2017 coding & coverage for the savi applicator · 2017 coding & coverage for the savi ......

2017 Coding & Coverage for the SAVI® Applicator

[email protected] or 866-369-9290

Prepared for:

Prepared by:

Updated January 2017

Procedure coding should be based upon medical necessity and procedures and supplies provided to the patient. Coding and reimbursement information is provided for educational purposes and does not assure coverage of the specific item or service in a given case. Cianna Medical® and The Pinnacle Health Group make no guarantee of coverage or reimbursement of fees. Contact your local Medicare Fiscal Intermediary, Carrier or CMS for specific information as payment rates listed are subject to change. To the extent that you submit cost information to Medicare, Medicaid or any other reimbursement program to support claims for services or items, you are obligated to accurately report the actual price paid for such items, including any subsequent adjustments. Current Procedural Terminology, numeric codes, descriptions, and modifiers are trademarks and copyrights of the AMA.

Introduction

The information contained in this document is provided to assist health care facilities understand reimbursement guidelines and procedures. It is intended to help obtain accurate coverage and reimbursement for medically necessary health care services provided to patients under physician orders. It is not intended to increase or maximize reimbursement.

The information referenced is based upon coding experience and research of current coding practices and published payer policies. They are based upon commonly used codes and procedures. The final decision for coding of any procedure must be made by the provider of care considering the medical necessity of the services and supplies provided, the regulations of insurance carriers and any local, state or federal laws that apply to the supplies and services rendered.

Although a particular service or supply may be considered medically necessary, the final coverage decision is based upon a review of the available clinical information and does not mean the service or supply will be covered by any payer. Each payer and benefit plan contains its own specific provisions for coverage and exclusions. Please consult individual payers to determine policy specific guidelines and whether there are any exclusions or other benefit limitations applicable to a particular service or supply.

Always code appropriately based upon procedures performed and medical necessity

Be aware of local coverage policies and correct coding initiative quarterly updates

Actual reimbursement will vary by geographic region and payer

Contact local carriers for specific coding guidelines for any procedure

This information is provided for educational purposes only

Coding Methodology

The Physicians’ Current Procedural Terminology (CPT) developed by the American Medical Association (AMA) and HCPCS Level II codes developed by the Centers for Medicare and Medicaid Services (CMS) are listings of descriptive and identifying codes for medical services and procedures performed by health care providers and reported to third party carriers. The codes in the CPT Manual are copyrighted by the AMA, and updated annually by the CPT Editorial Panel.

Third party payers have adopted the CPT coding system for use by providers to communicate payable services. Therefore, it is important to identify the various potential combinations of services to accurately adjudicate claims.

In order for this system to be effective, it is essential the coding description accurately describes what actually transpired at the patient encounter. Because many physician activities are so integral to a procedure, it is impractical and unnecessary to list every event common to all procedures of a similar nature as part of the narrative description for a code. Many of these common activities reflect simply normal principles of medical/surgical care.

Correct Coding Initiative

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative to ensure that payment policies and procedures were standardized for all carriers and to promote national correct coding methodologies. The coding policies developed are based on coding conventions defined in the American Medical Association’s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practice and reviews of current coding practice.

Procedures should be reported with the CPT/HCPCS codes that most comprehensively describe the services performed. Unbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code or when a single payment episode is split into two or more episodes so multiple payments can be collected.

The National Correct Coding Policy edits have been developed for application to services billed by a single provider for a single patient on the same date of service. The National Correct Coding Initiative represents a more comprehensive approach to unifying coding practices.

Quarterly updates are available for hospitals and physicians. Updates can be located on the web at: http://www.cms.hhs.gov/NationalCorrectCodInitEd

Terms, Acronyms and Footnotes

APC Ambulatory Payment Classification assigned by CMS for hospital payment classification

Carrier Priced Payment is determined by Medicare Administrator Contractor (MAC)

CMS Center for Medicare and Medicaid Services

MAC Medicare Administrator Contractor

N/A Reimbursement not available in this setting/fee schedule by CMS

OPPS Hospital Outpatient Perspective Payment System

Packaged Separate payment for this procedure is not made as the service is paid within the primary procedure by CMS

SI Status Indicator assigned by CMS

Status Indicator(s):

B = Not paid under OPPS

N = OPPS Items and Services Packaged into Primary APC Rate

J1 = Paid under OPPS; all covered Part B services on the claim are packaged with the primary service for the claim, except services with OPPS SI=F, G, H, L and U

Q1 = Paid under OPPS; Packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator “S,” “T,” or “V”; otherwise paid separately.

