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  • 1. AAPC – Omaha Chapter January 18, 2005 7:00 am Presented by: Cynthia A. Swanson, RN, CPC Paula L. Smith, RN, CPC, CCS-P Seim, Johnson, Sestak & Quist, LLP 8807 Indian Hills Drive, Suite 300 Omaha, NE 68114 402.330.2660 CPT 2005 Changes and Medicare Update
  • 2. AGENDA
    • 2005 CPT
      • Overview of CPT Code Changes
      • Category II Codes
      • Category III Codes
    • Medicare 2005 Changes
    • Other Issues/Discussion
    Disclaimer A presentation can neither promise nor provide a complete review of the myriad of facts, issues, concerns and considerations that impact upon a particular topic. This presentation is general in scope, seeks to provide relevant background, and hopes to assist in the identification of pertinent issues and concerns. The information set forth in this outline is not intended to be, nor shall it be construed or relied upon, as legal advice. Recipients of this information are encouraged to contact their legal counsel for advice and direction on specific matters of concern to them. CPT is a trademark of the American Medical Association. CPT codes, descriptions and modifiers are copyright 2004 CPT American Medical Association.
  • 3. Overview of Changes for CPT 2005
    • Number of Annual CPT Coding Changes
    162 1997 399 1998 273 1996 410 1995 796 1994 1,467 1993 732 1992 286 2004 277 2005 428 2003 502 2002 408 2001 320 2000 686 1999
  • 4. Overview of Changes for CPT 2005
    • Code changes
    • New Codes – 170
    • Revised – 61
    • Deleted – 46
    • Hundreds of “other changes” related to guidelines, introductory notes, explanatory text, headings, and cross-references
    • Total codes for CPT 2005 = about 8,492 compared to 8,368 in 2004
  • 5. Overview of Changes for CPT 2005
    • No longer a grace period for new codes – must be used for services on or after January 1, 2005
    • National Standard Code Set/HIPAA
    • AMA Publication
      • CPT ™ Changes 2005–An Insider’s View
    • CPT Editing Marks
      • The Symbols
  • 6. Overview of Changes for CPT 2005
    • CPT Symbols
      • ● -________________________
      •  -________________________
      • + -________________________
      •  -________________________
      •  -________________________
    • Fill in the descriptions for these symbols
    • Color coding scheme
  • 7. Overview of Changes for CPT 2005
    • CPT Symbols
      • A new symbol was added
      • Conscious sedation “bulls-eye” symbol has been added for 2005
      • Intended to indicate those procedures in which the provision of conscious sedation services is considered to be inherent
      • Not separately reported by the same physician performing the primary service
      • Appendix G
  • 8. CPT 2005 Coding Manual
    • Appendix A – Modifiers
    • Appendix B – Summary of Additions, Deletions, and Revisions
    • Appendix C – Clinical Examples
    • Appendix D – Summary of CPT Add-on Codes
    • Appendix E – Summary of CPT Codes Exempt from Modifier 51
  • 9. CPT 2005 Coding Manual Features Four New Appendixes
    • Appendix F – Summary of CPT Codes Exempt from Modifier 63
    • Appendix G – Summary of CPT Codes which Include Conscious Sedation
    • Appendix H – Alphabetic Index of Performance Measures by Clinical Condition or Topic
    • Appendix I – Genetic Testing Code Modifiers
  • 10. Evaluation and Management (E/M) Services - continued
    • Excluding minor editorial modifications, revisions to the E/M section for CPT 2005 consist solely of clarification of the neonatal age
    • Consistency between diagnostic (ICD-9-CM) and procedural (CPT) code sets
  • 11. Evaluation and Management (E/M) Services - continued
    • Editorial revision made to the neonatal and pediatric critical care codes
      •  99293,  99294,  99295,  99296
      • Most commonly utilized definition of the neonatal period is beginning at birth and lasting through the 28 th day following birth
      • Formerly, CPT utilized 30 days of age or less
        • A critically ill patient of 29 days of age was reported using a neonatal CPT code and a non-neonatal ICD-9-CM code
      • Resolution of discrepancy
  • 12. Evaluation and Management (E/M) Services - continued
    • E/M Documentation Guidelines
      • Nothing new to report
      • The 1995 or 1997 E/M Documentation Guidelines are still in effect
      • Medicare – Can continue to use either set of guidelines
  • 13. Anesthesia
