2016 regional coding seminar

5/25/2016

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06/04/2016 2016 AUA Coding Seminar Ft. Lauderdale 1

2016 Regional Coding Seminar

06/04/2016 2016 AUA Coding Seminar

Ft. Lauderdale 2

Faculty

Edna R. Maldonado, CPC, ACS-UR, ICD-10-CM Trainer

Natacha Graham, CPC

Susan L. Crews, CPC, ACS-UR, ICD-10-CM Trainer

M. Ray Painter, M.D.

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2016 AUA Coding Seminar Ft. Lauderdale

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CPT CODING CHANGES

AFFECTING UROLOGISTS

Edna Maldonado, CPC, ACS-UR


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2016 Coding Changes Affecting Urologist

Revised 50387 Removal and replacement of externally accessible nephroureteral catheter (eg. External/ internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation (For bilateral procedure, use modifier 50) (For removal and replacement of externally accessible ureteral stent via ureterostomy or ileal conduit, use 50688)


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NEW

50430 Injection procedure for antegrade nephrostogram and/ or ureterogram, complete diagnostic procedure including imaging guidance (eg. Ultrasound and fluoroscopy) and all associated radiological supervision and interpretation 50431 Existing access (Do not report 50430,50431, in conjunction with 50432,50433,50434,50435,50693,50694,50695,74425 for the same renal collecting system and/or associated ureter)

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New

50432 Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and / or ureterogram when performed, imaging guidance (eg, ultrasound and/ or fluoroscopy) and all associated radiological supervision and interpretation) (Do not report 50432 in conjunction with 50430, 50431, 50433 50694,50695,74425 for the same collecting system and/or associated ureter) (Do not report 50432 in conjunction with 50395 for dilation of nephrostomy tube tract)


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New 50433 Placement of nephroureteral catheter, percutaneous, including diagnostic nephrostogram and /or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, new access (Do no report 50433 in conjunction with 50430, 50431, 50432,50693,50694,50695,74425 for the same renal collecting system and/or associated ureter) (Do not report 50433 in conjunction with 50395 for dilation of the nephroureteral catheter tract) (For nephroureteral catheter removal and replacement ,use 50397)


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50434 Convert nephrostomy catheter to nephroureteral catheter, percutaneous, including diagnostic nephrostogram and / or ureterogram when performed, imaging guidance (eg, ultrasound and / or fluoroscopy) and all associated radiological supervision and interpretation, via- pre-existing nephrostomy tract.

(Do not report 50434 in conjunction with 50430, 50431, and 50435,50684,50693,74425 for the same renal collecting system and/or associated ureter.)


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50435 Exchange nephrostomy catheter , percutaneous, including diagnostic nephrostogram and/ or ureterogram when performed, imaging guidance (eg. Ultrasound and/ or fluoroscopy) and all associated radiological supervision and interpretation

(Do not report 50435 in conjunction with 50430,50431,50434,50693,74425 for the same renal collecting system and/or associated ureter)

(For removal of nephrostomy catheter requiring fluoroscopic guidance, use 50389)


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+50606 (add on code) Endoluminal biopsy of ureter and/ or renal pelvis, non-endoscopic, including imaging guidance (eg. Ultrasound and/ or fluoroscopy) and all associates radiological supervision and interpretation

(Use 50606 in conjunction with 50382,50384,50385,50386,50387,50389,50430,50431,50432,50433,50434,50435, 50684,50688,50690,50693,50694,50695,51610)

(Do not report 50606 in conjunction with 50555,50574,50955,50974,52007,74425 for the same renal collecting system and/ or associated ureter)

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Other Introduction (Injection/Change/Removal) Procedures Codes 50693, 50694, 50695 are therapeutic procedure codes describing percutaneous placement of ureteral stents. These codes include access, drainage, catheter manipulations, diagnostic nephrostogram; and /or ureterogram, when performed, imaging guidance (eg, ultrasonography and/ or fluoroscopy), and all associated radiological supervision and interpretation. When a separate ureteral stent and nephrostomy catheter are placed into a ureter and its associated renal pelvis during the same session through a new percutaneous renal access, use 50695 to report the procedure


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50693 Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and /or ureterogram when performed, imaging guidance (eg. Ultrasound and /or fluoroscopy”), and all associated radiological supervision and interpretation ;pre-existing nephrostomy tract

50694 New access, without separate nephrostomy catheter

50695 New access, with separate nephrostomy catheter

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+50705 (add-on code)

Ureteral embolization or occlusion, including imaging guidance (eg. Ultrasound and / or fluoroscopy), and all associated radiological supervision and interpretation

+50706 (add- on code)

Balloon dilation, ureteral stricture, including imaging guidance (eg. Ultrasound and/ or fluoroscopy), and all associated radiological supervision and interpretation


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Deleted Codes

50392 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous

50393 Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection


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Deleted Codes

50394 Injection procedure for pyelography (as nephrostogram pyelostogram, antegrade pyeloureterograms) through nephrostomy or pyelostomy tube, or indwelling ureteral catheter

50398 Change of nephrostomy or pyelostomy tube

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Deleted Codes:

74475 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation 74480 Introduction of ureteral catheter or stent, into ureter through renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation

(74475, 74480 have been deleted. To report, see 50432, 50433, 50434, 50435, 50606, 50693, 50694, 50695)


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Medicare and Medicaid

Updates

M Ray Painter M.D.


