CPT^©  2012 re-establishes the

“Decision Tree for news vs Established Patiens”

That was included in CPT^©  2010, out left out in 2011

 

Category I Changes

The majority of changes to CPT 2012"’ involve Category I codes, to include over 200 new codes, more than 180 deleted codes, and more than 130 revisions. Only the Anesthesia (00100-01999) and Surgery: Urinary System (50010-53899) portions of CPT° were untouched this year.

Evaluation and Management

El M changes include the addition of “reference times” to Initial Observation Care codes 99218, 99219, and 99220. For example, the descriptor for 99220 now specifies, “Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.” The new language allows physicians to report the initial observation care codes using time as the key component, when counseling or coordination of care dominates the encounter.

Prolonged Services codes 99354-99355 (office or outpatient) and 99356-99357 (inpatient or observation) gain instructions stating these codes may be used by physicians or other qualified health care professionals. These add-on services specifically include total faceto-face time with the patient, as well as non face-to-face services on the patient’s floor or hospital/nursing facility unit during the same session. The time does riot have to be continuous, but only a single prolonged service code may be reported per day.

Prolonged services without direct patient contact (99353-99359) also gain guidelines, clarifying that these add-on services may be provided on a different date than the related, primary service (which must have been face-to-face, but need not have a reference time).  Added guidelines now precede the Inpatient Neonatal and Pediatric Critical Care (99468—99476) and Initial and Continuing Intensive Care Services (99477-99480) codes to define more precisely the services included and how the codes are applied.

lntegumentary

The big news in the Integumentary section is a near complete overhaul of the skin replacement/skin substitute codes. Many codes in the 15300-15431 range have been deleted, replaced by fewer (and much simplified) codes, such as 15271 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to I00sq cm; first 25 sq cm or less wound surface area and +15272 each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure). The replacement codes (15271-+15278) do not include supply of the graft, which may be reported separately.

Add-on code 15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk) (List separately in addition ta code for primary procedure) has been established to describe biologic implant for soft tissue reinforcement. Many other integumentary code descriptors include minor revisions.

Musculoskeletal

Changes to musculoskeletal codes involve mainly descriptor revisions, either to clarify the intent of the service or to describe bundled services. For example, descriptors for percutaneous vertebroplasty (22520-22522) specifically identify bone biopsy as an included service when performed. A number of injection procedures (e.g., 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed)) now clearly include image guidance.

Two new codes (22633 and 22634) describe arthrodesis via combined posterior and posterolateral technique with posterior interbody technique.

Respiratory System

Codes describing thoracotomy and other procedures of the lung and pleura undergo significant changes, to include nearly a full page of new instructions and added parenthetical notes. Every “removal of lung” code (32440-32491) has been revised. There are six new codes for thoracotomy (32096-32098, with biopsy; and 32505-+32507, with wedge resection), and an entirely new category (32601-32674) has been established for video-assisted thoracic surgery (VATS), which includes a dozen new codes.

Cardiovascular

Pacemaker or Pacing Cardioverter-Defibrillator codes (33202-33249) have undergone frequent revisions in the past few years, and 2012 is no exception. There’s an additional page of instructions for code application, as well as a quick reference chart to help with code selection for the insertion, removal, etc. of a pulse generator and its various components. Over a dozen codes in this section have been revised, with nine codes added.

Combination codes were added to report renal catheterization and angiography (36251-36254). The new codes include the radiological supervision and interpretation.  Added instructions clarify that replacement of ventricular assist device pump (33981-33983) includes removal of the new pump, as well as connection, de-airing, and initiation of the new pump.

Digestive

There are relatively few changes to this section ofCPT@ Several parenthetical notes have been added to clarify code selection. For instance, a note added to the Stomach: Laparoscopy codes (43644-43659) instructs, “For laparoscopic implantation, revision or removal of gastric neurostimulator electrodes, lesser curvature [morbid obesity], use 43659.” Three new codes (49082-49084) describing abdominal paracentesis replace deleted codes 49080 and 49081. Liver biopsy (47000) now includes moderate sedation, when provided.

Genital Systems

There are no changes in the Surgeryl Male Genital System portion of CPT° The Surgeryl Female Genital ‘System codes also are unchanged, but several parenthetical notes have been added throughout the section. Among these is instruction to report 11981 for insertion of a non-biodegradable contraception implant, and 11976-11981 for removal with subsequent insertion.

