1. 3/13/2010
Slide 2
 SPECT Myocardial Perfusion
Imaging - 36 % cut
 Transthoracic echo with
spectral and color flow Doppler
10 % cut
 Coronary
Coronar Stent - 4 % c t
cut
 EKG - 5 %cut
 Consults eliminated by CMS
 APC for Remote interrogation
of implantable cardiovascular
monitor is reassigned
reimbursement from $771 to
$38
 Equipment Utilization impacts
practice expense formulas
◦ Cardiac MR / Cardiac CT
THE SKY IS FALLING …. THE SKY IS FALLING …
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2. 3/13/2010
Slide 3
 STOP
◦ Playing the game by the wrong rules
◦ Providing FREE CARE
◦ Adopting the wrong approach to
denial management
◦ Under estimating the TEAM approach
◦ Limiting technology to claim
submission
Slide 4
Document what was done
Document why it was done
When appropriate – speak CPT
2

3. 3/13/2010
Slide 5
The Rules

The accuracy of CPT coding on the provider’s
p
part unfortunately cannot g
y guarantee p y
payment
by all payers and plans. Providers must
review the coding and coverage policies of
each individual carrier with whom they are
contracted.
Copyright 2010, Coding Strategies, Inc.
Slide 6
 Medicare Guidelines
◦ Existing consultation codes will not be covered
g
(99241 – 99255)
 Primary or Secondary claims
◦ Report outpatient ‘consults’ as Office Services
 New / Established ( 99201 – 99215 )
 Has the patient been seen within 3 years?
 Documentation guidelines differ New – Est.
Copyright 2010, Coding Strategies, Inc.
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4. 3/13/2010
Slide 7
◦ Report inpatient ‘consults’ as Hospital Inpatient
Services
 Initial (99221-99223) for initial patient encounter
 Modifier AI admitting physician of record)
 Subsequent evaluation during the same admission
(99231 – 99233)
◦ Cross-walk … 5 levels of consults into 3 levels of
Hospital Initial Inpatient Services
 Documentation .. .documentation …
documentation
Copyright 2010, Coding Strategies, Inc.
Slide 8
Copyright 2010, Coding Strategies, Inc.
4

5. 3/13/2010
Slide 9
 CPT 76376
◦ 3D rendering with interpretation and reporting of
computed tomography, magnetic resonance
imaging, ultrasound, or other tomographic
modality; not requiring image postprocessing on an
independent workstation
◦ CPT 76377
 ; requiring i
i i image postprocessing on an
i
independent workstation
Copyright 2010, Coding Strategies, Inc.
Slide 10
 4 cardiac MRI codes that previously included flow/velocity
quantification (75558, 75560, 75562, 75564) deleted
CPT Description
75557 Cardiac MRI for morphology and function wo contrast;
75559 ..with stress imaging
75561 Cardiac MRI for morphology and function wo contrast, followed
by contrast material and further sequences;
75563 …with stress imaging
+75565 Cardiac MRI for velocity flow mapping (list separately)
 Velocity flow mapping (75565) may be used in
conjunction with any cardiac MRI codes – once per
encounter
Copyright 2010, Coding Strategies, Inc.
5

6. 3/13/2010
Slide 11
 Coronary Interventions
 Peripheral Interventions
e p e a te e t o s
 Cervical Carotid Interventions
◦ Diagnostic angiography/venography separate?
◦ Catheterizations separate?
◦ Imaging separate?
Copyright 2010, Coding Strategies, Inc.
Slide 12
 Diagnostic angiography/venography separately reportable if:
◦ No prior catheter-based angiography/venographic study is
available
◦ a full diagnostic study is performed and the decision to
intervene is based on the diagnostic study
 A study is available, but …
◦ The patient’s condition with respect to the clinical
indication has changed since the prior study, OR
◦ There is inadequate visualization of the anatomy and/or
pathology,
pathology OR
◦ There is a clinical change during the procedure that
requires new evaluation outside the target area of
intervention
Copyright 2010, Coding Strategies, Inc.
6

7. 3/13/2010
Slide 13
 Via transseptal puncture, ablation catheter into
the left atrium
 Ring of lesions is created at the ostium of each
affected pulmonary vein
 TIME CONSUMING procedure (6+ hrs)
 Report service with SVT ablation code (93651)
 Carriers may instruct to use unlisted code
(
(93799))
 Modifier -22 may be utilized for physician
claims
◦ Do more than just send in the report
Copyright 2010, Coding Strategies, Inc.
Slide 14
Copyright 2010, Coding Strategies, Inc.
7