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Plan

• Practice perspective

• Alphabet soup – timeline and impact

• Final rule

• Misvalued codes/RUC

• *** Many slides have been included in your syllabus for your reference and information only


Changing times

Payment reform /

Increased oversight

Employment

Healthcare Reform

Medical necessity /

Increased complexity of rules


Healthcare reform

Data driven

Eliminate fee-for-service

Increased patient share of costs

&

# of Medicaid

Medicare payments tried to quality Or Alternative payment models

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Payment

reform

APM

Alternative payment Models

ACO's

Co-ops

Medical homes

Bundle Payments

"Pilot" projects

Decreased fee-for-service Bonus/

penalty payments

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Urology 2016

• Top 7 specialties in Compensation

• 28% are participating in an ACO

• 5% take cash only / no insurance

• 3% classify themselves as a concierge practice

• Over 90% still accept Medicare or Medicaid

• 25% regularly discuss of cost of care with patients

• Nearly 46% of Self-employed and 59% of Employed physicians indicate at least 10 hours per week are spent on administrative work

*Medscape Urologist Compensation Report 2015


Laws of Economics

Shortage of Urologist

• Location specific

• ? Increased bargaining power

• Now vs. later

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Medicare Status

• Participating – • Non-Participating- • Opt Out –

• According to Medscape 2015 Survey of

Urologists- – 2% have stopped taking Medicare on Current patients – 6% of self-employed have stopped taking New

Medicare – 1% of employed have stopped taking New Medicare


Changes to Medicare Opt Out

• MACRA change

– Now a physician who Opts Out is out for two years and automatically renews as Opt Out for two more years (Old system required new Opt Out every two years)

– May cancel Opt Out with 30 days notice prior to end of 2 year period.


Changing Focus

• Premise – “Fee for Service healthcare increases costs.”

• Solution - “Get rid of fee for service Healthcare.”

• Problems –

– Some areas require fee for service

– Not all disease processes require long term care

– Lack of care, delayed care or bad care.


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CMS Strategic Vision

• Programs guided by input from patients, caregivers and health professions

• Data drives rapid cycle quality improvement

• Public reporting provides meaningful transparent and actionable information

• Quality reporting relies on the aligned measured portfolio

• Quality reporting and value based purchasing policies are aligned


It is All about DATA

• Patient Satisfaction Surveys

• Costs of doing business

• Collections from Payers and Patients

• Coding and Compliance

• Clinical Pathways

• Group Behavior

• Quality Measurement and Reporting


Medicare Advantage Plans

–Preparing for Pt. Satisfaction based scoring

• Monitor contracts and requirements

–Narrowing networks

– Increased management and Oversight


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2015 Medicare Update Medicare

Updates

2016

SGR ×

MACRA

MIPS

VBM

PQRS

APM

MU

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MIPS (Merit-based Incentive

Payment Systems)

PQRS

M U

VBM

Quality Resource

Use

Practice Improvement

Activities

Advancing Care

Information

2019 and beyond Now through 2018

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Medicare’s Current Shotgun

• Meaningful Use – Incentive/Penalty program to encourage widespread adoption of intraoperative EHR/EMR

• PQRS - Physician Quality Reporting System a series of measures to compare quality among Medicare providers

• VBM – Value-Based Payment Modifier – a two tiered system to adjust payments by Medicare for 2015 until 2018


Meaningful Use

The new Application deadline for the Medicare EHR Incentive Program hardship exception for

Eligible Professionals is July 1, 2016.


EHR reporting and participation timeline – 2016

• Attest to either 2015-2017 criteria

• All returning participants -EHR reporting 1 full calendar

• First-time participants and providers attesting to Stage 3 may use a 90- day EHR reporting period


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• Attest to either 2015-2017 criteria or full version of Stage 3

• All returning participants -EHR reporting 1 full calendar (bicameral bill to role back to to 90 days)




• Attest to full version of Stage 3

• All returning participants -EHR reporting 1 full calendar (bicameral bill to role back to to 90 days)



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PQRS Now through 2018------& Beyond

• Bonus is “gone”

• Must submit to qualify in 2016 or cuts in 2018

• On going required to avoid cuts in future years

• Claims based or Registry reporting Measures

• Success still defined at 50% of eligible patients for each measure


Value Based Payment for PQRS 2017

• Evaluated in 2015 on the following criteria:

– Successful PQRS reporting by eligible providers

• Participated in GPRO reporting and met success criteria OR

• Participated in individual PQRS reporting and at least half of your eligible providers reported successfully

– Result – no automatic adjustment and practice moves to the quality-tiering calculation



• Unsuccessful PQRS reporting by eligible providers: – Group size – 1-9 – automatic -2% – Group size – 10 or more – automatic -4%

• valuation of quality-tiering criteria and cost criteria from QRUR report – Group size – 1-9 – upward or neutral adjustment – Group size – 10 or more – downward, upward or neutral

adjustment – amounts TBD

• • Your practice is now being evaluated for payment

year 2018 under the same standards


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• Evaluation year – 2016

• Evaluation standards – same

• Penalties –Same


PQRS Reporting

Individual EPs may choose to report information on individual PQRS quality measures or measures groups using the following mechanisms:

(1) Medicare Part B claims (2) Qualified PQRS registry (3) Direct electronic health record (EHR) using certified EHR technology (CEHRT) (4) CEHRT via data submission vendor (5) Qualified clinical data registry (QCDR)


PQRS Reporting

Group Practices may choose to report information on PQRS quality measures using the following mechanisms:

(1) Qualified PQRS registry

(2) Web Interface (for groups of 25+ only)

(3) Direct EHR using CEHRT

(4) CEHRT via data submission vendor

(5) CAHPS for PQRS via CMS-certified survey vendor (for group practices of 2+) to supplement PQRS group practice reporting


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Measure Requirements

• Individual EPs and PQRS group practices should choose at least 9 individual measures across 3 National Quality Strategy (NQS) domains or 1 measures group as an option to report on measures to CMS (with the exception of GPRO Web Interface). Individual EPs or PQRS group practices are also required to report one (1) cross-cutting measure if they have at least one (1) Medicare patient with a face-to-face encounter.


