Hot Coding Topics / Provider News

Ordering/Referring PECOS Edits Won’t Be Instituted Until July

Here comes a late holiday gift for Part B practices. Thanks to a new transmittal on the topic, CMS has announced that MACs won’t institute ordering/referring PECOS edits until July.

Currently, if you submit claims for services or items ordered/referred and the ordering or referring physician’s information is not in the MAC’s claims system or in PECOS, your practice will get an informational message letting you know that the practitioner’s information is missing from the system. It was previously announced that MACs would start denying these claims on Jan. 3, but CMS announced on Dec. 16 that claim denials won’t begin until July 5.

In Part B, MACs will take two steps before denying your claims. First, the carrier will check whether the ordering/referring physician is in PECOS. If not, the MAC will try to find the provider in the Claims Processing System Master Provider File. If the physician is in neither system, the claim will be rejected starting this July.

Even though CMS won’t reject your claims this month, you should still take this time to ensure that you and your ordering/referring providers are in PECOS as soon as possible, just in case the MAC edits become a reality, said National Government Services’ Andrea Freibauer during a Nov. 9 webinar on ordered and referred services.

To read the updated CMS transmittal, visit http://www.cms.gov/transmittals/downloads/R825OTN.pdf.

Hospices benefited from a separate holiday gift that CMS delivered just before Christmas – a delay of the enforcement date for the new face to face encounter requirement.

For weeks, hospices, home care providers, and their representatives had been giving CMS the full court press about the burdensome new physician visit requirement. In a Dec. 15 letter to CMS Administrator Donald Berwick, more than 25 senior and long-term care organizations joined the National...

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January 18, 2011
Coder's Cranium

Report Picture Perfect Annual Wellness Visits With These 5 Tips

The Affordable Care Act (ACA) extended preventive coverage to more than 88 million patients covered by health insurance, and Medicare has codified that benefit in the form of an annual wellness visit. Medicare valued the new annual wellness codes based on a level 4, problem-oriented new and established E/M service. The two new codes are:

  • G0438 – Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit
  • G0439 – Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit.

Tip 1: Apply G0438 to Second Year of Coverage

Be wary of applying these codes to new Medicare patients coming in to your physician’s practice in 2011.

The reason is that Medicare will only reimburse the initial visit (G0438) during the second year the patient is eligible for Medicare Part B. In other words, during the first year of the patient’s coverage, Medicare will only cover the Initial Preventive Physical Exam (IPPE), also known as the Welcome to Medicare exam.

Tip 2: CMS Limits G0438 to One Physician

If your FP sees the patient for the initial visit (G0438) and the patient sees a different physician for the next annual wellness visit, that second physician will only receive reimbursement for the subsequent visit (G0439), despite having never seen the patient before.

CMS has indicated that when a patient returns to the same or new physician in a third year, they might only pay for the subsequent visit, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. “It is therefore important that you convey this information to any new physician the patient sees.”

Tip 3: Add Preventive Service Codes, If Performed

You can bill the new annual visit codes in addition to any other preventive service, such as G0102 (Prostate cancer...

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January 18, 2011
CPT 2011 / Hot Coding Topics / Provider News

CPT 2011: Pay Attention To These New Joint Injection Guidelines

Remember to check for updated or revised guidelines when preparing to use your new code books for 2011, not just code descriptors. CPT 2011 includes new details for coding some common injection procedures, as pointed out at the AMA’s CPT and RBRVS 2011 Annual Symposium in Chicago. Read on for a few pointers to help stay on the right track.

The introduction of new codes for paravertebral facet joint injections in 2010 (64490-64495) meant changes to how you reported related codes. During the CPT and RBRVS Symposium, Douglas G. Merrill, MD, MBA, of the American Society of Anesthesiologists, pointed out two revised guidelines dealing with paravertebral facet (spinal) joint procedures.

Instructions in CPT 2010 directed you to report 64999 (Unlisted procedure, nervous system) if the provider used ultrasound guidance during paravertebral facet joint injections. The AMA released a correction later in 2010, and the CPT 2011 clarifies the situation. If your provider used ultrasound guidance when administering paravertebral facet joint injections, report the appropriate code(s) from 0213T-0218T (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with ultrasound guidance …).

T12-L1 change: CPT 2010 guidelines mandated that you report 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [for nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) for an injection to the T12-L1 joint, or nerves innervating that joint. New 2011 guidelines direct you to submit 64490 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [for nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; single) instead.

