Download - 2011 CDM Updates Day 1

HFMA Western NY Chapter

January 25, 2011 – Day 1

2011 OPPS UPDATES, CODING CHANGES

AND CHARGE MASTER APPROACHES

INTRODUCTIONSINTRODUCTIONS� 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, 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 OBJECTIVES OF THE WORKSHOPWORKSHOP2011 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 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

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CPT® is registered trademark of the American Medical Association. All rights reserved.

OBJECTIVES OF THE OBJECTIVES OF THE WORKSHOPWORKSHOP

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 � 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 CHARGE DESCRIPTION MASTERDESCRIPTION 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. 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� the UB-04 revenue code number

� unit of service and/or multiplier

� corresponding charge dollar amount.

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CDM

NumberCDM Service Description

HCPCS/

CPT

UB04 Rev

CodeUOS

Charge

Amount

4500100 ED VISIT LEVEL I 99281 450 1 $200.00


� 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 � 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 � 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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CHARGE DESCRIPTION MASTERCHARGE DESCRIPTION MASTERCurrent 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:� 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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CHARGE DESCRIPTION MASTERCHARGE DESCRIPTION MASTERHealthcare 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

� B Codes Enteral and Parental Therapy

� K Codes DME Regional Carriers

� L Codes Orthotic and Prosthetic Procedures� B Codes Enteral and Parental Therapy

� C Codes Temporary codes for use with OPPS

� D Codes Dental procedures

� E Codes Durable Medical Equipment

� G Codes Procedures and Professional Services

� H Codes Alcohol & Drug Abuse Treatment Services

� J Codes Drugs Administered Other Than Oral

� L Codes Orthotic and Prosthetic Procedures

� M Codes Other Medical Services

� P Codes Pathology and Laboratory Services

� Q Codes Temporary

� R Codes Diagnostic Radiology Services

� S Codes Nat’l Codes (Non-Medicare)

� T Codes Nat’l Codes for State Medicaid Agencies

� V Codes Vision and Hearing Services

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CHARGE CHARGE DESCRIPTION MASTERDESCRIPTION MASTERCPT 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.CPT Code.

�Codes have a alpha character as the fifth digit.

�Category Code III assignment does not imply coverage.

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CHARGE DESCRIPTION MASTERCHARGE DESCRIPTION MASTERCPT 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.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 �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�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� 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 � Poor maintenance of the CDM can put the hospital at financial

risk and may introduce risk of regulatory non-compliance.

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Because the Healthcare Common Procedure Coding System (HCPCS) codes andAPCs are updated regularly, hospitals should pay particular attention to the taskof updating the CDM to ensure the assignment of correct codes to outpatientclaims. This should include timely updates, proper use of modifiers, and correctassociations between procedure codes and revenue codes.

- OIG Compliance Guidance for Hospitals

CHARGE CHARGE DESCRIPTION MASTERDESCRIPTION MASTER� 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� 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� 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� Compliance and Revenue Integrity

� Health Information Management

� Information Systems

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= CDM TEAM


� 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 � 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

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� 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.


Review StepLimited CDM

Review

Comprehensive

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 √√√√

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√√√√

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) √√√√


� 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

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� 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

OUTPATIENT REIMBURSEMENTOUTPATIENT 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

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� 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.

OUTPATIENT REIMBURSEMENTOUTPATIENT REIMBURSEMENT� 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

� 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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OUTPATIENT REIMBURSEMENTOUTPATIENT REIMBURSEMENT� 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. � 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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OUTPATIENT REIMBURSEMENTOUTPATIENT REIMBURSEMENT� 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. 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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Indicator Definition Explanation

A Indicates services that are paid under some other method:

• Durable medical equipment, prosthetics and orthotics are paid under

the DMEPOS fee schedule

• 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

Not paid under OPPS. Paid by Medicare

contractors under the appropriate fee schedule or

another payment system.

CMS Status Indicators

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• 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

Outpatient Hospital Part B bill type (12x,13x, and 14x)

Should not be used for OPPS billing since they are

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.



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

conditions:

• 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

Not paid under OPPS or any other Medicare

payment system.

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• 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

Radiophamaceuticals

Paid under OPPS. Separate cost-based pass-

through payment made.



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.

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M Service not billable to FI and not payable 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.



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

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(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.



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

Performed

Paid under OPPS; separate APC payment.

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.

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X Ancillary Service; Separate APC Payment Paid under OPPS; separate APC payment.

Y Non-Implantable Durable Medical Equipment:; Not paid

under OPPS

Not paid under OPPS. All institutional providers

other than home health agencies bill to durable

medical equipment regional carrier.


� 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.

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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”.


� 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

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� Mental Health Services

� Multiple Imaging Studies


Composite APC Composite APC Title Criteria for Composite Payment

8000 Cardiac Electrophysiologic

Evaluation and Ablation

Composite

At least one unit of CPT code 93619 or

93620 and at least one unit of CPT code

93650, 93651 or 93652 on the same date

of service.

8001 Low Dose Rate Prostate

Brachytherapy Composite

One or more units of CPT codes 55875

and 77778 on the same date of service.

8002 Level I Extended Assessment and 1) Eight or more units of HCPCS code

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8002 Level I Extended Assessment and

Management Composite

1) Eight or more units of HCPCS code

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


� 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

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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.


� 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.

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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.


� 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

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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.