Medicare Updates Value Based Modifiers

CY 2017 Groups of 10 or more / Solo or groups 2-9

Cost/Quality Low quality Average quality High quality

Low cost 0.0%/0.0%

+2.0%/1.0%*

+4.0%/2.0%*

Average cost -2.0%/0.0% 0.0%/0.0% +2.0%/1.0%*

High cost -4.0% /0.0% -2.0%/0.0% 0.0%/0.0%

* Dependent upon penalties collected


VBM Matrix • Quality domains 1. Effective Clinical Care 2. Person and Caregiver-Centered Experience and Outcomes 3. Community/Population Health 4. Patient Safety 5. Communication and Care Coordination 6. Efficiency and Cost Reduction • Cost domains 1. Per Capita Costs for All Attributed Beneficiaries 2. Per Capita Costs for Beneficiaries with Specific Conditions


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Obtaining Your Quality and Resource Use Reports (QRUR)

• EIDM account will be required to access QRURs at https://portal.cms.gov.

• QRURs are provided for each Medicare-enrolled Taxpayer Identification Number (TIN).


Group Access to QRUR

• To access a group's QRUR, one person from the group must first sign up for an EIDM account with the Security Official role.

• If additional persons are needed to access the group's QRUR, then they can also request the Security Official role or the Group Representative role in EIDM.

• If you do not have an IACS or EIDM account, then follow the instructions provided at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/Guide-for-Obtaining-a-New-User-EIDM-Account-with-a-Physician-Quality-and-Value-Programs-Role.pdf

• If you have an IACS account that you previously used to access QRURs or register for the PQRS GPRO, then follow the instructions provided at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/Guide-for-Completing-EIDM-Account-setup-for-Migrating-IACS-Users.pdf

• If you already have an EIDM account, then follow the instructions provided at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/Guide-for-Obtaining-Physician-Quality-and-Value-Programs-Role-for-Existing-EIDM-User.pdf


Individual Access to QRUR

• To access a solo practitioner's QRUR, one person must first sign up for an EIDM account with the Individual Practitioner role.

• If additional persons are needed to access the solo practitioner’s QRUR, then they can also request the Individual Practitioner role or the Individual Practitioner Representative role in EIDM.

• If you do not have an IACS or EIDM account, then follow the instructions provided at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/Guide-for-Obtaining-a-New-User-EIDM-Account-with-a-Physician-Quality-and-Value-Programs-Role.pdf

• If you have an IACS account that you previously used to access QRURs, then follow the instructions provided at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/Guide-for-Completing-EIDM-Account-setup-for-Migrating-IACS-Users.pdf

• If you already have an EIDM account, then follow the instructions provided at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/Guide-for-Obtaining-Physician-Quality-and-Value-Programs-Role-for-Existing-EIDM-User.pdf


https://portal.cms.gov

https://portal.cms.gov/

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/Guide-for-Completing-EIDM-Account-setup-for-Migrating-IACS-Users.pdf

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Sample QRUR




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MIPS New Pay-For-Performance Program

M U

-9%

0%

+9%

% of change possible after 2018



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• Based on PQRS reporting requirements

• Includes existing PQRS measures

• VBM quality measures • Also measures used by Qualified Clinical Data Registries

(QCDRs) – AUA has developed AQUA

• More urology quality measures will have to be developed

Quality (30%)


• Not yet defined, may include: – Extended access (same day visits, after hours access, being

on call)

– Population management (QCDR participation, monitor health)

– Care coordination (timeliness of test results, telehealth)

– Beneficiary engagement (plans of care, self management)

– Patient safety and practice assessment (checklists, MOC, etc.)

– APM participation (even if miss full participation, but tried)

Clinical Practice Improvement Activities


• Score Threshold (i.e., earn the mean composite score): no adjustment

• Above mean: positive payment adjustment on each claim (in 2 yrs)

• Below mean: negative payment adjustment on each claim (in 2 yrs)

• For 2019 – 2024, exceptional performers may receive an additional positive payment up to 10%

MIPS: Thresholds for Composite Scores


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APMs and the Future

• Premise – “Fee for Service healthcare increases costs.”

• Solution - “Get rid of fee for service Healthcare.”

• Problems –

– Some areas require fee for service

– Not all disease processes require long term care

– Lack of care, delayed care or bad care.


APMS • Alternative Payment (Cost Reduction ) Models

– Disease based payment

– Medical homes

– Modified Capitation

– Value based traffic models

– Value based payment

– Package payments

– Treat and Return Value

– Narrow Networks

– Increased Prior Authorization Hoops


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Qualifying APM participant

• 2019-2020: 25% of Medicare revenue - APMs

• 2021-2022: 50% of Medicare or 25% of Medicare and 50% of all-payer

• 2023 and beyond: 75% of Medicare revenue or 25% of Medicare revenue and75% of all- payer revenue

* 2019 – 2024 - 5% bonus on all Medicare payments


Final payment rules


Urology Payments 2016

• Overall Urology Impact according to Medicare 0.0%

• MACRA Update +0.5% for 2016

• ABLE update -0.77% for the misvalued code update

• Result is -0.029% update to conversion factor.


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Medicare “Incident to”

• NO change to Policy for 2016. Will only issue clarifying language indicating that a physician present and available in the office need not be in the room when services are provided “incident to.”


ASP Proposal

• 2.5% over ASP

• Plus $16.80 administration fee

• Forced study all participate assigned to control or study group

• Comments due May 19th

• Implementation 60 days after final rule issued


Changes

• ACA mandates all payers provide automated Prior Authorization beginning 1/1/16

– 278 transaction

– Documentation attachments allowed

– Some states have moved ahead

– Can still be pended for further review


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Medicare Misvalued Codes

• Were reviewed

– 51700 Irrigation of bladder

– 51702 Insert temp bladder catheter

– 51720 Treatment of bladder lesion

– 51784 Anal/urinary muscle study

– 51798 Ultrasound urine capacity measure

– 52000 Cystoscopy

– 55700 Prostate biopsy


RUC Process

CPT code (with vignette)

Survey sent to members (typical work)

Presented at the RUC

Value assigned

CMS: accept (or not)

(x Conversion Factor) = payment


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Evaluation and Management

Coding

M. Ray Painter, M.D.


E and M

??