T = Paid separately under OPPS; Significant Procedure, Multiple Reduction Applies

U = Paid under OPPS; Separate APC payment

Breast Surgery

Mastectomy, partial (e.g. lumpectomy, tylectomy, quadrantectomy, segmentectomy)

Mastectomy, partial (e.g. lumpectomy, tylectomy, quadrantectomy, segmentectomy) with axillary lymph nodes

Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion

Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure

CPT-4® Description StatusIndicator

HospitalOutpatient1

AmbulatorySurgery1 Center

19301

19302

19125

19126

J1

N N/A Packaged Packaged

J1 $1,936.51

$1,007.05

APC

5092 $4,419.46

5091 $2,499.48

J1 $1,007.055091 $2,499.48

H O S P I TA L O U T PAT I E N T A N D A M B U L AT O R Y S U R G E R Y C E N T E R

Mastectomy, partial (e.g. lumpectomy, tylectomy, quadrantectomy, segmentectomy)

Mastectomy, partial (e.g. lumpectomy, tylectomy, quadrantectomy, segmentectomy) with axillary lymph nodes

Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion

Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure

CPT-4® Description Facility RVUs Non-FacilityRVUs Non-Facility2

19125

19126

19301

19302

13.19

4.68 $167.95 0.00 N/A

18.77

25.90

N/A

N/A

$560.58

Facility2

$673.63

$929.52

0.00

0.00

$473.37 15.62

P H Y S I C I A N FA C I L I T Y A N D N O N - FA C I L I T Y

Procedure Coding for Surgery and Catheter Implant

All codes utilized during the patient’s course of treatment may not be indicated below. The total course of therapy may consist of patient consultation, surgery, treatment planning, treatment mapping, treatment delivery and management

and follow-up care. Coding for each medically necessary service provided should follow appropriate clinical and coding guidelines. Actual reimbursement will vary by geographic region and payer.

1. Hospital Outpatient Prospective Payment – Final Rule with Comment and Final CY2017 Payment Rates (CMS-1656-FC); Jan 2017 Addendum B and Jan 2017 ASC Addenda.

2. CY 2017 Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B; Addendum B. All MPFS Fee Schedules calculated using CF of $35.8887 effective January 2017.

3. 2017 AMA CPT Professional.

Catheter Implant

Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy

Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure)

Catheter, brachytherapy seed administration

Unlisted procedure, breast (e.g. placement of SAVI Prep™ Catheter)


HospitalOutpatient1

AmbulatorySurgery1 Center

19296

19499

19297

C1728

J1

J1 5091 $2,499.48 N/A

N Packaged

$3,383.61

APC

N/A Packaged

N PackagedN/A Packaged

5093 $6,486.35

H O S P I TA L O U T PAT I E N T A N D A M B U L AT O R Y S U R G E R Y C E N T E R

Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy

Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure)

Unlisted procedure, breast (e.g. placement of SAVI Prep™ Catheter)

Surgical supply; miscellaneous supplies and materials provided by the physician over/above those usually included with the services rendered (e.g. SAVI Prep™ Catheter)

CPT-4® Description

19296

A4649or

99070

19297

19499

6.09

N/A CarrierPriced N/A Carrier

Priced

2.75 N/A

$4,017.74

$98.69 0.00

N/A By ReportBy Report N/A

$218.56 111.95


Facility RVUs Non-FacilityRVUs Non-Facility2Facility2




Radiation Therapy: Treatment Planning and Management

Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete


HospitalOutpatient1

76641 Q1

APC

5522 $112.73

Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited76642 Q1 5521 $59.86

H O S P I TA L O U T PAT I E N T

CPT-4® Description Facility RVUs Non-FacilityRVUs Non-Facility2Facility2


Therapeutic radiology treatment planning, complex77263 B N/A N/A

Complex simulation77290 S 5612 $311.57

3-D Treatment Planning77295 S 5613 $1,066.24

Special medical radiation physics consultation77370 S 5611 $117.59

Special treatment procedure77470 S 5623 $494.63

Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2–12 channels), includes basic dosimetry calculation(s)

77317 S 5612 $311.57

76641 3.05 $109.46

Therapeutic radiology treatment planning, complex77263 4.71 $169.04

Complex simulation77290 14.64 $525.41

1.04

4.71

2.30

$37.32

76642 2.51 $90.080.97 $34.81

$169.04

$82.54

3-D Treatment Planning77295 13.92 $499.576.29 $225.74

Special medical radiation physics consultation77370 3.46 $124.17N/A N/A

Special treatment procedure77470 4.09 $146.782.99 $107.31

77317 6.97 $250.142.69 $96.54

Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete

Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited

Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2–12 channels), includes basic dosimetry calculation(s)

