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Chargemaster Update
Coastal Carolinas Health Alliance
Day One: January 15, 2015
8:00 - 10:00am
Session 1: Challenges for Outpatient Services and the Chargemaster in 2015
A review of the outpatient and CDM pain points and hot topics you need to watch out for
in 2015.
10:00 - 10:15am
BREAK
10:15 – 12:00pm
Session 1 (cont.): Challenges for Outpatient Services and the Chargemaster in 2015
A review of the outpatient and CDM pain points and hot topics you need to watch out for
in 2015.
12:00 - 1:00pm
LUNCH WITH AN EXPERT
Kimberly and Sarah will be available to address your questions one on one.
1:00 - 2:45pm
Session 2: Provider Based Clinics and Departments: Coverage, Coding and Billing
The requirements for coverage of services in provider based clinics and the coding of
those services, including modifier usage and differences for the professional vs. facility
services.
2:45 - 3:00pm
BREAK
3:00 - 4:30pm
Session 3: Chargemaster Maintenance
General tips for maintaining an up-to-date and compliant CDM.
4:30 - 5:00pm
WRAP UP & Q/A – INDIVIDUAL OR SMALL GROUP QUESTIONS
Copyright 2014 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express written
permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
Chargemaster Update
Coastal Carolinas Health Alliance
Day Two: January 16, 2015
8:00 – 9:45am
Session 4: NCCI Edits: Procedure to Procedure, Medically Unlikely, and Add-on
Code Edits
Discussion of changes to the NCCI edits, including replacement modifiers ( X{EPSU} )
for modifier 59, MAIs for MUEs, and Add-on code edits
9:45 - 10:00am
BREAK
10:00 – 12:00pm
Session 5: 2015 CPT Coding Update
Review of CPT code changes, additions and deletions for 2015
12:00 - 1:00pm
LUNCH WITH AN EXPERT
Kimberly, Sarah & Shannon will be available to address your questions one on one.
1:00 - 2:45pm
Session 6: Supplies, Drugs and Drug Administration
Tips for handling supplies and drugs in the CDM as well as reporting related drug
administration charges.
2:45 - 3:00PM
BREAK
3:00 -4:30
Session 7: Chart to Bill Auditing
Techniques for ensuring appropriate charge capture through chart to bill auditing.
4:30 – 5:00pm
WRAP UP & Q/A – INDIVIDUAL OR SMALL GROUP QUESTIONS
Copyright 2014 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express written
permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-1
Revenue Cycle Institute
Session 1:
Challenges for Outpatient Services
and the Chargemaster in 2015
Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS
President/CEO and Principal Consultant
SLG, Inc. Consulting
Disclaimer
• Every reasonable effort has been taken to ensure
that the educational information provided in today’s
presentation is accurate and useful. Applying best
practice solutions and achieving results will vary in
each hospital/facility situation.
2
Agenda
• Highlights of the 2015 OPPS Final Rule integrated
with an overview of CDM issues to watch out for in
2015
• Summary of potential compliance risks associated
with the 2015 changes
• CDM Examples*
• Discussion
* Participants are encouraged to provide own CDM examples for discussion as
well.
3
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-2
Learning Objectives
• Participant will understand the changing
chargemaster landscape for 2015.
• Participant will identify opportunities to make
changes for 2015.
• Participant will understand compliance risks in
2015 OPPS.
• Participant will understand the importance of
internally continuing certain concepts discontinued
by CMS.
4
2015 OPPS Final Rule
• Here are some highlights of the 2015 OPPS final
rule, released on October 31, 2014:
– Increase in OPPS payments by 2.3 percent
• Based on the projected hospital market basket
increase of 2.9 percent minus both a 0.5 percentage
point adjustment for multi-factor productivity and a
0.2 percentage point adjustment required by law
• Includes other payment changes, such as increased
estimated total outlier payments.
5
CDM Issues in 2015
• So what does this slight increase in payments
mean for your chargemaster (CDM)?
– Analyze your CDM pricing to ensure that you
cover your costs and are at or above APC or
MPFS reimbursement.
– Establish pricing for new procedures based
upon pricing for similar procedures already in
place and be sure to include costs for imaging
and other services that may now be bundled
into the HCPCS.
6
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-3
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule (continued)
– Elimination of the Ancillary Services status
indicator “X”
• Resulted in conditional packaging of most such
services, reassigning them to status indicator (SI)
“Q1,” which triggers packaged payment if any other
code with a status indicator S, T, or V is reported on
the claim, and separate payment if no other service
with an S, T, or V status indicator is reported.
7
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule (continued)
– Status indicator “X” (cont’d)
• Includes conditional packaging of services with a
geometric mean cost of $100.00 or less, with the
exception of preventative, psychiatric, and drug
administration services
• Facilitated an increase in the number of services
assigned status indicator Q1 (from 11 to 538).
8
CDM Issues in 2015
• So what does elimination of the SI=X mean for your
chargemaster (CDM)?
– If the HCPCS is still valid for the ancillary service,
ensure that you retain it on your CDM and report
when appropriate or if the HCPCS has been deleted
and replaced, update the coding as necessary.
Payment will be generated or packaged based upon
all codes reported on the claim.
– If deleted with no replacement, encompass the
costs in the related procedure or service.
9
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-4
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule (continued)
– Creation of Comprehensive-APCs (C-APCs)
• Packages into a single payment the comprehensive
service (i.e., a high cost primary service—generally
one including the implantation of a device and
accounting for a higher percentage of the total costs
of the hospital encounter) and all related items and
services.
10
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule (continued)
– Creation of Comprehensive-APCs (C-APCs)
• Assignment of the final C-APC is controlled by the
highest ranking primary procedure code
• Excludes OPPS statutory exclusions, pass-through
drugs and devices, and self-administered drugs
(SADs) as well as those paid separately by statute
such as preventative services and brachytherapy
seeds/sources, cost based services such as
vaccines, and services paid under other fee
schedules such as mammography.
* An excerpt from Table 6 of the 2015 OPPS Final Rule appears on the next
slide.
11
2015 OPPS Final Rule
Source: 2015 OPPS Final Rule
12
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-5
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule (continued)
– Comprehensive-APCs (cont’d)
• Identified in Appendix B with an SI=J1 as well as in
Appendix J*
• Comparable to the single payment made under the
inpatient prospective payment system (MS-DRG) for
a hospital stay.
* Excerpts from Addendums B and J appear on the next few slides.
13
2015 OPPS Final Rule
HCPCS
Code
Short Descriptor
CI
SI
0171T Lumbar spine proces distract
CH
J1
APC
Relative
Weight
0425
National
Minimum
Payment Unadjusted Unadjusted
Rate
Copayment Copayment
137.8399 $10,220.00
.
$2,044.00
0234T Trluml perip athrc renal art
CH
J1
0229
129.8028
$9,624.10
.
$1,924.82
0236T Trluml perip athrc abd aorta
CH
J1
0229
129.8028
$9,624.10
.
$1,924.82
0237T Trluml perip athrc brchiocph
0238T Trluml perip athrc iliac art
CH
J1
0229
129.8028
CH
J1
0319
200.1597 $14,840.64
0039
230.6235 $17,099.35
0268T Implt/rpl crtd sns dev gen
CH
J1
0282T Periph field stimul trial
CH
J1
0061
0283T Periph field stimul perm
CH
J1
71.3285
$9,624.10
.
.
$1,924.82
$2,968.13
.
$3,419.87
$5,288.58
.
$1,057.72
.
$5,230.44
0318
352.7212 $26,152.16
0302T Icar ischm mntrng sys compl
CH
J1
0089
127.9907
$9,489.74
.
$1,897.95
0303T Icar ischm mntrng sys eltrd
CH
J1
0090
88.2442
$6,542.78
.
$1,308.56
0304T Icar ischm mntrng sys device
CH
J1
0090
88.2442
$6,542.78
.
$1,308.56
0308T Insj ocular telescope prosth
CH
J1
0351
311.2228 $23,075.30
.
$4,615.06
0316T Replc vagus nerve pls gen
CH
J1
0039
230.6235 $17,099.35
.
$3,419.87
0387T Leadless c pm ins/rpl ventr
NI
J1
0319
200.1597 $14,840.64
.
$2,968.13
Source: CMS Addendum B, effective January 1, 2015
14
2015 OPPS Final Rule
HCPCS
Code
33249
0319T
33231
33264
33270
69930
0308T
C9732
33240
33230
33263
Addendum J for CY2015 ranks to determine primary assignment of comprehensive HCPCS codes
Geometric
APC
Full Claim Single J1
Mean
Rank
Geometric Populatio Unit Claim Cost of Used for
APC
Mean Cost n Service Service Single J1 Primary
Assignme of Single J1 Frequenc Frequenc
Unit
Assignme Comprehensiv
Short Descriptor
SI
nt
Unit Claims
y
y
Claims
nt
e Family
Insj/rplcmt defib
w/lead(s)
J1
0108
31,326.73
24,958
20,581 33,090.44
1
AICDP
Insert subq defib
J1
0108
31,326.73
90
85 31,529.18
2
AICDP
w/eltrd
Insrt pulse gen w/mult
leads
J1
0108
31,326.73
99
68 29,430.45
3
AICDP
Rmvl & rplcmt dfb gen
mlt ld
J1
0108
31,326.73
15,451
14,708 29,024.32
4
AICDP
Ins/rep subq
defibrillator
J1
0108
31,326.73
0
0
.
5
AICDP
Implant cochlear
J1
0259
30,750.92
2,401
2,363 30,750.92
6
ENTXX
device
Insj ocular telescope
prosth
J1
0351
23,946.68
54
54 23,946.68
7
EYEXX
Insert ocular telescope
pros
J1
0351
23,946.68
0
0
.
8
EYEXX
Insrt pulse gen w/singl
lead
J1
0107
23,619.78
222
196 25,305.30
9
AICDP
Insrt pulse gen w/dual
J1
0107
23,619.78
189
145 24,909.31
10
AICDP
leads
Rmvl & rplcmt dfb gen
2 lead
J1
0107
23,619.78
13,651
13,063 24,110.25
11
AICDP
Source: CMS Addendum J, effective January 1, 2015
15
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-6
CDM Issues in 2015
• So what do C-APCs mean for your chargemaster
(CDM)?
– It is critical to capture all separately reportable
procedures and services.
– Validate CDM-driven coding, including revenue
codes and modifier usage to ensure appropriate
reimbursement.
– Continue to report items excluded from C-APCs
such as pass-through drugs, devices and SADs.
16
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– Packaging of Orthotic/Prosthetic devices
• Not separately reimbursed—similar to most
implantable prosthetic devices and all other
supplies* used in the OPPS—when provided in
conjunction with a surgical or other procedure.
* Supplies will be covered in more detail in Session 6.
17
.
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– Orthotic/Prosthetic devices (cont’d)
• Exception applies to replacement prosthetic
supplies associated with an implantable prosthetic
device—provided after discharge—which continue
to be reimbursable under the Durable Medical
Equipment Prosthetic and Orthotics Supplies
(DMEPOS) fee schedule.
18
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-7
CDM Issues in 2015
• So what does DMEPOS packaging mean for your
chargemaster (CDM)?
– If the HCPCS for the item is still valid, ensure that
you retain it on your CDM and report when
appropriate or if the HCPCS has been deleted
and replaced, update the coding as necessary.
Payment will be generated or packaged based
upon all codes reported on the claim.
– If deleted with no replacement but still
commercially available, encompass the costs in
the related procedure or service or report with
revenue code 0270 or 0271 and no HCPCS.
19
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– Revisions to the Device-to-Procedure edits
• Still requires that facilities report a device code for
procedures currently assigned to a devicedependent APC
• However, providers may report any medical device
C-code listed among the device codes, rather than
a particular device C-code in order to meet this
requirement.
20
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– Device-to-Procedure edits (cont’d)
• Expectation is that hospitals should code and
report their costs appropriately, regardless of
whether there are claims processing edits in place.
21
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-8
CDM Issues in 2015
• So what do the revisions to the device-dependent
edits mean for your chargemaster (CDM)?
– If the HCPCS for the item is still valid, ensure that
you retain it on your CDM and report when
appropriate or if the HCPCS has been deleted
and replaced, update the coding as necessary.
– If deleted with no replacement but still
commercially available, encompass the costs in
the related procedure or service or report with
revenue code 027X and no HCPCS.
– Ensure parent/child linked charges, order entry
screens and encounter forms are updated
accordingly.
22
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– Finalizing Skin Substitute reimbursement
• Utilizes the weighted average mean unit cost
(MUC) for all skin substitute products from claims
data (rather than ASP) to promote more stable
high and low cost categories (updated in the
quarterly I/OCE releases*) and thresholds.
* Excerpt from I/OCE version 15.3, October 2014, appears on the next slide.
23
2015 OPPS Final Rule
Source: October 2014 Integrated Outpatient Code Editor (I/OCE) Specifications
Version 15.3
24
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-9
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– Skin Substitute reimbursement (cont’d)
• Processed through the device pass-through rather
than the drug pass-through process
• Aligns with the handling of similar implantable
biological products that have been evaluated
through the device pass-through process since
2010.
25
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule (continued)
– Skin Substitute reimbursement (cont’d)
• For CY 2015
– Skin substitutes with an MUC above $25/cm² are
assigned to the high cost group
– There are 62 skin substitute codes, which
represent the following products:
• 30 high cost skin substitutes
• 24 low cost skin substitutes
• 7 powdered, liquid, or micronized skin substitutes
• 1 miscellaneous skin substitute code.
* Excerpt from Table 34 in the Federal Register, Vol 79, No 217, November 10, 2014,
appears on the next slide.
26
2015 OPPS Final Rule
Source: Federal Register, Vol 79, No 217, November 10, 2014
27
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-10
CDM Issues in 2015
• So what do the skin substitute updates mean for your
chargemaster (CDM)?
– Ensure all being utilized at your facility are
accurately established in the CDM.
– Verify that units of service (UOS) match what is
actually being provided.
– Educate staff on which are considered high vs. low
cost so that the appropriate procedural codes can
be selected.
– Validate pricing and ensure parent/child linked
charges, order entry screens and encounter forms
are updated accordingly.
28
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– Introduction of a new modifier for Off-Campus
Provider-Based Departments*
• Reporting new HCPCS modifier PO (services,
procedures and/or surgeries furnished at offcampus provider-based outpatient departments)
for applicable services will be voluntary in 2015
and required beginning on January 1, 2016.
* This topic will be covered in more detail in Session 2.
29
.
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– New modifier for Off-Campus Provider-Based
Departments* (cont’d)
• Not applicable to CMS-1500 professional claims—
instead practitioners will report these services
using a new place of service (POS) code so stay
tuned for more details from CMS.
* This topic will be covered in more detail in Session 2.
.
30
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-11
CDM Issues in 2015
• So what does the new off-campus provider-based
department modifier mean for your chargemaster
(CDM)?
– Since more details are yet to come and the modifier
is not required until 2016, begin by making a list of
all your off-campus provider-based departments—
including who is in charge of the coding and billing
for that area.
– Identify any system or logistical constraints that may
impact modifier reporting in the off-campus setting.
– Educate staff and brainstorm how to best
implement.
31
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– Finalizing payment for Part B Drugs in the
outpatient department
• No change in reimbursement methodology for
non-pass-through drugs and biologicals that are
payable separately under the OPPS—currently
average sales price (ASP) + 6%.
32
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– Part B Drugs in the outpatient department
(cont’d)
• Increase to $95.00 from the proposed $90.00
amount for the packaging threshold for non-passthrough drugs.
33
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-12
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– Part B Drugs in the outpatient department
(cont’d)
• Reference to the 35 pass-through drugs for 2015
can be found in Table 29 of the OPPS final rule,
with many having been assigned J-codes to
replace the original C-codes
• Downloadable files can be accessed at the link
below:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-BDrugs/McrPartBDrugAvgSalesPrice/2015ASPFiles.html
34
2015 OPPS Final Rule
DME Bloo
HCPCS
Vacci Infusio Infusi d
HCPCS
Code Paymen Vaccine ne
n
on AWP Blood Clotting
Code Short Description Dosage t Limit AWP% Limit AWP% Limit % limit Factor Notes
J0133
Acyclovir injection
J0135
Adalimumab
injection
J0153
5 MG
0.068
20 MG 630.647
Adenosine inj 1mg
1 MG
0.847
J0171
Adrenalin
epinephrine inject
0.1 MG
0.137
J0220
Alglucosidase alfa
injection
10 MG 206.634
J0221
Lumizyme injection 10 MG 153.618
J0280
J0285
J0287
J0289
Added January 2015
Aminophyllin 250
MG inj
250 MG
3.211
Amphotericin B
50 MG
16.895
95
10.280
Amphotericin b lipid
complex
10 MG
11.012
95
21.850
16.984
95
35.800
Amphotericin b
liposome inj
10 MG
Source: Jan 15 ASP Pricing File 120914.xls
35
2015 OPPS Final Rule
Source: 2015 OPPS Final Rule
36
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-13
2015 OPPS Final Rule
Source: 2015 OPPS Final Rule
37
CDM Issues in 2015
• So what do the changes to Part B drugs mean for your
chargemaster (CDM)?
– If the HCPCS for the drug is still valid, ensure that you
retain it on your CDM and report when appropriate or
if the HCPCS has been deleted and replaced, update
the coding as necessary.
– If deleted with no replacement but still commercially
available, report the drug without a HCPCS but with a
valid revenue code such as 0250.
– Verify that units of service (UOS) match what is
actually being provided for multi-dose vials (MDVs)
and that there is a mechanism for capturing wastage
on single-dose vials (SDVs).
38
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule
(continued)
– Revisions to the Inpatient-Only List (SI=C)
• Removed the following add-on procedure codes
from the list and reassigning them to SI=N:
– 63043 (Laminotomy addl cervical)
– 63044 (Laminotomy addl lumbar)
• Added the following to the list:
– 22222 (Incis w/discectomy thoracic)
* An excerpt from Addendum E appears on the next slide.
39
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-14
2015 OPPS Final Rule
Addendum E.‐Final HCPCS Codes That Are Paid Only as Inpatient Procedures for CY 2015
HCPCS Code
Short Descriptor
CI
SI
G0341
Percutaneous islet celltrans
C
G0342
Laparoscopy islet cell trans
C
G0343
Laparotomy islet cell transp
C
G0412
Open tx iliac spine uni/bil
C
G0414
Pelvic ring fx treat int fix
C
G0415
Open tx post pelvic fxcture
C
Source: CMS Addendum E, effective January 1, 2015
40
CDM Issues in 2015
• So what do the Inpatient-Only List updates mean
for your chargemaster (CDM)?
– If the HCPCS for the procedure is still valid,
ensure that you retain it on your CDM and
report when appropriate or if the HCPCS has
been deleted and replaced, update the coding
as necessary.
– Educate staff on how and when inpatient-only
procedures may be reported without financial
impact to your facility.
41
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule (continued)
– Updates to the hospital outpatient Outlier
Payment methodology
• Grants outlier payment under the OPPS if the cost of
a service exceeds the multiple threshold of 1.75 times
the APC payment rate and exceeds the CY 2015
fixed dollar threshold of the APC payment plus
$2,775.00
• Required of CMS by the BBRA when a hospital’s
charges, adjusted to cost, exceed certain criteria
• Targets an estimated 1% of total OPPS spending in
outlier payments.