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Knowledge Understanding

Comfort zone

Location Technology

E and M

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Plan

At the end of this session you:

– will know how to select the correct code level for the work you have performed

– apply time-saving shortcuts to your documentation

– avoid time-wasting unnecessary work

– be comfortable in charging the highest level of code for the medically necessary work performed and document


Basics

• Medical necessity

• Service performed

• Documentation

• Picking the correct code

– Category

– Level


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Targets

Work (and documentation) required to charge highest level codes?

Algorithms

• New patient levels 4 & 5

• Established patient levels 4 & 5

• Initial hospital visits 1, 2, & 3

• Subsequent hospital visit 2 & 3


E & M - Coding

Encounter

Time Components


New patient/Consult


Complete Hx & PE Highest level MDM – level 5

Moderate MDM–level 4

Incomplete HX or PE Level 3

Level 2 Level 1

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MDM


Highest level MDM – level 5 Dx - Extensive (4 points) Data – Extensive (4 points) Risk – High

Moderate MDM–level 4 DX – multiple (3 points) Data – moderate (3 points) Risk – moderate

MDM - Problem Documentation

• Include details of all problems

– Discussed

– Considered

– Treated


MDM - Data Documentation

• Lab & X-Ray

‒ All ordered

‒ All reviewed

‒ All viewed

• Chart review

• Physician to Physician calls


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MDM - Risk Documentation

• All drugs - include dose

• Started, including samples

• Renewed, or,

• Discontinued

• Surgeries/ Diagnostic procedures - discussed or scheduled

• Severity of illness


New patient



Moderate MDM – level 4

Incomplete HX or PE Level 3

Level 2

Level 1

Practice Statistics New Patient

• InfoDive data sets include data from 512 urology providers that subscribe to the InfoDive platform marketed by Intrinsiq Specialty Solutions a division of Amerisource Bergen.


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Established Patient

Code based on

*” Medical Decision Making”*

*HX or PE must match the level


Established patient


Complete Hx or PE

Highest level MDM – level 5


Little or no HX or PE Level 3

Level 2

Level 1

Almost Complete Hx or PE

Established Patient "Time-Saving Pearls"

• Start with a complete history

– New complete HPI

– Review ROS and PFSH

“Complete ROS and PFS reviewed from, (exact date - xx/xx/xx), no change

except_____.”

• PE only as clinically indicated


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Practice Statistics Est. Patient



Problem #1 Initial hospital visit


93

Cross

Consults

Walk Initial Visit - Hospital

Level 5 Level 3

Level 4 Level 2

Level 3 (H & P =1)

Level 1 (MDM-less)

Level 2 Level –99232 (3)

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Initial hospital care code


Complete Hx & PE



Almost Complete HX & PE

MDM - minimum or greater Level 1

Minimum Hx or PE ??????


Billing Based on Time

E & M - Coding

Encounter

Time Components


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E&M - Time

• Counseling/Coordinating care - over 50%

• Office – Face to Face

• Hospital – Floor time

• Total time spend "Average" – not Threshold


Initial Hospital Care

"Time-Saving Pearls"

Charge based on components • HX – Complete HPI , review ROS and PFSH

“Complete ROS and PFS reviewed from, .(exact date - xx/xx/xx), no change except_____.”

• PE –Complete or Extended

Or ----

Charge based on time


Subsequent Hospital Care

Complete HPI/2 ROS or Extended/Extended PE



Incomplete HPI/1 ROS or Limited PE


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Emergency Room Visit

100


Moderate MDM–level 4 Almost complete HX and PE

Moderate MDM–Level 3

Level 2 Level 1

Limited HX and PE



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Diagnosis with

Medical Necessity and proper

Documentation

M Ray Painter M.D.


“New era” (evolution)

Importance of Documentation • Medical necessity

• Value based payments • ICD-10 • Interoperability of EHR’s • Scrutiny from patients • Scrutiny from insurers and

auditors


Plan

• Set the stage/ Why

• Medical Necessity

• ICD-10

• The Game

• Documentation

• *** Many slides have been included in your syllabus for your reference and information only


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AMA Definition of Medical Necessity

• Health care services or products that a prudent physician would:

• provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms

• ----------

• --------.

• American Medical Association, Policy H-320.953[3] AMA Policy Compendium


AMA Definition of Medical Necessity (con't) • ------- • ----------

• In a manner that is:

– (a) in accordance with generally accepted standards of medical practice;

– (b) clinically appropriate in terms of type, frequency, extent, site and duration; and

– (c) not primarily for the convenience of the patient, physician, or other health care provider.

• American Medical Association, Policy H-320.953[3] AMA Policy Compendium


ACMQ Definition of Medical Necessity

• Accepted health care services and supplies provided by health care entities, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care.

• Appropriate Services and Supplies are those that are neither more nor less than what the patient requires at a specific point in time.

• ACMQ.org Policy 8, Definition and Application of Medical Necessity, Adopted 12/5/92 Amended 11/97, 2/04, 2/10


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Application of Medical Necessity ACMQ.org Policy 8

• 1. Determinations of medical necessity must adhere to the standard of care that applies to the actual direct care and treatment of the patient.

• 2. Medical necessity is the standard terminology that all health care professionals and entities will use in the review process when determining if medical care is appropriate and essential.