In addition, the 2011 guidelines direct providers to report paravertebral facet joint injections performed without image guidance with the appropriate trigger point injection code. Submit either 20552 or 20553 (Injection[s]; single or multiple trigger...

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January 18, 2011
Hot Coding Topics / Provider News

96446 And Dozen Others Join The List of CCI Edits

Effective Jan. 1, 2011, new CPT codes and, inevitably, new Correct Coding Initiative (CCI) physician edits are there for physicians. For version 17.0, “19,822 new edit pairs have been added to the database while 9,778 have been terminated, for a net gain of 10,044 new edit pairs,” according to Frank Cohen, MPA, MBB, of the Frank Cohen Group, in his Dec. 14, 2010, “NCCI Version 17.0 Change Analysis” announcement.

The main edits you want to be sure to watch for are those related to new code 96446 (Chemotherapy administration to the peritoneal cavity via indwelling port or catheter).

The 96446 non-mutually exclusive (NME) edits are largely what you would expect based on other chemotherapy code edits — bundles with E/M, anesthesia, venipuncture and other vascular procedures, for example. You want to be sure to watch which is the column 1 code and which is the column 2 code for these bundles.

CCI places E/M codes 99217-99239 in the column 1 position and 96446 in the column 2 position. On the other hand, CCI places 96446 in the column 1 position and E/M codes 99201-99215 in the column 2 position, as shown below:

Column 1 Column 2
99217-99239 96446
96446 99201-99215

Remember that if you report both codes in an NME edit pair without a modifier, Medicare (and payers who adopt these edits) will deny the column 2 code and pay you only for the column 1 code. The edits in the table above all have a modifier indicator of 1, meaning that you may override the edits with a modifier when appropriate, such as in the case of distinct,...

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January 17, 2011
CPT Medical Changes / Hot Coding Topics

CPT 2011: 37220 to +37223 Revamp Interventional Coding

Think outside the box for iliac atherectomy.

Are you ready to apply CPT’s new revascularization codes starting January 1? Check out these six tips to get you on your way.

CPT 2011 offers up new codes to help you report services more accurately, including endovascular revascularization, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

Specifically, CPT 2011 adds several new codes that represent lower extremity endovascular revascularization, meaning angioplasty, atherectomy, and stenting. Here’s how the codes break down:

  • Iliac: 37220-+37223– Revascularization, endovascular, open or percutaneous, iliac artery …

  • Femoral, popliteal: 37224-37227– Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral …

  • Tibial/peroneal: 37228-+37235– Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral …

In this article, iliac artery services are the focus. Look to future articles to discuss femoral, popliteal, and tibial/peroneal services.

Watch Procedure and Vessel to Choose Among 37220-+37223

The new iliac service codes are as follows:

  • 37220– Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty

  • 37221– … with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
  • +37222– Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)

  • +37223– … with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure).

Reading through the definitions, you see that the codes for iliac services differ based on whether you’re coding a service in an initial vessel or in an additional vessel. Your options also differ based on whether you’re reporting (1) angioplasty alone or...

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January 12, 2011
CPT 2011 / Hot Coding Topics

CPT 2011: Vaccine Product to 90460, 90461 Crosswalk

How to count components for Boostrix, Pediarix – and other immunizations.

Excited by the new vaccine administration codes’ payment per component but not sure how many components specific vaccines have? This chart does the work for you.

Find the product name for a quick cross reference to how many components the vaccine includes and the administration with counseling code combination to report using the new pediatric/adolescent codes.

Note: The ICD-9 vaccine product code listed in the chart uses the generalized vaccine product code (V06.8, Need for prophylactic vaccination and inoculation against other combinations of diseases). For vaccine administration provided outside of a preventive medicine service, the American Academy of Pediatrics recommends using V06.8 for combination vaccines that do not have their own individual single ICD-9 code.

Vaccine Product Manufacturer Components CPT Product Code Number  of Components CPT 2011 Administration with Counseling Code ICD-9-CM 2011 Code
ActHIB Sanofi Pasteur Hib 90648 1 90460 V03.81
Adacel Sanofi Pasteur Tdap (tetanus- diphtheria-acellular pertussis) 90715 3 90460, +90461 x 2 V06.1
Boostrix GlaxoSmithKline Tdap 90715 3 90460, +90461 x 2 V06.1
Cervarix GlaxoSmithKline HPV 90650 1 90460 V04.89
Comvax Merck HepB-Hib 90748 2 90460, +90461 V06.8
Daptacel

...