Nervous System

Codes 64622-64627 have been deleted, replaced by 64633-64636 for destruction ofparavertebral facet joint by neurolytic agent. The new codes specify location (cervical or thoracic and lumbar or sacral) and the number of joints injected (single and each additional). Many additional code descriptors have undergone revision to better specify the intent or application of the code. For example, the term “array” was added to implantation of neurostimulator code (64553-64565 and 64575-64585) descriptors to clarify that the codes are applied per array, not per individual electrode (an array may contain several electrodes). New parenthetical notes and instructions appear throughout the section.

Eye/Ocular Aclnexa and Kuditory System

These sections include only minor chalnges, including new parenthetical instructions (e.g., “For fitting of contact lens for treatment of disease, see 92071, 92072”) and the deletion of 69802 Labyrinthotomy, with perfusion of vestibuloactive drug(s); with mastoidectomy.

Radiology

Of the many changes to the Radiology section, the most significant include the creation of new codes to report intra-operative radiation treatment delivery (77424, 77425) and intra-operative radiation treatment management (77469). New instructions specify that radiation treatment management is reported in units offive fractions or treatment sessions, regardless of the actual time period in which the services are furnished.

Atherectomy codes 75992‘-75996 have been deleted and replaced with other codes. For instance, in 2012, in place of 75995, use Category III code 0235T Transluminal peripheral atherectomy, open or percutaneaus, including radiological supervision and interpretation; visceral artery (except renal), each vessel.

Path and Lab

CPT° 2012 establishes an entirely new section for molecular pathology, including two full pages of instruction and dozens of new codes for Tier 1 (81200-81383) and Tier 2 (81400-81408) molecular pathology procedures. Molecular pathology procedures involve analyses of nucleic acid to detect variants in genes that may be indicative of germline or somatic conditions, or to test for histocompatibility antigens. Code selection is based on the specific gene analyzed.

Parenthetical notes now accompany HIV-1 and HIV-2 testing code 86703 (single result) to clarify proper coding for alternative testing, such as HIV-1 antigens(s) with HIV-1 and HIV-2 antibodies (87389), and when to apply modifier 92 with 86701-86703 and 87389.

Medicine

Descriptor revisions clarify immunization coding (90460, +90461) by vaccine component, rather than per injection. Esophageal motility studies will no longer be reported with 91011 or 91012; instead, you will use revised codes 91010 (for motility study) and +910l3 (an add-on code for stimulation or perfusion). Code 92070 is deleted and replaced by two new codes (92071 and 92072) for contact lens fitting to treat ocular surface disease or to manage keratoconus, respectively.

A full page of instructions has been added for sleep medicine testing, and new codes have been added to report needle electromyography, per extremity (95885, limited; and 95886, complete) or non extremity (95887). Hydration codes (96360 and +93631) also come with significant additional instructions in 2012, to better explain the meaning of “initial infusion,” “sequential infusion,” and “concurrent infusion.”

Category III Codes

Over 30 new Category III codes have been added to CPT° 2012, including those for intramuscular autologous bone marrow cell therapy (0263T-0265T), percutaneous laminotomy/laminectomy (0274T, 0275T), corneal incision (0289T, 0290T), and more. Category III codes describe emerging technologies and, unlike Category I “unlisted procedure” codes, allow for tracking and collection of specific data. If a Category III code is available, it must be reported instead of a Category I unlisted procedure code.

Look for more: We’ll be covering specific information on individual CPT° code changes in upcoming issues of Coding Edge.

© 2012 AAPC, Coding Edge Magazine. March Edition - www.aapc.com

 

 

Revisit the Rules

With a Revised ABN

Get a signature or you may not get paid

The Centers for Medicare 86 Medicaid Services (CMS) recently released a new Advanced Beneficiary Notice ofNoncoverage (ABN).  If you are unsure ofwhen or how to apply an ABN, now is the perfect time to brush up on the details.

ABN Basics

The ABN is a standard form to inform a patient that Medicare may deny coveragéfor a recommended or desired item or service. It explains why Medicare may deny the item or service, and provides a cost estimate for it. Finally, an ABN notifies the patient of his responsibility to pay for the noncovered item or service, if he chooses to receive it. In many cases, a provider cannot seek payment from the patient for unpaid Medicare services if an ABN was not properly issued.

CMS periodically revises the ABN. The most recent version, Form CMS-R-131 (release date March 2011), is mandatory as ofjan. 1, 2012. Previous versions of the ABN (release date March 2008) are no longer being accepted. The “Revised ABN CMS-R-131 Form and Instructions” may be downloaded from the CMS website: http://www.cms.gov/BNl/02_ABN.asp.