• 3. Determinations of medical necessity must reflect the efficient and cost-effective application of patient care including, but not limited to, diagnostic testing, therapies (including activity restriction, after-care instructions and prescriptions), disability ratings, rehabilitating an illness, injury, disease or its associated symptoms, impairments or functional limitations, procedures, psychiatric care, levels of hospital care, extended care, long-term care, hospice care and home health care.



• 4. Determinations of medical necessity made in a concurrent review should include discussions with the attending provider as to the current medical condition of the patient whenever possible. A physician advisor/reviewer can make a positive determination regarding medical necessity without necessarily speaking with the treating provider if the advisor has enough available information to make an appropriate medical decision. A physician advisor cannot decide to deny care as not medically necessary without speaking to the treating provider and these discussions must be clearly documented.

• 5. Determinations of medical necessity must be unrelated to payors’ monetary benefit.

• 6. Determinations of medical necessity must always be made on a case-by-case basis consistent with the applicable standard of care and must be available for peer review.

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• 7. Recommendations approving medical necessity may be made by a non-physician reviewer. Negative determinations for the initial review regarding medical necessity must be made by a physician advisor who has the clinical training to review the particular clinical problem (clinically matched) under review. A physician reviewer or advisor must not delegate his/her review decisions to a non-physician reviewer.

• 8. The process to be used in evaluating medical necessity should be made known to the patient.

• 9. All medical review organizations involved in determining medical necessity shall have uniform, written procedures for appeals of negative determinations that services or supplies are not medically necessary.


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Cigna Definition of Medical Necessity

• Health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: – in accordance with the generally accepted standards of medical practice;

– clinically appropriate, in terms of type, frequency, extent, site and duration,

and considered effective for the patient's illness, injury or disease; and

– not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.

• Cigna • Cigna HealthCare Definition of Medical Necessity


Accepted Standards Cigna HealthCare Definition of Medical Necessity

• For these purposes, "generally accepted standards of medical practice" means:

– standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community;

– Physician Specialty Society recommendations;

– the views of Physicians practicing in the relevant clinical area; and

– any other relevant factors.

• Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.


Definition of Medical Necessity -#3

• Health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: – in accordance with the generally accepted standards of medical practice;

– clinically appropriate, in terms of type, frequency, extent, site and

duration, and considered effective for the patient's illness, injury or disease; and

– not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.

• Cigna HealthCare Definition of Medical Necessity


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Clinically Appropriate

• Type

• Duration

• Extent

• Site

• Frequency


Practice Statistics New Patient 2015



Medicare Policy

• Section 1833(e) which states, in part "...no payment shall be made to any provider... unless there has been furnished such information as may be necessary in order to determine the amounts due such provider ...;"

• Section 1842(a)(2)(B) which requires ACs and MACs to "assist in the application of safeguards against unnecessary utilization of services furnished by providers ...; "

• Section 1862(a)(1) which states no Medicare payment shall be made for expenses incurred for items or services that "are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member;"

• Medicare Program Integrity Manual Chapter 1 - Medicare Improper Payments: Measuring, Correcting, and

Preventing Overpayments and Underpayments 3/14/13


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Medicare example

• Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

• Medicare Claims Processing Manual Chapter 12, Section 30.6.1. A


ICD-10

• Documentation should match specificity

• One year grace period for family of codes ends 10/1/2016 (CMS)

• Expect Ramp Up

• ICD– 9 was poor in most groups. ICD-10 must improve

• Medicare beginning to refine Dx specificity in some LCDs. (i.e.. UA LCD removal some unspecified codes) -CAC still has influence

• Minimize use of “unspecified” codes


ICD Tells a Story

• Visit 1 Hematuria –

– R31.0 Gross hematuria

• Visit 2 Cysto finding Lateral Wall and Posterior Wall lesions

– D49.4 Neoplasm of unspecified behavior of bladder

• Visit 3 TURBT Lateral Wall and Posterior Wall lesions

– D49.4 Neoplasm of unspecified behavior of bladder


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ICD Tells a Story (continued)

• Visit 4 – 9 – BCG 6 monthly treatments – Z51.12 Encounter for antineoplastic immunotherapy – C67.2 Malignant neoplasm of lateral wall of bladder – C67.4 Malignant neoplasm of posterior wall of bladder

• Visit 10+ - Follow-up/Surveillance Cysto Negative – Z85.51 Personal history of malignant neoplasm of bladder

• Visit X Recurrent Tumor Lateral Wall – D49.4 Neoplasm of unspecified behavior of bladder – or C67.2 Malignant neoplasm of lateral wall of bladder


ICD-10 Phase II

• Focus on the Future

• Capture what you know – Do not get bogged down in details you are not

expected to know

– Use your extenders

– Work with your EMR not against it.

– Expand History Intake forms

– Increase communication with PCP and other Providers


• Report all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management

• Do not code conditions that were previously treated and no longer exist

• History codes may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment

• Personal history is a valid primary code

• Eliminate/limit use of unspecified codes.

Diagnoses "Pearl"


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The Game

• Insurance company rates are based on statistics

• Profits for payers capped under PPACA

• Payment for unneeded or un-contracted services ruins statistical projections.

• Aggressive abuse detection leads to lower rates and more business.