42
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-15
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule (continued)
– Updates to the Hospital Outpatient Quality
Reporting (OQR) program
• Decrease in the number of measures for the Hospital
OQR program to 25 from 27 for payment year 2017
• Includes the removal of two chart abstracted
measures, adoption of one new claims-based
measure, and a change to one chart-abstracted
measure
• Modifies the Hospital OQR program validation
process and formalizes the review and corrections
period.
43
2015 OPPS Final Rule
• Highlights of the 2015 OPPS final rule (continued)
– Remaining virtually unchanged functionally but
with payment updates where applicable based
upon geometric mean costs
•
•
•
•
•
•
Blood
Facility E/M (HCPCS G0463)
Imaging Composite APCs
Low Dose Brachytherapy (LDR)
Mental Health/Partial Hospitalization (PHP)
Observation Extended Assessment (APC 8009)
44
CDM Issues in 2015
• So even though some services remained
virtually unchanged in the OPPS final rule, what
does that mean for your chargemaster (CDM)?
– If you are providing these services, ensure
that the applicable codes have been
established in your CDM, that they are active,
and that they have been priced appropriately.
– Keep in mind that some codes, though valid,
may not apply to your setting (e.g., G0463,
introduced in 2014, is for OPPS facilities
only).
45
Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S1-16
CDM Compliance Risks for 2015
• What are some compliance risks in the CDM for
2015?
– CPT vs. HCPCS coding variances particularly in
GI, Radiation Oncology and Lab*
• For example:
– A major change in the Drug Assay section is the deletion of
the Drug Screening services (codes 80100, 80101, 80102,
80103, and 80104) and their replacement with new codes
that more clearly define the drug class and the
methodologies involved (80300, 80301, 80302, 80303,
80304); however, Medicare is still requiring HCPCS G0431
and G0434.
* Refer to a sample crosswalk on the next slide.
46
CDM Compliance Risks for 2015
HCPCS
Long Description
Crosswalk
G0431
Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter
80301, 80302
G0434
Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter
80300
Amitriptyline
80335 ‐ 80337
G6031
Benzodiazepines
80346 ‐ 80347
G6032
G6030
Desipramine
80335 ‐ 80337
G6034
Doxepin
G6035
80335 ‐ 80337
Gold
80375
G6036
Assay of imipramine
80335 ‐ 80337
G6037
Nortriptyline
80335 ‐ 80337
G6038
Salicylate
80329 ‐ 80331
G6039
Acetaminophen
80329 ‐ 80331
G6040
Alcohol (ethanol); any specimen except breath
80320
Source: ChargemasterCare “Testing for Drugs in 2015” webinar
47
CDM Compliance Risks for 2015
• What are some compliance risks in the CDM for
2015? (continued)
– Some codes applicable only to professional
services* and others to facility billing
• For example:
– Lower GI endoscopy coding (i.e., colonoscopy, colonoscopy
through stoma, ileoscopy, pouchoscopy, and flexible
sigmoidoscopy) should be reported with combination
CPT/HCPCS G-codes for physician services provided to
Medicare beneficiaries while facilities should utilize the 2015
CPT code.
* Refer to sample pro fee crosswalks on the next few slides.
48
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S1-17
CDM Compliance Risks for 2015
HCPCS
Long Description
44381
Ileoscopy w/dilation
Crosswalk
44380, G6021
44403
C‐stoma w/endoscopic mucosal resection (EMR)
44388, G6021
44404
C‐stoma w/submucosal injection
44388, G6021
44405
C‐stoma w/dilation
44388, G6021
44406
C‐stoma w/endoscopic ultrasound (EUS)
44388, G6021
44407
C‐stoma w/EUS‐guided fine needle aspiration (FNA)
44388, G6021
44408
C‐stoma w/decompression
44388, G6021
45349
Flexible sigmoid w/endoscopic mucosal resection (EMR)
45330, G6021
45350
Flexible sigmoid w/band ligation (e.g. hemorrhoids)
45330, G6021
45390
Colonoscopy w/endoscopic mucosal resection (EMR)
45378, G6021
45393
Colonoscopy w/decompression
45378, G6021
45398
Colonoscopy w/band ligation (e.g., hemorrhoids)
45378, G6021
Source: American Gastroenterological Association (AGA) Coding
FAQs
49
CDM Compliance Risks for 2015
2014 Code
2015 HCPCS Code
Long Description
44383
G6018
Ileoscopy, through stoma; with transendoscopic stent placement (includes predilation)
44393
G6019
Colonoscopy through stoma; with ablation of tumor(s), polyp(s) or other lesion(s), not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
44397
44799
G6020
G6021
Colonoscopy through stoma; with transendoscopic stent placement (includes predilation)
Unlisted procedure, intestine
45339
G6022
Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s) or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45345
G6023
Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)
Source: American Gastroenterological Association (AGA) Coding
FAQs
50
CDM Compliance Risks for 2015
• What are some compliance risks in the CDM for
2015? (continued)
– Many-to-one relationship between old and new
codes, Medicare vs. non-Medicare* and/or
codes applicable to pro fee vs. facility billing
• Complexity in pricing
• Increased potential for error
• Inability to split-bill
* Refer to breast tomosynthesis example on the next slide.
.
51
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S1-18
CDM Compliance Risks for 2015
Film
Digital
Digital with Tomosynthesis
Screening Mammogram
77057
G0202
G0202 + 77063
Unilateral Diagnostic Mammogram
77055
G0206
G0206 + G0279 (vs. 77061)
Bilateral Diagnostic Mammogram
77056
G0204
G0204 + G0279 (vs. 77062)
Source: American College of Radiology (ACR) “CMS Establishes Breast
Tomosynthesis Values in 2015 MPFS Final Rule,” November 5, 2014
52
CDM Compliance Risks for 2015
• What are some compliance risks in the CDM for 2015?
(continued)
– Certain modifiers may no longer be appropriate
• Modifier 59 vs. the new X{EPSU} modifiers*
– XE (separate encounter—service that is distinct because it
occurred during a separate encounter )
– XP (separate practitioner—a service that is distinct because
it was performed by a different practitioner)
– XS (separate structure—a service that is distinct because it
was performed on a separate organ/structure)
– XU (unusual non-overlapping service—the use of a service
that is distinct because it does not overlap usual
components of the main service)
* This topic will be covered in more detail in Session 4.
53
.
CDM Compliance Risks for 2015
• What are some compliance risks in the CDM for
2015? (continued)
– Certain modifiers may no longer be appropriate
(cont’d)
• LT, RT and 50 for breast biopsy and localization
procedures per recent clarification from the AMA*
– Essentially, if procedures are performed in both
breasts, report only one initial code per imaging
modality. All the rest become add-on codes.
* Refer to AMA Errata and Technical Corrections, November 11, 2014.
.
54
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S1-19
CDM Examples
• Now for some actual CDM examples…
55
Thank you. Questions?
56
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S2-1
Revenue Cycle Institute
Session 2:
Provider Based Clinics and
Departments:
Coverage, Coding and Billing
Kimberly Anderwood Hoy Baker, JD, CPC
Director of Medicare and Compliance
HCPro, a division of BLR, Inc.
Agenda
• Provider-Based Designation
• Coverage in Provider-Based Departments
– Integral through incidental to
– Physician supervision
• Coding in Provider-Based Departments
– Modifiers
• Packaging of Services to Visits
2
Provider-Based Designation
Scope:
• This presentation will focus on outpatient providerbased departments, including those providing
clinic-type services
• Inpatient provider-based organizations and entities
will not be addressed
3
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S2-2
Provider-Based Designation
Why is qualifying as provider-based
important?
• It is required for coverage of most services
provided in hospital outpatient departments
– Easy within the hospital, harder outside hospital
• Reimbursement is generally higher for providerbased services
– Potential compliance and/or revenue issue
4
On and Off Campus Provider-Based
Departments
Example of reimbursement at a provider-based
clinic:
• Office visit
• Physician: 99214
• Facility: G0463
Professional services
(99214)
Freestanding
Provider
based
Difference
$108.48
$79.12
-$29.36
Facility services (G0463)
N/A
$96.22
$96.22
Total payment
$108.48
$175.34
+$66.86
5
Provider-Based Designation
Two categories of provider-based department:
• On campus: Within 250 yards of the main buildings of the
provider
– Joint ventures must be on the campus of the provider
claiming the joint venture as provider based
• Off campus: Farther than 250 yards but within 35 miles (or
certain other criteria)
– Must meet additional requirements to be considered
provider based
– Normally must be in the same state
6
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S2-3
On and Off Campus Provider-Based
Departments
CMS finalized a new modifier and place of service to report
off-campus provider based services
• Hospital Claims
– Modifier –PO “Services, procedures and/or
surgeries provided at off-campus provider-based
outpatient departments”
– Effective 1/1/15, required 1/1/16
• Physician Claims
– Place of Service code – TBD
– Proposed to be effective 7/1/15, required 1/1/16
7
Provider-Based Designation
Why is CMS tracking off-campus services?
• CY2014 Final Rule discusses public concern about
increased copays
– “Why You Might Pay Twice for One Visit to a Doctor,” Seattle
Times, November 3, 2012 by Carol M. Ostrom
– Rising Hospital Employment of Physicians: Better Quality, Higher
Costs?, Issue Brief No. 136, Center for Studying Health System
Change, August 2011 by Ann O’Malley, Amelia M. Bond and Robert
Berenson
• MedPAC is questioning appropriateness of increased
payment by Medicare and cost-sharing for the patient
– Not the first government agency to do so
8
Provider-Based Designation
What is the purpose of the new modifier?
• Data gathering related to:
– Frequency of services at provider-based clinics
– Type of services provided
– Payment for those services
• Focused on physician practice type provider-based
clinics/departments
9
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S2-4
Provider-Based Designation
Requirements for on- and off-campus departments:
• Licensure: On the main provider’s license, unless
prohibited by state law
• Clinical integration:
– Staff have privileges at the main provider
– The main provider maintains monitoring and oversight, including
quality assurance and utilization review
– Medical director has same reporting relationship to medical
staff/chief medical officer
– Unified retrieval system for medical records
– Outpatients have full access to care at main provider
10
Provider-Based Designation
Requirements for on- and off-campus departments
(continued):
• Financial integration
– Shared income and expenses
– Costs are reported on the main provider’s cost report
• Public awareness
– Held out to the public as part of the main provider
• Comply with Conditions of Participation, including Life
Safety Code® provisions
– State licensure requirements may also have significant Life Safety
Code provisions
11
Provider-Based Designation
Requirements for on- and off-campus departments
(continued):
• Physician services
– Ensure appropriate site of service billing
– Ensure compliance with nondiscrimination provisions
• All patients treated as hospital outpatients; may not treat
some as physician office patients
• Comply with the three-day payment window
12
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S2-5
Provider-Based Designation
Additional requirements for off-campus
departments:
• Prior to services, written notice of:
– The beneficiary’s financial liability, OR
– A statement specifying they will incur a hospital copay (they would
not if not provider based) and an estimate based on an average
visit
• Operated under ownership and control of the main
provider (i.e., same Board of Directors, bylaws, etc.)
• Administration and supervision: Must have same
relationship as other departments
– Same frequency, intensity, and level of accountability
– Billing, medical records, human resources, payroll, employee
salary and benefits, and purchasing are integrated with main
provider
13
Provider-Based Designation
• Additional requirements for off-campus
departments operated under management
contracts:
– Main provider employs patient care staff
– The management contract is held by the main provider
and not a parent entity
• Joint ventures and management arrangements
may be affected by other requirements under
Stark, anti-kickback, nonprofit, or state laws and
bond or financing covenants
14
Provider-Based Designation
EMTALA obligations
• On-campus departments and off-campus dedicated
emergency departments
– Must comply with EMTALA provisions, including:
• EMTALA signage/posting requirements
• A list of on-call physicians
• A central log and records of transfers to and from the facility
• Reporting inappropriate transfers
• General EMTALA requirements
• Off-campus departments
– Must comply with CoPs, have a policy for care of patients with
emergency conditions
15
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S2-6
Provider-Based Designation
Attestations
• What are they?
– Provider’s statement of compliance with provider-based
requirements
16
Provider-Based Designation
Attestations
• Are they required?
– Most departments: NO
– Off-campus departments that “provide
physician services of a kind normally provided
in a physician office”: MAYBE
• 413.65(b)(4): presumed freestanding unless
determined to be provider based
• 2014 OPPS Final Rule: “Since October 1, 2002 we
have not required hospitals to seek from CMS a
determination of provider-based status for a facility
that is located off campus” – in discussion of offcampus physician office
17
Provider-Based Designation
Attestations
• If they are not required, why do them?
– Provides some protection from recoupment in
the event the facility is later found to not be
provider based
– Is treated as provider based until CMS
determines not provider based, including after
reporting a material change to CMS
18
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S2-7
Provider-Based Designation
Attestations
• Is there a specific form?
– No; CMS does provide a “Sample Attestation Format”
but providers are not required to use it
• See Program Memorandum A-03-030
• Where are attestations filed?
– With the MAC and regional office for the state in which
the main provider is located
19
COVERAGE OF SERVICES
IN PROVIDER-BASED
DEPARTMENTS/CLINICS
20
Coverage in Provider-Based
Departments
• Therapeutic services paid under OPPS (and paid
to CAHs at cost) must be provided “incident to” a
physician’s service.
• Exceptions:
– PT, OT, ST excluded in Benefit Policy Manual (BPM)
(i.e. not paid under OPPS):
– Education services not paid under OPPS but not
mentioned in the BPM:
• Diabetes self management training
• Medical nutrition therapy
• Kidney disease education
21
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S2-8
Coverage in Provider-Based
Departments
• Note: Physician “incident to” often refers to the
billing of professional services as “incident to” the
physician’s service
– These professional services may have a separate basis
for coverage
• Failure to meet physician “incident to” requirements
does not defeat coverage
• Services may still be billable at a lower rate
– Due to time limitation and to avoid confusion, we will not
address physician “incident to” rules because they are
not applicable to physician services in facility settings
22
Coverage in Provider-Based
Departments
Requirements for “incident to” coverage of hospital
outpatient therapeutic services
•Three requirements in CFR 410.27
– Furnished by the hospital, in the hospital, or a providerbased department of the hospital
– An integral, although incidental, part of a physician’s
service (not required for diagnostic services)
– Furnished under “direct supervision”
•One additional requirement in manual
– On the order of a physician or Non-Physician
Practitioner
23
Coverage in Provider-Based
Departments
Incident-to requirements are set out in:
• 42 CFR 410.27
– Substantially amended in 2010 and 2011, slight
revisions for 2014
• Medicare Benefit Policy Manual, Chapter 6 §20.5.1
– Amended several times
24
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S2-9
REQUIREMENT:
INTEGRAL, ALTHOUGH
INCIDENTAL,
PART OF A PHYSICIAN’S
SERVICE
25
Incident To: Integral, Though
Incidental
• Physician must see patient “periodically” and
“sufficiently” often to assess treatment
• Requires ongoing physician involvement,
managing the course of treatment
– Not covered if the physician “merely wrote an order for
the services or supplies and referred the patient to the
hospital without being involved in the management of
that course of treatment”
• Does not require a physician see them every visit
26
Incident To: Integral, Though
Incidental
What is “sufficiently” often?
• CMS does not specify
• Consider OIG cardiac rehab audits
– 12 weeks was not sufficient
• Watch out for chronic, stable patients
– Wound care
– Infusions/injections
27
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S2-10
Incident To: Integral, Though
Incidental
But it must be at least once!
• Consider patients presenting to the emergency
department (ED) and leaving without being seen
(LWBS) by a physician
• No basis for coverage of this service
– Level is not relevant, if not covered
– Other services (i.e., diagnostic services) not
relying on “incident to” may be covered
28
REQUIREMENT:
PHYSICIAN SUPERVISION
29
Physician Supervision Requirement
• Direct physician supervision is the default level
of supervision for hospital outpatient therapeutic
services
• Hospital diagnostic services must be provided at
the level of supervision specified in the Medicare
Physician Fee Schedule, which may include:
• General
• Direct
• Personal
30
30
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S2-11
Physician Supervision Requirement
• CMS adopted a sub-regulatory process to
change the level of supervision applicable to
therapeutic services for individual services at the
request of hospitals
– Hospital Outpatient Payment Panel makes
recommendations to CMS on requests
– See Attachment 1 for latest list dated December
8, 2014 effective January 1, 2015 or refer to the
OPPS home page for updates
31
– HOP Panel recommended
general supervision for
chemotherapy, but CMS declined
31
Physician Supervision Requirement
Direct Supervision
• “Direct supervision means that the physician or
nonphysician practitioner must be immediately
available to furnish assistance and direction
throughout the performance of the procedure. It
does not mean that the physician or nonphysician
practitioner must be present in the room when the
procedure is performed.” 42 CFR 401.27(a)(iv)(A)
32
32
Physician Supervision Requirement
Direct Supervision
• No physical location requirement (e.g. does not
have to be within the department or on the
campus) as long as the physician is immediately
available
• Non-hospital property close to the hospital is ok
– E.g. private physician office or sleep house
• “Any location in a building off campus that houses
multiple provider based departments”
– Eliminated the need for a physician in every
33
department as long as the physician is immediately
available
33
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S2-12
Physician Supervision Requirement
Direct Supervision
• Supervising practitioner must have within their
scope of practice/hospital-granted privileges the
ability to perform the service they are supervising
–
“Hospitals can adjust their bylaws and privileging
standards sufficiently to cover practitioners whom they
wish to act in a supervisory capacity”
–
Need not be in the same specialty of the service they
are supervising, but not all practitioners are qualified to
supervise any specialty
–
Must be knowledgeable enough about the service to be
34
able to furnish assistance
and direction and not merely
manage an emergency
34
Physician Supervision Requirement
Direct Supervision
• NPPs: nurse practitioners, physician assistants, clinical
nurse specialists, certified nurse mid-wives, clinical
psychologists, licensed clinical social workers
– CRNAs are not NPPs for supervision purposes
• NPPs can only supervise services they can personally
perform within their license and hospital bylaws
• NPPs can not supervise cardiac, intensive cardiac, and
pulmonary rehab or DIAGNOSTIC SERVICES
35
– They can personally perform
diagnostic services
within their licensure without supervision
35
Physician Supervision Requirement
Other levels of supervision:
• General: Under the overall supervision and control of
physician, but they need not be physically present
– See Attachment 1
• Personal: Physician must be present during the
procedure
– No therapeutic services designated as personal
supervision, however, presumably surgical services
requiring skill/license of physician would be in this
category
36
36
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S2-13
Extended Duration Services
“Non-surgical extended duration services”
• See Attachment 1
– E.g. observation, initial non-chemotherapy infusions
• Initiation of the service must be under direct supervision
and transition to general supervision
– Physician must determine and document the patient is
stable and the remainder of the services can be
rendered under general supervision
37
CODING IN
PROVIDER-BASED
DEPARTMENTS AND CLINICS
38
Coding of Provider-Based Services
Hospitals in general (but not always) are billing
the facility portion of a physician’s service,
which may include:
• Evaluation and management of the patient
• Procedures
39
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S2-14
Coding of Provider-Based Services
Procedures
• Procedures are generally coded with the
same HCPCS codes as the physician uses
• A physician’s service is not necessary to bill
many common procedure codes (e.g.