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January 7, 2011
Hot Coding Topics

Dental Codes MIA in HCPCS Code Updates

You won’t find D codes in the 2011 HCPCS Level II codes as you have in previous versions of  some HCPCS Level II manuals and datasets. To avoid companies inadvertently including copyrighted dental codes as part of the royalty free HCPCS codeset,...

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January 5, 2011
CMS / Medicaid / Medicare / Provider News

Registration open for electronic health records incentives

On Jan. 3, the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) opened the registration for the Medicare and Medicaid electronic health record (EHR) incentive programs. It was started in Alaska, Iowa, Kentucky, Louisiana, Oklahoma, Michigan, Mississippi, North Carolina, South Carolina, Tennessee, and Texas and broad participation is invited from eligible professionals and eligible hospitals who wish to participate.

In February, the registration will open in California, Missouri, and North Dakota and in other states during the spring and summer of 2011.

“With the start of registration, these landmark programs get underway, and patients, providers, and the nation can begin to enjoy the benefits of widespread adoption of electronic health records,” CMS Administrator Donald Berwick, MD was quoted as saying in the news release. “CMS has many resources available to help providers register and participate, and we look forward to working with eligible professionals and eligible hospitals to facilitate the process, beginning on January 3rd and going forward.”

“It’s time to get connected,” said David Blumenthal, MD, MPP, National Coordinator for Health Information Technology. “ONC and CMS have worked together over many months to prepare for the startup on January 3rd. ONC’s Certified HIT Product List includes more than 130 certified EHR systems or modules and is updated frequently. ONC also has hands-on assistance available across the country through 62 Regional Extension Centers. We look forward to continuing to work with CMS to assist eligible providers in 2011 and future years.”

The news release said that interested providers can acquaint themselves with the programs’ requirements by visiting CMS’ Official Web Site for the Medicare and Medicaid EHR Incentive Programs.

Eligible providers seeking to participate in the Medicaid programs must initiate registration at CMS’...

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January 4, 2011
Coder's Cranium

Here’s How You Can Bill The Correct New G Code

If you find choosing the right G code for your claims difficult, help is at hand.

Starting Jan. 1, CMS is requiring eight new billing codes in addition to the existing six codes for home health agency services. Those include new nursing codes for RN management and evaluation of the plan of care (G0162), LPN or RN observation and assessment (G0163), and LPN or RN training and education (G0164). CMS is revising G0154 to cover only direct skilled care by an RN or LPN, CMS notes in Dec. 17 Transmittal No. 824 (CR 7182).

“We recognize that, in the course of a visit, a nurse or qualified therapist could likely provide more than one of the nursing or therapy services reflected in the new and revised codes,” CMS says.

But “HHAs must not report more than one G-code for the nursing visit regardless of the variety of nursing services provided during the visit.” The same goes for therapy.

“In cases where more than one nursing or therapy service is provided in a visit, the HHA must report the G-code which reflects the service for which the clinician spent most of his/her time,” CMS instructs. Hopefully this will ease providers’ concerns, voiced at the most recent home health Open Door Forum, about how to choose the right code.

“If direct skilled nursing services are provided, and the nurse also provides training/education of a patient or family member during that same visit, we would expect the HHA to report the G-code which reflects the service for which most of the time was spent during that visit,” CMS says in the transmittal. “Similarly, if a qualified therapist is performing a therapy service and also establishes a maintenance program during the same visit, the HHA should report the G-code which reflects...

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January 3, 2011
Coding Challenge / Hot Coding Topics

Primary vs. Secondary Diagnosis

Question: Many of our ophthalmology patients claim general reasons for their visit, such as “I can’t see well,” or “My vision is foggy.” We code these visits with 368.8 as the primary diagnosis because this is the primary reason for the visit. Any other problems or underlying causes of the blurry vision we report as secondary diagnoses. Is 368.8 the most appropriate code to use in these situations, and should we list it first?

Answer: You should only report 368.8 (Other specified visual disturbances) as a primary diagnosis code when the ophthalmologist doesn’t find a more definitive diagnosis during the course of the visit.

Carriers often consider a visit for blurred vision the same thing as a routine exam— and Medicare will not pay for this service.