• Aggressive abuse detection protects projected profits


Additional Consideration

• Medical necessity may be affected by: • Plan type and benefits

• Payment policy - NCD, LCD

• Device, Drug or Procedure – classification • Experimental

• Off Label

• Preventative

• Patient Comfort

• Life style

• Recommendations of outside entities - PSA


Medicare Watchdogs

• Medicare Administrative Contractor (MAC) and

Affiliated Contractor (AC)

• Zone Program Integrity Contractor (ZPIC) and

Program Safeguard Contractor (PSC)

• Recovery Audit Program (RA)

• Office of Inspector General (OIG)

• Comprehensive Error Rate Testing (CERT) contractor

• Quality Improvement Organization (QIO)


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Private Payers

• Recovery Auditors

• In-House Auditors & Statisticians

• Variable Contract language

• Detailed Payment policies

• Denials pending supporting documentation

• Pre-authorizations and pre-certifications

• And the list goes on


Payer Tools

• Benchmarking Data Comparison

• Denial Tracking and Analysis

• Targeted Provider Education

• Targeted Denials

• Changes to LCD or NCD

• Payment Code Changes

• Reimbursement Rate Reduction

• Provider Investigation and/or Exclusion

• Pre- and Post-payment Audits


• The question is not if you will be audited but when. It is best to adopt an attitude of no fear.

• Document what you do

• Charge what you document as allowed by contract

• Appeal everything.


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Documentation


Documentation/ Medical Necessity "The Bottom Line"

• Proof of Service - Details of procedure and/or service

• Medical Necessity - Reason for procedure(s) and/or services (UA,PVR, etc.)

• Separate documentation for each service to be charged


Copying What’s the Problem?

• Each encounter must stand alone

• If you copied the ROS, and made only a few changes, did you really do all the work that day?

• Copying the PFSH presents two problems

– Did you recapture all the information that day?

– If so, what was the medical necessity for doing so?

• Copying the PE presents two problems

– Did you re-examine all exam points?

– If so, what was the medical necessity for doing so?


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Cloning

– OIG work Plan

– "Medicare contractors have noted an increased frequency of medical records with identical documentation across services,”

–

– "We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records [EHR] documentation practices associated with potentially improper payments.”


Copying What’s the Problem?

• Waste time

• Increased risk of payback

• Clutters chart with unnecessary information

• Makes it difficult for others to determine actual treatment plan


E&M 95 Documentation Guide Lines

DG: The review and update may be documented by:

“Complete ROS and PFS reviewed from,(exact date - xx/xx/xx), no change except_____.”


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• !DG: A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information.

• This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record.



DG: The review and update may be documented by:

• Describing any new ROS and/or PFSH information or noting there has been no change in the information; and

• Noting the date and location of the earlier ROS and/or PFSH.


Documentation

for

Medical Decision Making


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Documentation-MDM

Problem

• Include details of all problems -

•discussed,

•considered, or

•Treated


Documentation-MDM

Data

• Lab & X-Ray

• All ordered

• All reviewed

• All viewed

• Chart review

• Physicians called


Documentation-MDM Risk

• All drugs - include dose

• started, including samples

• renewed or discontinued

• Surgeries/ Diagnostic procedures

- discussed or scheduled

• Severity of illness


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Take-home message

• Medical Necessity will be married to quality (PQRS, guidelines, ICD-10 codes, etc.) outcomes (cost, complications, etc.), and patient satisfaction

• Documentation and accurate, detailed reporting will be key to future payments



Coding Challenges

Edna Maldonado, CPC


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Differences of Opinion

Due to the complexity of coding guidance and the variety of interpretation of that guidance by payers, coding experts can often have differences of opinion on certain issues. Each billing provider should interpret varying opinions offered based on his/her own situation and code claims in his/her best judgment, realizing the inherent risk of recoupment. 06/04/2016


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Imaging Guidance

• When imaging guidance or imaging supervision and

interpretation is included in a surgical procedure, guidelines for image documentation and report, included in the guidelines for Radiology (Including Nuclear Medicine and Diagnostic Ultrasound) will apply.

• A written report (eg, handwritten or electronic) signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation.


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MRI Fusion Prostate Biopsy

Currently, for the MRI/ultrasound image fusion, there is no CPT code to report this. Urologists should not bill CPT code 77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation. One may try to bill 76498 Unlisted Magnetic Resonance procedure, (e.g., diagnostic, interventional) for the additional work of fusing the MRI and the ultrasound, but it is unlikely to be reimbursed. It may be appropriate to check with the insurance provider for their reimbursement/coverage policy.


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Xiaflex Injections

Visit #1 – 54235 Injection of Corpora Cavernosa with

pharmacologic agent(s) (eg, papaverine, phentolamine)

– 96372 Therapeutic, prophylactic, or diagnostic injection

– J0775 Injection, collagenase, clostridium histolyticum (Xiaflex )

– 54200 Injection procedure for Peyronie disease

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Xiaflex Injections

• Visit #2 – J0775 Injection, collagenase, clostridium

histolyticum (Xiaflex )

– 54200-58 Injection procedure for Peyronies disease

(10 day global period)

• Visit #3 – 99024 Post-op visit


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Provenge

Provenge

Q2043- effective 7/7/2011

Infusion Code Sets

96413-96415 or 96365-96366 should be used.

Select the appropriate codes based on the length of the infusion.

Diagnosis:

C61 – Malignant neoplasm of prostate,

At least one from C77.1 – C79.82 as documented in the medical record.


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Prolia

• J0897 Injection, denosumab, 1mg (Prolia) Effective 1/1/2012

• 96372 Therapeutic, prophylactic, or diagnostic injection

– OR

• 96401 Chemotherapy administration, subcutaneous or intramuscular, non-hormonal antineoplastic

Consult your payer or Medicare to determine which code is most appropriate for administration of Prolia


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Urodynamic

• A separate report and interpretation should be provided for each of the services performed as part of the urodynamic study

• Additionally, all printed components of the test should be included in the patient’s chart as supporting documentation for the technical component of the urodynamic test

• The report should include the results of the tests and the interpretation of the provider in order to bill the professional component of the CPT code

• Urodynamic Documentation 06/04/2016


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Cysto/Dilation

http://www.auanet.org/advnews/hpbrief/view.cfm?i=2678&a=5368

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52005/74420

• 52005 Cystourethroscopy, with ureteral

catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service;

• 74420-26 Urography, retrograde, with or without KUB

Carrier makes payment to provider who submits claim first.