8. 3/13/2010
Slide 15
“One of the top billing
One
errors determined by
federal, state and private
payors involves the
incorrect use of modifiers.”
Copyright 2010, Coding Strategies, Inc.
Slide 16
 “Increased Procedural Services”
 Parenthetical notes define criteria for code as
 Increased:
 Intensity
 Time
 Technical difficulty
 Severity of PT condition
Copyright 2010, Coding Strategies, Inc.
8

9. 3/13/2010
Slide 17
Copyright 2010, Coding Strategies, Inc.
Slide 18
 Q: What would be the correct way to code the
following scenario?
A patient presents with atrial flutter or atrial
fibrillation. Right atrial pacing cannot be performed
because the arrhythmia cannot be paced. Right
ventricle pacing/recording is not performed. Pacing
and recording from the coronary sinus are done to
assist in mapping the arrhythmia. Once the
arrhythmogenic focus is mapped and ablated,
programmed stimulation and pacing is performed
in an attempt to induce the arrhythmia.
Copyright 2010, Coding Strategies, Inc.
9

10. 3/13/2010
Slide 19
 … Because the right atrium could not be
paced, and the right ventricle may not have
been paced and recorded. Alth
b d d d d Although th
h the
procedures described in the add-on codes
93621/93623 were done, a full comprehensive
study was absent.
 A: To use the add-on codes, a base code must
first be reported and if all the elements of a
reported,
comprehensive are not done, then modifier 52,
Reduced services, is appropriate. (93620-52).
Copyright 2010, Coding Strategies, Inc.
Slide 20
However, it is usually proper to perform a complete
study once a sinus rhythm is obtained after
cardioversion or ablation f atrial fl
d bl for l flutter and
d
fibrillation. This is to ensure that there is not a
hidden accessory pathway or another problem. If
atrial and ventricular pacing is done before or after
the ablation, the code for a complete EP study can
be reported. Whether the induction of arrhythmia is
successful is irrelevant, because the code describes
irrelevant
the attempt at induction, not the success of the
procedure, and supports the use of code 93620.
CPT Assistant October, 2008 Q&A
Copyright 2010, Coding Strategies, Inc.
10

11. 3/13/2010
Slide 21
 Procedure was set up, patient came down and
was prepped for an EP study. 12-lead
p pp y
showed no arrhythmia and the decision was
made to give IV Isoprel.
 Option 1 – report the infusion (approx $125)
 Option 2 – 93620-(discontinued 53/73) (50% of
the APC rate or approx. $1700)
Copyright 2010, Coding Strategies, Inc.
Slide 22
 Designed to reduce errors due to clerical entries and
incorrect coding.
 “..each line of a claim is adjudicated separately against
“ h li f l i i dj di t d t l i t
the MUE of the code on that line, the appropriate use
of CPT modifiers to report the same code on separate
lines of a claim will enable a provider/supplier to
report medically reasonable and necessary units of
service in excess of a MUE. CPT modifiers such as -
76, -77, -91, and -59 will accomplish this purpose.
Modifier -59 should be utilized only if no other
modifier describes the service.
Copyright 2010, Coding Strategies, Inc.
11

12. 3/13/2010
Slide 23
Fluoroscopic guidance can
be reported by both the
physician and the facility –
when documented
CPT® Definition
Code
71090 Insertion pacemaker, fluoroscopy and
radiography,
radiography radiological supervision
and interpretation
Copyright 2010, Coding Strategies, Inc.
Slide 24
 Importance of clinical history
◦ Medical necessity
◦ Signs and symptoms, or
symptoms
◦ Confirmed diagnosis
 Documentation of procedure:
◦ Complete description of technique
◦ Identify ancillary services such as mapping and ICE
◦ When a diagnostic procedure is performed followed
by a therapeutic procedure describe the sequence of
procedure,
events including the decision to perform the
therapeutic service
Copyright 2010, Coding Strategies, Inc.
12