infusions, injections, wound care)
40
Coding of Provider-Based Services
Evaluation and management (E/M) in clinics:
• Until 2014 the CPT E/M codes for new and
established outpatient visits were used by
hospitals
– Hospitals established their own criteria
• Beginning January 1, 2014, all E/M visits at
hospital clinics are billed with a single
HCPCS code (G0463 Hospital Outpatient
Clinic Visit for Assessment and
Management of a Patient) for Medicare
– Other payers continue to require the new and
established CPT codes
41
Coding of Provider-Based Services
G0463 - Hospital Outpatient Clinic Visit for
Assessment and Management of a Patient:
– Used for facility services provided in conjunction
with physician E/M services
– Used for facility staff services covered under the
incident to benefit that do not meet the definition
of another HCPCS code
– Hospitals may still maintain multiple (i.e. tiered)
charge levels to represent costs of multiple levels
of service
42
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S2-15
Coding of Provider-Based Services
Evaluation and management (E/M) in EDs:
• Uses CPT codes and HCPCS codes
– Type A ED coded with 99281-99285
• DED open 24/7
– Type B ED coded with G0380-G0384
• Dedicated Emergency Department (DED) not open
24/7 (certain urgent care clinics)
• Used for facility services provided in conjunction
with physician E/M services in the ED/urgent care
clinic
43
Coding of Provider-Based Services
Hospitals develop their own criteria for assignment of the five
levels of ED/urgent care clinic codes:
• Should reasonably relate the hospital resources to the level
of the code
• Must be based on hospital resources and not on
physician resources
• Should be clear and result in verifiable code selection to
facilitate audits
– Written, not changed frequently, and be readily available to auditors
– Provide basis for selection of specific code
– Not facilitate gaming or upcoding
44
Coding of Provider-Based Services
Hospitals develop their own criteria for assigned of the five
levels of ED/urgent care clinic codes:
• Should not require documentation not necessary for clinical
care
• Should be applied consistently across patients of the
department
– May have separate guidelines for different specialties
For more information, see 72 Fed. Reg. 66805
45
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S2-16
PROPER USE OF MODIFIERS
IN PROVIDER-BASED
DEPARTMENTS AND CLINICS
46
Modifiers in Provider-Based Clinics
• Two scenarios requiring modifiers for providerbased services on same day as other services
– Multiple E/M services on the same day (27)
– E/M services with a procedure (25)
47
Modifiers in Provider-Based Clinics
Multiple E/M encounters in one day
• Hospitals may bill each E/M encounter that is separate and
distinct
– CMS: Two visits to the emergency room for chest pain
are independent visits
– This may result in the hospital billing more E/M codes for
the facility services than are billed for the physician
professional services
48
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S2-17
Modifiers in Provider-Based Clinics
Billing multiple E/M encounters in one day
• Visits may be reported on the same or separate claims
– See Medicare Claims Processing Manual, Chapter 4 §180.4
• Same claim
– Report modifier 27 on second and subsequent visits
– Report condition code G0 if the visits are billed in the same revenue
code
• Separate claims
– Report condition code G0 if the visits are billed in the same revenue
code
49
Modifiers in Provider-Based Clinics
E/M services provided with a procedure on the same
day
• E/M service must be “significant” and “separately
identifiable” to be reported separately in addition to the
procedure
• Reported with modifier 25 on the E/M code if “significant”
and “separately identifiable”
• Care should be taken to not bill E/M services separately for
the “usual preop and postop care” associated with clinic
procedures
50
Modifiers in Provider-Based Clinics
Should an E/M be billed with a procedure?
• Start with procedure performed: Was care beyond “usual
pre-op and post-op” care associated with the procedure?
– If no, no E/M is billed
• For example nursing assessment of a wound prior to wound
care
– If yes, E/M is billed with modifier 25
• For example nursing assessment of patient’s blood sugar
readings during a visit for wound care of a non-healing wound
51
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S2-18
Modifiers in Provider-Based Clinics
Proper use of modifier 25
• Taking the patient’s blood pressure, temperature, and
getting the consent form signed IS NOT considered
significant (i.e. it is part of usual pre-op)
• Hospital documentation must show facility services and
not just physician evaluation for hospital to bill separate
facility E/M services
– This may result in different codes being billed by the
facility and physician
– WATCH OUT FOR MATCHING USE OF MODIFIER
25!!!
52
Modifiers in Provider-Based Clinics
Proper use of modifier 25
• Modifier 25 may apply when the E/M services and the
procedure were provided in separate encounters in
different departments or by separate physicians
– Example: Lesion removal in one clinic in the
morning and E/M visit in another clinic later
– Note – physician service may not require the
modifier
– Operationally difficult to identify
53
Modifiers in Provider-Based Clinics
Modifier 25 Case Study:
• Patient presents for simple mole removal
• Facility nurse “checks in” the patient including taking their
blood pressure, weight, and documenting the history
regarding the mole removal
• During the appointment, the patient requests that the
physician address a medication change for a chronic
condition
• The physician completes the mole removal, evaluates the
patient’s chronic condition, and writes a prescription for a
new medication
54
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S2-19
Modifiers in Provider-Based Clinics
Assuming complete documentation of the services
provided,
• Would the physician bill an E/M code in addition to
the mole removal?
• Would the hospital bill an E/M code in addition to
the mole removal?
55
Packaging of Services to Visits
• Note modifiers 59 or 79 will not override new
packaging of laboratory services:
• Laboratory services are packaged to other services on
the same day, including clinic visits, unless:
– They are unrelated (e.g. ordered by a different
physician than the other service/visit and ordered
for a different purpose)
– They are the only service provided on that day
• If laboratory services are provided that are not ordered
by the clinic physician and are unrelated to the reason
for the clinic visit, bill with modifier L1
56
Packaging of Services to Visits
Packaged Laboratory Case Study:
• Patient sees their cardiologist at the provider-based
cardiology clinic
• Cardiologist orders lab tests related to patient’s
congestive heart failure (CHF)
• Patient goes to hospital lab at another location to
receive the laboratory tests ordered by cardiologist
AND tests ordered the prior week by their
endocrinologist related to their diabetes
HOW ARE THESE LABORATORY TESTS BILLED AND
PAID?
57
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S2-20
Packaging of Services to Visits
HOW ARE THESE LABORATORY TESTS BILLED
AND PAID?
• Tests related to the CHF ordered by the
cardiologist receive no separate payment and are
packaged to the clinic visit
• Tests related to the diabetes ordered by the
endocrinologist may receive separate payment –
MUST be coded with modifier L1
58
Packaging of Services to Visits
Packaged Ancillary Services
• Effective January 1, most services with a cost of less
than $100, except psychotherapy and drug
administration, are conditionally packaged
– Status indicator was changed from “X” to “Q1”
(“STV Packaged”)
• No modifier will override packaging
• This will result in many common diagnostic tests being
packaged (i.e. receiving no separate payment),
including x-rays, pathology services, respiratory
services when provided on the same day as a clinic
visit
59
Packaging of Services to Visits
Packaged Services Case Study:
• Patient sees their primary care physician at the
provider-based clinic
• The physician orders a chest x-ray for suspected
pneumonia and spirometry
• Patient goes to the hospital radiology department
for the chest x-ray and then the pulmonology
department for the spirometry
HOW ARE THESE TESTS BILLED AND PAID?
60
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S2-21
Case Study
• The clinic visit is paid:
– 2014: $92.53
– 2015: $96.22
• The x-ray is billed on the claim with the clinic visit and paid:
– 2014: $57.35
– 2015: $0
• The spirometry is billed on the claim with the clinic visit and
paid:
– 2014: $88.74
– 2015: $0
• Total
– 2014: $238.62
– 2015: $96.22
61
Thank you. Questions?
62
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SESSION 2, ATTACHMENT 1
S2-22
December 8, 2014
Hospital Outpatient Therapeutic Services That Have Been Evaluated for a Change in Supervision Level
Medicare requires direct supervision of all hospital outpatient therapeutic services unless CMS makes an assignment of either general or
personal supervision for an individual service. There is also a hybrid level of supervision for certain services described as non-surgical extended
duration therapeutic services (NSEDTS). Refer to CFR 410.27(a)(1)(iv)(E) for a description of NSEDTS. The following table lists the hospital
outpatient therapeutic services that have been evaluated by the Hospital Outpatient Payment (HOP) Panel for a change from direct supervision
and the final CMS decision on the supervision levels. Also listed are select codes with CMS-initiated supervision level changes. For new code(s),
we list the effective date for the change in supervision level that applied to the predecessor code(s). For codes with N/A in the effective date
column, there is no effective date provided because CMS has not made a change in supervision level.
HCPCS
Code
Short Descriptor
C8957
Prolonged iv inf, req pump
11719
HOP Panel
Evaluation Date
HOP Panel
Recommendation
CMS Decision
Effective Date
N/A
N/A
NSEDTS
January 1, 2011
Trim nail(s) any number
Aug, 2012
General
General
January 1, 2013
29580
Application of paste boot
Aug, 2012
General
General
January 1, 2013
29581
Apply multlay comprs lwr leg
Aug, 2012
General
General
January 1, 2013
36000
Place needle in vein
Aug, 2012
General
General
January 1, 2013
36430
Blood transfusion service
March, 2014
General
General
July 1, 2014
36591
Draw blood off venous device
Aug, 2012
General
General
January 1, 2013
36592
Collect blood from picc
Aug, 2012
General
General
January 1, 2013
36593
Declot vascular device
March, 2014
General
General
July 1, 2014
36600
Withdrawal of arterial blood
March, 2014
General
General
July 1, 2014
51700
Irrigation of bladder
Aug, 2012
General
General
January 1, 2013
51701
Insert bladder catheter
Feb, 2012
General
General
July 1, 2012
51702
Insert temp bladder cath
Aug, 2012
General
General
January 1, 2013
51705
Change of bladder tube
Aug, 2012
General
General
January 1, 2013
51798
Us urine capacity measure
Aug, 2012
General
General
January 1, 2013
90471
Immunization admin
Feb, 2012
General
General
July 1, 2012
90472
Immunization admin each add
Feb, 2012
General
General
July 1, 2012
1|Page
SESSION 2, ATTACHMENT 1
S2-23
December 8, 2014
90473
Immune admin oral/nasal
Feb, 2012
General
General
July 1, 2012
90474
Immune admin oral/nasal addl
Feb, 2012
General
General
July 1, 2012
90832
Psytx pt&/family 30 minutes
Feb, 2012
General
General
July 1, 2012
90834
Psytx pt&/family 45 minutes
Feb, 2012
General
General
July 1, 2012
90837
Psytx pt&/family 60 minutes
Feb, 2012
General
General
July 1, 2012
90785
Psytx complex interactive
Feb, 2012
General
General
July 1, 2012
90846
Family psytx w/o patient
Feb, 2012
General
General
July 1, 2012
90847
Family psytx w/patient
Feb, 2012
General
General
July 1, 2012
90849
Multiple family group psytx
Feb, 2012
General
General
July 1, 2012
90853
Group psychotherapy
Feb, 2012
General
General
July 1, 2012
90857
Intac group psytx
Feb, 2012
General
General
July 1, 2012
94640
Airway inhalation treatment
Feb, 2012
NSEDTS
Direct
July 1, 2012
94640
Airway inhalation treatment
March, 2014
None
Direct
N/A
94667
Chest wall manipulation
March, 2014
General
General
N/A
94668
Chest wall manipulation
March, 2014
General
General
July 1, 2014
96360
Hydration iv infusion init
Aug, 2012
General
General
January 1, 2013
96361
Hydrate iv infusion add-on
Aug, 2012
General
General
January 1, 2013
96365
Ther/proph/diag iv inf init
Aug, 2012
General
NSEDTS
N/A
96366
Ther/proph/diag iv inf addon
Aug, 2012
General
General
January 1, 2013
96367
96368
96369
Tx/proph/dg addl seq iv inf
Ther/diag concurrent inf
Sc ther infusion up to 1 hr
Aug, 2012
Aug, 2012
March, 2014
General
General
General
NSEDTS
NSEDTS
NSEDTS
N/A
N/A
N/A
96370
Sc ther infusion addl hr
March, 2014
General
General
July 1, 2014
96371
Sc ther infusion reset pump
March, 2014
General
NSEDTS
N/A
96372
Ther/proph/diag inj sc/im
Aug, 2012
General
General
January 1, 2013
96374
Ther/proph/diag inj iv push
Aug, 2012
General
NSEDTS
N/A
96375
Tx/pro/dx inj new drug addon
Aug, 2012
General
NSEDTS
N/A
96376
Tx/pro/dx inj same drug adon
Aug, 2012
General
General
January 1, 2013
2|Page
SESSION 2, ATTACHMENT 1
S2-24
December 8, 2014
96401
Chemo anti-neopl sq/im
March/August 2014
General
Direct
N/A
96402
Chemo hormon antineopl sq/im
March/August 2014
General
Direct
N/A
96409
Chemo iv push sngl drug
March/August 2014
General
Direct
N/A
96411
Chemo iv push addl drug
March/August 2014
General
Direct
N/A
96413
Chemo iv infusion 1 hr
March/August 2014
General
Direct
N/A
96415
Chemo iv infusion addl hr
March/August 2014
General
Direct
N/A
96416
Chemo prolong infuse w/pump
March/August 2014
General
Direct
N/A
96417
Chemo iv infus each addl seq
March/August 2014
General
Direct
N/A
96521
Refill/maint portable pump
Aug, 2012
General
General
January 1, 2013
96523
Irrig drug delivery device
Aug, 2012
General
General
January 1, 2013
97597
Rmvl devital tis 20 cm/<
March, 2014
General
Direct
July 1, 2014
99406
Behav chng smoking 3-10 min
Feb, 2012
General
General
July 1, 2012
99407
Behav chng smoking > 10 min
Feb, 2012
General
General
July 1, 2012
99490
Chron care mgmt srvc 20 min
N/A
N/A
General
January 1, 2015
99495
Trans care mgmt 14 day disch
N/A
N/A
General
January 1, 2015
99496
Trans care mgmt 7 day disch
N/A
N/A
General
January 1, 2015
G0008
Admin influenza virus vac
Aug, 2012
General
General
January 1, 2013
G0009
Admin pneumococcal vaccine
Aug, 2012
General
General
January 1, 2013
G0010
Admin hepatitis b vaccine
Aug, 2012
General
General
January 1, 2013
G0127
Trim nail(s)
Aug, 2012
General
General
January 1, 2013
G0176
Opps/php;activity therapy
March, 2014
General
General
July 1, 2014
G0177
Opps/php; train & educ serv
Feb, 2012
General
General
July 1, 2012
G0378
Hospital observation per hr
Aug, 2012
None
NSEDTS
N/A
G0379
Direct refer hospital observ
Aug, 2012
General
NSEDTS
January 1, 2013
G0410
Grp psych partial hosp 45-50
Feb, 2012
General
General
July 1, 2012
G0411
Inter active grp psych parti
Feb, 2012
General
General
July 1, 2012
3|Page
S3-1
Revenue Cycle Institute
Session 3:
Chargemaster Maintenance
and Charge Capture
Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS
President/CEO and Principal Consultant
SLG, Inc. Consulting
Agenda
• Overview of the Chargemaster
– Definition/Example
– Reimbursement
• Ancillary Department Review
– Structural Issues
– Ongoing Maintenance/Charge Capture
Strategies
• Discussion
2
Learning Objectives
• Participant will understand the structure of a
chargemaster (CDM) and common reimbursement
methodologies.
• Participant will learn general tips for maintaining an
up-to-date and compliant CDM.
• Participant will be able to identify charge capture
strategies for typical ancillary services.
3
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S3-2
Chargemaster – Definition
• What is a Chargemaster?
– A Chargemaster is a file containing all of the
procedures, services, pharmaceuticals, supplies,
and professional fees provided by a hospital or
under hospital contract and billed on a UB-04
and/or CMS-1500.
– Sometimes referred to as a CDM or Charge
Description Master, it may contain several thousand
lines.
– It can be equated to a “Super Bill” on the pro fee
side.
4
Chargemaster - Example
• Here are some fields from a typical CDM:
Dept
Description
Default/
NonMedicare
HCPCS
Code
Default/
NonMedicare
Revenue
Code
Medicare
HCPCS
Code
Medicare
Revenue
Code
SI
RX
PANTOPRAZOLE
40MG INJ
S0164 or
J3490
0636
C9113
0250 or
0636
N
SLP
SLP SPEECH
SCREENING
V5362
0444
(noncovered)
CARD
ECHO 2D WO DPLR 93307
COMP W/CON
0483
C8923
E
0483
S
5
Chargemaster – Reimbursement
• Medicare reimburses most outpatient services
under the OPPS
– OPPS stands for Outpatient Prospective
Payment System, which began in August
2000.
– However, those of us who have been in the
industry a while know that it really means . . .
“Oh Please Pay Something” . . . and
especially after some of the changes for 2015!
https://www.cms.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage
6
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S3-3
Chargemaster – Reimbursement
• Under the OPPS, Medicare pays the hospital a
rate-per-service basis known as an APC or
Ambulatory Payment Classification system that:
• Varies depending on the CPT/HCPCS code(s) and
status indicators
• Is CPT/HCPCS-driven and updated/published
quarterly
• Can include multiple APC payments (and even other
payment methodologies) on a given claim for a given
outpatient encounter
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/hospitaloutpaysysfctsht.pdf
7
Chargemaster – Reimbursement
• Other outpatient payment methodologies include:
– Fee schedule/Fee-for-service
– Contracted/Capitated rate
– Percentage of charges
– Per diem
– Any combination of the aforementioned
methodologies
8
Chargemaster - Reimbursement
• APC Addendum B Example:
HCPCS
Code
Short Descriptor
CI
SI
APC
Relative
Weight
Payment Rate
National
Unadjusted
Copayment
Minimum
Unadjusted
Copayment
70010
Contrast x-ray of brain
Q2 0274
8.2817
$614.04
.
$122.81
70015
Contrast x-ray of brain
Q2 0274
8.2817
$614.04
.
$122.81
70030
X-ray eye for foreign body
CH
Q1 0260
0.8004
$59.34
.
$11.87
70100
X-ray exam of jaw <4views
CH
Q1 0260
0.8004
$59.34
.
$11.87
70110
X-ray exam of jaw 4/> views
CH
Q1 0261
1.2810
$94.98
.
$19.00
70120
X-ray exam of mastoids
CH
Q1 0260
0.8004
$59.34
.
$11.87
70130
X-ray exam of mastoids
CH
Q1 0261
1.2810
$94.98
.
$19.00
https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html
9
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S3-4
Chargemaster – Reimbursement
• APC-Included Services
• APC-Excluded Services*
– Surgical Procedures
– Molecular Pathology
– Radiology
– PT, OT, and SLP
– Radiation Therapy
– Prosthetics/Orthotics
– Clinic Visits
– Dialysis for ESRD
– ED Visits
– Ambulance Services
– Diagnostic Services
– DME
– Partial Hospitalization
– Inpatient SNF
– Surgical Pathology
– Hospice/Home Health
– Chemotherapy
– Screening Mammography
– Blood Products
– Professional Fees
* Paid under other methodologies, e.g., fee schedules, as mentioned previously.