Procedure Coding for Radiation Therapy




Radiation Therapy: Treatment Delivery

Simple simulation (verification simulation)


HospitalOutpatient1

77280 S

APC

5611 $117.59

H O S P I TA L O U T PAT I E N T

CPT-4® Description Facility RVUs Non-FacilityRVUs Non-Facility2Facility2


Weekly continuing medical physics77336 S 5611 $117.59

HDR 2-12 channels****77771 S 5624 $738.63

Brachytherapy source, IridiumC1717 U 2646 $281.58

Unlisted procedure, Clinical brachytherapy (e.g. catheter removal by non-implanting physician)77799 S 5621 $114.35

Simple simulation (verification simulation)77280 7.77 $278.86

Weekly continuing medical physics77336 2.25 $80.75

HDR 2-12 channels****77771 16.95 $608.31

Brachytherapy source, IridiumQ3001 N/A ReportInvoice Cost

Unlisted procedure, Clinical brachytherapy (e.g. catheter removal by non-implanting physician)77799 N/A

1.03

0.00

5.58

N/A

N/A

$36.97

N/A

$200.26

N/A

CarrierPriced

CarrierPriced




Common Modifiers Reported

In some circumstances, payers require modifiers when the SAVI applicator is implanted. Modifiers provide the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Common reasons for Modifiers when using the SAVI applicator include:

• Only a professional or technical component of the procedure was furnished,

• More than one provider participated in the performance of the procedure,

• A service or procedure was increased or reduced,

• Another related or non-related service/procedure was performed at the same visit,

• A bilateral procedure was performed,

• A service or procedure was provided more than once,

• Unusual events occurred

CPT Modifier 58

Description:

Indicates a Staged or Related Procedure or Service by the Same Physician during the Postoperative Period

Appropriate Use:

• Surgery procedure codes with 010 or 090 global periods on the Medicare Physician Fee Schedule Database

• To report a staged procedure planned at the time of the original procedure

• When the staged procedure is more extensive than the original procedure

• For therapy following a diagnostic surgical procedure

• When performing a second or related procedure during the postoperative period.

Inappropriate Usage:

• Appending the modifier to ASC facility fee claims

• Appending the modifier to a procedure with XXX global period on the MPFSDB

• Appending the modifier to services listed in CPT as multiple sessions,

• Reporting the treatment of a complication form the original surgery that requires a return to the operating room,

• Unrelated procedures during the postoperative period.

Facts:

• A new postoperative period begins when the next procedure in the staged procedure series is billed.

• Staged procedures do not apply to claims for assistant at surgery or services of an ASC.

• Used during the post-operative period starting the day after the initial procedure.

Example:

The same physician that performed the lumpectomy implanted the SAVI applicator on a different date of service.

• Append modifier 58 to CPT 19296 to bypass the 90-day global period assigned to the lumpectomy.

CPT Modifier 78

Description:

Indicates the return to the Operating/Procedure Room for a related procedure, by the same physician, during the post-operative period

Appropriate Usage:

• Surgery procedure codes with 010 or 090 global periods on the Medicare Physician Fee Schedule

• To report a procedure, related to the original procedure, performed in an operating room* (OR) during the post-operative period

• Used to identify a return to the OR* on the same day as the procedure or during the post-operative period

• To treat the patient for complications resulting from the original surgery

• When the procedure code used to describe a service for treatment of complications is the same as the procedure code used in the original procedure, modifier 78 is the correct modifier to use.

Inappropriate Usage:

• For any procedure code other than a surgery with 010 or 090 global periods on the Medicare Physician Fee Schedule

• When the surgery is unrelated to the original procedure

• When performed any place other than the OR*.

• When the procedure performed by a different physician who is not related to the physician performing the original procedure (must be outside the original physician group practice).

Facts:

• Modifier 78 does not begin a new post-operative period.

Examples:

The same physician that implanted the initial SAVI catheter must remove and replace the catheter for a clinical purpose during the post-operative period.

• Append modifier 78 to CPT 19296 to bypass the 90 day global period assigned to the lumpectomy (NOTE: for most payers reimbursement includes the cost of the SAVI applicator)

*An OR is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a special procedures room, a laser suite, or an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit.

Coverage

Most payers permit coverage for breast brachytherapy based upon specific coverage criteria. In most cases the criteria considers coverage for accelerated partial breast irradiation when the patient is:

In women undergoing initial treatment for stage I or II breast cancer; and Who are also treated with breast-conserving surgery and whole-breast external beam radiation therapy

Always check with the patient’s plan coverage/policy guidelines for appropriate coverage criteria prior to treatment.