� 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

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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.


� 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

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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”

REGULATORY CONSIDERATIONSREGULATORY 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.

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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.


� 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

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� 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


� 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)

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� 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.


� Target Areas/Identified Issues� Medical Necessity

� Infusion Therapy

� ICDs and Pacers

� Coronary Artery Stents

� Frequency Limitations

Screening and Preventive Services

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� 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

REGULATORY CONSIDERATIONSREGULATORY CONSIDERATIONS� 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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� Taking a holistic approach

REGULATORY CONSIDERATIONSREGULATORY CONSIDERATIONS� 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;

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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.


The Holistic View of Revenue Integrity

50

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

CY2011 HCPCS/CPT AND OPPS UPDATESCY2011 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

51

� HCPCS Updates

� 287 deleted codes

� 140 new codes

� 43 revised codes

� OPPS Updates

� Published Federal Register Final Rule, November 24, 2010

CY2011 HCPCS/CPT AND OPPS UPDATESCY2011 HCPCS/CPT AND OPPS UPDATES� Outline for remainder of work shop:

� Laboratory (inc. Blood Bank)

� Radiology (inc. Nuclear Medicine)

� Pain Management

� Interventional Radiology

� Cardiac Catheterization

� Electrophysiology

� Medical and Surgical Supplies

D

A

Y

1

52

� Medical and Surgical Supplies

� Outpatient Facility E/M Services; Clinic and Emergency Services

� Outpatient Observation Services

� Infusions and Injections

� Pharmaceuticals

� Diagnostic Cardiology

� Respiratory/Pulmonary

� Cardiac and Pulmonary Rehabilitation

� Radiation Oncology

1

D

A

Y

2

CY2011 HCPCS/CPT AND OPPS UPDATESCY2011 HCPCS/CPT AND OPPS UPDATES� 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

53

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

LABORATORYLABORATORY� 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

54


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.

LABORATORYLABORATORY� 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

55

� Code Selection

� Modifier Use

� Date of Service Reporting

� Reference Laboratory Testing

LABORATORYLABORATORY� 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

56

� 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.

LABORATORYLABORATORY� 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

57

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

LABORATORYLABORATORY� 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

58

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.

LABORATORYLABORATORY� 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.

59

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.

LABORATORYLABORATORY� 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

60

� Panels

� Urinalysis

� Blood Counts

LABORATORYLABORATORY� 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

61

� If the test resulted is deemed not medically necessary, the

venipuncture to obtain the specimen is also considered to not be

medically necessary.

LABORATORYLABORATORY� 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

62


� 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.”

LABORATORYLABORATORY� 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

63

� 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.

LABORATORYLABORATORY� 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.

64

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


� 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

65

� 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.


� 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.


66


� HCPCS P3000 is payable under the Medicare Laboratory Fee Schedule

� Submit diagnosis code V76.2, “routine cervical PAP”


� 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.


67


�� HCPCS G0103 is payable under the Medicare Laboratory Fee HCPCS G0103 is payable under the Medicare Laboratory Fee

Schedule Schedule -- errorerror

� CORRECTION:

� HCPCS G0328 (iFOBT, or immunoassay-based).

� CPT 82270 non-Medicare


� 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)

68

� 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”


� 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

69

� 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”

LABORATORYLABORATORY� 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.

70

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.

LABORATORYLABORATORY� Analyzing the laboratory CDM line item usage can identify

potential areas of financial and/or compliance risk.

� Examples


� 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

71

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.

LABORATORYLABORATORY� 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

72

� 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.

LABORATORYLABORATORY� 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,

73

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.


�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”

74

� 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”


�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


75


� 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


�Chemistry


� 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

76

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.


�Chemistry


� 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

� CPT Code 85598 is a child code to 85597


� 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

78

mediated immunity antigen response measurement


� 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.


�Transfusion


� 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

79

� 86903, “Blood typing; antigen screening for compatible blood unit

using reagent serum, per unit screened”

� Use CPT Code 86902


�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,

80

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)”


�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

81

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.


� 87906, “Infectious agent genotype analysis by nucleic acid (DNA or

RNA); HIV-1, other region (eg, integrase, fusion)”


�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”

82

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


�Cytopathology


� 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)”

83

separately in addition to code for primary procedure)”

� Created to report each additional evaluation of a fine needle

aspiration at the same site


�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

84

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


� 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


� Lab Procedures


� 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

85


� 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”


� Lab Procedures


� 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

86


specimen, for chemical analyses or cytopathology;”


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”


� Lab Procedures



(eg, gastric secretory study); 2 hours including gastric

stimulation (eg, histalog, pentagastrin)”


87


(eg, gastric secretory study); 3 hours, including gastric

stimulation”

� 89225, “Starch granules, feces”

� 89235, “Water load test”

RADIOLOGYRADIOLOGY� 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.


88


radiology services� Packaging of Imaging Services under APCs

� Code Selection


� Modifiers

� Contrast and Radiopharmaceuticals

� Multiple Day Studies

RADIOLOGYRADIOLOGY� 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

89

� Imaging Supervision and Interpretation

� Contrast and Diagnostic Pharmaceuticals

� Special Packaging

� Multiple Imaging Procedures

RADIOLOGYRADIOLOGY� 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

90

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.

RADIOLOGYRADIOLOGY� 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.

91

� 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.