10
Chargemaster – Reimbursement
• Status Indicators (SI) identify what services are
payable under APCs, i.e., which are included and
which are excluded. Status Indicators are:
– A single alpha or dual alpha-numeric character
that correlates to each HCPCS code
– Referenced annually in Addendum B (a detailed
listing by HCPCS code and its assigned status
indicator) and defined in Addendum D1 of the
OPPS Final Rule each year
11
Chargemaster – Reimbursement
• Status Indicators (continued):
– Packaged (SI = N)
• Separately billable in most instances but payment
included in related service under OPPS
• Subject to Correct Coding Initiative (CCI) edits and
standards of coding practice
– Examples of instances whereby ‘Packaged’
services would not be separately billable include:
• Moderate Sedation (99143-99145) performed in
conjunction with procedures in Appendix G or other
packaged services such as Pulse Oximetry (94760-94761)
• IV Starts (36000) to facilitate infusion services
12
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S3-5
Chargemaster – Reimbursement
• Status Indicators (continued):
– Non-reportable (SI = B)
• Not separately billable under OPPS but may be paid by
intermediaries when submitted on a different bill type, e.g.,
75x (CORF)
• An alternate code that is recognized by OPPS may be
available
• Often synonymous with the term ‘non-billable’
– Examples of ‘Non-reportable’ services with alternate
coding include:
• Magnetic resonance imaging breast, without and/or with
contrast material(s); unilateral (77058 vs. C8903-C8905)
13
Chargemaster – Reimbursement
• Status Indicators (continued):
– Non-covered (SI = E)
• Separately billable but not reimbursable under OPPS
• Should be reflected in non-covered column of UB-04
• Statutorily non-covered items or services do not require
Medicare denial
• Beneficiary responsible for payment
– Examples of ‘Non-covered’ services include:
•
•
•
•
•
Self-administered Drugs*
Autopsies (88000-88099)
Acupuncture (97810-97814)
Specimen Handling (99000-99001)
Visual Acuity Screen (99173)
* Refer to note on next slide.
14
Chargemaster – Reimbursement
• Note regarding Self-administered Drugs:
– Neither the OPPS nor other Medicare payment
rules regulate the provision or billing by hospitals of
non-covered drugs to Medicare beneficiaries.
However, a hospital’s decision not to bill the
beneficiary for non-covered drugs potentially
implicates other statutory and regulatory provisions,
including the prohibition on inducements to
beneficiaries, section 1128A(a)(5) of the Act, or the
anti-kickback statute, section 1128B(b) of the Act
(Medicare Program Memorandum, A-02-129, Jan 3,
2003).
15
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S3-6
Chargemaster – Reimbursement
• Status Indicators (continued):
– Blood and Blood Products (SI = R) and
Brachytherapy Sources (SI = U)
• Became effective as of January 1, 2009
• Formerly assigned SI = K
• Payable under OPPS
– Inpatient Procedures (SI=C)
• Not paid under OPPS unless patient admitted as inpatient
• For emergently performed procedure on an outpatient
who expires prior to admission, report SI=C procedure
with modifier CA and discharge status code 20 (Medicare
PM A-02-129).
16
Chargemaster – Reimbursement
• Status Indicators (continued):
– Hospital Part B Services Paid via a Comprehensive
APC (SI = J1)
• New for 2015
• Payable under OPPS
• All covered Part B services on the claim are packaged
with the primary “J1” service for the claim, except for:
– Services with OPPS SI=F, G, H, L or U
– Ambulance services
– Diagnostic and screening mammography
– All preventive services
– Certain Part B inpatient services
17
Ancillary Depts – Structural Issues
• The following are general questions to ask when
structuring the CDM for ancillary departments:
– Will the services be reported on a UB-04 or
CMS-1500 claim form?
• Technical vs. Professional Fees
– e.g., split-billing TC/PC onto two claims (UB-04
and CMS-1500) vs. reporting both on UB-04 with
different revenue codes such as 032x and 0972
18
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S3-7
Ancillary Depts – Structural Issues
• Structuring the CDM (continued):
– Must any of the services be billed globally such
as in a clinic setting?
• e.g., reporting 93000 (ECG with interpretation and
report) on one claim vs. 93005 (…tracing only) and
93010 (…interpretation and report only) on separate
claims
• Generally required on the CMS-1500 and
necessitates use of different sets of chargecodes
19
Ancillary Depts – Structural Issues
• Structuring the CDM (continued):
– Are there coding differences by payer?
• Level I vs. Level II codes
– e.g., 71555 [MRA Chest with or without contrast material(s)]
vs. C8909-C8911 specified as with, without, or without/with
contrast
– e.g., 93318 (TEE 2D monitoring) vs. C8927 (TEE 2D
monitoring with contrast)
• Level II code variances, e.g., S-codes (non-Medicare) vs. Ccodes (Medicare OPPS) or G-codes (Temporary Procedures)
– e.g., G0109 [Diabetes outpatient self-management training
services, group session (2 or more), per 30 minutes] vs.
S9455 (Diabetic management program, group session)
• Level III codes still in existence, e.g., Medi-Cal
• Worker’s Comp using outdated code sets in some locales
20
Ancillary Depts – Structural Issues
• Structuring the CDM (continued):
– Is there a need for different revenue codes?
• e.g., 051x (Clinic) vs. 0761 (Treatment Room)
• e.g., 0760 (Treatment/Observation—General) vs.
0762 (Observation Room)
– What about coverage issues?
•
•
•
•
Inpatient vs. Outpatient
Screening vs. Diagnostic
Medical Necessity
Contract Exclusions
21
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S3-8
ED/Clinics – Charge Capture
• CDM maintenance and charge capture focus areas
for the ED/Trauma/Urgent Care/Clinics should
include:
– Verifying
• Appropriateness of HCPCS, hard-coded modifiers, i.e.,
25, and revenue code assignment, i.e., 045X vs. 051X
• Clarity of CDM vs. HCPCS descriptions, e.g., levels,
size or type of repair, etc.
• Surgical component setup, i.e., soft vs. hard-coding
• Routine items and equipment are bundled, e.g., IV start
kits, tongue depressors and 4x4s
• Non-routine supplies, DMEPOS items and
pharmaceuticals are reported
22
ED/Clinics – Charge Capture
• ED/Trauma/Urgent Care/Clinics charge capture
focus areas (continued):
– Ensuring
• Procedures such as CPR, EKGs, and venipunctures,
as well as minor surgical repair, are billed separately
in addition to E/M level of service while being careful
to avoid potential duplicate billing when multiple
departments respond to, assist with, provide overreads for, or attach such services to ancillary system
order sets.
23
ED/Clinics – Charge Capture
• ED/Trauma/Urgent Care/Clinics charge capture focus
areas (continued):
– Confirming
• Facility E/M criteria adhere to CMS’s 11-point guidance
introduced in 2008, i.e., coding guidelines should follow the
intent of the CPT code descriptor in order to reasonably
relate the intensity of hospital resources to the different levels
of effort represented by the code. In order words, facility
internal E/M criteria should:
– Be consistent
– Meet medical necessity
– Demonstrate stability over time
– Be linked to hospital resources, not physician ones
– Be available to and verifiable by outside entities
24
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written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S3-9
ED/Clinics – Charge Capture
• ED/Trauma/Urgent Care/Clinics charge capture
focus areas (continued):
– Verifying
• HCPCS G0463 introduced in 2014 is reported in
place of outpatient visit codes 99201–99215 for
OPPS hospital-based clinic services (MLN
Matters® Special Edition Article, SE1407, January
29, 2014).
• Physician, CAH and other non-OPPS entities
continue to report codes 99201-99215 as
appropriate.
https://www.federalregister.gov/articles/2013/12/10/2013-28737/medicare-and-medicaidprograms-hospital-outpatient-prospective-payment-and-ambulatory-surgical
25
ED/Clinics – Charge Capture
• ED/Trauma/Urgent Care/Clinics charge capture
focus areas (continued):
– Establishing
• A mechanism for logging and charging non-emergent
or scheduled return visits to the Emergency
Department (due to lack of space elsewhere, afterhours coverage, etc.) for Rabies vaccination series,
blood transfusions, antibiotic therapy, dressing
changes, and other minor procedures. Such services
should be billed as ‘outpatient’ not ED visits, as they
have separate revenue coding requirements, and
generally should be identified on a separate encounter
form or order entry screen.
26
ED/Clinics – Charge Capture
• ED/Trauma/Urgent Care/Clinics charge capture
focus areas (continued):
– Reviewing
• Policies for Critical Care reporting. Note that as of
January 1, 2011, hospitals may separately report
the services that are included in 99291 and 99292
for physicians, but Medicare will not separately
reimburse for them. Facilities that provide less
than 30 minutes of critical care should bill for a
visit, typically an emergency department visit, at a
level consistent with their own internal guidelines.
27
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S3-10
ED/Clinics – Charge Capture
• ED/Trauma/Urgent Care/Clinics charge capture focus
areas (continued):
– Capturing
• Infusions started via ambulance, which may be billed
separately when properly documented, including the 1st
hour received at the hospital and subsequent hours as
necessary (CMS Transmittal 785, December 16, 2005).
• Up to a 24-hour supply of certain anti-cancer take-home
medications as they are a covered service under
Medicare. Multi-day supplies of certain take-home drugs,
however, must be billed to the DMERC and require a
separate provider number (CMS Transmittal 882, March
3, 2006).
28
Observation – Charge Capture
• CDM maintenance and charge capture focus areas
for Observation services should include:
– Ensuring
•
•
•
•
Validity of a dated and timed physician order
Documentation of Placement/discharge times
Medical necessity
Accuracy of the hourly calculation, i.e., rounding, as
well as total number of hours
• There is an initial E/M assessment, i.e., direct admit
(HCPCS G0379) or one originating from a Clinic visit
(HCPCS G0463), Critical Care or the ED, reported in
conjunction with HCPCS G0378 (Hospital observation
services, per hour) when appropriate.
29
Observation – Charge Capture
• Observation charge capture focus areas (continued):
– Reporting
• HCPCS code G0378 (Hospital observation services, per
hour) for Medicare and other payers as required. Note
that a composite APC may be triggered when certain
criteria are met. One is that the patient must be observed
for a period of eight or more hours, so it is imperative that
observation time begin as soon as the order is written, not
when the patient reaches the DOU or a nursing floor
(CMS Transmittal 787, December 16, 2005).
30
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S3-11
Observation – Charge Capture
• Observation charge capture focus areas (continued):
– Reviewing
• Observation orders to ensure they are written by providers
authorized by the facility’s medical staff bylaws to admit
patients or order outpatient tests.
• Units of service to be sure they represent the number of
hours the patient spent in observation status.
– Fractions of an hour should be rounded down to the
nearest hour.
– Services requiring ‘active monitoring’ should be carved
out of observation time
31
Imaging – Charge Capture
• CDM maintenance and charge capture focus areas
for Imaging services should include:
– Verifying
• Appropriateness of HCPCS (including unlisted codes),
hard-coded modifiers, i.e., LT/RT/50, and revenue code
assignment, i.e., 032X vs. 036X range
• Clarity of CDM vs. HCPCS descriptions, e.g., number of
views, type of imaging, with or without contrast, etc.
• Surgical component setup*, i.e., soft vs. hard-coding
• Routine items and equipment are bundled, e.g., film,
drapes, tubing and oximeters
• Contrast, radiopharmaceuticals and non-routine supplies
dispensed by department are reported
* Refer to example crosswalk on next slide.
32
Imaging – Charge Capture
• Imaging to Surgical Code Crosswalk Example
Radiology Code
Related Procedure Codes
70170
68850
70332
21116
70390
42550
70450, 70460, 70470
61751
70551‐70553
61751
76942
see appropriate organ or site
33
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S3-12
Lab/Pathology – Charge Capture
• CDM maintenance and charge capture focus
areas for Laboratory/Pathology should include:
– Verifying
• Appropriateness of HCPCS (including unlisted
codes), hard-coded modifiers, i.e., 91, and revenue
code assignment, i.e., 030X or 031X range
• Clarity of CDM vs. HCPCS descriptions, e.g.,
methodology vs. specific testing, number of
specimens, etc.
• No non-approved/unbundling of panels
• Routine items and equipment are bundled, e.g.,
specimen containers and empty blood bags
34
Lab/Pathology – Charge Capture
• Laboratory/Pathology charge capture focus areas
(continued):
– Reviewing
• The Lab National Coverage Determinations (NCD)
database, which can be found on the CMS web site
at:
https://www.cms.gov/Medicare/Coverage/Coverage
GenInfo/LabNCDs.html
35
Cardiopulmonary – Charge Capture
• CDM maintenance and charge capture focus
areas for Cardiopulmonary should include:
– Verifying
• Appropriateness of HCPCS (including unlisted
codes), tracking code usage, and revenue code
assignment, i.e., 041X vs. 046X vs. 048X range
• Clarity of CDM vs. HCPCS descriptions, e.g., initial
vs. subsequent, frequency, etc.
• Routine items and equipment are bundled, e.g.,
suction tubing and electrodes
36
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S3-13
Rehabilitation – Charge Capture
• CDM maintenance and charge capture focus areas
for Rehab (PT/OT/SLP) should include:
– Verifying
• Appropriateness of HCPCS (including unlisted codes),
hard-coded modifiers, i.e., GO/GP/GN, and revenue
code assignment, i.e., 042X vs. 043X vs. 044X vs. 047X
• Clarity of CDM vs. HCPCS descriptions, e.g., per 15
minutes, untimed modalities, etc.
• Routine items and equipment are bundled, e.g., cold
packs and traction
• DMEPOS items and equipment dispensed by
department are reported
37
Rehabilitation – Charge Capture
• Rehab (PT/OT/SLP) charge capture focus areas
(continued):
– Capturing
• Functional data reporting and collection system
requirements, which became effective for therapy
services with dates of service on and after January 1,
2013 and required as of July 1, 2013. For more
information, refer to CMS’s National Provider Call
summary and therapy required functional reporting
implementation resource:
http://www.cms.gov/Outreach-andeducation/Outreach/NPC/Downloads/FunctionalReportingNPC.pdf
38
Surgery – Charge Capture
• CDM maintenance and charge capture focus
areas for Surgery/Anesthesia/Recovery should
include:
– Verifying
• Appropriateness of HCPCS (including unlisted
codes), i.e., 036X vs. 0761 vs. 051X vs. 052X
• Correct use of soft-coding vs. hard-coding
• Routine items and equipment are bundled, e.g.,
drapes, gowns, gloves and monitors
• Non-routine supplies, DMEPOS items and
pharmaceuticals dispensed by department are
reported
39
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S3-14
Surgery – Charge Capture
• Note regarding time charges:
– Time is generally charged in the operating room
(OR) so that HIM can append the appropriate
coding from chart documentation; however,
certain minor procedures performed in
treatment rooms associated with the OR may be
hard-coded.
40
Supplies – Charge Capture
• CDM maintenance and charge capture focus
areas for Supplies should include:
– Verifying
• Appropriate reporting of device-dependent codes
• Routine items and equipment are bundled, e.g.,
drapes, gowns, gloves and monitors
• Non-routine supplies, DMEPOS items and implants
dispensed by department are reported
* Refer to note on next slide.
41
Supplies – Charge Capture
• Note that routine supplies such as gloves, drapes, and
blood pressure cuffs and equipment such as monitors
and pumps should be bundled into surgery time or the
related accommodation code or service. Non-routine
items and services may be billed separately when they
are:
– directly identifiable items and services provided to
individual patients*
– furnished under the direction of a physician
because of specific medical needs
– not reusable or represent a cost for each
preparation
* This also means that such items should be charted in the patient’s permanent
medical record.
42
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S3-15
Supplies – Charge Capture
• Medical/Surgical Supplies
and Devices 027X*:
– General 0270
– Nonsterile Supply 0271
– Sterile Supply 0272
– Take-Home Supplies 0273
– Prosthetic/Orthotic Devices
0274
– Pacemaker 0275
• Medical/Surgical Supplies
(Extension of 027X) 062X*:
– Supplies Incident to Radiology
0621
– Supplies Incident to Other
Diagnostic Services 0622
– Surgical Dressings 0623
– FDA Investigational Devices
0624
– Intraocular Lens 0276
– Oxygen (Take-Home) 0277
– Other Implants 0278
– Other Supplies/Devices 0279
* All UB‐04 Revenue Codes are copyrighted by the American Hospital Association.
43
Pharmacy – Charge Capture
• CDM maintenance and charge capture focus areas for
Pharmacy should include:
– Verifying
• Units of Service
– HCPCS code description vs. manufacturer dose
– Wastage documentation (modifier JW, if required)
• Self-administered drugs have been established as noncovered for Medicare outpatients under most
circumstances, but covered for inpatients and other
payers
• Accuracy of NDC data
44
Thank you. Questions?
45
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S4-1
Revenue Cycle Institute
Session 4:
NCCI Edits: Procedure to Procedure,
Medically Unlikely,
and Add-on Code Edits
Kimberly Anderwood Hoy Baker, JD, CPC
Director of Medicare and Compliance
HCPro, a division of BLR, Inc.
Agenda
• New NCCI Manual
• Procedure to Procedure Edits
• Medically Unlikely Edits and Adjudication
Indicators
• Add-On code edits
• Modifiers
2
NCCI Manual
New NCCI Manual Guidance
– A new version of the NCCI Manual was
published effective January 1, 2015
– Providers should review new text added to most
sections (in red) for new coding guidance for
particular services
3
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S4-2
NCCI Manual
New NCCI Manual Guidance
• Chapter 1: General Correct Coding Policies
– New instructions on modifier 59 – including adding new X{EPSU} to list of modifiers that override NCCI
procedure to procedure edits
– Addition of information on new MUE Adjudication
Indicators (MAIs) and other MUE related information
4
NCCI Manual
New NCCI Manual Guidance
• Chapter 2: Anesthesia Guidelines
– No significant clarifications
• Chapter 3: Surgery: Integumentary System
– New instruction stating creation of a flap is not
reportable with breast reconstruction or prosthesis
procedures
5
NCCI Manual
New NCCI Manual Guidance
• Chapter 4: Surgery: Musculoskeletal System
– Single closed fracture treatment may be reported if
multiple fractures occur in an area that would be (but is
not) treated with a single cast, splint or strapping
– Arthrocentesis for aspiration or injection is reported per
joint and surrounding bursae, regardless of how many
are injected or aspirated
– Clarification for arthrodesis by lateral extracavitary
technique and add-on codes for additional vertebral
segments
• Also appears in Chapter 8, 9
6
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S4-3
NCCI Manual
New NCCI Manual Guidance
• Chapter 4: Surgery: Musculoskeletal System
(cont.)