SAVI Prep™ Catheter Device

The physician can bill for the placement of the SAVI Prep Catheter when implanted at the time of lumpectomy. Since the SAVI Prep Catheter is implanted at the time of lumpectomy, the implant must be reported using CPT 19499 in

addition to the CPT code for the Lumpectomy.

To report the SAVI Prep Catheter device, report A4649 for Medicare claims or 99070 for commercial payers. Payment for these supply codes (A4649 and 99070) are typically ‘packaged’ into the reimbursement for the procedure reported by 19499.

Since CPT 19499 is an unlisted code it is important to make sure that the clinical documentation is clear and outlines the procedure performed. Payers will review the claim and documentation related to the use of CPT 19499 to

determine appropriate coverage and payment. The operative report must be available and a description of the procedure such as “Placement of the SAVI Prep Catheter for Cavity Evaluation” should be entered in the comment field

of the electronic claim. The description will then appear on the electronic claim. The claim may be pended and a request for clinical documentation sent to the provider. Attach the operative report to the request letter and forward to the payer

immediately to avoid delay in reimbursement.

LIT0130 Rev. O

Cianna Medical, Inc., 6 Journey, Suite 125, Aliso Viejo, California 92656866.920.9444 • 949.360.0059 • Fax 949.297.4527 www.ciannamedical.com

Customer Care: [email protected]

©2017 Cianna Medical, Inc. All rights reserved. These products covered by U.S. Patents 7,497,819, 7,497,820, 7,601,113, 7,662,082, 7,736,292, 7,862,496, 7,862,498, 8,398,534, 9,072,893. Other patents pending. BEST Forum, SAVI, SAVI Sisters, and Cianna Medical are registered trademarks of Cianna Medical, Inc.

This sample report is provided as a resource and reference during the development of the narrative physician report for the SAVI applicator implant procedure. The actual procedure performed should be dictated to support the medical necessity of the

procedure and should become a permanent part of the patient’s medical record.

CY 2017 Payment Rate for CPT 19296 by Locality

Locality Name Carrier Locality Adjusted Non-Facility Payment

Alabama 10102 00 $3,572.21

Alaska** 02102 01 $4,506.16

Arizona 03102 00 $3,959.40

Arkansas 07102 13 $3,502.87

Bakersfield, CA 01112 54 $4,313.84

Chico, CA 01112 55 $4,313.84

El Centro, CA 01182 71 $4,313.84

Fresno, CA 01112 56 $4,313.84

Hanford–Corcoran, CA 01112 57 $4,313.84

Los Angeles–Long Beach–Anaheim (Los Angeles County), CA

01182 18 $4,669.75

Los Angeles–Long Beach–Anaheim (Orange County), CA

01182 26 $4,776.97

Madera, CA 01112 58 $4,313.84

Merced, CA 01112 59 $4,313.84

Modesto, CA 01112 60 $4,313.84

Napa, CA 01112 51 $5,054.73

Oxnard–Thousand Oaks–Ventura, CA 01182 17 $4,700.44

Redding, CA 01112 61 $4,313.84

Riverside–San Bernardino–Ontario, CA 01112 62 $4,314.32

Sacramento–Roseville–Arden-Arcade, CA 01112 63 $4,317.69

Salinas, CA 01112 64 $4,329.27

San Diego–Carlsbad, CA 01182 72 $4,348.55

San Francisco–Oakland–Hayward (Alameda/Contra Costa County), CA

01112 07 $5,139.88

San Francisco–Oakland–Hayward (Marin County), CA

01112 52 $5,054.86

San Francisco–Oakland–Hayward (San Francisco County), CA

01112 05 $5,387.92

San Francisco–Oakland–Hayward (San Mateo County), CA

01112 06 $5,356.46

San Jose–Sunnyvale–Santa Clara (San Benito County), CA

01112 65 $4,476.76

San Jose–Sunnyvale–Santa Clara (Santa Clara County), CA

01112 09 $5,364.83

San Luis Obispo–Paso Robles–Arroyo Grande, CA

01182 73 $4,313.84

Santa Cruz–Watsonville, CA 01112 66 $4,406.41

Santa Maria–Santa Barbara, CA 01182 74 $4,360.13

Santa Rosa, CA 01112 67 $4,367.84

Stockton–Lodi, CA 01112 68 $4,313.84

Vallejo–Fairfield, CA 01112 53 $5,054.73

Visalia–Porterville, CA 01112 69 $4,313.84

Yuba City, CA 01112 70 $4,313.84

Rest of California 01112 75 $4,313.84

Colorado 04112 01 $4,077.59

Connecticut 13102 00 $4,479.40

Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy.