RADIOLOGYRADIOLOGY� 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.

92

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)

RADIOLOGYRADIOLOGY� 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

93

available, and revenue code 636. In the absence of a HCPCS/CPT, the

charge should be captured with revenue code 255 only.

RADIOLOGYRADIOLOGY� 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.

94

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.

RADIOLOGYRADIOLOGY

HCPCS/

CPT HCPCS/CPT Description

Per

Study Quantity

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 √ √

95

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

√

RADIOLOGYRADIOLOGY� 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.

96

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)

RADIOLOGYRADIOLOGY� Charge Capture Tips for Radiology Services

� Understand the relationship between the clinical subsystem and the CDM.



� Radiopharmaceuticals

� Reconcile the radiopharmaceuticals to the nuclear medicine volumes

reported.

97

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.

RADIOLOGYRADIOLOGY� 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

98

� 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


�Deleted CPT Codes

� Examinations considered to be obsolete

� 76150, “Xeroradiography”

� 76350, “Subtraction in conjunction with contrast studies”

�Replaced CPT Code 76880

Deleted CPT Code

99

� 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).


� 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”

�Revised CPT Code 77003

100

Revised CPT Code 77003

� 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”

RADIOLOGYRADIOLOGY� 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

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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.


� 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

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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


� 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)

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� 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.


� 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.

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radiopharmaceuticals in 2011.

PAIN MANAGEMENTPAIN 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

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� Facet injections

� Kyphoplasty

� Implantable Infusion Pumps

� Neurostimulators

� Vertebroplasty


performed.

PAIN MANAGEMENTPAIN MANAGEMENT� There are essential coding and billing guidelines to consider when

capturing pain management services


� Modifier Use

� Radiologic Guidance


Documentation Requirements

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� Documentation Requirements

PAIN MANAGEMENTPAIN MANAGEMENT


� 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

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� 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



� 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


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� Nerve destruction by neurolytic agent

� Epidural injection

� Vertebroplasty

� Kyphoplasty

� Percutaneous Neurostimulator (see exceptions)



� 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.

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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)


� 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.

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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)

PAIN MANAGEMENTPAIN 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

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� 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.


� 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

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� 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.


� 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.

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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


� 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.

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injected. Count each injection.

� Radiologic guidance can be captured separately.



� MR CPT Code 77021


� 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.

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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


� 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.

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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.




� 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.


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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.




� 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

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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.


� 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.

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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.


� 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.

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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.

PAIN MANAGEMENTPAIN MANAGEMENT� Analyzing the pain management CDM line item usage can identify


� 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.

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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.

PAIN MANAGEMENTPAIN 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)

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� 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.

PAIN MANAGEMENTPAIN 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

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� 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

INTERVENTIONAL RADIOLOGYINTERVENTIONAL RADIOLOGY� Interventional Radiology is a subspecialty of radiology in which

minimally invasive procedures are performed using image

guidance.

� Procedures can include the following:

� Percutaneous Transluminal Coronary Angioplasty (PTCA)

� Percutaneous Transluminal Angioplasty (PTA)

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� Percutaneous Transluminal Angioplasty (PTA)

� Angiography

� Interventional Radiology services are included in CPT code 70,000

range for the radiology component and the CPT code range for

surgical services for the surgical component.

� UB04 revenue codes are specific to the radiologic and surgical

components.

INTERVENTIONAL RADIOLOGYINTERVENTIONAL RADIOLOGY� There are essential coding guidelines to consider when capturing

interventional radiology services:


� In general, more than one HCPCS/CPT is used to describe the complete

procedure.

� Exception lies with lower extremity revascularization (NEW!)

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� Coding is performed in components and can include the following:

� Introduction of needle

� Surgical intervention(s)

� Radiological guidance

INTERVENTIONAL RADIOLOGYINTERVENTIONAL RADIOLOGY

� Rules for Upper Extremity Revascularization� Code separately for each component or step of the procedure (i.e.

angiography, intervention, etc)

� Code each vascular family separately.

� Within a vascular family, code only the highest order catheterization.

� If multiple vessels within a vascular family are selected, an add-on code

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may be used to describe the additional selective effort and supervision

& interpretation

� Catheter movement (retrograde and antegrade) and vascular families

determine vessel ordering.

� Each vascular access site is coded separately.

� Code for each vessel treated, not each lesion treated.


Example - Bilateral renal artery balloon angioplasty

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� Rules for Lower Extremity Revascularization

�Provided by the American College of Radiology� http://www.acr.org/Hidden/Economics/FeaturedCategories/Pubs/coding_source/archives/Sept

Oct10/2011-CPT-Code-Update.aspx

� Report only one primary code for each vascular territory treated per

limb. If multiple vascular territories are treated during the same

session, it is appropriate to report the primary code for the initial

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session, it is appropriate to report the primary code for the initial

vessel in each vascular territory.

� Add-on codes are used to report additional second or third vessels

treated within the same vascular territory, such as in the iliac or

tibial/peroneal territory. Since the iliac and tibial/peroneal territories

include three vessels, a maximum of two add-on codes may be

reported within each territory.

� Add-on codes are used when treatments are performed in different

vessels within the same vascular territory, not for distinct lesions in

the same vessel.


� Rules for Lower Extremity Revascularization� The femoral/popliteal territory is considered one vessel; therefore,

add-on codes do not apply.