– Clarification for percutaneous vertebroplasty and add-on
codes for additional levels
• Also appears in Chapter 8, 9
– Clarification of non-payment for lumber laminotomy or
laminectomy with arthrodesis in the same interspace,
but modifier 59 appropriate if different interspaces
• Also appears in Chapter 8
7
NCCI Manual
New NCCI Manual Guidance
• Chapter 5: Surgery: Respiratory, Cardiovascular,
Hemic and Lymphatic systems
– Reporting of vascular embolization procedures with
selective, but not non-selective, catheterization
– Clarification of inclusion of fluoroscopic/ultrasound
guidance and echocardiography to transcatheter aortic
or mitral valve replacement procedures
– Clarification that ligation procedures of the lower
extremities include application of compression dressings
8
NCCI Manual
New NCCI Manual Guidance
• Chapter 5: Surgery: Respiratory, Cardiovascular,
Hemic and Lymphatic systems
– Clarification that cystourethroscopy “performed near the
termination” of an intra-abdominal, intra-pelvic, or
retroperitoneal procedure to confirm no injury to
ureters/bladder is not separately reportable
• Also appears in Chapter 6, 7
9
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S4-4
NCCI Manual
New NCCI Manual Guidance
• Chapter 6: Surgery: Digestive System
– Example regarding not reporting control of bleeding with
endoscopy procedure
– Clarification that injection of air into the abdominal or
pelvic cavity with laparoscopic procedures is not
reportable
• Also appears in Chapter 7, 8
10
NCCI Manual
New NCCI Manual Guidance
• Chapter 6: Surgery: Digestive System
– Clarification that dilation of strictures with
gastrointestinal endoscopy is reported with unit of 1
regardless of the number of strictures dilated
– Clarification that coding of ERCP with balloon dilation of
ducts is per duct for each duct dilated
11
NCCI Manual
New NCCI Manual Guidance
• Chapter 7: Surgery: Urinary, Male Genital, Female
Genital, Maternity Care and Delivery
– No significant clarification, except as mentioned above
related to injection of air and cystourethroscopy
12
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S4-5
NCCI Manual
New NCCI Manual Guidance
• Chapter 8: Surgery: Endocrine, Nervous, Eye and
Ocular Adnexa, and Auditory Systems
– Clarification that injection of antibiotics, steroid and nonsteroid anti-inflammatory drugs during cataract or
ophthalmic procedures aren’t reportable
– Clarification of injection that are not reportable with
paracentesis
13
NCCI Manual
New NCCI Manual Guidance
• Chapter 8: Surgery: Endocrine, Nervous, Eye and
Ocular Adnexa, and Auditory Systems
– Clarification that procedures to correct trichiasis is per
eye not eyelid and if performed bilaterally they should be
reported with modifier 50
– Clarification of units of service for injection of anesthetic
agents around a nerve area
14
NCCI Manual
New NCCI Manual Guidance
• Chapter 9: Radiology Services
– Clarification of reporting for repeat procedures for
substandard views
– Clarification of reporting of CT of the spine with
intrathecal contrast and myelography together
– Clarification that supervision and handling of
radionuclides is integral to nuclear medicine procedures
and not separately reportable
– Clarification of guidance on localization of radiation field
and inclusion of new radiation therapy codes
15
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S4-6
NCCI Manual
New NCCI Manual Guidance
• Chapter 10: Pathology/Laboratory
– Clarification that testing to be sure a sample was not
contaminated/adulterated is not separately billable
because it is not for the purpose of treating the patient
(new section on Drug Testing)
– Clarification on reporting on staining procedures by the
pathologist
– Clarification that immunohistochemistry stain
procedures with multiple antibodies that are not
separately interpretable are reported as one unit
16
NCCI Manual
New NCCI Manual Guidance
• Chapter 11: Medicine, Evaluation and
Management Services
– Clarification of reporting of family psychotherapy
– Clarification that for certain procedures requiring
swallowing of a capsule, endoscopic placement for
patients that can’t swallow is not separately reportable
and the procedure may not be reported with modifier 52
– Clarification of reporting transesophageal
echocardiography (TEE) and critical care, including with
modifier 59 if not part of critical care
17
NCCI Manual
New NCCI Manual Guidance
• Chapter 11: Medicine, Evaluation and
Management Services
– Clarification of allergy testing and immunotherapy coded
together on the same day and units of service for allergy
testing with positive and negative controls
– Clarification of reporting Osteopathic Manipulative
Treatment and injections of anesthetic
– Clarification that therapeutic repetitive transcranial
magnetic stimulation (TMS) is reported once per day
18
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S4-7
NCCI Manual
New NCCI Manual Guidance
• Chapter 11: Medicine, Evaluation and
Management Services
– Clarification regarding electrical stimulation and needle
electromyography for guidance with chemodenervation
– Clarification on per day reporting of dialysis and
hemodialysis procedures
– Clarification that audiologic function testing is reported
for both ears, with modifier 52 if only a single ear is
tested
– Clarification of reporting on endomyocardial biopsy from
19
more than one site
NCCI Manual
New NCCI Manual Guidance
• Chapter 12: Supplemental Services, HCPCS Level
II Codes
– Clarification of proper reporting of refill kits with refilling
and maintenance of implantable drug pumps
– Clarification of separate reporting of amniotic
membranes with procedures for placement of amniotic
membranes on the ocular service
– Clarifications regarding new telehealth inpatient
consulation codes
20
NCCI Manual
New NCCI Manual Guidance
• Chapter 13: Category III CPT Codes
– No significant clarifications
21
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S4-8
NCCI Edits
• Three types of NCCI edits:
– Procedure to Procedure (PTP) edits
– Medically Unlikely Edits (MUEs)
– Add-on Code Edits (new in 2013)
• The latest version of each of the edit files is available on
their own respective home pages
– A listing of each quarters additions, deletions and
revisions to PTP edits and MUEs is posted on a
separate “Quarterly NCCI and MUE Version Update
Changes” page
– The quarterly changes for Add-On code edits is on the
home page for Add-On code edits
22
Procedure to Procedure Edits - PTP
Procedure to Procedure (PTP) Edits
• Formerly the column 1/column 2 (i.e.
comprehensive/component) and the mutually
exclusive edits
– Files were combined into 1 file, effective April 1, 2012
– File became too large, now posted in two smaller files,
split at CPT code 40460
23
Procedure to Procedure Edits - PTP
Procedure to Procedure (PTP) Edits
• Code in first column pays, code in second column
rejects - if no modifier
• Code in the first column is:
– Highest paying for column 1/column 2 BUT
– Lowest paying for mutually exclusive (CAUTION)
• Caution: if no modifier reevaluate coding, second
column code (that does not qualify for modifier) may
be the correct code rather than the first column code
24
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S4-9
Procedure to Procedure Edits - PTP
What if a modifier does not apply
• Evaluate what to do with the unreportable code
– Has the cost of the service been incorporated in another
line already reported (e.g. the code that is reported)
• If yes, do not report the charge separately – remove
complete line and charge from the claim
• If no, report the charge (to capture the cost of the
service):
– as part of another code (e.g. the code that is
reported) OR
– on an uncoded (i.e. no HCPCS code) line with an
appropriate revenue code
25
Medically Unlikely Edits
Medically Unlikely Edits
• New version format posted as of 7/1/14
– Includes MUE Adjudication Indicator (MAI) and
MUE Rationale
• Medicare One Time Notice Transmittal 1421
– Explains MAIs: MUE Adjudication Indicator
26
Medically Unlikely Edits
MUE Adjudication Indicator (MAI)
• MAI of 1 – applied by line
– Bill excess units on a separate line with an
appropriate modifier, if medically necessary
• Allows up to 2 times the MUE to be billed
– Appeal if more than 2 times the MUE and no
other modifier applies
27
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S4-10
Medically Unlikely Edits
MUE Adjudication Indicator (MAI)
• MAI of 2 – applied by date of service – “not appealable”
– Based on regulations, statute, description of the code,
anatomy,
– Binding on providers and the MAC
– Considered subregulatory guidance –
• QIC and ALJ must give “substantial deference”, but they are not
bound by them
– Applied by summing all units of the code on a DOS
• Includes current claim and all prior paid claims with same DOS
28
Medically Unlikely Edits
MUE Adjudication Indicator (MAI)
• MAI of 3 – applied by date of service – “appealable”
– Based on clinical benchmarks
– MAC may pay units in excess of MUE if there is
documentation that the units were provided, coded
correctly and medically necessary
– Applied by summing all units of the code on a DOS
• Includes current claim and all prior paid claims with same
DOS
29
Medically Unlikely Edits
MUE Adjudication Indicator (MAI)
• MAI of 0 – unpublished indicators that may not
be shared outside the MAC
30
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S4-11
Add-on Edits
Add-on Code Edits
• Added to NCCI in 2013
• New version available for 1/1/2015 that includes
effective and deletion dates
• Add-on codes describe a service that is always
performed in conjunction with a primary service
• Add-on codes are eligible for payment only if reported
with a primary procedure*
– Add-on codes can not be paid if it is the only procedure
reported*
*There is an exception for 99292 inapplicable to facility reporting
31
Add-on Edits
Add-on Code Edits
• Three types of Add-on Code Edits
– Type I – add-on code with a limited number of specific
acceptable primary procedures defined by CPT/ HCPCS
manuals
– Type II – add-on codes without a specific list of primary
procedures
• Contractors must develop a list of acceptable primary
procedures
– Type III – add-on codes with partial list of acceptable
primary procedures defined by CPT/HCPCS manuals
• Contractors must develop a list of additional acceptable
primary procedure codes
32
Modifiers
Multiple procedures on the same day
• Coding is different depending on whether the
services occur in the same or separate encounters
– Generally, procedures in the same encounter use
modifier 59 (if no more specific modifier applies)
– Generally, procedures in separate encounters use
modifier 79 to ensure proper application of the
multiple procedure discount
33
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S4-12
Modifiers
Multiple procedure on the same day
• Modifier 59 or 79 may apply when procedures are provided
in separate encounters or separate departments
– Particularly problematic when combining claims for
multiple encounters on the same day
– Operationally difficult because sometimes only required
after encounters are coded and combined at the time of
billing
• Who can apply the modifier – billers may be appropriate with
education for some of these circumstances
34
Modifiers
Modifier 59 is used for distinct procedural
services:
• Different sessions (watch out–not for hospitals)
• Different procedure/surgery
• Different site or organ system
• Separate incision/excision
• Separate lesion
• Separate injury
Modifier 59 is a “modifier of last resort” used
if no more specific modifier applies
35
Modifiers
MLN Matters SE1418
• Special Edition MLN: “Proper Use of Modifier 59”
– Reiterates different anatomic site
– Reiterates different encounters
– Inappropriate if use is based on the fact the
description of the two codes is different
– Clarified use for timed codes when the services are for times
that do not overlap (i.e. not interspersed with each other)
– Clarified use for diagnostic and therapeutic
procedures performed on the same day
– Provides 11 specific examples
36
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S4-13
Modifiers
Medicare One Time Notification Transmittal 1422
• Introduced 4 new modifiers to “replace” -59
– XE “Separate Encounter”: A service that is distinct
because it occurred during a separate encounter.
– XS “Separate Structure”: A service that is distinct
because it was performed on a separate
organ/structure
– XP “Separate Practitioner”: A service that is distinct
because it was performed by a different practitioner
– XU “Unusual Non-Overlapping Service”: The use of a
service that is distinct because it does not overlap
usual components of the main service
37
Modifiers
New –X{EPSU} Modifiers
• Not exactly “replacements”
– “More selective” versions of -59
– Modifier 59 will remain in use when a “more descriptive
modifier” (e.g. –X{EPSU} is not available
• Effective 1/1/15, not required
– CMS encourages “rapid migration” to the new
modifiers
– CMS may selectively require a more specific –
X{EPSU} modifier for codes at high risk of incorrect
billing
– Contractors can required before CMS does
38
Modifiers
• Modifier 59 and 79 are both NCCI associated modifier
(i.e. they override NCCI edits)
• Modifier 79 (along with 76 through 78) also overrides
the multiple procedure reduction
• Failure to properly apply modifiers 76 through 79 (i.e.
using modifier 59 when 76 through 79 would apply)
may result in inappropriate application of the multiple
procedure reduction and significant underpayment
39
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S4-14
Modifiers
Multiple Procedure Reduction
• 100% payment for highest paying procedure with status
indicator “T”
– Generally surgical services requiring anesthesia
• 50% payment for all other status indicator “T” procedures in
the same surgical encounter on the same day
• Surgical procedures performed in separate encounters on
the same day are each eligible for 100% payment
• CMS assumes surgical procedures are performed in the
same encounter (and applies the reduction) unless
modifiers 76-79 are reported
40
Modifiers
Multiple Procedure Reduction
• Modifier 76: Repeat Procedure or Service by the Same
Physician
• Modifier 77: Repeat Procedure by Another Physician
• Modifier 78: Unplanned Return to OR by Same Physician
for a Related Procedure
• Modifier 79: Unrelated Procedure or Service by the Same
Physician During the Postoperative Period
41
Modifiers
Multiple Procedure Reduction
• No modifier for unrelated procedure by a different
physician in postoperative period (i.e. separate
surgical encounter)
– Not needed in physician reporting
– Modifier 79 - “same physician” read as “same facility” when
used for reporting by facility results in correct payment
– Ensure only used when procedures occur in separate
surgical encounters
– See 42 CFR 419.44(a)
42
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S4-15
Modifiers
Financial impact of proper use of modifier 79
• Modifier 79 is sometimes confused with modifier 59
(more commonly used) when NCCI edits apply
– E.g.: Excision of benign lesion from the scalp (> .5 cm)
(11420, $584) in clinic in morning and intermediate
laceration repair of the scalp (>2.5 cm) (12031, $252) in
the ED in the afternoon
– NCCI edit applicable, reported with modifier 59, both
codes paid: $584 + (50% of $252) = $710
– Reported with modifier 79 because separate surgical
encounters, both codes paid: $584 + $252 = $836
43
Modifiers
Financial impact of proper use of modifier 79
• Modifier 79 is commonly missed when no NCCI edits apply
– E.g.: Excision of benign lesion from the scalp (> .5 cm)
(11420, $584) in clinic in morning and unrelated
diagnostic upper GI endoscopy (43235, $623)
– No NCCI edits applicable, reported with no modifiers:
$623 + (50% of $584) = $915
– Reported with modifier 79 because separate surgical
encounters: $623 + $584 = $1207
44
Thank you. Questions?
45
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S5-1
Revenue Cycle Institute
Session 5:
Preparing for 2015’s
CPT Code Changes
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I
CEMC, CCDS
Director of HIM and Coding
HCPro, a division of BLR, Inc.
Learning Objectives
• At the completion of this educational activity, the
learner will be able to:
– Implement relevant changes in their own
practice reflecting revisions to the 2015 CPT
code set
– Apply knowledge regarding the performance of
newly added procedure codes
– Reduce denials by being familiar with new,
revised, and deleted code descriptions
2
Summary of Changes
Additions – 266
Revisions – 128
Deletions – 123
Grand total – 517
– No changes to integumentary or respiratory
sections
3
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S5-2
Evaluation and Management
Additions – 3
Revisions – 2
Deletions – 3
4
Inpatient Neonatal and Pediatric
Critical Care
Pediatric critical care for neonates through age 5
years (99468–99476) are per-day codes based upon
the age of the baby:
•
99468 – Initial neonate critical care, 28 days or younger
•
99469 – Subsequent neonate critical care, 28 days or younger
•
99471 – Initial critical care, 29 days–24 months
•
99472 – Subsequent critical care, 29 days–24 months
•
99475 – Initial critical care, 2–5 years
•
99476 – Subsequent critical care, 2–5 years
Guidelines clarify initial critical care codes can only
be reported once per hospital stay even if patient
regresses back to critical care
5
Total Body and Selective Head
Hypothermia Deletions
Add-on hypothermia codes have been deleted from
the E/M chapter, combined, and moved to the
medicine chapter
+ 99481 Total body systemic hypothermia in a
critically ill neonate per day
+ 99482 Selective head hypothermia in a critically ill
neonate per day
99184 – Initiation of selective head or total body
hypothermia in the critically ill neonate …
You will now find it in the medicine chapter!
6
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S5-3
Care Management Services
Care
Management
Services
Complex
Chronic Care
Mgmt Svcs
99487
Chronic Care
Mgmt Svcs
99489
99490
7
Care Management Services (cont.)
• These are management and support services
provided by clinical staff under the direction of a
physician or NPP
• Reported once per calendar month
• Time may or may not be F2F, but only clinical staff
time is counted
– Clinical staff time spent on the same day as an
E/M may NOT be counted
• Providers must utilize an EHR system
8
Chronic Care Management (CCM)
Services
99490 – Chronic care management services, at least 20
minutes of clinical staff time directed by a physician or
other qualified healthcare professional, per calendar month
with the following required elements:
– Multiple (two or more) chronic conditions expected to last at least 12
months, or until the death of the patient
– Chronic conditions place the patient at significant risk of death,
acute exacerbation/decompensation, or functional decline
– Comprehensive care plan established, implemented, revised, or
monitored
9
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S5-4
CCM Services (cont.)
• Medicare will adopt CPT code 99490 instead of
the initially proposed G code
• The 2015 Physician Fee Schedule rule reflects a
total RVU value:
– Nonfacility = 1.19 RVUs
– Facility = 1.19 RVUs
– This RVU total is comparable to 99212
(established patient office/outpatient visit;
nonfacility total RVU of 1.22)
10
Revised Complex CCM Services
99487 and +99489
• With or without F2F visit is no longer a
consideration in these codes
• For complex CCM code
have:
99487, patient must
– Two or more chronic conditions
– Conditions place the patient at significant risk
– Establishment or substantial revision of comprehensive care plan
– Moderate or high complexity medical decision-making
– 60 minutes of clinical staff time direction by physician or NPP per
calendar month
11
Complex CCM (cont.)
+ 99489 = Complex CCM, each additional 30
minutes
 Must be reported with 99489
 Requires a minimum of 90 minutes of CCM in a
calendar month to report both 99487 and +99489
 Cannot be reported during the same month as
ESRD services, education and training services,
care plan oversight services, transitional care
management services, medication therapy
services, etc.
12
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S5-5
Complex CCM (cont.)
Deleted code 99488 for complex chronic care
coordination, first hour with one F2F visit
 E/M codes are reported separately
13
Advance Care Planning
99497 – Advance care planning including the
explanation and discussion of advance directives
… first 30 minutes, F2F with the patient, family
member(s), and/or surrogate
+99498 – each additional 30 minutes
̶ 99498 must be used with 99497
̶ These codes may be reported on the same day
as an E/M, but NOT with critical care or
intensive care
14
Anesthesia Services
Additions – 0
Revisions – 0
Deletions – 3
15
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S5-6
Deleted Codes
00452 – Anesthesia for clavicle and scapula; radical
00622 – Anesthesia for thoracic spine and cord,
thoracolumbar sympathectomy
00634 – Anesthesia for procedures in lumbar region,
chemonucleolysis
No replacement codes
16
Musculoskeletal Section
Additions – 15
Revisions – 7
Deletions – 11
17
Arthrocentesis
20600 – Arthrocentesis, or inj. small joint or bursa
(e.g., fingers, toes); w/o ultrasound
20604 – with ultrasound
20605 – Arthrocentesis or inj. interm. joint or
bursa (e.g., wrist, elbow); w/o ultrasound
20606 – with ultrasound
20610 – Arthrocentesis or inj. major joint or bursa
(e.g., hip, knee); w/o ultrasound
20611 – with ultrasound
18
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S5-7
Arthrocentesis (cont.)