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Laparoscopic/Robotic

• 55866- Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed

• 38571- Laparoscopy, surgical; with bilateral total pelvic Lymphadenectomy

• 38572 - Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple

Do not submit S2900 Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)


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Laparoscopic/Cystectomy

• 51999- Unlisted laparoscopy procedure, bladder

• Equating a code can be challenging- query your

physician – may need to use combinations

• Equate to a similar procedure • No what your carriers prefer

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Understanding Modifiers

Edna Maldonado, CPC


Ft. Lauderdale 158

Payment Modifiers

Modifier 22 - Increased Procedural Service:

• Used when the work required to provide a service is substantially greater than its typically required.

• Documentation must support the substantial additional work and the reason for the additional work

• Automatic manual review

• Payers will not automatically increase reimbursement • Ask for additional compensation

• Some increase fees by 20-25 percent when submitting


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Payment Modifiers

Modifier 50 - Bilateral procedure:

• Procedures performed on both sides of the body or identical anatomical sites, aspects or organs during same operative session

• Medicare has maintained the policy of approving 150% of the global amount when bilateral modifier is used.


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Payment Modifiers

Modifier 51 - Multiple procedures:

• Used when multiple procedures are performed during the same surgical session by the same provider.

• Medicare payment policy is based on the lesser of the actual charge or 100% of the payment schedule for the procedure with the highest payment, while payment for the second through fifth surgical procedures is based on the lesser of the actual charge or 50% of the payment scheduled.


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Payment Modifiers

Modifier 52 - Reduced services:

• Indicates that a service or procedure is reduced or eliminated at the discretion of the physician or other qualified health care professional.

• Carriers may reduce payment to 50% of allowed amount.

• Other carriers may reduce the normal fee by the percentage of the service not provided


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Payment Modifiers

Modifier 53 - Discontinued Procedure • Due to extenuating circumstances or

circumstances or those that threaten the well-being of the patient,

• It may be necessary to indicate that a surgical procedure was started by discontinued.

• Payment carrier discretion some are reimbursed by percentage of procedure completed


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Payment Modifiers

Modifier 62 - Co-surgeons:

• When 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure,

Payment is based on 125% of the global amount, which is divided equally between the two surgeons.

Documentation to establish medical necessity for both surgeons is required.


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Payment Modifiers

Modifier 78 - Unplanned return to the operating/procedure room by the same physician or other qualified health care

professional following initial procedure for a related procedure during the postoperative period

• Payment for reoperations is made only for the

intraoperative services. No additional payment is made for preoperative and postoperative care because CMS considers these services to be part of the original global surgery package.

• The approved amount will be set at the value of the intraoperative service the surgeon performed when an appropriate CPT code exists.


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Payment Modifiers

Modifier 80 - Assistant Surgeon

Modifier 81 – Minimum Assistant Surgeon

Modifier 82 – Assistant Surgeon when qualified resident surgeon not available

• Current law requires the approved amount for assistant surgeons to be set at the lower of the actual charge or 16% of the global surgical approved amount.


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Informational Modifiers

Modifier 58 - Staged or Related procedure or service by the same physician other qualified health care professional during the postoperative period

It may be necessary to indicate that the performance of a procedure

or service during the postoperative period was: (a) planned or anticipated (staged); or (b) more extensive than the original procedure; Should be documented in original operative report that something

else may be necessary to treat the problem


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Modifier 59 - Distinct procedural service: • Under certain circumstances, it may be

necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day

• Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate injury not ordinarily encountered or performed on the same day by the same individual.


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Modifier 76 - Repeat Procedure or Service by Same

Physician or Other Qualified Health Care Professional:

• It may be necessary to indicate that a procedure

or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service.


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Modifier 77 – Repeat Procedure by Another Physician or Other Qualified

Health Care Professional:

• It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service.


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Modifier 79 - Unrelated procedure or service by the same

physician or other qualified health care professional during the postoperative period

• The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.

• Use New Diagnosis


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XE, XP, XS and XU Modifiers

The four new HCPCS modifiers – XE, XP, XS and XU – are designed to define specific subsets of modifier 59: -XE Separate Encounter: A service that is distinct because it occurred during a separate encounter -XS Separate Structure: A service that is distinct because it was performed on a separate organ/structure -XP Separate Practitioner: A service that is distinct because it was performed by a different practitioner -XU Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service

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Other Sites of Service

Faculty

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Place of Service

19 Off Campus-Outpatient Hospital

A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. (Effective January 1, 2016)


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Place of Service


22 On Campus-Outpatient Hospital

A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. (Description change effective January 1, 2016)

Skilled Nursing Facility (SNF)

Skilled care is health care given when a patient needs skilled nursing or therapy to treat, manage, observe and evaluate care.

Certain SNF care services are covered by Medicare up to 100 days

Coverage falls under Medicare Part A

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• SNF Consolidated Billing – In the Balanced Budget Act of 1997, Congress mandated

that payment for the majority of services provided to beneficiaries in a Medicare covered SNF stay be included in a bundled prospective payment made through the Part A Medicare Administrative Contractor (MAC) to the SNF.

• Physicians, non-physician practitioners, and suppliers should contact their Part B MAC or Durable Medical Equipment (DME) MAC with questions about SNF consolidated billing.

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• https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2016-Part-B-MAC-Update.html


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LCDs and NCDs How do I use these?

Susan L. Crews, CPC, ACS-UR


Ft. Lauderdale 180

https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2016-Part-B-MAC-Update.html










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What is a NCD & LCD?

• National Coverage Determinations (aka NCD’s) and Local Coverage Determination (aka LCD’s)- Are decisions by Medicare and their administrative contractors (MAC’s) that provide coverage information and determine whether services are reasonable and necessary on certain services offered by participating providers.