� The common peroneal trunk is considered part of the three vessels

in the tibial/peroneal territory and is not treated as a separate,

fourth vessel for CPT reporting of lower extremity endovascular

revascularization procedures.

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� Multiple stent placements in the same vessel are reported once.

� For a bilateral procedure, use modifier 59 if the same territory(ies) is

treated (even if mode of therapy is different). For example, use

modifier -59 when the right external iliac artery is treated with

angioplasty (37220), and the left external iliac artery is treated with

angioplasty and stent (37221-59).

� Lesions treated which cross vascular territories should only be coded

once.


� Rules for Lower Extremity Revascularization� Diagnostic angiography performed at a separate session from an

interventional procedure is reported separately. Diagnostic

angiography supervision and interpretation codes are reportable

when the criteria for the appropriate reporting of them at the same

time as interventions are satisfied.

� Mechanical thrombectomy and/or thrombolysis, when used, is

reported separately

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reported separately


Example - PTA, common iliac arteries, bilateral and intravascular stent(s) placement

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INTERVENTIONAL RADIOLOGYINTERVENTIONAL RADIOLOGY� Angiography

� If the catheter or needle is placed directly into an artery or

vein and is not manipulated further, assign a nonselective

code.

� Nonselective placement includes direct placement into the aorta

or vena cava from any approach, and direct puncture of arteries,

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veins, or the vena cava without further manipulation. These CPT

Codes include 36200 and 36010.

� If the catheter requires additional movement or

manipulation beyond the initial placement, assign a

selective code.

� This indicates that the catheter is guided into a position of the

artery other than the aorta or where the artery is punctured.


�Only the most selective placement (highest order) in each

vascular family may be coded in procedures involving both

nonselective and selective placements. The exception is if

more than one access is utilized.

� If a nonselective catheter placement (with the same

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� If a nonselective catheter placement (with the same

access) is then converted to a selective catheter placement,

only the selective catheter placement is reported. The

work of the non-selective catheter placement is included in

the selective placement, and has been taken into account

when the fee schedule for selective levels was determined.


�To assign the correct selective code, imagine the vascular

system as a tree:

� The main trunk (aorta or vena cava) has several primary branches

(first order)

� The aorta as the main trunk is considered non-selective.

134

� Secondary branches (second order) spring from each of the

primary branches, also resulting in tertiary branches (third order).

� A single primary branch with all of its secondary and tertiary

branches is a “vascular family”.


135

INTERVENTIONAL RADIOLOGYINTERVENTIONAL RADIOLOGYExample - Abdominal Aortogram with Study of Pelvic Vessels and Proximal Lower

Extremity Vessels.

The catheter is placed via femoral approach and repositioned into the distal abdominal aorta.

The catheter is exchanged over a guidewire for a selective catheter, which is first positioned in

the common femoral artery and then repositioned in the external iliac artery.

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INTERVENTIONAL RADIOLOGYINTERVENTIONAL RADIOLOGY� “Drive-bys”

� Where the attending physician does not request, and where the

medical condition (documented in the chart) does not

warrant additional procedures, than the addition of other, unrelated

procedures may be seen as medically unnecessary and may result in

payment denials, refunds and more, if identified during an audit. In

such cases, an investigation may be initiated to determine if other

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such cases, an investigation may be initiated to determine if other

"schemes to defraud", have occurred.

� Hospitals should be very careful with what they consider to be "drive

by" procedures. Remember, without regard to what the physician

codes and bills, the hospital has a fiduciary responsibility to code and

bill for only those procedures that meet medical necessity guidelines,

have written orders, and have signed reports to document existence.

INTERVENTIONAL RADIOLOGYINTERVENTIONAL RADIOLOGY� Charge Capture Tips for Interventional Radiology Services




� Understand for radiologic guidance and other services that

another HCPCS/CPT may also be captured.

� Venous Access Procedures

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� Venous Access Procedures

� Angiography

� Upper Extremity Revascularization

� Assess the charge capture, coding and documentation practices to

understand the best practice for your hospital

� Should the CDM be hard-coded or should HIM, or a departmental

coder, assign all codes?

INTERVENTIONAL RADIOLOGYINTERVENTIONAL RADIOLOGY� CY2011 CPT Code Updates

� Deleted Codes

� 6 codes have been deleted to accommodate the addition of the new

lower extremity endovascular revascularization procedures (37220 –

37235)

� Transluminal balloon angioplasty, open; renal or other visceral

artery

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artery

� 35454 – iliac

� 35456 – femoral-popliteal

� 35459 – tibioperoneal trunk and branche

� 35470 – Transluminal balloon angioplasty, percutaneous;

tibioperoneal trunk or branches, each vessel

� 35473 – iliac

� 35474 – femoral-popliteal



� 35471, “Transluminal balloon angioplasty, percutaneous; renal or

visceral artery”

� With the deletion of parent CPT Code 35470, 35471 was revised to

become the parent code rather than a child code.

New Codes

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� New Codes

� Category III Codes 0234T – 0238T

� Describe atherectomy performed by any method in arteries above

the inguinal ligaments.

� Includes radiologic guidance.