 Do not report a separate code for ultrasound
(76942) with any of these codes
 If other type of imaging guidance is used, it may be
reported additionally:
̶ Fluoroscopy 77002
̶ CT 77012
̶ MRI 77021
 Do not report
27370 (Inj of contrast for knee
arthrography) with arthrocentesis of major joint
(20610 and 20611)
19
Ablation Therapy
20982 – Ablation therapy for reduction or
eradication of 1 or more bone tumors (e.g.,
metastasis) including adjacent soft tissue when
involved by tumor extension, percutaneous,
including imaging guidance when performed;
radiofrequency
20983 – cryoablation
̶ Do not report ultrasound (76940), fluoroscopy (77002),
CT (77013), or MRI (77022) with these codes
20
Deleted Rib Fracture Codes
21800 – Closed treatment of rib fracture,
uncomplicated
̶ Simply report the appropriate level of E/M
21810 – Treatment of rib fracture requiring external
fixation (flail chest)
̶ Use 21899 – Unlisted procedure, neck or thorax
21
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S5-8
New Rib Fracture Codes
Reported for the open treatment with internal fixation
based upon the number of ribs involved:
21811 – 1–3 ribs
21812 – 4–6 ribs
21813 – 7 or more ribs
Use modifier -50 for bilateral procedures
22
New Subsection: Percutaneous
Vertebroplasty and Vertebral
Augmentation Codes
Vertebroplasty is the process of injecting a material (cement)
into the vertebral body to reinforce the structure using image
guidance
 Deleted codes 22520–22522. Replaced with:
22510 Percutaneous vertebroplasty (bone biopsy included
when performed), 1 vertebral body, unilateral or bilateral
inj, inclusive of imaging; cervicothoracic
22511 – lumbosacral
+22512 – each additional cervicothoracic or lumbosacral
vertebral body
23
Percutaneous Vertebroplasty Codes
(cont.)
22510,
22511, and
+22515
 Do not report a bone biopsy (20225), open
treatment of vertebral fractures (22325 and
22327), or closed treatment of a vertebral body
fracture regardless whether reduced or not (22310
and 22315) with these codes
24
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S5-9
New Vertebral Augmentation Codes
Vertebral augmentation is the process of cavity creation
followed by the injection of the material (cement) under image
guidance
•
Deleted codes 22523–22525. Replaced with:
22513 – Percutaneous vertebral augmentation, including
cavity creation (fracture reduction and biopsy included
when perf’d) using mechanical device, 1 vertebral body,
unilateral or bilateral, inclusive of imaging; thoracic
22514 – lumbar
+22515 each additional thoracic or lumbar vertebral body
25
Vertebral Augmentation Codes (cont.)
22513,
22514, and
+22515
 Do not report a bone biopsy (20225), open
treatment of vertebral fractures (22325 and
22327), or closed treatment of a vertebral body
fracture regardless whether reduced or not (22310
and 22315) with these codes
Same guidelines that we have for
vertebroplasty procedures
26
Sacral Augmentation
For vertebral augmentation at the sacral level, use
Category III codes, which include the creation of the
cavity followed by injection of material to fill the
cavity
0200T – unilateral
0201T – bilateral
27
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S5-10
Total Disc Arthroplasty
28
Changes to Total Disc Arthroplasty
Comma changes to a semicolon!
22856 – Total disc arthroplasty (artificial disc),
anterior approach, including discectomy with end
plate preparation (includes osteophytectomy for
nerve root or spinal cord decompression and
microdissection); single interspace, cervical
+22858 – second level, cervical
29
New Arthrodesis Code for Sacroiliac
Joint
27279 – Arthrodesis, sacroiliac joint,
percutaneous or minimally invasive …include
image guidance, bone grafting when performed
and placement of transfixing device
27280 – Arthrodesis, open, sacroiliac joint,
including bone graft and instrumentation when
performed
 Use modifier -50 on these codes if performed
bilaterally
30
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S5-11
Deletion of Turnbuckle Jacket Cast
Codes
Deleted without replacement:
 29020 – Application of turnbuckle jacket, body;
only
• 29025 – including head
 29715 – Removal turnbuckle jacket
31
Cardiovascular System
Additions – 33
Revisions – 23
Deletions – 6
32
Cardiovascular – ICDs
33270–33273 – Distinction is made between the
two general categories of implantable
defibrillators
– Transvenous implantable pacing cardioverterdefibrillator (ICD)
• Use a combination of anti-tachycardia pacing (or
chronic pacing), low-energy cardioversion to treat Vtach or V-fib
– Subcutaneous implantable pacing cardioverterdefibrillator (S-ICD) – New codes added
• Uses a single subcutaneous electrode to treat
ventricular tachy-arrhythmias
33
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S5-12
Cardiovascular – Transvenous ICDs
Source: Wikipedia Commons; author, Bruce Blaus:
http://en.wikipedia.org/wiki/File:Blausen_0543_ImplantableCardioverterDefibrillator_InsideLeads.png
34
Cardiovascular – Subcutaneous ICDs
33270 – Insertion or replacement of permanent
subcutaneous ICD system, with subcutaneous
electrode
– Includes threshold evaluation,
programming/reprogramming when performed
• Do not report with 93260, 93261, 93644
33271 – Insertion of subcutaneous implantable
defibrillator electrode
– Do not report with 33240, 33262, 33270, 93260,
93261
35
Cardiovascular – ICDs
33272 – Removal of subcutaneous implantable
defibrillator electrode
33273 – Repositioning of previously implanted
subcutaneous defibrillator electrode
– These 4 new codes replaced 0319T–0325T
– Do not report radiological supervision and
interpretation separately from any of the new SICD codes (33270-33273)
36
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S5-13
Cardiovascular – ICD Revisions
• Selected codes within the CPT range of 33215–
33264 were revised by replacing the description of
“pacing cardioverter” to “implantable” to
distinguish:
– Transvenous implantable vs. new codes for
subcutaneous
37
Cardiovascular – TMVR
33418 – Transcatheter mitral valve repair
(TMVR), percutaneous approach, including
transseptal puncture when performed; initial
prosthesis (replaces 0343T)
+33419 – Additional prosthesis(es) during same
session (replaces 0344T)
– Can only be reported once per session
– Procedure is performed to treat mitral
regurgitation, which is the most common heart
valve insufficiency
38
Cardiovascular – TMVR
33418 and 33419 include:
– Percutaneous access
– Placing the access sheath
– Transseptal puncture
– Advancing the repair device into position
– Repositioning the device as needed
– Deploying the device
– Angiography, radiological S&I to guide
placement
39
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S5-14
Cardiovascular – TMVR
40
Cardiovascular – TMVR
• Like many other interventions performed in the
cardiac cath lab, selected codes for diagnostic
catheterizations are typically considered an
integral component and should not be reported
separately
– Exceptions: No prior study available, prior study
is available but is inadequate to visualize
anatomy, patient’s condition has changed,
clinical change during the procedure
• Modifier -59 would need to be appended if reported
separately
41
Cardiovascular – TMVR
• Additional services that CAN be reported
separately:
– Percutaneous coronary interventional
procedures
– Ventricular assist devices
– Balloon pump insertion
– Cardiopulmonary bypass (add-on codes)
42
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S5-15
Cardiovascular – TMVR
• Why repair instead of replace?
– Better long-term outcomes
– Better preservation of heart function
– Lower risk for infection
– Eliminates the need for anticoagulants
43
Cardiovascular – TMVR
• CMS will cover TMVR and released an national
coverage determination (NCD) in August 2014
– www.cms.gov/Medicare/Coverage/Coveragewith-Evidence-Development/TranscatheterMitral-Valve-Repair-TMVR.html
• Transcatheter mitral valve repair via the coronary
sinus remains Category III code 0345T
44
Cardiovascular – ECMO/ECLS
33946–33989 – extracorporeal membrane
oxygenation (ECMO) or extracorporeal life
support services (ECLS)
– Procedure that provides cardiac and/or
respiratory support to the heart and/or lungs
which allows them to rest and recover when sick
or injured
45
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S5-16
Cardiovascular – ECMO
Van Meurs, K, Lally, KP, Peek, G, Zwischenberger, Extracorporeal Life Support Organization, Ann Arbor 2005
46
Cardiovascular – ECMO/ECLS
• Two methods of ECMO/ECLS
– Veno-arterial – placement of two cannula(e),
one in a vein, the other in an artery
• Supports both the heart and lungs
– Veno-venous – placement of 1–2 cannula(e) in
a vein
• Used for lung support only
• New codes represent initiation of ECMO, insertion,
repositioning, and removal of cannula(e)
47
Cardiovascular – ECMO/ECLS
• ECMO/ECLS commonly involve multiple
physicians and nonphysicians to manage the
patient
• Different physicians (usually from different
specialties) may be involved
– For example, one initiates, another manages
– Similarly, one physician may manage conditions that
relate to the ECMO (anticoagulation, complications) and
another manages the patient’s overall condition and
underlying conditions all on a daily basis
48
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S5-17
Cardiovascular – ECMO/ECLS
33946 – Initiation of ECMO/ECLS; veno-venous
33947 – Initiation of ECMO/ECLS; veno-arterial
– Initiation is performed by the physician, which
determines blood flow, gas exchange, and other
necessary parameters
– Cannot be reported on the same day as
repositioning codes
– Do not append modifier -63 even when
applicable
49
Cardiovascular – ECMO/ECLS
33948 – Daily management of ECMO/ECLS; venovenous
33949 – Daily management of ECMO/ECLS; venoarterial
– Requires physician oversight and includes
management of blood flow, oxygenation, CO2
clearance, systemic response, positioning of
cannula(e), etc.
• Cannot be reported on the same day as initiation
services
• Do not append modifier -63 even when applicable
50
Cardiovascular – ECMO/ECLS
33951–33956 – Insertion of peripheral or central (arterial
and/or venous) cannula(e)
33957–33964 – Reposition peripheral or central (arterial
and/or venous) cannula(e)
33965–33986 – Removal of peripheral or central (arterial
and/or venous) cannula(e)
– Differentiated by approach
• Open
• Percutaneous
– Patient’s age
• Birth – 5 years
• 6 years and older
51
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S5-18
Cardiovascular – ECMO/ECLS
• If a physician places a patient on an ECMO/ECLS
circuit, they may report:
– Initiation (33946 or 33947)
– Insertion of cannula(e) (33941–33956)
– Overall patient management (E/M codes such as
observation care, initial hospital care, critical care, etc.)
• Repositioning at the same session as insertion is
not reported separately
– Repositioning includes fluoroscopic guidance when
performed
52
Cardiovascular – ECMO/ECLS
+33987 – Arterial exposure with creation of
graft conduit (e.g. chimney graft) to facilitate
arterial perfusion for ECMO/ECLS
-Use in conjunction with insertion of
cannula(e) codes, if performed
33988 – Insertion of left heart vent by
thoracic incision for ECMO/ECLS
33989 – Removal of left heart vent by
thoracic incision for ECMO/ECLS
53
Cardiovascular – Fenestrated
Endograft Planning
34839 – Physician planning of a patient-specific
fenestrated visceral aortic endograft requiring a
minimum of 90 minutes of physician time
– Reported for planning and sizing of endograft
• Includes: CT, CTA, MRI, 3-D software use
• Do not report with 76376–76377 (3-D rendering)
– Cannot be reported if planning is performed on
the day of or day prior to a fenestrated
endovascular repair procedure (34841–34848)
54
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S5-19
Cardiovascular – Intravascular Stents
37218 – Transcatheter placement of intravascular
stent(s), intrathoracic common carotid artery or
innominate artery, open or percutaneous
antegrade approach
– Includes angioplasty when performed and
radiological S&I
– Code was added to identify open or
percutaneous placement antegrade approach
55
Digestive System
Additions – 24
Revisions – 33
Deletions – 3
56
Digestive – Esophagoscopy
43180 – Esophagoscopy, rigid, transoral with
diverticulectomy of hypopharynx or cervical
esophagus with cricopharygeal myotomy
– Includes use of telescope or operating
microscope and repair, when performed
– For open procedure, see 43130, 43135
57
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S5-20
Digestive – Anatomy
58
Digestive – Endoscopy, Stomal
44381 – Ileoscopy through stoma; with
transendoscopic balloon dilation
– If fluoroscopic guidance is performed, report 74360
– If multiple strictures are dilated during the same session,
report 44381 with modifier -59 for each additional
stricture
44384 – Ileoscopy, through stoma; with
placement of endoscopic stent (includes pre-post
dilation and guide wire passage)
– If fluoroscopic guidance is performed, report 74360
59
Digestive – Endoscopy, Stomal
44401 – Colonoscopy through stoma; with
ablation of tumor(s), polyp(s), or other lesion(s)
(includes pre-post dilation and guide wire
passage)
44402 – Colonoscopy through stoma; with
endoscopic stent placement (includes pre-post
dilation and guide wire passage)
– If fluoroscopic guidance is performed, report
74360
60
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S5-21
Digestive – Endoscopy, Stomal
44403 – Colonoscopy through stoma; with
endoscopic mucosal resection
44404 – Colonoscopy through stoma; with
directed submucosal injection(s), any substance
44405 – Colonoscopy through stoma; with
transendoscopic balloon dilation
– If fluoroscopic guidance is performed, report 74360
– If multiple strictures are dilated during the same session,
report 44381 with modifier -59 for each additional
stricture
61
Digestive – Endoscopy, Stomal
44406 – Colonoscopy through stoma; with
endoscopic ultrasound examination
– Includes all segments and adjacent structures
– Can only be reported one time per session
44407 – Colonoscopy through stoma; with
transendoscopic ultrasound guided intramural or
transmural fine needle aspiration/biopsy(s)
– Includes all segments and adjacent structures
– Can only be reported one time per session
62
Digestive – Endoscopy, Stomal
44408 – Colonoscopy through stoma; with
decompression (for pathologic distention)
including placement of decompression tube
– Treatment for volvulus or megacolon
– Can only be reported one time per session
63
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S5-22
Digestive – Volvulus
Source: HCPro, a division of BLR
64
Digestive – Sigmoidoscopy
45346 – Sigmoidoscopy flexible; with ablation of
tumor(s), polyp(s), or other lesion(s) (includes
pre-post dilation and guide wire passage)
– Do not report with 45340 for balloon dilation if the same
lesion
45347 – Sigmoidoscopy flexible; with placement
of endoscopic stent (includes pre-post dilation
and guide wire passage)
– Do not report with 45340 for balloon dilation
– If fluoroscopic guidance is performed, report 74360
65
Digestive – Sigmoidoscopy
45349 – Sigmoidoscopy flexible; with endoscopic
mucosal resection
– Do not report with 45331 (biopsy), 45335 (mucosal
injections), 45338 (removal by snare), 45350 (with band
ligation) if the same lesion
45350 – Sigmoidoscopy flexible; with band
ligation (e.g., hemorrhoids)
– Do not report with 45344 (control of bleeding), 45349
(mucosal resection), 46221 (hemorrhoidectomy)
– Can only be reported one time per session
66
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S5-23
Digestive – Colonoscopy
45388 – Colonoscopy flexible; with ablation of
tumor(s), polyp(s), or other lesion(s) (includes
pre-post dilation and guide wire passage)
– Do not report with 45386 (balloon dilation) for the same
lesion
45389 – Colonoscopy flexible; with endoscopic
stent placement (includes pre-post dilation and
guide wire passage)
– Do not report with 45386 for balloon dilation
– If fluoroscopic guidance is performed, report 74360
67
Digestive – Colonoscopy
45390 – Colonoscopy flexible; with endoscopic
mucosal resection
– Do not report with 45380 (biopsy), 45381 (mucosal
injections), 45385 (removal by snare), 45398 (with band
ligation) if the same lesion
45393 – Colonoscopy flexible; with
decompression (for pathologic distention)
including placement of decompression tube
– Treatment for volvulus or megacolon
– Can only be reported one time per session
68
Digestive – Colonoscopy
45398 – Colonoscopy flexible; with band ligation
(e.g., hemorrhoids)
– Do not report with 45382 (control of bleeding),
45390 (mucosal resection), 46221
(hemorrhoidectomy)
– Can only be reported one time per session
69
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S5-24
Digestive – Colonoscopy
• Colonoscopy decision tree was added to the CPT
manual
– Clarifies when to report as a sigmoidoscopy vs. a
colonoscopy
– Identifies appropriate modifier usage (-52 vs. -53)
• Please note CPT Errata- Last box bottom row (right)
should not include Modifier-52- should be NO
modifier
Colonoscopy
(45379-45398);
(Modifier 52)
70
Digestive – Colonoscopy
45399 – Unlisted procedure, colon
– Added to distinguish from CPT code 44799
(Unlisted procedure, small intestine)
– Prior code just stated “intestine” generically
71
Digestive – Anoscopy
46601 – Anoscopy; diagnostic, with high
resolution magnification (HRA) and chemical
agent enhancement, including collection of
specimen(s) by brushing/washing
– Includes use of colposcope and operating microscope
46607 – Anoscopy; with high resolution
magnification (HRA) and chemical agent
enhancement, with biopsy, single or multiple
- Replaces Category III codes 0226T-02227T
72
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S5-25
Digestive – Endoscopy
For 2015, CMS established G codes that mirror
the 2014 CPT codes that were deleted for 2015
Please note the reporting of the G codes may
only be limited to Medicare plans so it is always
advisable to check with your payers.
73
Digestive – Endoscopy
Please see Mappings for CY 2015
Handout
If the endoscopy
• Report the CPT
code is
Code (e.g., 45331)
unchanged from
2014-2015
If the endoscopy
code has been • Report the G code
revised/deleted
(e.g., 44383 G6018
from 2014-2015
74
Digestive – Endoscopy
• CMS maintained the work RVUs based on the
2014 values
– Pending decision on removing moderate
sedation from the endoscopy codes
75
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S5-26
Digestive – Endoscopy-Anesthesia
• Effective January 1, 2015 Anesthesia
professionals who furnish separately reportable
anesthesia services in conjunction with a
colorectal cancer screening test should append
modifier-33 (preventive services)
– If the screening test is converted to another
service like a colonoscopy with polyp removal
only report modifier-PT (Colorectal CA
screening test; converted)
76
Digestive – Liver
47383 – Ablation, 1 or more liver tumor(s),
percutaneous, cryoablation
– Imaging guidance use 76940, 77013, 77022
separately
77
Urinary/Genital/Obstetrics
Additions – 2
Revisions – ZERO
Deletions – ZERO
78
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S5-27
Urinary – Cysto
52441 – Cystourethroscopy, with insertion of
permanent adjustable transprostatic implant;
single implant
+52442 – Each additional permanent adjustable
transprostatic implant
– Typically can involve 4–5 implants per patient
79
Urinary – Cysto
80
Urinary – Cysto
• Prior to 2015, this procedure was reported with
unlisted codes
• If the implant is removed, report 52310
• For insertion of a permanent urethral stent, report
52282
• For insertion of temporary prostatic urethral stent,
report 53855
81
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S5-28
Maternity Care/Delivery-Guideline
• Pregnancy confirmation during a problem oriented
or preventive visit is not considered a part of
antepartum care
– Report using appropriate E/M codes for the visit
82
Nervous System
Additions – 8
Revisions – 1
Deletions – 3
83
Nervous – Myelography
62302–62305 – Myelography via lumbar injection,
including radiological S&I
– Distinction is made by area being studied:
• Cervical (62302)
• Thoracic (62303)
• Lumbosacral (62304)
• 2 or more regions (62305)
– Do not report more than one of this series (62302–
62305) – Notice parenthetical notes!