D.C. + Maryland/Virginia Suburbs 12202 01 $4,822.91

Delaware 12102 01 $4,118.52

Fort Lauderdale, FL 09102 03 $4,121.53

Miami, FL 09102 04 $4,183.38

Rest of Florida 09102 99 $3,858.18

Atlanta, GA 10202 01 $4,022.08

Rest of Georgia 10202 99 $3,627.82

Hawaii, Guam 01212 01 $4,600.45

Idaho 02202 00 $3,617.24

Chicago, IL 06102 16 $4,187.47

East St. Louis, IL 06102 12 $3,792.19

Suburban Chicago, IL 06102 15 $4,249.44

Rest of Illinois 06102 99 $3,692.97

Indiana 08102 00 $3,694.02

Iowa 05102 00 $3,623.38

Kansas 05202 00 $3,648.13

Kentucky 15102 00 $3,533.61

New Orleans, LA 07202 01 $3,931.32

Rest of Louisiana 07202 99 $3,587.95

Southern Maine 14112 03 $4,034.37

Rest of Maine 14112 99 $3,398.78

Baltimore/surrounding counties, MD 12302 01 $4,398.21

Rest of Maryland 12302 99 $4,155.12

Metropolitan Boston, MA 14212 01 $4,675.74

Rest of Massachusetts 14212 99 $4,273.80

Detroit, MI 08202 01 $4,002.26

Rest of Michigan 08202 99 $3,708.73

Minnesota 06202 00 $4,059.59

Mississippi 07302 00 $3,489.40

Metropolitan Kansas City, MO 05302 02 $3,857.21

Metropolitan St. Louis, MO 05302 01 $3,853.05

Rest of Missouri 05302 99 $3,461.38

Montana*** 03202 01 $4,030.67

Nebraska 05402 00 $3,646.83

Nevada*** 01312 00 $4,147.78

New Hampshire 14312 40 $4,217.17

Northern New Jersey 12402 01 $4,721.68

Rest of New Jersey 12402 99 $4,499.73

New Mexico 04212 05 $3,715.30

Manhattan, NY 13202 01 $4,716.49

New York City Suburbs/Long Island, NY 13202 02 $4,857.57

Poughkeepsie/North NYC Suburbs, NY 13202 03 $4,309.19

Queens, NY 13292 04 $4,830.68

Rest of New York 13282 99 $3,807.45

North Carolina 11502 00 $3,743.51

North Dakota*** 03302 01 $4,004.08

Ohio 15202 00 $3,701.41

Oklahoma 04312 00 $3,559.56


Portland, OR 02302 01 $4,211.71

Rest of Oregon 02302 99 $3,882.79

Metropolitan Philadelphia, PA 12502 01 $4,342.76

Rest of Pennsylvania 12502 99 $3,759.60

Puerto Rico 09202 20 $3,451.49

Rhode Island 14412 01 $4,217.93

South Carolina 11202 01 $3,667.26

South Dakota*** 03402 02 $3,999.50

Tennessee 10302 35 $3,617.69

Austin, TX 04412 31 $4.087.56

Beaumont, TX 04412 20 $3,679.05

Brazoria, TX 04412 09 $3,994.10

Dallas, TX 04412 11 $4,059.05

Fort Worth, TX 04412 28 $3,976.57

Galveston, TX 04412 15 $4,063.53

Houston, TX 04412 18 $4,053.43

Rest of Texas 04412 99 $3,738.11

Utah 03502 09 $3,733.48

Vermont 14512 50 $4,045.43

Virginia 11302 00 $3,955.84

Virgin Islands 09202 50 $4,040.67

Seattle (King County), WA 02402 02 $4,594.93

Rest of Washington 02402 99 $4,058.51

West Virginia 11402 16 $3,436.28

Wisconsin 06302 00 $3,831.65

Wyoming*** 03602 21 $4,019.25

* January 1, 2017 through December 31, 2017, the Work GPCIs reflect a 1.0 floor as required by Section 201 of the MACRA of 2015. The 1.0 Work GPCI floor expires on December 31, 2017

**Work GPCI reflects a 1.5 floor in Alaska established by the MIPPA.

***PE GPCI reflects a 1.0 floor for frontier states established by the ACA.

2017 coding & coverage for the savi applicator · 2017 coding & coverage for the savi ......

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