� Deleted codes



37235) and atherectomy procedures (0234T – 0238T)

� 35480 , “Transluminal peripheral atherectomy, open; renal or other

visceral artery” – to report use 0234T, 0235Y

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visceral artery” – to report use 0234T, 0235Y

� 35481 , aortic – to report use 0236T

� 35482 - iliac – to report use 0238T

� 35483 – femoral-popliteal – to report use 37225, 37227

� 35484 – brachiocephalic trunk or branches, each vessel – to report use

0237T

� 35485 – tibioperoneal trunk or branches – to report use 37229, 37231,

37233, 37235


� Deleted codes



37235) and atherectomy procedures (0234T – 0238T)

� 35490 , “Transluminal peripheral atherectomy, percutaneous;

renal or other visceral artery” – to report use 0234T, 0235T

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renal or other visceral artery” – to report use 0234T, 0235T

� 35491 – aortic – to report use 0236T

� 35492 – iliac – to report use 0238T

� 35493 – femoral-popliteal – to report use 37225, 37227

� 35494 – brachiocephalic trunk or branches – to report use 0237T

� 35495 – tibioperoneal trunk and branches – to report use 37229,

37231, 37233, 37235


� Revised Codes

� In support of the new lower extremity endovascular revascularization

procedures, revised for consistency purposes by adding “iliac and

lower extremity arteries” to the parentheses

� 37205, “Transcatheter placement of an intravascular stent(s)

(except coronary, carotid, vertebral, iliac, and lower extremity

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arteries), percutaneous; initial vessel”

� 37206 – each additional vessel

� 37207, “Transcatheter placement of an intravascular stent(s)


arteries), open; initial vessel”

� 37208 – each additional vessel


� New Codes

� New codes for reporting lower extremity endovascular

revascularization services performed for occlusive disease

� 37220 – 37223 – iliac vascular territory

� 37224 – 37227 – femoral / popliteal territory

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� 37228 – 37235 – tibial / peroneal territory

� CY2011 OPPS Updates

� The new endovascular revascularization CPTs map to a device

dependent APC, and are assigned a status indicator “NI”.

CARDIAC CATHETERIZATIONCARDIAC CATHETERIZATION� ALL NEW IN 2011!

� CPT Codes 93451 – 93568

� New introductory section

� The primary cardiac catheterization procedures include all

roadmapping angiography in order to place the catheters,

including any injections and imaging supervision, interpretation,

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and report.

� The primary cardiac catheterization procedures DO NOT include

contrast injection(s) and imaging supervision, interpretation, and

report for imaging that is separately identified by specific

procedure codes(s) (e.g. pulmonary angiography)

CARDIAC CATHETERIZATIONCARDIAC CATHETERIZATION� There are essential coding guidelines to consider when capturing

cardiac catheterization services:

� Injection and Imaging Procedures

� Reporting of Vascular Closure Device

� Administration of Pharmacologic Agent

� Angiography During Catheterization

Swan Ganz Insertion

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� Swan Ganz Insertion

� Cardiac Catheterization and Other Procedures

CARDIAC CATHETERIZATIONCARDIAC CATHETERIZATION� Injection and Imaging Procedures

� All injection CPT Codes include radiological supervision, interpretation,

and report.

� Cardiac catheterization, other than that for congenital anomalies,

includes the typical injection of contrast and imaging.

� Coronary angiography

� Left ventricular or Left atrial angiography

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� Left ventricular or Left atrial angiography

� Non typical injections can be captured separately when performed

with any cardiac catheterization procedure.

� Right ventricular or Right atrial angiography

� Supravalvular aortography

� Pulmonary angiography

CARDIAC CATHETERIZATIONCARDIAC CATHETERIZATION

2011 CPT 2010 CPT Component

93510 Insertion of Catheter

93543 Injection, Ventriculography

93545 Injection, Coronary Angiography93458

Example – Left Heart Catheterization, Ventriculography and Coronary Angiography

148

93545 Injection, Coronary Angiography

93555 Imaging, Ventriculography

93556 Imaging, Coronary Angiography

93458

CARDIAC CATHETERIZATIONCARDIAC CATHETERIZATION� Reporting of Vascular Closure Device

� The contrast injection to place and the act of placing the vascular

closure device are inherent to the cardiac catheterization procedure

and should not be captured separately.

� The actual device (e.g. Angioseal, Star Close) can be captured and

reported separately as an implant supply

� C1760, “Closure device, implantable (insertable)“

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� C1760, “Closure device, implantable (insertable)“

� Administration of Pharmacologic Agent

� The administration of a pharmacologic agent (e.g. dobutamine) to

repeat hemodynamic measurements for the purposes of evaluating

hemodynamic measurement can be reported separately.

� When the administration is for the purposes of completing a coronary

interventional or imaging procedure, it is not separately reportable.

CARDIAC CATHETERIZATIONCARDIAC CATHETERIZATION� Angiography During Catheterization

� HCPCS Codes were created in 2003 for use by hospitals in describing

renal and iliac angiography for non-selective angiography.

� G0275 - renal

� G0278 - iliac

� The Codes were not created for “drive bys” or for a guiding shot for

closure.

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closure.

� Reporting of G0275 and G0278 is expected to be low.

� Increased volumes could open the hospital and physicians to an audit

and compliance risk.

� The G-codes will be considered reasonable if the patient has a clear

indication of renal artery stenosis or the patient undergoes stenting at

a later date should significant renal artery stenosis be discovered.