– Created for situations where one provider performs both
the injection and imaging
• Codes include S&I
84
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S5-29
Nervous – Myelography
• Lumbar injection myelography can either be
performed by:
– One provider doing the injection and imaging
(use new CPT codes 62302–62305)
– Two separate providers; one performing the
injection (62284) and another the imaging
(72240, 72255, 72265, 72270)
85
Nervous – TAP Block
64486–64489 – Transversus abdominus plane
(TAP) block (abdominal plane block, rectus
sheath)
– Differentiated by:
• Laterality (unilateral vs. bilateral)
• Administration type (injection(s) vs. continuous
infusions)
– Includes imaging guidance, when performed
– Utilized as a peripheral nerve block to anesthetize the
nerves supplying the anterior abdominal wall (T6-L1)
86
Nervous – TAP Block
87
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S5-30
Eye/Auditory System
Additions – 2
Revisions – 3
Deletions – 4
88
Eye – Aqueous Shunt
66179 – Aqueous shunt to extraocular equatorial
plate reservoir, external approach; without graft
–
66180 – ; with graft
66184 – Revision of aqueous shunt to extraocular
equatorial plate reservoir; without graft
–
66185 – ; with graft
89
Eye – Vitrectomy Codes
• Evaluation of the Vitrectomy codes (67036-67043)
– Physician time has decreased since technology
and techniques have been improved over the
last 20 years
– Many of these codes can expect to see a 7-28%
decrease in Work RVUs in CY 2015 as a result.
90
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S5-31
Radiology
Additions – 15
Revisions – 4
Deletions – 23
91
Radiology – Breast Ultrasound
76641 – Ultrasound, breast, unilateral, real time
with image documentation, including axilla when
performed; complete
– Consists of all 4 quadrants and retroareolar region (and
axilla if performed)
76642 – Ultrasound, breast, unilateral, real time
with image documentation, including axilla when
performed; limited
– Assigned when less than all elements for 76641 are
performed
– Also includes the axilla when performed
92
Radiology – Breast Ultrasound
• The new codes can:
– Only be reported one per breast, per session
– Only be reported with thorough evaluation of the
organ(s)/anatomic regions, with image
documentation and final written report
• Replaces deleted code 76645
93
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S5-32
Radiology – Tomosynthesis
77061–77063 – Digital breast tomosynthesis
(DBT)
Commonly known as “3-D mammography”
– Unilateral (77061)
– Bilateral (77062)
• Do not report with 3D interpretation (76376-76377) or
screening mammography (77057)
– Screening, bilateral (+77063)
• Do not report with 3D interpretation (76376-76377)
diagnostic mammography codes (77055-77056)
94
Radiology – Mammography
• CMS did not valuate the new
tomosynthesis codes (77061-77062)
Procedure
CPT Codes
G codes
Film only
77055-77057
N/A
(2D) Digital, screening
N/A
G0202
(2D) Digital, diagnostic
N/A
G0204 or G0206
(bilateral or unilateral)
(3D) Digital breast
tomosynthesis,unilateral
77061
G0206 and G0279
(3D) Digital breast
tomosynthesis, bilateral
77062
G0204 and G0279
(3D) Screening digital
breast tomosynthesis
+77063
G0202, +77063
(CMS will recognize
when used together)
95
Radiology – Bone Density
77085 – Dual-energy X-ray absorptiometry
(DXA), bone density study, 1 or more sites; axial
skeleton (e.g., hips, pelvis, spine), including
vertebral fracture assessment
– Do not use with 77080, 77086
77086 – Vertebral fracture assessment via dualenergy X-ray absorptiometry (DXA)
– Do not use 77080, 77085
96
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S5-33
Radiology – Isodose Plans
77306–77307 – Teletherapy isodose plan
– Differentiated by complexity (simple vs complex)
– Only one teletherapy isodose plan may be
reported for a given course of therapy to a
specific treatment area
– Cannot be reported with basic dosimetry
calculations (77300)
• Replaces deleted codes 77310–77315
97
Radiology – Isodose Plans
77316–77318 – Brachytherapy isodose plan
– Differentiated by complexity (simple,
intermediate or complex)
– Replaces deleted codes 77326–77328
98
Radiology – IMRT
77385–77386 – Intensity modulated radiation
treatment delivery (IMRT), including guidance and
tracking, when performed
– 77385 – Simple
– 77386 – Complex
• Definitions provided in the guidelines preceding the
section (differ from other delivery definitions)
• For professional services, append modifier -26
• Do not report with stereotactic treatment delivery
(77371–77373)
99
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S5-34
Radiology – IMRT
77387 – Guidance for localization of target
volume for delivery of radiation treatment delivery,
includes intrafraction tracking, when performed
100
Radiology – Radiation Oncology
• Much like the GI endoscopy codes the new and
revised CY 2015 CPT codes for Radiation Therapy
will not be recognized by Medicare.
• G codes were created for the deleted CY 2014
CPT codes (see Mappings Handout)
– Payment amounts and policies will be applicable
to the replacement G codes
101
Radiology – Radiation Oncology
• A new radiation management and treatment
table was added to the CPT manual
– Helpful to identify which codes are considered
professional services vs. technical services
– Also, helpful to identify which services include
either the professional (-26) or technical (-TC)
components of new CPT code 77387
102
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S5-35
Pathology and Laboratory
Additions – 107
Revisions – 32
Deletions – 42
103
Subsections of Drug Procedures
Drug
procedures
Drug assay
80300–83077
Drug Class A
80300–80301
Therapeutic
drug assay
80150–80299
Presumptive
screening
80300–80304
Definitive drug
testing
80320–80377
Drug Class B
80302
Class A or B
80303 – TLC
80304 – NOS,
TOF, MALDI, etc.
Chemistry
82009–84999
104
New Presumptive Drug Screening
Codes
80300 – Drug screen, any number of drug classes from Drug
Class List A; … capable of being read by direct optical
observation, including instrumented-assisted … (e.g., dipsticks,
cups, cards, cartridges), per DOS
80301 – by instrumented test systems (e.g., discrete
multichannel chemistry analyzers …), per DOS
80302 – Drug screen, … single class drug from Drug Class List
B … non-TLC …, each procedure
80303 – Drug screen, any number of classes … TLC, per DOS
80304 – not otherwise specified presumptive procedure (e.g.,
TOF, MALDI, LDTD, DESI, DART), each procedure
105
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S5-36
Definitive Drug Testing
80320 – Alcohols
80332 – Antidepressants, serotonergic;
80321 – Alcohol biomarkers, 1–2
1–2
80322 – 3 or more
80323 – Alkaloids, NOS
80324 – Amphetamines; 1–2
80325 –
3–4
80326 –
5 or more
80331 –
6 or more
80336 –
3–5
80337 –
6 or more
80339 – Antiepileptics, 1–3
80329 – Analgesics, 1–2
3–5
6 or more
80338 – Antidepressants, NOS
3 or more
80330 –
3–5
80334 –
80335 – Antidepressants, tricyclic; 1–2
80327 – Anabolic steroids; 1–2
80328 –
80333 –
80340 –
4–6
80341 –
7 or more
106
Definitive Drug Testing (cont.)
80355 – Gabapentin, non-blood
80342 – Antipsychotics; 1–3
80356 – Heroin metabolite
80343 –
4–6
80344 –
7 or more
80345 – Barbiturates
80357 – Ketamine and
norketamine
80358 – Methadone
80346 – Benzodiazepines; 1–12
80347 –
80359 – Methylenedioxyamphet.
13 or more
80360 – Methylphenidate
80348 – Buprenorphine
80361 – Opiates, 1 or more
80349 – Cannabinoids, natural
80350 – Cannabinoids,
synthetic; 1–3
80351 –
4–6
80352 –
7 or more
80362 – Opioids and opiate
analogs; 1–2
80363 –
3 or 4
80364 –
5 or more
80365 – Oxycodone
80353 – Cocaine
83992 – Phencyclidine (PCP)
80354 – Fentanyl
80366 – Pregabalin
107
Definitive Drug Testing (cont.)
80367 – Propoxyphene
80368 – Sedative hypnotics
80369 – Skeletal muscle
relaxants; 1–2
80370 –
3 or more
80371 – Stimulants, synthetic
80372 – Tapentadol
80374 – Tramadol
80374 – Stereoisomer analysis,
single drug class
80375 – Drug(s), NOS, 1–3
80376 –
4–6
80377 –
7 or more
108
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S5-37
Therapeutic Drug Assays
80162 – Digoxin; total
80163 –
free
80171 – Gabapentin, whole blood, serum, or
plasma
80164 – Valproic acid (dipropylacetic acid); total
80165 –
free
80299 – Quantitation of therapeutic drug, not
elsewhere specified
109
Tier 1 Molecular Pathology
Procedures
Comma changes to a semicolon
81245 – FLT3 (fms-related tyrosine kinase 3)
(e.g., acute myeloid leukemia), gene analysis;
internal tandem duplication (ITD) variants (i.e.,
exons 14, 15)
81246 – tyrosine kinase domain (TKD) variants
(e.g., D835, I836)
110
Tier 1 Molecular Pathology
Procedures (cont.)
81288 – MLH1 (mutL homolog 1, colon cancer,
nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome)
gene analysis; promoter methylation analysis
81313 – PCA3/KLK3 (prostate cancer antigen 3
[non-protein coding]/kallikrein-related peptidase 3
[prostate specific antigen]) ratio (e.g., prostate
cancer)
111
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S5-38
Tier 2 Molecular Pathology
Procedures
81402 – Level 3
81403 – Level 4
81404 – Level 5
81405 – Level 6
112
Genomic Sequencing and Other
Molecular Multianalyte Assays
113
Genomic Sequencing and Other
Molecular Multianalyte Assays (cont.)
81410 – Aortic dysfunction
81435 – Hereditary colon cancer
81411 –
81436 –
dup/del analysis
81415 – Exome
+81416 –
exome
81417 –
each comparator
re-evaluation
81420 – Fetal chromosomal
aneuploidy (e.g., trisomy 21)
81425 – Genome
+81426 –
each comparator
81427 –
re-evaluation
81430 – Hearing loss
81431 –
dup/del
dup/del
81440 – Nuclear mitochondrial
81445 – Solid organ neoplasm
81450 – Hematolymphoid
neoplasm
81455 – Solid organ or
hematolymphoid neoplasm
81460 – Whole mitochondrial
genome
81465 – Mitochondrial deletion
analysis
81470 – X-linked intellectual
disability
81471 –
dup/del
114
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S5-39
Multianalyte Assays With
Algorithmic Analyses (MAAAs)
81519 – Oncology (breast), mRNA, gene
expression profiling by real-time RT-PCR of 21
genes, utilizing formalin-fixed paraffin embedded
tissue, algorithm reported as recurrence score
115
Chemistry
82541 – Column chromatography/mass
spectrometry (e.g. GC/MS, or HPLC/MS), nondrug analyte not elsewhere specified; qualitative,
single stationary and mobile phase
82542 –
quantitative
82543 –
stable isotope dilution, single analyte
82544 –
analytes
stable isotope dilution, multiple
 For drug tests, go to the appropriate code
116
Chemistry (cont.)
83006 – Growth stimulation expressed gene 2
(ST2. Interleukin 1 receptor like-1)
84600 – Volatiles (e.g., acetic anhydride,
diethlether
 Parenthetical remark now directs coder to other
codes for different volatiles that used to be part of
this code
117
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S5-40
Transfusion Medicine
86900 – Blood typing; serologic; ABO
86901 – Rh (D)
86902 – antigen testing of donor blood
86904 – antigen screening for compatible unit
86905 – RBC antigens, other than ABO or Rh
(D), each
86906 – Rh phenotyping, complete
118
Microbiology
87501 – Infectious agent
detection by DNA or RNA; influenza
virus includes reverse transcription,
when performed, and amplified
probe technique, each type or
subtype
87502 – influenza virus, for
multiple types or sub-types,
includes multiplex reverse
transcription and multiplex amplified
probe technique, first 2 types or
sub-types
+87503 – influenza virus, for
multiple types or sub-types,
includes multiplex reverse
transcription and multiplex amplified
probe technique, each additional
influenza virus type or sub-type
beyond 2
87505 – gastrointestinal
pathogen…, 3–5 targets
87506 –
6–11 targets
87507 –
12–25 targets
87623 – Human
Papillomavirus (HPV), low risk
87624 –
HPV, high risk
87625 – HPV, types 18 and
18, includes 45 if performed
87631 –
3–5 targets
respiratory virus,
87632 –
6–11 targets
87633 –
12–25 targets
87806 – HIV-1 antigens
119
Surgical Pathology
88342 –
Immunohistochemistry or
immunocytochemistry, per
specimen; initial single antibody
stain procedure
+88341 – each additional single
antibody stain procedure
88344 – each multiplex antibody
stain procedure
88360 – Morphometric analysis,
tumor immunohistochemistry, per
specimen
88361 – using computer
assisted technology
88365 – In situ hybridization, per
specimen
+88364 – each additional single
probe stain procedure
88366 – each multiplex probe
stain procedure
88367 – Morphometric analysis,
using computer assisted
technology, per specimen
+88373 – each additional probe
stain procedure
88374 – each multiplex probe
stain procedure
88368 – Morphometric analysis,
in situ, manual, per specimen
+88369 – each additional single
probe stain procedure
88377 – each multiplex probe
stain procedure
120
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S5-41
Reproductive Medicine Procedure
89337 – Cryopreservation, mature oocyte(s)
0357T – Cryopreservation, immature oocyte[s]
121
Medicine Chapter
Additions – 15
Revisions – 16
Deletions – 0
122
Vaccines, Toxoids
90651 – Human Papillomavirus vaccine
90654 – Influenza virus, trivalent
90630 – Influenza virus, quadrivalent
90721 – Diphtheria, tetanus, and acellular
pertussis and H. influenza B (DtaP/Hib)
90723 – Diphtheria, tetanus, acellular pertussis,
hepatitis B and poliovirus
90734 – Meningococcal conjugate vaccine,
quadrivalent
123
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S5-42
Gastroenterology
91200 – Liver elastography, mechanically
induced shear wave (e.g., vibration), without
imaging, with interpretation and report
 Nice alternative to an invasive liver biopsy
procedure
124
Special Ophthalmological Services
92145 – Corneal hysteresis determination, by air
impulse stimulation, unilateral or bilateral, with
interpretation and report
125
Implantable and Wearable Cardiac
Device Evaluations
93282 – Programming device
eval (in person) … single lead
transvenous implantable
defibrillator system
93283 – dual lead transvenous
implantable defibrillator system
93284 – multiple lead
transvenous implantable defib
93260 – implantable
subcutaneous lead defibrillator
system
93261 – implantable SC lead
93295 – Interrogation device
eval(s) (remote), up to 90 days;
single, dual, or multiple lead
implantable defib system … by a
physician or other qualified health
care professional
93296 – single, dual, or multiple
lead pacemaker system or
implantable defib system …
technician review
93287 – Peri-procedural device
eval (in person) before or after
surgery … single, dual, or multiple
lead implantable defib system
93289 – Interrogation device
eval (in person) … single, dual, or
multiple lead TV implantable defib
126
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S5-43
Echocardiography
93355 – Echocardiography, transesophageal (TEE) for
guidance of a transcatheter intracardiac or great vessel(s)
structural inventions(s) … real-time image acquisition and
documentation, … probe manipulation, interp and report,
including diagnostic TEE and when performed,
administration of ultrasound contrast, Doppler, color flow,
and 3-D
 For placement of the probe, use 93313
 Imaging, diagnostic TEE, and Doppler studies are included
127
Intracardiac Electrophysiological
Studies (EPS)
93642 – Electrophysiological eval of single or dual
chamber transvenous pacing cardioverterdefibrillator …
93644 – Electrophysiological eval of
subcutaneous implantable defibrillator …
Not to be reported at the time of insertion of the
system ( 33270)
128
Noninvasive Physiologic Studies
93702 – Bioimpedance spectroscopy (BIS),
extracellular fluid analysis for lymphedema
assessment(s)
– For bioelectrical impedance analysis of whole
body composition, use 0358T
129
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S5-44
Cerebrovascular Arterial Studies
93895 – Quantitative carotid intima media
thickness and carotid atheroma evaluation,
bilateral
– Includes the acquisition and storage of images
bilaterally with quantification of intima media
thickness and determination of presence of
atherosclerotic plaque
130
Neurostimulators, Analysis –
Programming
95972 – Electronic analysis of implanted
neurostimulator pulse generator system; complex
spinal cord, or peripheral … with intraoperative
programming, up to 1 hour
131
Central Nervous System
Assessments/Tests
96110 – Developmental screening (e.g.,
developmental milestone survey, speech and
language delay screen), with scoring and
documentation, per standardized instrument
96127 – Brief emotional/behavioral assessment
(e.g., depression inventory, attentiondeficit/hyperactivity disorder, [ADHD] scale), with
scoring and documentation, per standardized
instrument
132
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S5-45
Active Wound Care Management
97605 – Negative pressure wound therapy …
utilizing DME, including topical applications … per
session; … less than or equal to 50 square
centimeters
97606 – greater than 50 sq. centimeters
97607 – Negative pressure wound therapy …
utilizing disposable, non-durable medical
equipment … less than or equal to 50 sq.
centimeters
97608 – greater than 50 sq. centimeters
133
Other Services and Procedures
99188 – Application of topical fluoride varnish by a
physician or other qualified health care
professional
134
Category II
Additions – 3
Revisions – 1
Deletions – 1
135
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S5-46
Category II
3126F – Esophageal biopsy report with a
statement about dysplasia (present, absent, or
indefinite and if present contains appropriate
grading)
– Replaces deleted code 3125F
– Now includes appropriate grading
3775F–3776F – Adenoma or other neoplasm
– 3775F – Detected during screening colonoscopy
– 3776F – Not detected during screening colonoscopy
136
Category III
Additions – 39
Revisions – 6
Deletions – 24
137
Category III
0345T – Transcatheter mitral valve repair
percutaneous approach via the coronary sinus
– Do not report with diagnostic caths
+0346T – Ultrasound, elastography
– Can be used in conjunction with a number of
ultrasound codes – see parenthetical note
138
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S5-47
Category III
0347T – Placement of interstitial device(s) in bone
for radiostereometric analysis (RSA)
0348T-0350T – Radiologic examination,
radiostereometric analysis
– Differentiated by site
• 0348T – Spine (cervical, thoracic, lumbosacral)
• 0349T – Upper extremities (shoulder, elbow, wrist)
• 0350T – Lower extremities (hip, proximal femur, knee
and ankle)
139
Category III
0351T–0352T – Optical coherence tomography of breast or
axillary lymph nodes, excised tissue each specimen
– 0351T (real time intraoperative)
– 0352T (interpretation and report, real-time or referred)
• Do not report the two codes in conjunction with each if performed by
the same physician
0353T–0354T – Optical coherence tomography of breast,
surgical cavity
– 0353T (real time intraoperative)
– 0354T (interpretation and report, real-time or referred)
140
Category III
0355T – Gastrointestinal tract imaging,
intraluminal (e.g., capsule endoscopy), colon, with
interpretation and report
– Can also be used for imaging of the distal ileum
0356T – Insertion of drug-eluting implant
(including dilation and implant removal when
performed) into lacrimal canaliculus, each
141
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S5-48
Category III
0359T–0363T – Adaptive behavior assessments
0364T–0372T – Adaptive behavior treatment
0373T–0374T – Exposure adaptive behavior
treatment with protocol modifications
142
Category III
0359TAssessment
“Gateway Code”
0360T-0363T
F/U
Assessment
Designed to fine tune the
baseline results and
develop plan of care
Reported once within a
defined treatment period (6
mth-1 yr)
0364T-0374T
Treatment
Protocol Modification
(F2F); Time Based
Group Adaptive (F2F);
Time Based
Family (F2F w/
guardian/caregiver)
F2F; Time Based Codes
Multiple Family Group
(F2Fw/ guardian/caregiver
Untimed code
Reported by a single
MD/QHP
Subcategorized:
- Observation
- Exposure
Social Skills Group (F2F)
Exposure Adaptive (F2F)
143
Sources
• 2015 AMA’s CPT Manual, Professional Edition
• 2015 AMA’s CPT Symposium (Nov 19-21, 2014)
• 2015 AMA’s CPT Changes: An Insider’s View
• 2015 MPFS Final Rule
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/index.html?redirect=/physicia
nfeesched/
• 2015 HCPCS II file
http://www.cms.gov/Medicare/Coding/HCPCSReleaseCode
Sets/Alpha-Numeric-HCPCS.html
144
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S5-49
Thank you. Questions?