Primary vs. secondary: Whenever possible, you should list a more definitive diagnosis as primary and then the patient’s complaint of blurred vision as secondary. For example, if the ophthalmologist discovers that a cataract is causing the patient’s blurry vision, you would first list 366.12 (Incipient cataract) and then 368.8. You should always strive to report the most descriptive and accurate ICD-9 codes possible. If a patient claims her only reason for the visit is a routine exam, experts recommend that the ophthalmologist ask her a series of detailed questions to uncover any other complaints she may have but doesn’t think of right away. In obtaining a comprehensive history when a patient denies any blurriness of vision, the ophthalmologist should also ask, “Do your eyes chronically itch, burn, or water?” This may lead you to report dry eye syndrome (375.15, Tear film insufficiency, unspecified) or allergic conjunctivitis (372.14, Other chronic allergic conjunctivitis).

Do this: Rather than ask if a patient’s vision is blurry, ask if there is...

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January 3, 2011
Hot Coding Topics / Provider News

Watch Changes to EEG, Joint Injection Guidelines

You report several EEG codes such as 95812 (Electroencephalogram [EEG] extended monitoring; 41-60 minutes) and 95813 (… greater than 1 hour) based on the amount of recording time. But what constitutes recording time?

Jeffrey Cozzens, MD, professor and chair of the neurosurgery division of Southern Illinois University School of Medicine and a presenter at the AMA’s CPT and RBRVS 2011 Annual Symposium in Chicago, addressed the issue during his presentation about neurosurgery and neurology changes for 2011. Keep two things in mind when calculating recording time for these EEGs:

  • Recording time is when the recording is underway and the healthcare provider is collecting data.
  • Recording time excludes set-up and take-down time.

Other EEG codes, however, focus on the amount of physician time rather than recording time. Watch for that specificity in guidelines for 95961 (Functional cortical and subcortical mapping by stimulation and/or recording of electrodes or brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance) and +95962 (… each additional hour of physician attendance [List separately in addition to code for primary procedure). If the physician is in attendance for a total of 30 minutes or less, only report 95961 and append modifier 52 (Reduced services) to indicate he didn’t fulfill the full hour represented by the code.

Two codes for special EEG tests now specify who attends during the procedure:

  • 95953 -- Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours, unattended
  • 95956 -- Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours, attended by a technologist or nurse.

According to information on the...

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January 3, 2011
Hot Coding Topics / Provider News

Learn the Best Ways to Navigate Codes For Cisplatin, Cyclophosphamide, and Vincristine

The recently released HCPCS 2011 code-set reveals a slew of deletions, streamlining your drug coding choices. Cisplatin, cyclophosphamide, and vincristine are among the affected drugs.

This change should simplify billing, particularly if the system your practice or facility uses, such as Pyxis or Lynx, limits you to a single code and billable unit for a drug, says Lisa S. Martin, CPC, CIMC, CPC-I, chargemaster specialist for OSF Healthcare System in Peoria, Ill. “As a consultant, I saw different facilities using only the 100 mg code [for example] for that very reason, so this change should facilitate more consistent and compliant billing practices.”

While these changes have a positive side, “there are always considerations that will arise,” Martin says. For example, if your practice uses different vial sizes, you will need to be alert for the different and specific national drug code (NDC) numbers for the agent dispensed to the patient when you send a claim to a payer who requires NDC information, she warns.

Cisplatin, ordered particularly for patients with metastatic testicular or ovarian neoplasms, or advanced bladder cancers, is one of the many agents affected by the HCPCS 2011 shake-up.

HCPCS 2011 makes a small wording revision to J9060, notes Roberta Buell, MBA, of onPoint Oncology in her Nov. 9 e-Reimbursement newsletter:

  • 2010: J9060 – Injection, cisplatin, powder or solution, per 10 mg
  • 2011: J9060 – Injection, cisplatin, powder or solution, 10 mg.

Delete code J9062 (Cisplatin, 50 mg). It will no longer be available for use in 2011. You should use J9060 to report cisplatin, brand name Platinol, when supplied for 2011 dates of service.

Cyclophosphamide is an alkalyting agent that works as an antineoplastic and immunosuppressant. You may see it called Cytoxan or Neosar.

At 1 unit per 100 mg, J9070 (Cyclophosphamide, 100 mg)...

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January 3, 2011
CPT 2011 / Hot Coding Topics

2011 Medical Coding Updates Are Available on Supercoder.com

Raise your glass to the new year without worries of 2011 medical code changes. SuperCoder’s got you covered with new CPT codes, CCI edits, and supply coding revisions. Starting Dec. 31, SuperCoder.com will offer the complete codesets for CPT 2011...

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December 29, 2010