CARDIAC CATHETERIZATIONCARDIAC CATHETERIZATION� Swan Ganz Insertion

� When a flow directed catheter is placed for hemodynamic monitoring,

and not for diagnostic reasons, the insertion of the catheter should be

coded as a stand alone procedure.

� The passage of a catheter into or through the chambers of the heart

does not itself constitute a diagnostic cardiac catheterization.

� The insertion of a flow directed catheter during catheterization is not

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� The insertion of a flow directed catheter during catheterization is not

coded separately.

� Cardiac Catheterization with Other Procedures

� When cardiac catheterization is the approach for another procedure,

and it is not being performed for specific evaluation (beyond the

approach) it should not be coded separately.

CARDIAC CATHETERIZATIONCARDIAC CATHETERIZATION� CY2011 CPT Code Updates

� Deleted codes:

�Cardiac Catheterization Procedures

� CPT Codes 93501, 93508-93529 have been deleted, to report see

93451-93461

� Injection and Imaging

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� Injection and Imaging

� CPT Codes 93539-93556 have been deleted and replaced by new

codes 93563-93568.


� New Codes

� 93451, “Right heart catheterization including measurement(s) of

oxygen saturation and cardiac output, when performed”

� 93452, “Left heart catheterization including intraprocedural injection(s)

for left ventriculography, imaging supervision and interpretation, when

performed”

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performed”

� 93453, “Combined right and left heart catheterization including

intraprocedural injection(s) for left ventriculography, imaging

supervision and interpretation, when performed”


� New Codes

� 93454, “Catheter placement in coronary artery(s) for angiography,

including intraprocedural injection(s) for coronary angiography,

imaging supervision and interpretation”

� 93455 – with catheter placement(s) in bypass graft(s) (internal mammary,

free arterial venous grafts) including intraprocedural injection(s) for

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bypass graft angiography

� 93456 – with right heart catheterization

� 93457 – with catheter placement(s) in bypass graft(s) (internal mammary,


bypass graft angiography and right heart catheterization

� 93458 – with left heart catheterization including intraprocedural

injection(s) for left ventriculography, when performed

� CY2011 CPT Code Updates

� New Codes� 93459 - with left heart catheterization including intraprocedural

injection(s) for left ventriculography, when performed, catheter

placement(s) in bypass graft(s) (internal mammary, free arterial, venous

grafts) with bypass graft angiography

� 93460 – with right and left heart catheterization including intraprocedural

CARDIAC CATHETERIZATIONCARDIAC CATHETERIZATION

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� 93460 – with right and left heart catheterization including intraprocedural

injection(s) for left ventriculography, when performed

� 93461 - with right and left heart catheterization including intraprocedural

injection(s) for left ventriculography, when performed, catheter

placement(s) in bypass graft(s) (internal mammary, free arterial, venous

grafts) with bypass graft angiography


� New Codes

� 93462, “Left heart catheterization by transseptal puncture through

intact septum or by transapical puncture “

� 93463, “Pharmacologic agent administration (eg, inhaled nitric oxide,

intravenous infusion of nitroprussidee, dobutamine, milrinone or other

agent) including assessing hemodynamic measurements before,

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agent) including assessing hemodynamic measurements before,

during, after, and repeat pharmacologic agent administration, when

performed”

� 93464, “Physiologic exercise study (eg, bicycle or arm ergometry)

including assessing hemodynamic measurements before and after”


� New Codes

� 93563, “Injection procedure during cardiac catheterization including

imaging supervision, interpretation, and report; for selective coronary

angiography during congenital heart catheterization”

� 93564 – for selective opacification of aortocoronary venous or arterial

bypass graft(s) (eg, aortocoronary saphenous vein, free radial artery, or

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bypass graft(s) (eg, aortocoronary saphenous vein, free radial artery, or

free mammary artery graft) to one or more coronary arteries and in situ

conduits (eg, internal mammary), whether native or used for bypass to

one or more coronary arteries during congenital heart catheterization,

when performed

� 93565 – for selective left ventricular or left arterial angiography

� 93566 – for selective right ventricular or right atrial angiography

� 93567 – for supravalvular aortography

� 93568 – for pulmonary angiography


� New Codes

� New codes for reporting cardiac catheterization

� New codes – 93451-93464 for diagnostic cardiac cath

� New codes – 93452 – 93461 include contrast injections

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� CY2011 OPPS Updates

� The new cardiac catheterization CPTs are assigned a status

indicator “NI”.

ELECTROPHYSIOLOGYELECTROPHYSIOLOGY� Electrophysiology procedures treat heart rhythm disorders and

can include the following types of procedures:

� Pacemaker Insertion

� ICD/AICD Insertion

� Studies/Procedures

� Procedures include the use of surgical intervention, radiologic

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guidance and involve high dollar supplies and implants.

� These procedures are costly and charge capture is critical to

reimbursement.

ELECTROPHYSIOLOGYELECTROPHYSIOLOGY� There are essential coding guidelines to consider when capturing

electrophysiology services:


� In general, more than one HCPCS/CPT is used to describe the complete

procedure.

� Surgical Intervention

Radiologic Guidance

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� Analysis

� To best understand the components , an understanding of the

individual procedures is essential.

ELECTROPHYSIOLOGYELECTROPHYSIOLOGY� Pacemaker Procedures

� A pacemaker is a device that controls the rhythm of the heart and may

also improve total cardiac output (the amount of blood pumped by the

heart). Increased cardiac output improves blood perfusion to the vital

organs and extremities.

