2011 CDM Updates Day 1

HFMA Western NY Chapter
January 25, 2011 – Day 1

2011 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.

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OBJECTIVES OF THE WORKSHOP
2011 includes 400 CPT® revisions, deletions, and additions. In order to
avoid claim denials and coding errors as well as capture revenue for
accurately documented services, it is critical that you keep current on
relevant and significant updates to CPT as well as HCPCS codes.

The workshop will address specific code changes, the rationale behind the
change, and the impact these changes will have on your charge description
master. 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.

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OBJECTIVES OF THE WORKSHOP
After 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.

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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.

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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

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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

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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.

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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).

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Current 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

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Healthcare 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

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CPT 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.

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CPT 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.

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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

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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

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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

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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

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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.

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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

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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

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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.

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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.

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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) √

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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

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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.

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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.

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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 Association's 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.

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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

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CMS Status Indicators
Indicator 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.

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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.

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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.

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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.”

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.

through a separate APC payment

or packaged into payment for other services.

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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.

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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”.

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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

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Composite APC Composite APC Title Criteria for Composite Payment

8000 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

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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.

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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.

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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.

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Source: New York State Office of Health Insurance Programs, “APG Implementation Ambulatory Patient Groups (APGs) and
Ancillary Lab/Radiology Services”, September 2009.

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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

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”

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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.

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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

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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.

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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

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

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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.

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The Holistic View of Revenue Integrity

MedAssets. (n.d.). Securing Revenue with Improved Data Use. Retrieved December 2010, from Healthcare Financial
Management Association: www.hfma.org

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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

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Outline for remainder of work shop:
Laboratory (inc. Blood Bank)
D Radiology (inc. Nuclear Medicine)
Pain Management
A Interventional Radiology
Y Cardiac Catheterization
Electrophysiology
1 Medical and Surgical Supplies
Outpatient Facility E/M Services; Clinic and Emergency Services
D Outpatient Observation Services
Infusions and Injections
A Pharmaceuticals
Y Diagnostic Cardiology
Respiratory/Pulmonary
2 Cardiac and Pulmonary Rehabilitation
Radiation Oncology

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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

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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.

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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

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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.

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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

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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
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
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.
HCPCS P3000 is payable under the Medicare Laboratory Fee Schedule
Submit diagnosis code V76.2, “routine cervical PAP”

66

LABORATORY
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.
HCPCS G0103 is payable under the Medicare Laboratory Fee
Schedule - error
CORRECTION:
HCPCS G0328 (iFOBT, or immunoassay-based).
CPT 82270 non-Medicare

67

LABORATORY
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
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.
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”
influenza virus, for multiple types or sub-types, reverse transcription and
amplified probe technique, first 2 types or sub-types”
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
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”
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”
(eg, gastric secretory study); 2 hours”

86

LABORATORY
CY2011 CPT Updates
Lab Procedures
Deleted CPT Codes
(eg, gastric secretory study); 2 hours including gastric
stimulation (eg, histalog, pentagastrin)”
(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
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”
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
performed.

105

PAIN MANAGEMENT
There are essential coding and billing guidelines to consider when
capturing pain management services
Diagnosis Coding
Modifier Use
Radiologic Guidance
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
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 patient's 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.

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PAIN MANAGEMENT
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
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

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PAIN MANAGEMENT
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.
CT CPT Code 77012
MR CPT Code 77021

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PAIN MANAGEMENT
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
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.
CT CPT Code 72292

116

PAIN MANAGEMENT
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.
CT CPT Code 72292

117

PAIN MANAGEMENT
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
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
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.

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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.

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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.

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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

2011 CDM Updates Day 1

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