13. 3/13/2010
Slide 25
 Right heart catheterization and atrial and
ventricular angiography (93501, 93529-
g g p y( ,
93533, 93539, 93543, 93555) are integral
components of percutaneous transcatheter
closure of septal defect and should not be
reported separately.
 Echocardiography (including transthoracic,
transesophageal, and intracardiac) may be
reported separately.
Copyright 2010, Coding Strategies, Inc.
Slide 26
 Do not rely on the coding team
◦ Can’t abstract what wasn’t documented
◦ Can’t confirm what was done was documented
 Clinical staff – providers and non-physician
staff need to understand CPT guidelines for
the top procedures
Copyright 2010, Coding Strategies, Inc.
13

14. 3/13/2010
Slide 27
Understand Medical Necessity – the
carrier’s version
Communicate Medical Necessity
Expect patient participation and share
of cost(s)
Copyright 2010, Coding Strategies, Inc.
Slide 28
 Health plans deny service
◦ 47% … not medically necessary
◦ 23% lack information to approve coverage
◦ 17% are non-covered services
 Do not assume all plans under the same
payer are equal
◦ Employers exclude services and/or conditions to
reduce medical expenses
Copyright 2010, Coding Strategies, Inc.
14

15. 3/13/2010
Slide 29
Copyright 2010, Coding Strategies, Inc.
Slide 30
 Be familiar with evidence-based clinical
g
guidelines
◦ Confirm which guidelines are used by the health
plan(s)
◦ Submit documentation clearly stating the reason(s)
for the requested service
 Because it was ordered …
 Because the patient needs it ….
 Why is this path of treatment better than the next
 What is unique with this patient’s care that needs to be an
exception to the rule
Copyright 2010, Coding Strategies, Inc.
15

16. 3/13/2010
Slide 31
Copyright 2010, Coding Strategies, Inc.
Slide 32
Copyright 2010, Coding Strategies, Inc.
16

17. 3/13/2010
Slide 33
Copyright 2010, Coding Strategies, Inc.
Slide 34
Copyright 2010, Coding Strategies, Inc.
17

18. 3/13/2010
Slide 35
Copyright 2010, Coding Strategies, Inc.
Slide 36
Copyright 2010, Coding Strategies, Inc.
18

19. 3/13/2010
Slide 37
Copyright 2010, Coding Strategies, Inc.
Slide 38
Copyright 2010, Coding Strategies, Inc.
19

20. 3/13/2010
Slide 39
Copyright 2010, Coding Strategies, Inc.
Slide 40
 Most often used for:
◦ Exam ordered for a
condition that is not
covered under the
Medicare LCD
◦ Screening Studies
◦E
Exam subject t
bj t to
frequency limitations.
Copyright 2010, Coding Strategies, Inc.
20

21. 3/13/2010
Slide 41
More than resubmitting a claim
Think Dandelions
Copyright 2010, Coding Strategies, Inc.
Slide 42
 All services are coded correctly
 All modifiers are assigned correctly
 All services are preauthorized correctly
 Medical necessity is clearly explained simply
with ICD-9 codes
 All carrier requirements are met consistently
 All systems are p g
y programmed correctly y
 Insurance carriers pay for all services
performed
 Pigs fly
Copyright 2010, Coding Strategies, Inc.
21

22. 3/13/2010
Slide 43
1) Recipient not eligible on DOS
2) Recipient has other insurance coverage
3) Past filing time w/o acceptable documentation
4) NDC missing or invalid
5) Duplicate claim
6) Procedure code / age conflict
7) Service is bundled into another service
8) Service is not covered
9) Procedure requires preauthorization
10) Lack of medical necessity
Copyright 2010, Coding Strategies, Inc.
Slide 44
 Working denials to be paid?
 Working denials to get it off my desk?
 Working denials to improve the process?
◦ Consider the feedback /communication
◦ Consider tracking mechanisms – education
 Think Dandelions!
Copyright 2010, Coding Strategies, Inc.
22

23. 3/13/2010
 Appeals Alert!
Highmark Medicare Services Appeals department is
seeing numerous requests for Monitored Anesthesia
Care (MAC) where the diagnosis does not meet the
medical necessity requirements outlined in the Local
Coverage Determination (LCD). Please double check
your medical documentation against the requirements
outlined in LCD L27489 prior to requesting a
redetermination.
redetermination Remember to report diagnosis codes
that are supported by the medical documentation.
Slide 46
 Effective January 1, 2010 … sort of
◦ CMS will delete the edit retroactively but not until
April 1st
Copyright 2010, Coding Strategies, Inc.
23