� A pacemaker may be temporary or permanent.

� Pacemakers are also described as single or dual chamber.

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� Pacemakers are also described as single or dual chamber.

� Pacemaker procedure CPT Codes are separated into categories:

� Insertion/Replacement

� Repair

� Subsequent Analysis



� Fluoroscopic guidance can be captured separately (CPT 71090).

� The insertion/replacement of the pacemaker generator may or may

not include electrodes.

� When replacing a previously implanted pacemaker, the insertion

remains to be coded the same as if an initial implantation was

performed

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performed

� To assign the appropriate CPT Code you should know the following:

� Method employed (e.g. transvenous, xiphoid, thoracotomy

� Area of the heart to be paced (i.e. atrium or ventricle)

� Type of pacemaker system (e.g. temporary, permanent, single or

dual chamber)

� Analysis performed at the time of insertion is included in the CPT

code and not separately reportable.


� Repair

� Permanent pacemakers may at times require repair. For example, an

electrode may fracture or an insulation defect may occur. In both

examples it may be possible to repair the pacemaker electrode and

continue with its use.

� CPT Codes for repair of electrodes describe the repair of the

electrode, single and dual chamber systems. The Codes include the

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electrode, single and dual chamber systems. The Codes include the

removal and reinsertion of the pacemaker leads. If when the repair

is performed and the pulse generator requires replacement, CPT

Codes for the pacemaker generator only should also be captured.

� Radiologic guidance should be captured separately.

� Note CPT 71090 is for insertion of pacemaker only, and not

reportable if procedure does not involve the insertion of a

pacemaker generator.



� Subsequent analysis of the pacemaker system may include the

evaluation of the programmable parameters at rest and activity,

electrocardiographic recording, event markers, and device response.

� Pacemaker analysis is only reportable when performed subsequent

to the insertion of the pacemaker. The initial analysis is included in

the CPT Code for the insertion/replacement.

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the CPT Code for the insertion/replacement.

ELECTROPHYSIOLOGYELECTROPHYSIOLOGY� ICD/AICD Procedures

� An ICD, or implantable cardioverter-defibrillator, can also be referred to

as an AICD or pacing cardioverter-defibrillator.

� An ICD includes a pulse generator and electrodes. Unlike a pacemaker,

an ICD may require multiple electrodes, even if only one heart

chamber is to be paced.

� ICDs systems can be single or dual chamber.

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� ICDs systems can be single or dual chamber.

� The systems are utilized to treat ventricular tachycardia or fibrillation

by low energy cardioversions or defibrillating shocks.

� ICD procedure CPT Codes are separated into categories:


� Removal

� Repair




� The insertion of implantable cardioverter defibrillators (ICD) can be

accomplished by an open approach using either a sternotomy or a

thoracotomy, or by a closed approach using a variety of electrode

configurations. In the closed approach, one or more electrodes may

be inserted in the heart, usually by cannulation of the subclavian

vein. In some circumstances, a subcutaneous patch may also be

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vein. In some circumstances, a subcutaneous patch may also be

required.

� ICDs are either inserted as a whole system (with electrodes and pulse

generator) or as a pulse generator only. The Codes do not

discriminate between a single or dual chamber pacing system.

� Fluoroscopic guidance can be captured separately (CPT 71090).

� Unlike the insertion of a pacemaker, the evaluation of the electrodes

or pulse generator can be identified separately from the insertion

(CPTs 93640 – 93641).


� Removal

� When an ICD system is removed and not replaced CPT Codes for the

removal of the generator AND electrodes should be captured.

� The ICD CPT Codes do not discriminate between a single or dual

chamber pacing system.

� When an ICD system is removed and either reinserted (or another

system is inserted) CPT Codes for the removal of the generator and

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system is inserted) CPT Codes for the removal of the generator and

electrodes, AND the insertion of the system should be captured.



� Repair

� CPT Codes 33218 and 33220 describe the repair of the electrode and

include the removal and reinsertion of the leads. If when the repair

is performed and the pulse generator requires replacement, CPT

Codes 33240 and 33241 should be reported in addition to CPT Code

33218 or 33220.

� One of the following CPT Codes should be reported based on the

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� One of the following CPT Codes should be reported based on the

number of electrodes/




� The ICD may require post-implantation evaluations, which are not

performed on the same date as the implantation or replacement of

the ICD. The evaluation may include defibrillation threshold

evaluation, induced arrhythmia, and the evaluation of sensing and

pacing. To report post-implantation evaluations CPT Code 93642

should be reported.

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should be reported.

� To determine the effectiveness of the ICD, electronic analysis may

also be necessary. Electronic analysis includes an evaluation at rest

and during activity, using electrocardiographic recording, analysis of

event markers and device response. CPT Codes 93741 – 93744

describe the electronic analysis of ICDs. The Codes are distinguished

by the number of chambers involved and whether the ICD was

reprogrammed. Electronic analysis can be reported with CPT Code

93642.

ELECTROPHYSIOLOGYELECTROPHYSIOLOGY� Studies/Procedures

� EP Studies

� A comprehensive EP with induction includes six sub-component

procedures each with their own CPT code.