    • Minimal revisions
      • Addition of a single code
      • ● 00561 – Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, under one year of age
      •  (Do not report 00561 in conjunction with 99100, 99116 and 99135) 
  • 14. Anesthesia (continued)
    • Revision of the Anesthesia guidelines in tandem with the addition of Appendix G
    • Summary of CPT Codes Which Include Conscious Sedation
  • 15. Surgery
    • Notable changes in the surgery section this year include:
      • Six new transplant series of codes and guidelines
      • Conversion of Category III codes to Category I codes
        • Addition of 10 Category I codes
      • Guideline additions
      • New codes for skin debridement for necrotizing infections
      • New codes for gastric restrictive procedures
      • Revisions and additions to the bronchoscopy codes
  • 16. Surgery/Integumentary System
    • - Codes ● 11004 – ● 11006 were added to identify extensive debridement procedures
    • High risk patients, soft tissue infections such as Fournier’s gangrene
    • In addition to the risk and extensiveness involved in the performance of debridement procedure, transplantation or removal of organs, hernia and/or intestinal repair, or fistula repair may be necessary
  • 17. Surgery/Integumentary (continued)
    • Add-on code  ● 11008 has been established to identify concurrent removal of a mesh or prosthetic device
      • Includes parenthetical notes to identify procedures that should be separately reported and a list of exclusionary codes
  • 18. Surgery/Integumentary System (continued)
    • Three codes added to the Breast Introduction Section
      • ● 19296
      •  ● 19297
      •  ● 19298
    • Describe catheter placement and subsequent catheter removal for interstitial radioelement application in the breast following partial mastectomy
  • 19. Surgery/Integumentary System (continued)
      • Clarify reporting of spinal procedures related to:
      • - Exploration of spinal fusion
      • - Revision of previously placed instrumentation
      • Introductory language has been revised and expanded
  • 20. Surgery – Musculoskeletal
    • Clarify reporting of spinal procedures related to:
      • Exploration of spinal fusion
      • Revision of previously placed instrumentation
      • Introductory language of the Spinal Arthrodesis and Spinal Instrumentation subsections has been revised and expanded
  • 21. Surgery – Musculoskeletal (continued)
    • Exploration Subsection
      • Instructs the appropriate method of reporting arthrodesis procedures which would be performed at the same session as the definitive spinal procedure
      • Clarifies the use of 51 modifier
  • 22. Surgery – Musculoskeletal (continued)
    • Deletion of Category III codes 0012T, 0013T, 0014T
    • Five codes and nine cross-references were established to report techniques to provide hyaline or hyaline-like repair for articular knee defects
    • New codes
      • ● 27412 – Autologous chondrocyte implantation, knee
      • ● 27415 – Osteochondral allograft, knee, open
  • 23. Surgery/Respiratory System
    • Codes ● 31545 & ● 31546 were added to describe direct operative laryngoscopy with removal of non-neoplastic lesion(s) of the vocal cord
    • Revisions to the bronchoscopy section to distinguish airway stents placed in the trachea versus the bronchus or bronchi
  • 24. Surgery – Transplantation Services
    • Transplantation Background
    • Transplantation Procedures
    • Donor Backbench Codes
    • Rationale for Changes
  • 25. Surgery/Respiratory System
    • Lung Transplantation
      • Three distinct components of physician work
        • 1) Cadaver donor pneumonectomy(s)
        • 2) Backbench work
        • 3) Recipient lung allotransplantation
      • Two new codes ( ● 32855 and ● 32856) for backbench preparation of cadaver donor lung allograft prior to transplant
  • 26. Surgery/Cardiovascular System
    • Heart/Lung Transplantation
      • Codes ● 33933 and ● 33944 were added to describe backbench preparation of cadaver donor heart/lung allograft prior to transplantation
  • 27. Surgery/Cardiovascular System (continued)
    • Four new codes added to report endovenous ablation therapy for incompetent veins
    • ● 36475, ● 36476, ● 36478 and ● 36479
    • Add-on code to each of the initial codes intended to report performance of ablation for each additional vein after the first vein
  • 28. Surgery/Digestive System
