review by physicians including signature or initials and data review. Dosimetry The typical course of radiation therapy may require from one to six dosimetry calculations, depending upon the complexity of the patients problem. Medicare would expect to see documentation in the patients medical record that would include any changes in dosimetry calculations and change in radiation treatment and frequency. 55
  56. 56. RADIATION ONCOLOGY General Coding and Billing Tips Teletherapy Isodose Plan The typical course of radiation therapy will require from one to three isodose plans. Usually only one plan per volume of interest will be sufficient, though some patients may require multiple teletherapy plans during the course of therapy. Situations that may require an extra teletherapy plan include the need to change the machine or the volume of interest. Toward the end of treatment, due to clinical variations of the patient, another plan may be required. 56
  57. 57. RADIATION ONCOLOGY General Coding and Billing Tips Teletherapy Isodose Plan While multiple plan calculations may be required for a given condition, the one chosen for optimal therapy is the only one that can be charged. Only one isodose plan may be reported for a given course of therapy to a specific treatment area; however, additional isodose plans may be reported if fields or equipment are changed for medically necessary conditions. The addition of a boost, requiring a separate isodose plan, is separately coded and billed. 57
  58. 58. RADIATION ONCOLOGY General Coding and Billing Tips Special Teletherapy Port Plan This service is considered medically necessary only when a plan for a special beam consideration is required. Only one plan should be billed per treatment course. Special Dosimetry This service is considered medically necessary once per port when the physician determines that it is necessary to have a measurement of the amount of radiation that a patient has actually received at a given point with the final results being utilized to accept or modify the current treatment plan. When special dosimetry is employed, the usual frequency will vary from one to four times during the radiation course. 58
  59. 59. RADIATION ONCOLOGY General Coding and Billing Tips Treatment Devices If devices of two separate levels of complexity are used for the same treatment port, only the device of the highest complexity will be billable – unless each device has been custom designed for that port. An individual treatment device may be reported and charged only one time for the entire course of therapy. Items that are not billable as treatment devices include sandbags, pulleys, passive restraints, sponges and pads, armrests, pillows, T-bar, leg immobilizers. 59
  60. 60. RADIATION ONCOLOGY General Coding and Billing Tips Physics Planning Procedure code 77336 can be billed if detailed documentation in the medical record reflects that all aspects of the patient’s care has been reviewed and appropriate recommendations have been made as a result of that review. A "week" consists of five treatments. The date of service billed for 77336 must be the same date as the last treatment for that week. 60
  61. 61. RADIATION ONCOLOGY General Coding and Billing Tips Special Physics Consultation Capture for consultative purposes when a problem or special situation arises during radiation therapy. The procedure requires a detailed written report by the physicist to the radiation oncologist with reference to the problem being addressed. This is not routinely assigned for complex services, such as all 3D services or for IMRT planning. Some examples of cases where a special physics consult would be requested are: analysis of customized beam modification devices and special blocking procedures to protect critical organs during treatment plan development for multiple primary cancers, treated simultaneously analysis and recommendations for transplanted organ protection 61
  62. 62. RADIATION ONCOLOGY General Coding and Billing Tips Port Films CPT code 77417 is a technical service only. No modifier is required. Documentation in the medical record must verify that the port films were done as per the physician order. The date, location and views of the films along with the name of the radiology technician who performed the imaging must be documented in the medical record Port films should be reported as one charge per five fractions of therapy per portal regardless of the number of films required. Additional films may be necessary if the patient’s clinical status changes. 62
  63. 63. RADIATION ONCOLOGY General Coding and Billing Tips Stereotactic Radiosurgery For non-Medicare claims CPT codes 77371–77373, and 77432 may be used to report stereotactic radiosurgery (SRS). For Medicare claims, report SRS planning with the available CPT treatment planning codes that most accurately reflect the services provided, regardless of the mode of treatment delivery planned. For Medicare claims, the reporting of SRS delivery depends on the mode of treatment. Report CPT code 77371 for multisource photon (cobalt-60) SRS, delivery including collimator changes and custom plugging, complete course of treatment, all lesions HCPCS code G0173 is used to report linear accelerator based SRS, delivery including collimator changes and custom plugging, complete course of treatment in one session, all lesions. 63
  64. 64. RADIATION ONCOLOGY General Coding and Billing Tips Stereotactic Radiosurgery Report HCPCS code G0339 for image-guided robotic linear accelerator based SRS, including collimator changes and custom plugging, complete course of treatment in one session or first session of a fractionated treatment. HCPCS code G0251 is used to report linear accelerator based SRS, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum of five sessions per course of treatment. Report HCPCS code G0340 for image-guided robotic linear accelerator based SRS, including collimator changes and custom plugging, second through fifth sessions, maximum of five sessions per course of treatment. 64
  65. 65. RADIATION ONCOLOGY General Coding and Billing Tips Intensity modulation radiation therapy (IMRT) Hospitals should report CPT code 77301 for IMRT planning. IMRT treatment delivery is reported using CPT code 0073T or 77418. Hospitals should bill CPT code 77418 for multileaf collimator-based IMRT delivery and category III CPT code 0073T for compensator-based IMRT delivery. Payment for IMRT planning does not include payment for CPT codes 77332–77334 when furnished on the same day. When services described by CPT codes 77332–77334 are furnished on the same date of service with 77301, these services should be billed in addition to the CPT IMRT planning code 77301. 65
  66. 66. RADIATION ONCOLOGY General Coding and Billing Tips Intensity modulation radiation therapy (IMRT) Hospitals billing for both IMRT treatment planning, CPT code 77301, and design and construction of complex treatment devices, CPT code 77334, on the same day should append modifier 59 to CPT code 77334. Hospitals may report other services, CPT codes from range 77401– 77416, or 77418, if they are performed at different treatment sessions on the same day as IMRT. Append modifier 59 to the appropriate codes. 66
  67. 67. RADIATION ONCOLOGY CY2011 OPPS Update Intensity modulation radiation therapy (IMRT) Hospitals billing for both IMRT treatment planning, CPT code 77301, and design and construction of complex treatment devices, CPT code 77334, on the same day should append modifier 59 to CPT code 77334. Hospitals may report other services, CPT codes from range 77401– 77416, or 77418, if they are performed at different treatment sessions on the same day as IMRT. Append modifier 59 to the appropriate codes. 67
  68. 68. REFERENCES Federal Register Final Rule for CY2011 http://edocket.access.gpo.gov/2010/pdf/2010-27926.pdf CMS Addendum A and B Updates http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage CMS Internet Only Manuals http://www.cms.gov/Manuals/IOM/list.asp CMS Transmittals http://www.cms.gov/Transmittals/2011Trans/list.asp CMS Frequently Asked Questions http://questions.cms.hhs.gov/ CMS HCPCS File http://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage 68
  69. 69. REFERENCES CMS Device to Procedure & Radiopharmaceutical Edits http://www.cms.gov/HospitalOutpatientPPS/02_device_procedure.asp#TopOfPage CMS Integrated Outpatient Code Editor http://www.cms.gov/OutpatientCodeEdit/ 69
  70. 70. THANK YOU!
  71. 71. 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

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