• Medicare contractors develop LCDs when there is not an NCD or when there is a need to further define an NCD. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual.

• This information is defined in Section 1869(f)(2)(B) of the Social Security Act (the Act).


What is Supplemental Article?

• Supplemental Article (aka SA or Article)- Is a guidance document.

• Any non-reasonable and necessary language a Medicare contractor wishes to communicate to providers.

• At the end of an LCD that has an associated article, there is a link to the related article and vice versa.


What happens when there is not a LCD or Supplemental Article?

In the absence of a Local Coverage Determination (LCD), National Coverage Determination (NCD), or CMS Manual Instruction, Reasonable and Necessary guidelines still apply. Section 1862(a)(1)(A) of the Social Security Act (SSA) directs the following: • “No payment may be made under Part A or Part B for any expenses

incurred for items or services not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

• Therefore, to be considered “reasonable and necessary” the patient’s medical record must clearly document all of the following: – The item or service is for the diagnosis or treatment, or to improve the

functioning of a malformed body member – The item or service is appropriate for the symptoms and diagnosis or

treatment of the patient’s condition, illness, disease or injury


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What happens when there is not a LCD or Supplemental Article Cont.

– The item or service is furnished in accordance with current standards of good medical practice

– The item or service is not primarily for the convenience of the patient or physician or health care provider

– The item or service is the most appropriate supply or level of service that can be safely provided to the patient

– The item or service is delivered in the most appropriate setting – The item or service is ordered and/or furnished by qualified

personnel For any service reported to Medicare, it is expected that the medical record documentation clearly demonstrates that the service meets all of the above criteria. All documentation must be maintained in the patient’s medical record and be available to the contractor upon request


Lets take a moment and review a LCD


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Insurer Updates

Natacha Graham, CPC Susan L. Crews, CPC, ACS-UR


Ft. Lauderdale 194

Different Payers – Different Rules

• Traditional Medicare (Part B) – gold standard for published coding and payment rules – CCI Edits

– Relative Value Updates

– Confusing Incentive and Payment Adjustments

• Commercial Managed Care – rules driven by contract language and accompanying policies – Policies provided “on demand”

– Black box edits

– Pay for performance tied to costs

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More Payers – More Rules

• Medicare Advantage (Part C) – fixed revenue, sales driven benefits, contracts misunderstood

• Medicaid – multi-state practices forced to honor different rules

• Worker’s Comp – Fixed fee schedules, delayed by disputes

• Patients – varying payment expectations and assumption of no duty to pay

• More frequent migration among all options


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Payers are not the Same

• Billing – Use different Fee Schedules?

– Use different codes

– Use different Modifiers

– Rules Change • Try new things not in violation of contract

• CPT rules are a guide

– Transparency Check web sites

– Never Bill What You Cannot Appeal


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Know your Payers

• Contract Analysis •Payment Rate

•Medicare based (what year?) •Conversion factor and RVUS •Other Methods •Request fee schedule

•Watch the games •What is not eligible


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Know your Payers

• Yearly Review • Contract Analysis

•Contract vs. Actual •Rules Variation •Payment Delay •% of practice

• Quit Bad Payers


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Eligibility

• Eligibility Check – Web portal

– 270/271 transaction

•Payers differ on what is provided •Minimum check benefits for DOS •Can provide deductible, co-pay and

co-insurance • Future Full claim adjudication?


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The Claim Appeal Process

Odds are good with CMS appeals Every third party payer has their own appeal

process Develop a protocol for appeals to each carrier Most carriers have the appeals process posted

on their web site Compare the cost of appeals to the potential

payment Sometimes it is worth losing money to prove a

point


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Medicare Appeals Process

– Reopening – correction of typographical or mathematical errors

•Up to one year from original claim – Redetermination

• Submitted on Redetermination Notice (CMS 20027)-No minimum Amount in controversy (AIC)

• 120 days to request -MAC has 60 days to decide

– QIC Reconsideration • Submitted (CMS 20033) and performed by Qualified

Independent Contractor – no minimum AIC

• 180 days to request -QIC has 60 days to decide


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– Administrative Law Judge (ALJ)

• Appellant must prepare (CMS 20034) and a position paper -Minimum $120 AIC

• 60 days to request -ALJ has 90 days to decide

• Plaintiff’s attorney is advisable – Medicare Appeals Council (MAC)

• Request for oral argument must be made in writing (DAB 101) -No minimum AIC

• 60 days to request review -MAC has 90 days to decide


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–Federal Court

•Request must be filled in federal district court -$1180 AIC

•Plaintiff’s attorney is required


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Prompt Payment Rule

• 47 states have prompt payment laws - insurance plans must pay within a specified time period – know your rights – Contact your state Insurance Dept.

• Insist that contracts refer to prompt payments rules for your state

• Negotiate liquidated damages from health plan for delayed claims


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National Government Services - NGS

• Proposed Draft DL36601 Prostatic Urethral Draft for the coverage of the Urolift (Prostatic Urethral Lift Procedure) for the treatment of Benign prostatic hyperplasia (BPH) has been released for comment through April 9, 2016. Once comment period ends, future policy will be posted.

• Denosumab (Prolia, Xgeva) -A52399- Updated policy to include ICD- 10 code Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system.

• Effective 1/1/2016 the inflow Intraurethral Valve-Pump was assigned a HCPCS code – A4335- Incontinence supply, miscellaneous. This HCPCS code must be used on the claims for initial issue of InFlow TM, and is all-inclusive (catheter, wand and batteries). Claims must include the manufacturer and product name in the narrative field of the electronic claim.


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Thank you

Practice Management Department Coding Hotline

1-866-746-4282 Opt 3 [email protected]


mailto:[email protected]