24. 3/13/2010
Slide 47
 Working denials means understanding
◦ Coding conventions
g
◦ Medical framework of the procedures
◦ Communication skills needed to speak to multiple
audiences
◦ IR cases
◦ EP studies – not the typical mix of services must be
yp
appealed – with more than the report
Copyright 2010, Coding Strategies, Inc.
Slide 48
 An add-on code is used for ICE:
CPT® Code Definition
+93662(-26) Intracardiac echocardiography during therapeutic/diagnostic
intervention, including imaging supervision and interpretation (List
separately in addition to code for primary procedure)
 Appropriate for specific base CPT codes;
otherwise, ICE may be reported using an
, y p g
unlisted procedure code (93799)
Copyright 2010, Coding Strategies, Inc.
24

25. 3/13/2010
Slide 49
 The mapping codes can be reported in
conjunction with:
◦ Comprehensive EP study (93620)
◦ Ablation of arrhythmogenic focus (93651-93652)
 Only one mapping code can be reported for
each encounter
◦ If both were done, report 3D mapping
 Do not apply modifier 26 to 3-D mapping
for professional component billing
Copyright 2010, Coding Strategies, Inc.
Slide 50
Copyright 2010, Coding Strategies, Inc.
25

26. 3/13/2010
Slide 51
Copyright 2010, Coding Strategies, Inc.
Slide 52
 Understand the patient’s coverage
 Understand the carrier’s meaning of medical necessity
 Gear the letter to your audience
h l d
 Explain beneficiary’s condition
◦ Make the patient a real person facing a difficult
situation
◦ Impact of the condition of patient’s life without the
treatment
◦ Describe the alternative treatments that have been
considered
 Explain how the treatment will reduce risk for further
treatment
Copyright 2010, Coding Strategies, Inc.
26

27. 3/13/2010
Slide 53
 Maintain an appeals resource file
◦ Template letters for frequently challenged
g
procedures
 Persistence pays off
“ Keep appealing. It may take more than one
appeal to reverse a health plan’s incorrect denial.
When a procedure or service has been
appropriately p
pp p y performed, documented and
,
reported, be persistent to ensure your practice
obtains the proper compensation based on the
negotiated health plan contracted rate. “ AMA Practice
Management Center
Copyright 2010, Coding Strategies, Inc.
Slide 54
◦ “Appeal of a Medical Necessity or Experimental /
Investigational Adverse Determination”
Determination
 90 days from date of notice (denial)
 Anthem acknowledges within 5 days of receipt
 Request for information must be received within 10
days
 Reviewed by specialist in same or similar specialty not
involved in initial review
 Resolution letter within 30 days
◦ Request for external review is also an option
Copyright 2010, Coding Strategies, Inc.
27

28. 3/13/2010
Slide 55
 Specific forms for appeals / reconsiderations
 State specific forms
Copyright 2010, Coding Strategies, Inc.
Slide 56
Training – education –
Feedback –
I’m just a “ x “
Copyright 2010, Coding Strategies, Inc.
28

29. 3/13/2010
Slide 57
 Communication between provider and coding
p
staff is a critical component
◦ Routine opportunities to discuss issues
 Protocols in conflict with coverage guidelines
 Discuss procedures – medical necessity
 Communication within the coding staff is a
critical component
◦ Eliminate the need for staff to hoard information
Copyright 2010, Coding Strategies, Inc.
Slide 58
 Illustrate for each employee how they impact
the real bottom line.
 PATIENT CARE
 Accept the diversity in work style, motivation,
and adapt wherever possible
 Clearly id tif Th Customer and respond
Cl l identify The C t d d
accordingly
Copyright 2010, Coding Strategies, Inc.
29

30. 3/13/2010
Slide 59
Analysis (RAC) data mining
Internal Edits / Audits
Natural language processing
Web based learning
Copyright 2010, Coding Strategies, Inc.
Slide 60
 Learn the rules
◦ Educate the key stakeholders
 Perform internal review of coding
/documentation / denials
◦ Identify opportunities to improve dictation –
revenue
◦ Don’t pick the weeds – eliminate ‘em
 Evaluate the team
◦ Best fit for each task
◦ Accept the hard task if necessary
 Maximize the technology available
Copyright 2010, Coding Strategies, Inc.
30

31. 3/13/2010
Slide 61
Your Presenter:
Karna W. Morrow
Coding Strategies, Inc.
Karna.Morrow@codingstrategies.com
31