ABNs must be reproduced on a single page (either letter or legalsize). To be safe, reproduce the ABN “as is” from the CMS website: Except where specifically allowed by the form instructions, “to integrate the ABN into other automated business processes,” you may not customize the ABN. 

Who Should Use an ABN

Per CMS instructions, ABN “notifiers” may include:

• Physicians
• Providers (including institutional providers, such as outpatient hospitals)
• Practitioners
• Suppliers paid under Part B (including independent laboratories)
• Hospice providers and religious non-medical health care institutions (RN I-ICIs) paid exclusively under Medicare Part A
• Skilled nursing facilities (SNFs), for items or services expected to be denied under Medicare Part B

The notifier must list her name in section A of the ABN form. The physician, provider, etc., does not have to present the ABN to the patient personally; employees or subcontractors of the notifier may deliver the ABN.

When to Use an ABN

The ABN gives a Medicare beneficiary notice that Medicare “ is not likely to provide coverage in a specific case.” The patient’s name is listed in section B of the ABN, and the item or service must be listed in section D. Section C is an optional field to enter an identification number for the beneficiary to link the notice with a related claim. Section C is not used to indicate the provider’s identification number.

The provider must explain “in beneficiary friendly language” Why he or she believes Medicare may not cover the items or services (section E). Common reasons a service may be denied include:

• Medicare does not pay for the procedure or service for the patient’s condition.
• Medicare does not pay for the procedure or service as frequently as proposed.
• Medicare does not pay for experimental procedures or services.

The explanation of why _/Medicare may deny the item or service should be as specific as possible. A simple statement of “Medicare may not cover this procedure” is not sufficient.  Providers should list on the ABN each and every item or service that might not be covered. Medicare relieves beneficiaries from financial liability where they did not know and did not have reason to know a service would not be covered. Without a valid ABN, the Medicare beneficiary cannot be held responsible for denied charges.

Estimating Costs

The provider must provide a cost estimate for the proposed procedure or service (section F). CMS instructions stipulate, “Notifiers must make a good faith effort to insert a reasonable estimate” and “within $100 or 25 percent of the actual costs, whichever is greater.” CMS would allow an estimate to substantially exceed the actu- al costs because the beneficiary “would not be harmed if the actual costs were less than predicted.”  CMS allows exceptions if the provider is unable to give a goodfaith estimate of costs, but these circumstances are expected to be infrequent.  

Complete the Form, Confer with the Patient

After ABN sections A-F have been completed, the Medicare beneficiary may choose to proceed with the procedure or service a.nd assume financial responsibility, or may elect to forego the procedure or service (section G). Under no circumstances can the notifier decide this for the beneficiary. If the patient chooses to proceed, he may nevertheless request that the charge be submitted to Medicare for consideration (with the understanding that it will probably be denied).

The ABN “must be verbally reviewed with the beneficiary or his/ her representative and any questions raised during that review must be answered” bejbre the patient signs and dates theABN (sections I and  CMS requires that the provider present the ABN “far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice.”  A copy of the completed, signed form must be given to the beneficiary or representative, and the provider must retain the original notice on file.

You Can Proceed Without a Signature, If Necessary

If the beneficiary refuses to sign an ABN, but still requests the procedure or service, the provider should document the patient’s refusal.  The provider and a witness should then sign the form. The patient’s signature is not required for assigned claims (claims submitted by and paid to a physician on behalf of the beneficiary).

To hold the patient financially liable, a signature is required on the ABN for unassigned claims (claims submitted by the patient, who then reimburses the physician). If the patient refuses to sign, the options are not to provide the service or procedure (which might raise potential negligence issues), or to provide the service knowing that the provider may not get paid.

Append Modifiers to Your Claim

When filing your claim, apply modifier GA Waiver ofliability statement on file when the provider believes the service is not covered and the office has a signed ABN on file.  Modifier GY Item ar sert/ice statutorily excluded or does not meet the definition ofizn)/Medicare benefitapplies when Medicare excludes the item or service from coverage. When you report modifier GY, Medicare will generate a denial notice that the beneficiary may use to seek payment from secondary insurance, for instance.

If the provider fails to issue an ABN for a potentially uncovered service, append modifier GZ Item orserz/ice expected to be denied as not reasanable and necessary to the claim. This indicates that the provider cannot hold the patient financially responsible if Medicare denies the service, but will reduce the risk of fraud or abuse allegations for claims deemed “not medically necessary.”

© 2012 AAPC, Coding Edge Magazine. March Edition - www.aapc.com

 

 

Same-day E/ M and Office Procedure:

Yes, You Can!