� Bundle of His recording Intra-atrial pacing

� Intra-atrial recording Intraventricular pacing

� Right ventricular recording Induction of arrhythmia

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� Right ventricular recording Induction of arrhythmia

� If fewer than the six sub-components of the comprehensive EP

study are performed, look to the individual CPT codes for charge

capture.

� If all components are present with exception of induction of

arrhythmia, capture the comprehensive EP without induction.

ELECTROPHYSIOLOGYELECTROPHYSIOLOGY� Studies/Procedures

� EP Studies

� A comprehensive EP without induction includes five sub-

component procedures each with their own CPT code.

� Bundle of His recording Intra-atrial pacing

� Intra-atrial recording Intraventricular pacing

� Right ventricular recording

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� Right ventricular recording

� If fewer than the five sub-components are documented, look to

the individual CPT codes for charge capture.

� Ablations

� Ablation procedures can be performed independently or the same

time as a diagnostic electrophysiology study.

� When a study, mapping and ablation are performed on the same

day, all components are reported separately.

ELECTROPHYSIOLOGYELECTROPHYSIOLOGY� Analyzing the electrophysiology CDM line item usage can identify


� Examples

� Generator Insertion and Supply

� It is expected that with each insertion of a pacemaker or ICD

generator that a supply would also be captured. Review usage

statistics for the insertion procedures against the C-codes for the

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statistics for the insertion procedures against the C-codes for the

devices. Look beyond Medicare!

� ICD Implant and Analysis

� It is expected that for each implant of an ICD an analysis will be

performed at the time of the implant. The analysis can be captured

separately.

MEDICAL AND SURGICAL SUPPLIESMEDICAL AND SURGICAL SUPPLIES� The vast majority of supplies used in a hospital do not require HCPCS codes.

� Supplies should be identified by HCPCS in the following situations:

� The device is classified as a pass-through item that generates additional

reimbursement.

� The item is a prosthetic, orthotic, or implanted durable medical equipment (DME)

(including pacemakers, slings, braces and trusses).

� The item is used with stoma care and is provided at the initial surgery creating the

opening.

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opening.

� The item qualifies as DME and the hospital is certified as a DME supplier and bills

the DME MAC.

� The item qualifies as total parenteral nutrition (TPN) or enteral nutrition (EN)

permanent nutritional therapy, and the hospital is registered as a provider and bills

directly to the designated carrier.

� Other payers may require the hospital to identify different supplies using

HCPCS codes or a payer-specific code.

MEDICAL AND SURGICAL SUPPLIESMEDICAL AND SURGICAL SUPPLIES� For the most part HCPCS codes are not required for supplies when billed under

revenue codes 0270, 0271, 0272, 0273, 0277, and 0279.

� Hospitals must report all pass-through devices using HCPCS C codes under

revenue code 0275, 0276, 0278, or 0624.

� Hospitals are encouraged to report all charges for a procedure even though

some of the payment may be packaged.

� For determining whether supplies are separately billable determine the

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� For determining whether supplies are separately billable determine the

following:

� Is the supply directly identifiable to a specific patient?

� Is the supply furnished at the direction of a physician because of specified medical

needs?

� Is the supply disposable?

� In determining how the supply CDM should be structured, a hospital must

weigh pros and cons of different methodologies.

MEDICAL AND SURGICAL SUPPLIESMEDICAL AND SURGICAL SUPPLIES

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MEDICAL AND SURGICAL SUPPLIESMEDICAL AND SURGICAL SUPPLIES� Coding and Billing Considerations

� KITS

� Hospitals may buy kits that contain surgical supplies and devices. For

kits that contain devices with a HCPCS code but the pass-through

status has expired, the hospital may report the charge for the whole kit

with the HCPCS code for the device. If the hospital wants to bill only

the charge for the device, the rest of the kit should be billed under the

appropriate supply revenue code. In either case the payment will be

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appropriate supply revenue code. In either case the payment will be

packaged into the payment for the procedure.

� For kits that contain devices with a pass-through status, hospitals

should report the device separately, with the appropriate HCPCS codes.

They should not bill other supplies billed in the kit with the pass-

through device. However, the charges should be reported under the

appropriate supply revenue code.


� Device to Procedure Code Edits

� Current edits require a device code whenever certain procedures are

billed. Device edits will require a procedure code whenever a device

code is billed. The devices for which edits are to be implemented

include such high dollar supplies as pacemaker and ICD generators and

neurostimulator generators.

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� Pass-Through Supplies

� Devices that qualify for transitional pass-through payments are those

that fit in one of the established active device categories.

� Devices qualifying for pass-through status are indicated with status

indicator “H”.


� Vendor/Manufacturer Coding Guidance

� Medical device manufacturers are now recognized as an authoritative

source of coverage information for devices receiving pass-through

payments.

� CMS has stated that the information from a device company is

“reasonable support for a coding decision.” Hospitals are advised to

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“reasonable support for a coding decision.” Hospitals are advised to

maintain a copy of any data from a manufacturer, should the need

arise to prove their decision.

THANK YOU!

PRESENTER INFORMATIONPRESENTER INFORMATION

Caroline Rader, MBA, MSHCA, CHC

Associate Director, Navigant Consulting

[email protected]

410-463-9867

Deborah S. Zarick, R.N., BSN, CPC, CCS-P, CEMC, CPC-I, CPMA

Associate Director, Navigant Consulting

[email protected]

484-764-6688

Download - 2011 CDM Updates Day 1

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