    • Several new gastric restrictive surgery codes were added to reflect the rapidly expanding field of bariatric surgery
      • ● 43644 and ● 43645 – laparoscopic techniques
      • ● 43845 – added to describe biliopancreatic diversion with duodenal switch
      •  43846 – editorial revision to existing open Roux-en-Y gastric bypass for morbid obesity (150 cm or less)
      • For greater than 150 cm, use 43847
  • 29. Surgery/Digestive System
    • New codes for backbench work
      • Intestine Transplant
        • New codes ( ● 44715 – ● 44721)
      • Liver Transplant
        • New codes ( ● 47143 – ● 47147)
      • Pancreas Transplant
        • New codes ( ● 48551 – ● 48552)
      • Kidney Transplant
        • New codes ( ● 50323 – ● 50329)
  • 30. Surgery/Nervous System
    • Two new codes have been added to describe laminoplasty procedures
      • ● 63050
      • ● 63051
    • Laminoplasty is an alternative approach for posterior decompression of the cervical spinal cord
  • 31. Radiology
    • New Coding Tool
      • Clinical Examples in Radiology Newsletter
      • Authors: American Medical Association, American College of Radiology
      • Quarterly case-orientated format
  • 32. Radiology
    • Guideline additions to the Radiology Section
    • Provide greater clarity in coding
      • Guidelines for reporting diagnostic angiographies in the Aorta and Arteries, Veins and Lymphatics, and Transcatheter Procedures subsections of Radiology
      • Guidelines for ultrasound imaging services in the Abdomen and Peritoneum and Non-Obstetrical subsections of Radiology
  • 33. Radiology (continued)
    • New codes for fetal ultrasound services
      • ● 76820
      • ● 76821
    • Revisions in the Therapeutic Nuclear Medicine subsection
      • Tumor Imaging
  • 34. Radiology (continued)
    • Six new ( ● 78811 – ● 78816) codes for reporting tumor imaging by positron emission tomography (PET) and computed tomography (CT) procedures have been added to the Nuclear Medicine Diagnostic subsection of CPT.
  • 35. Pathology and Laboratory
    • Codes and cross-references added to report Helicobacter pylori testing/interpretation
    • Additions and revisions made to the morphometric analysis codes in the Surgical Pathology subsection
    • Guidelines added to the Molecular Diagnostics and Cytogenetics subsections
  • 36. Medicine
    • Revisions to:
    • Vaccine administration procedure codes
    • Gastric testing codes
    • Acupuncture codes
    • Neurostimulator codes
    • Echocardiography guidelines
  • 37. Medicine (continued)
    • Immunization Administration for Vaccines/Toxoids
    • Series of new codes ( ● 90465 – ● 90468) for immunization administration which incorporates the work of physician immunization counseling for young children (under 8 yrs. of age)
  • 38. Medicine (continued)
    • Gastroenterology
      • Five new codes ( ● 91034 – ● 91040) to report esophagus reflux testing, esophageal function testing and esophageal balloon distension provocation study
      • New testing methods in recent years
  • 39. Medicine (continued)
    • Active Wound Care Management
      • Updated section includes revised introductory guidelines
      • Revised codes to report selective debridement based on total surface area of wound(s) size
      • New procedures to describe negative pressure wound therapy techniques based on total surface area wound(s) size
  • 40. Medicine (continued)
    • Acupuncture
      • Codes 97780 and 97781 were deleted
      • Codes ● 97810 –  ● 97814 were established to more clearly describe acupuncture and electroacupuncture services
      • Codes based on 15 minute increments of personal contact with the patient
  • 41. Category II Codes
    • A new section of Category II (Performance Measurement) CPT codes and introductory notes was added to CPT 2004
    • All of the 2004 Category II codes have been deleted and renumbered
    • Four new codes have been added to represent Maternity Care Management
    • Eight new categories added for future expansion
  • 42. Category III Codes
    • Emerging Technology, Services and Procedures
    • CPT Codes – Alphanumeric identifier with a letter (T) in last field
    • 27 new codes added
    • Many Category III codes have been converted to Category I codes for 2005
  • 43. Category III Codes
    • Series of codes added for reporting
      • Percutaneous transcatheter placement of extracranial vertebral or intrathoracic carotid artery stents