Documentation and proper modifier 25 application is essential.

Providers generally learn from their billing and coding staff that reimbursement for office procedures includes the immediate pre- and post-procedure management of the patient. In my experience, providers sometimes “over learn” this lesson, and conclude that it is never possible to receive separate reimbursement for an evaluation and management (El M) service and an office procedure at the same encounter.  To capture all appropriate revenue, it is important to know what is included in the global package for office-based and surgical procedures, and understand when an El M service and an office procedural service can be billed in the same encounter, with appropriate documentation. 

What's Included in the Global Package

The American Medical Association’s (AMA’s) 2012 CPT'Pr0fi'ssi0nal Edition codebookdefines the following as “always included” in the global fee for a surgery or procedure:

• Subsequent to the decision for surgery (procedure), one related El M encounter on the date immediately prior to, or on the date of, the procedure 
• Immediate postoperative (post-procedure) care, including talking with the family and other physicians

Regarding diagnostic procedures, CPT' further specifies, “Followup care for diagnostic procedures includes only that care related to recovery from the diagnostic procedure itself. Care of the condition for which the diagnostic procedure wasperformcd or of other co-existing conditions is not included.” [emphasis added]

Medicare’s definition of the global package is broader than the AMA’s, but clearly states, “Services not included in the global surgical package are as follows:

• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery [procedure] 
• Treatment For the underlying condition or an added course of treatment, which is not part of normal recovery from surgery 
• Diagnostic tests and procedures, including diagnostic radiological procedures.”

Common Scenarios for Separate Services

With a clearer understanding of what is meant by “global package” (and what counts as counseling for El M services), you can identify two common scenarios where billing for an El M at the same encounter as a procedure is legitimate—provided there is the appropriate documentation in the medical record. 

1. A related El M service provided prior to an unplanned procedure may be billed separately.

The procedure must not have been the reason for the visit, and documentation must reflect the medical decision making (M DM) based on the evaluation undertaken at that visit that preceded the recommendation of a specific procedure. Documenting the options offered to the patient (with the eventual choice of the performed procedure) strongly supports billing an El M and procedure together. 

Example: A postmenopausal woman is seen for an urgently scheduled appointment in her gynecologist’s office because she noticed blood in her underwear. Upon examination, the source of the blood appears to be the cervix. The gynecologist offers the patient a choice of scheduling a pelvic ultrasound or undergoing immediate endometrial biopsy (EMBx). The patient chooses an immediate EMBx.

The proper coding in this example is 58100 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) and the appropriate level El M service (e.g., 99212-99215, “Qffice or other outpatient visit for the evaluation and management of an established patient”) with modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service appended.

Note that it is not unexpected that an EMBx was going to be performed, but the documentation supports that it was not planned prior to the El M service.

2. “Counseling and coordination of care” that take place immediately after a diagnostic procedure may qualify as a separate El M service.

Remember, the global payment for any procedure includes pre-procedure explanation and preparation, as well as post-procedure instructions, restrictions, and precautions, plus information about what to expect during the recovery period. It does not include the MDM that follows as a result of the procedure performed. That work is separate, and if documented clearly, separately billable. Documentation should be specific as to the time involved and the content of the counseling. In addition to providing a reasonable narrative of “counseling and coordination of care” that follows the interpretation of the results of an office procedure, it is important to include in the documentation a statement such as, “Exclusive of the procedure, greater than 50 percent of the visit was spent in counseling and coordination of care. Total visit time: 15 minutes.”

Example: A patient undergoes cystoscopy in the physician office because of bladder pain syndrome. Multiple fields of glomerulations are noted. Immediately following the procedure, the physician counsels the patient on the pathophysiology of interstitial cystitis (IC), as well as posible treatment options. After discussion, the patient chooses to start Elmiron® (Pentosan polysulfate). She will follow up in six weeks.

In this case, proper coding is 52000 Cystouret/Jroscopy (veparateprocedure) and the appropriate El M service level (e.g., 99211:) with modifier 25 appended. Documentation must substantiate that the El M service is both significant and separately identifiable from the El M component included in the payment for 52000.

Careful and Deliberate Documentation ls Essential

Although the immediate pre-procedure and post-procedure care and counseling of the patient is included in the global fee for an office procedure, other related El M work is not. The immediately preceding evaluation that leads to the recommendation of an office procedure can be billed on the same day as the procedure itself. Similarly, counseling and MDM that arise from the results of a procedure may take place immediately following it and are separately billable.  In both cases, careful and deliberate documentation to separate the work embodied in the two CPT' codes is essential.