      • Ultrasound ablation of uterine leiomyomata
      • Acoustic heart sound recording and computer analysis
      • Computed tomographic colonoscopy
      • Percutaneous intradiscal annuloplasty
  • 44. MMA 2003
    • Medicare Prescription Drug, Improvement, and Modernization Act of 2003
      • Largest change to the Medicare program since its inception
      • Huge social debate
    • Medicare 1964 – Disease Specific benefit
    • Movement to preventive medicine benefit with a co-pay
  • 45. MMA 2003 (continued)
      • Other Changes
        • Regulation
        • Managed Care
        • Fee Schedule Changes
        • Demonstration Projects
  • 46. 2005 Medicare Changes
    • MMA provision replaced a 4.5% reduction with a 1.5% increase for 2004 and a 3.3% reduction with a 1.5% increase for 2005
  • 47. 2005 Medicare Changes (continued)
    • Medicare Physician Fee Schedule Conversion Factor
      • 2004 - Conversion Factor $37.3374
      • 2005 - Conversion Factor $37.8975
    • Anesthesia Conversion Factor
      • 2004 - Conversion Factor $17.4969
      • 2005 - Conversion Factor $17.7594
  • 48. Medicare Changes 2005 (continued)
    • Venipuncture HCPCS Code G0001 is deleted for 2005
    • Report venipuncture service with CPT code 36415
    • In the final rule, the status indicator for CPT code 36415 reflects “I” – Invalid for Medicare. This is an error and it should be a “C” – Carrier priced.
    • Medicare reimbursement remains at $3.00 for 2005
  • 49. Medicare Changes 2005 (continued)
    • New Medicare Preventive Services
      • 1) Initial preventive physical examination (HCPCS “G” codes)
      • 2) Cardiovascular screening blood tests
      • 3) Diabetes screening tests
      • Specific coverage provisions apply for each of these new benefits
  • 50. Medicare Changes 2005 (continued)
    • Preventive Physical Examination
      • Eligible beneficiary
      • An initial preventive physical examination
        • Medical history
        • Physician
        • Qualified NPP
        • Social History
        • Review of individual’s functional ability and level of safety
        • Performance and interpretation of ECG
  • 51. Medicare Changes 2005 (continued)
    • Initial Preventive Physical Examination (IPPE)
      • G Codes
        • G0344 IPPE; face to face visit services limited to new beneficiary during the first six months of Medicare enrollment
        • G0366 EKG, routine EKG with at least 12 leads with interpretation and report, performed as a component of the IPPE
        • Report IPPE and the applicable EKG (G code)
  • 52. Medicare Changes 2005 (continued)
    • G0367 tracing only, without interpretation and report, performed as a component of the IPPE
    • G0368 interpretation and report only, performed as a component of the IPPE
  • 53. Medicare Changes 2005 (continued)
    • Diabetes Screening
      • The term “diabetes screening tests” is defined in Section 613 of the MMA as testing furnished to an individual at risk for diabetes and includes a fasting blood glucose test and other tests
      • Not a benefit if previously diagnosed diabetic
  • 54. Medicare Changes 2005 (continued)
    • Diabetes Screening
      • Individual at risk
        • Hypertension
        • Dyslipidemia
        • Obesity, BMI < or = to 30 kg/m2
        • Previous elevated fasting glucose
        • Two out of four risk factors
          • Overweight, as defined
          • Family history of diabetes
          • History of gestational diabetes mellitus or delivery of a baby weighing greater than 9 lbs
          • 65 years of age or older
  • 55. Medicare Changes 2005 (continued)
    • Diabetes Screening
      • Pre diabetic twice per 12 month period
      • V77.1 diagnosis code
      • CPT codes 82947, 82950, 82951
    • Watch for additional Medicare instructions regarding applicable coding and billing of these services
  • 56. Medicare Changes 2005 (continued)
    • Cardiovascular Screening
      • Ordered as panel or individually 80061
        • 82465 Cholesterol – total
        • 83718 HDL – cholesterol
        • 84478 Triglycerides
      • Once every five years
      • Labs must offer lipid panel without doing LDL above certain parameters
      • V81.0, V81.1 and V81.2
    • Watch for additional Medicare instructions regarding applicable coding and billing of these services
  • 57. 2005 Medicare Changes (continued)
    • Chemotherapy Drug Demonstration Project
      • Goals and Objectives