© 2012 AAPC, Coding Edge Magazine. March Edition - www.aapc.com

 

 

Successfully Bill  
a Preventive Service with a Sick Visit 
Documentation is the key to avoiding billing issues.

There are two types of office encounters: preventive and problem-oriented.  Billing either type of visit alone is relatively straightforward, but when billing both visit types during the same encounter, documentation and billing issues can occur.  We’ll focus on the Centers for Medicare 86 Medicaid Services (CMS) and CPT' rules that govern this unique billing situation.

Distinguish Preventive Services Preventive medicine evaluation and management (E/M) visits, or annual exams, are comprehensive exams for the sole purpose of preventive care (i.e., to promote wellness and disease prevention).  These services are represented by CPT ® 99381-99397. The codes are agebased, and distinguish between new and established patients:

99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/ risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age youngerthan 1 year)

99382 early childhood (age 1 through 4 years)

99383 late childhood (age 5 through 11 years)

99384 adolescent (age 12 through 17 years)

99385 18-39 years

99386 40-64 years

99387 65 years and older

99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year)

99392 early childhood (age 1 through 4 years)

99393 late childhood (age 5 through 11 years)

99394 adolescent (age 12 through 17 years)

99395 18-39 years

99396 40-64 years

99397 65 years and older

Do not confuse the term “comprehensive” used in the context of defining a preventive service, with the definition of “comprehensive” as used in the 1995 or 1997 Documentation Guidelinesfir Evaluation andManagementServices.  CPT' stresses, “The ‘comprehensive’ nature of Preventive Medicine Services codes 99381-99397 reflects an age and ç gender appropriate history/exam and is not synonymous with the ‘comprehensive’ examination required in Evaluation and Management codes 99201-99215.” The extent of examination and anticipatory guidance associated with a preventive service is based upon the provider’s judgment.

Medical Necessity ShouldDetermine Services and Coding

During a preventive exam, patients often say, “Oh, by the way. . .,” which will prompt an additional, problem-oriented service. Several variables influence how you report a combination preventivel problem-oriented encounter. Billing largely depends on the payer, and sometimes on contractual agreements, as well as provider documentation.

The key is to document what you medically need to do and bill for what you document. In fact, this statement is my personal motto: Document what you do and bill for what you document. CPT° instructs, “If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented El M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported.”

There will likely be ‘work’ done for the problem-oriented service that would have been performed during the course of a routine preventive service. In other words, there will be an overlap of work. If any portion of the history or exam was performed to satisfy the preventive service, that same portion of work should not be used to calculate the additional level of E/ M service. When selecting the additional El M level of service, only the work that was performed “above and beyond ” what would have been performed during the preventive service should be used to calculate the additional E/ M level.  Documentation needs to support billing both services.  The provider may elect to create two separate notes to support the two separate services. This may be the besr practice, but it also creates more work for a provider. If the provider creates one document for both services, he or she must clearly delineate the problem-oriented history, exam, and decision making from those of the preventive service. For example:

• The key elements supporting the additional E/ M service must be apparent to an outside reader. 
• A separate history of present illness (HPI) paragraph describing the chronic/acute condition supports additional work needed in the history (there shouldn’t be an I-IPI in a preventive service). 
• The provider should clearly list in the assessment the acute / chronic conditions that are being managed at the time of the encounter. If there is a portion of the exam that is not routinely performed at the time of a preventive service, the provider should clearly identify those exam pieces (e.g., “A thorough MS and neuro exam of the left hip performed as it relates to the I-IPI”).

Consider Your Payer when Billing

When billing a commercial payer, a preventive service and additional problem-oriented El M service are billed on the same claim form and at the full fee schedule. Some clinics may elect to reduce the fee for the additional El M service when performed at an annual exam as a customer service benefit.  When billing Medicare, the additional El M service must be “carved out” from the preventive service. That is, any part of the history, physical exam, or plan portion of the annual exam performed to address a chronic or new issue can be separated from the non-covered preventive exam. This carved out portion of the service may be submitted to Medicare for coverage. In this case, the overlap of work can be used to calculate the additional level of service. Only those elements in the history, exam, and plan that directly address the chronic illness or new problem may be used to determine the appropriate level of E/ M.  Whether you are billing to a commercial payer or to Medicare, you must append modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of theprocedure or other service to the additional E/M code.  Modifier 25

 

 

© 2012 AAPC, Coding Edge Magazine. March Edition - www.aapc.com