        • Review and analyze pain control management
        • Minimization of nausea and vomiting
        • Assess lack of energy
        • Assess quality of life
        • Assess patient symptoms and complaints
  • 58. 2005 Medicare Changes (continued)
    • Chemotherapy Drug Demonstration Project
      • Calendar Year 2005
      • Chemotherapy encounter
      • 12 new G codes for assessment
        • Not at all
        • A little
        • Quite a bit
        • Very much
  • 59. 2005 Medicare Changes (continued)
    • Chemotherapy Assessment
      • G0921 – G0924 Assessment of nausea and vomiting
      • G0925 – G0928 Assessment of pain
      • G0929 – G0932 Assessment of lack of energy (fatigue)
  • 60. 2005 Medicare Changes (continued)
    • Chemotherapy Assessment
      • Participating physicians must bill the applicable G-codes for each patient status factor assessed in each of the three categories during a chemotherapy encounter
      • A G-code for each patient status factor must appear on the claim for payment to be made
  • 61. 2005 Medicare Changes (continued)
    • A patient chemotherapy encounter is defined as chemotherapy administered through intravenous infusion or push, limited to once per day
    • An additional payment of $130 per encounter will be paid to participating providers for submitting the patient assessment data as described, during the demonstration project
  • 62. Medicare Changes 2005 (continued)
    • MMA – Drugs Paid by Average Selling Price
      • Beginning January 1, 2005, the payment limit for Part B drugs and biologicals, not paid on a cost or prospective payment basis, will be paid based on the Average Sales Price (ASP) plus 6 percent.
      • Drugs will be paid based on the date of service and the lower of:
        • The submitted charge; or
        • The ASP plus 6 percent
      • Quarterly pricing updates
  • 63. Medicare Changes 2005 (continued)
    • Medicare Incentive Payment
      • 5% incentive payment to physicians furnishing services in physician scarcity areas (PSA)
      • Primary care and specialty physicians
        • MMA defines a primary care physician as a general practitioner, family practice practitioner, general internist, obstetrician, or gynecologist
      • Applies to the professional services including E/M, surgery, consultation, and home, office and institutional visits (technical services are not eligible)
      • Dentists, Optometrists, Podiatrists and Chiropractors are not eligible
  • 64. Medicare Changes 2005 (continued)
    • Clinical Psychologists
    • Supervision of Diagnostic Tests
      • CP may supervise the performance of diagnostic psychological and neuropsychological testing services in addition to performing them
  • 65. Medicare Changes 2005 (continued)
    • Other Provisions
      • ESRD
      • Care Plan Oversite (CPO)
      • Hospice Consultation
      • CMS Replacement Drug Demonstration
        • “G” Codes
      • Vaccinations
        • Increase in allowances
      • Others that may be applicable to your practice
  • 66. Other 2005 Changes
    • CPT 2005 Errata
    • www.ama-assn.org
    • 2005 Medicare Physician Fee Schedule
    • HCPCS 2005 Additions, Revisions, and Deletions
    • 2005 ICD-9-CM Diagnosis Codes
      • Effective Oct. 1 your practice should already be using
    • Office of Inspector General (OIG) Work Plan Fiscal Year 2005
    • www.oig.hhs.gov
  • 67. OIG Work Plan Fiscal Year 2005
    • Medicare Physicians and Other Health Professionals
      • Billing Service Companies
      • Medicare Payments to VA Physicians
      • Care Plan Oversight
      • Ordering Physicians Excluded from Medicare
      • Physician Services at Skilled Nursing Facilities
  • 68. OIG Work Plan Fiscal Year 2005 (continued)
      • Physician Pathology Services performed in the physician office
      • Cardiography and Echocardiography Services
      • Physical and Occupational Therapy Services
      • Part B Mental Health Services
  • 69. OIG Work Plan Fiscal Year 2005 (continued)
      • Wound Care Services
      • Coding of E/M Services
      • Use of Modifier 25
      • “Long Distance” Physician Claims
      • Provider-Based Entities
  • 70. Considerations
    • Practitioner/staff education on changes
    • Available tools/resources
    • Update of office and out of office encounter forms
    • Fee analysis/updates
    • Computer updates/changes
  • 71. Other Issues/Concern
    • Questions
    • Discussion