145
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S5-50
2014 CPT Code Endoscopy Mappings for CY 2015 2015 CPT Code Description G Code Ileoscopy
44383 44384 Ileoscopy, through stoma with endoscopic stent placement G6018 Colonoscopy through Stoma
44393 44401 44397 44402 45339 45346 45345 45347 Colonoscopy, through stoma with ablation tumor(s) Colonoscopy, through stoma with endoscopic stent placement G6019 G6020 Sigmoidoscopy Sigmoidoscopy, flexible G6022 with ablation of tumor(s) Sigmoidoscopy, flexible G6023 with endoscopic stent placement Colonoscopy 45383 45388 45387 45389 Colonoscopy, flexible with ablation of tumor(s) Colonoscopy, flexible with endoscopic stent placement G6024 G6025 Anoscopy 0226T 46601 0227T 46607 Anoscopy, high resolution; diagnostic, incl collection of specimen(s) Anoscopy, high resolution; with biopsy(ies) G6027 G6028 Unlisted Procedure 44799 44799 45399 45399 Unlisted procedure, small intestine Unlisted procedure, colon G6021 G6021 **Per CY 2015 Final Rule, page 67665‐67667** Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S5-51
2015 Endoscopy Crosswalk (w/ no G code) New 2015 CPT Code 44381 44403 44404 44405 44406 44407 44408 45349 45350 45390 45393 45398 Description Ileoscopy through stoma; with dilation Colonoscopy through stoma; with EMR Colonoscopy through stoma; with submucosal injection Colonoscopy through stoma; with dilation Colonoscopy through stoma; with endoscopic ultrasound (EUS) Colonoscopy through stoma; with needle aspiration and/or biopsy(ies) with EUS Colonoscopy through stoma; with decompression, inc tube Sigmoidoscopy; w/EMR Sigmoidoscopy; w/band ligation Colonoscopy; with EMR Colonoscopy; w/decompression Colonoscopy; w/band ligation CMS CY 2015 Crosswalk 44380, 44799** 44388, 44799** 44388, 44799** 44388, 44799** 44388, 44799** 44388, 44799** 44388, 44799** 45330, 44799** 45330, 44799** 45378, 44799** 45378, 44799** 45378, 44799** **Please note: The 2014 description of 44799 (Unlisted procedure, intestine) has been revised in 2015 to state (Unlisted procedure, SMALL intestine) and a new CPT code was created 45399 (Unlisted procedure, colon). CMS is using the 2014 description of 44799 in their above crosswalk since they do not recognize the 2015 new GI codes. **Per CY 2015 Final Rule, page 67665‐67667** Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S5-52
New 2015 Radiation Therapy G Codes 2014 CPT Code 76950 77421 77402 77403 77404 77406 77407 77408 77409 77411 77412 77413 77414 77416 77418 0073T 0197T Description U/S guidance for place of rad tx fields Stereoscopic X‐ray guidance for local target volume for deliv rad tx Rad tx delivery, single treatment area….up to 5 MeV Rad tx delivery, single treatment area….6‐10 MeV Rad tx delivery, single treatment area….11‐19 MeV Rad tx delivery, single treatment area….20+ MeV Rad tx delivery, two separate treatment areas.….up to 5 MeV Rad tx delivery, two separate treatment areas.…6‐10 MeV Rad tx delivery, two separate treatment areas.….11‐19 MeV Rad tx delivery, two separate treatment areas.….20+ MeV Rad tx delivery, 3 or more separate treatment areas.….up to 5 MeV Rad tx delivery, 3 or more separate treatment areas.….6‐
10 MeV Rad tx delivery, 3 or more separate treatment areas.….11‐
19 MeV Rad tx delivery, 3 or more separate treatment areas.….20+ MeV IMRT, single or multiple fields..per tx session Compensator‐based beam modulation..per tx session Intra‐fraction localization and tracking of target/patient motion, each fraction of tx New G codes G6001 G6002 G6003 G6004 G6005 G6006 G6007 G6008 G6009 G6010 G6011 G6012 G6013 G6014 G6015 G6016 G6017 **Per CY 2015 Final Rule, page 67665‐67667** Copyright 2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without the express
written permission of HCPro. No claim asserted to any U.S. Government or American Medical Association works.
S6-1
Revenue Cycle Institute
Session 6:
Supplies, Drugs and Drug
Administration
Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS
President/CEO and Principal Consultant
SLG, Inc. Consulting
Disclaimer
• Every reasonable effort has been taken to ensure
that the educational information provided in today’s
presentation is accurate and useful. Applying best
practice solutions and achieving results will vary in
each hospital/facility situation.
2
Agenda
• Drug Administration
– Supervision of outpatient therapeutic services
– Infusion/injection hierarchy
– Hydration therapy vs. diagnostic/therapeutic
infusions
• Pharmaceuticals
– Pass-through vs. Nonpass-through drugs
– Self-administered drugs
• Supplies
• Discussion
3
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S6-2
Learning Objectives
• Participant will receive a refresher on reporting
related drug administration charges and the
current supervision rules for outpatient therapeutic
services.
• Participant will understand how to handle supplies
and drugs in the CDM.
• Participant will “take away” some tips on identifying
routine vs. nonroutine supplies.
4
Supervision
• Advisory Panel on Hospital Outpatient Payment
– The independent technical review process for
assigning supervision levels to hospital outpatient
therapeutic services began in 2012 and was
spearheaded by the existing APC Advisory Panel,
which was expanded to include CAH and small
rural hospital representatives.
– Now referred to as the Advisory Panel on Hospital
Outpatient Payment (also known as the HOP
Panel or the Panel), panel members are full-time
employees of hospitals, hospital systems, or other
Medicare providers.
5
Supervision
• Advisory Panel on Hospital Outpatient Payment
(continued)
– As a result of Panel efforts, CMS has reduced the
level of supervision for 56 outpatient therapeutic
services since 2012.
– On July 1, 2014, the level of supervision was
changed to “general” for the following two codes
that will be covered in this presentation:
• 36430 (Transfusion, blood or blood components)
• 96370 (Subcutaneous infusion for therapy or prophylaxis
(specify substance or drug); each additional hour)
6
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S6-3
Supervision
• Advisory Panel on Hospital Outpatient Payment
(continued)
– The panel is still weighing in on whether eight codes for
the administration of Chemotherapy, complex drugs and
biologic agents be changed from direct to general
supervision: 96401, 96402, 96409, 96411, 96413,
96415, 96416, and 96417.
– Additional information can be found on the HOP Panel
section of the CMS website:
http://www.cms.gov/Regulations-and-Guidance/Guidance/
FACA/AdvisoryPanelonAmbulatoryPaymentClassificationGroups.html
7
Infusion/Injection Hierarchy
• Understanding the ‘hierarchical’ nature of infusion
and injection services, including Chemotherapy, is
a must. The hierarchy for selecting the ‘initial’
service in the facility setting is:
– Chemo initiation of prolonged infusion (greater than eight
hours, requiring pump)
– Chemo infusions
– Chemo injections
– Non-Chemo, initiation of prolonged infusion (greater than
eight hours, requiring pump)
– Non-Chemo, diagnostic/therapeutic infusions
– Non-Chemo, diagnostic/therapeutic injections
– Hydration infusions
8
Infusion/Injection Hierarchy
• Non-chemo Hierarchy
– Highest circle = initial
code
Prolonged
Dx/Tx
pump
infusion
Dx/Tx
infusion(
s)
Dx/Tx
injection(s)
Hydration
infusion(s)
9
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S6-4
Infusion/Injection Hierarchy
• This hierarchy is contrary to the reporting methodology
for the physician office setting where the ‘initial’ code
that best describes the key or primary reason for the
encounter would be reported regardless of the order in
which the infusions or injections occur.
• The facility drug hierarchy rules should not be reset for
outpatient encounters continuing past midnight.
“Multiple initial services should not be reported for a
single encounter, even if the encounter crosses dates
of service. Do not ‘reset’ the initial definition each
calendar day” (CMS Open Door Forum, January
2007).
10
Hydration vs. Dx/Tx
• General Infusion/Injection Facts
– Reporting of infusion and injection services has
changed dramatically over the past several
years and continues to pose challenges to
appropriate charge capture.
– Each set has an initial 1st hour and additional
hour code; however, the infusion must be
medically necessary and last at least 16 minutes
(Dx/Tx) or 31 minutes (hydration) in order for the
1st hour to be billed.
11
Hydration vs. Dx/Tx
• General Infusion/Injection Facts (continued)
– Infusions started via ambulance may be billed
separately when properly documented,
including the first hour received at the hospital
and subsequent hours as necessary (CMS
Transmittal 785, December 16, 2005).
12
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S6-5
Hydration vs. Dx/Tx
• General Infusion/Injection Facts (continued)
– The key to proper reporting of infusion/injection
services is documentation of start and stop
times, not simply the infusion flow rate.
– In addition, the name and dosage of each
substance, the route of administration, and the
vascular access site location are paramount to
appropriate coding and reimbursement.
– A MAR may be utilized as long as it contains
all of the above elements and is retained in the
chart for audit purposes.
13
Hydration vs. Dx/Tx
• General Infusion/Injection Facts (continued)
– If performed to facilitate the infusion or injection,
the following services are included and are not
separately reportable/billable, even if
provided/performed by other departments or staff:
• Use of local anesthesia
• IV start
• Access to indwelling IV, subcutaneous catheter, or port
• Flush at conclusion of infusion
• Routine supplies such as tubing or syringes
14
Hydration vs. Dx/Tx
• General Infusion/Injection Facts (continued)
– If the sole reason for an outpatient encounter/visit
is for infusion/injection services, an E/M service,
such as 99211, should not customarily be charged
in addition, even if nursing triages the patient
and/or spends extensive time in providing
education or counseling services.
– Since almost all infusion/injection services have a
status indicator of “S” under the OPPS, if a
separately identifiable E/M service is provided,
append modifier 25 to the E/M for Medicare and
other payers as appropriate.
15
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S6-6
Hydration vs. Dx/Tx
HCPCS‐CPT Description APC‐
APC‐
Number APC‐Status Weight APC‐Rate 96360
Hydration iv infusion init
0438
S
1.4593
96361
Hydrate iv infusion add‐on
0436
S
0.4393
$32.57
96365
Ther/proph/diag iv inf init
0439
S
2.3404
$173.53
96366
Ther/proph/diag iv inf addon
0436
96367
Tx/proph/dg addl seq iv inf
0437
96368
Ther/diag concurrent inf
96369
$108.20
S
0.4393
$32.57
S
0.7218
$53.52
S
2.3404
$173.53
S
0.7218
$53.52
N
Sc ther infusion up to 1 hr
0439
96370
Sc ther infusion addl hr
0437
96371
Sc ther infusion reset pump
96372
Ther/proph/diag inj sc/im
0437
S
0.7218
$53.52
96373
Ther/proph/diag inj ia
0438
S
1.4593
$108.20
96374
Ther/proph/diag inj iv push
0438
S
1.4593
$108.20
0436
S
0.4393
$32.57
0.4393
$32.57
96375
Tx/pro/dx inj new drug addon
96376
Tx/pro/dx inj same drug adon
96379
Ther/prop/diag inj/inf proc
N
N
0436
S
Source: CMS Addendum B, effective January 1, 2015
16
Hydration vs. Dx/Tx
• General Infusion/Injection Facts (continued)
– Always report the corresponding drug(s) or
fluid(s) in addition to the infusion/injection
services utilizing the applicable HCPCS code
and/or revenue code, as most payer systems
edit for this.
17
Hydration vs. Dx/Tx
• General Infusion/Injection Facts (continued)
– Modifiers such as 59 or one of the new X{EPSU} modifiers
should only be used for infusion/ injection services when:
• The drug administration occurs during a distinct encounter on the
same date of service of previous drug administration services.
• The same HCPCS code has already been billed for services
provided during a separate and distinct encounter earlier on that
same day.
• A distinct and separate drug administration service is provided on
the same day as a procedure when there is an OPPS NCCI edit for
the drug administration service and procedure code pair that may
be bypassed with a modifier, and the use of the modifier is clinically
appropriate.
18
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S6-7
Hydration vs. Dx/Tx
• General Infusion/Injection Facts (continued)
– Modifier 59 should not be used when a
beneficiary receives infusion therapy at more
than one vascular access site of the same type
(intravenous or intra-arterial) during the same
encounter or when an infusion is stopped and
then started again in the same encounter (CMS
Transmittal 902, April 7, 2006).
19
Hydration vs. Dx/Tx
• Hydration
– Hydration infusions, i.e., those consisting of prepackaged fluid and electrolytes, have been
differentiated from therapeutic, prophylactic and
diagnostic ones.
– Hydration infusions lasting less than 31 minutes
and/or considered an inherent component of
other procedure or service, i.e., KVO in the ED
or to facilitate a trip to the OR, are not
separately billable.
20
Hydration vs. Dx/Tx
• Diagnostic/Therapeutic (Dx/Tx) – Infusion
– A therapeutic, prophylactic, or diagnostic IV
infusion or injection is for the administration of
medicated substances/drugs. When fluids are
used to administer such Dx/Tx medications, the
administration of the fluid is considered incidental
hydration and is not separately reportable.
– When appropriately documented and allowable
under payer guidelines, a Dx/Tx infusion lasting
less than 16 minutes may be coded as an
intravenous push injection.
21
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S6-8
Hydration vs. Dx/Tx
• Diagnostic/Therapeutic (Dx/Tx) – Infusion
– Sequential infusions of a different drug or
substance may be reported a maximum of one
time per infusate mix and may be added-on to
Dx/Tx or chemotherapy infusions as well as initial
IV push injections.
– A concurrent infusion may be charged when two
drugs are infused simultaneously, but hung in two
separate bags. The quantity reported should
never exceed one per outpatient encounter/visit
and may be added-on to Dx/Tx or chemotherapy
infusions.
22
Hydration vs. Dx/Tx
• Diagnostic/Therapeutic (Dx/Tx) – Infusion
– Subcutaneous pump infusions may be reported when
appropriate with codes 96369-96371. Such infusions
lasting 15 minutes or less may be reported with code
96372. Note that the ‘subcutaneous’ pump codes
should not be used for infusions via ‘IV’ pump. There
are no specific IV pump codes except for C8957
[Intravenous infusion for therapy/diagnosis; initiation of
prolonged infusion (more than 8 hours), requiring use of
portable or implantable pump] which may be utilized for
IV pump infusions lasting eight hours or more. HCPCS
C8957 is payable under Medicare OPPS.
23
Hydration vs. Dx/Tx
• Diagnostic/Therapeutic (Dx/Tx) – Infusion
– When infusing blood or blood products, do not
report the timed infusion codes in the 9636596368 range. Transfusions should be reported
utilizing code 36430 (Transfusion, blood or
blood components). Note that this code does
not have a time element and may be reported
only once per date of service/encounter.
24
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S6-9
Hydration vs. Dx/Tx
• Diagnostic/Therapeutic (Dx/Tx) – IV Push
– An IV or intra-arterial push is an injection in
which the individual administering the
substance/drug is continuously present to
manage the injection and observe the patient or
an infusion of 15 minutes or less.
25
Hydration vs. Dx/Tx
• Diagnostic/Therapeutic (Dx/Tx) – IV Push
– IV push injections have been differentiated
with single/initial and additional sequential
codes.
– For IV push of the same medication, report
code 96376. Note that this code applies only
to facilities and at least 30 minutes must
elapse between injections.
26
Hydration vs. Dx/Tx
• Diagnostic/Therapeutic (Dx/Tx) – IM/SQ
– Therapeutic, prophylactic, or diagnostic
injections provided subcutaneously or
intramuscularly may be reported with code
96372. Note that this code should not be used
to report the administration of vaccines/toxoids.
Codes 90465-90472 should be used to report
IM/SQ immunization administration.
27
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S6-10
Coding Examples
• Scenario 1
– Question: A patient was given an IV infusion in
one bag of two different substances. A second
bag of a third therapeutic substance was
piggybacked on the same line at the same time.
The infusions ran for 62 minutes. What code(s)
should be reported?
28
Coding Examples
• Scenario 1
– Answer: Assign code 96365 (for the first bag
with the two substances) and 96368 (for the
concurrent infusion of a different substance).
Reasoning: Since the codes are intended to measure
work associated with separate administration access
and not the number of substances, the bag containing
two drugs counts as the first hour.
29
Coding Examples
• Scenario 2
– Question: A patient presented to the ED for
treatment of acute pain. The patient was
administered Ketorolac Tromethamine 30 mg
via IV push. A second dosage of 15 mg was
administered because the pain continued, but
the time of the second administration was not
clear in the nursing notes. What code(s) should
be reported?
30
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S6-11
Coding Examples
• Scenario 2
– Answer: Only one unit of code 96374 may be
reported.
Reasoning: Documentation of administration time is
critical to the reporting of IV push injections as a second
administration code for the same drug (96376) may only
be reported if at least 31 minutes have lapsed between
doses. In this instance, the time lapse is unknown.
31
Pharmaceuticals
• When it comes to reporting pharmaceuticals, areas
requiring particular attention include:
– Units of Service
• HCPCS code description vs. manufacturer dose
• Single Dose Vials (SDVs) vs. Multi-Dose Vials
(MDVs)
• Wastage documentation (modifier JW, if required)
– Accuracy of NDC data
• How often updated
• Where stored in system
32
Pass-Through Drugs
• Pass-through Drugs
– Certain drugs are granted “transitional passthrough” status for two, but no more than three
years. These drugs are paid for separately
under the OPPS.
– Pass-through drugs are assigned to a status
indicator (SI) of “G”* in Addendum B.
– For 2015, 35 drugs have been assigned to this
category.
* An excerpt from Addendum B of SI=G drugs appears on the next slide.
33
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S6-12
Pass-Through Drugs
HCPCS
Code
Short Descriptor
A9520
A9586
C9025
C9026
C9027
C9132
C9136
Tc99 tilmanocept diag 0.5mci
Florbetapir f18
Injection, ramucirumab
Injection, vedolizumab
Injection, pembrolizumab
Kcentra, per i.u.
Factor viii (eloctate)
C9349
C9442
C9443
C9444
C9446
C9447
Fortaderm, fortaderm antimic
Injection, belinostat
Injection, dalbavancin
Injection, oritavancin
Inj, tedizolid phosphate
Inj, phenylephrine ketorolac
C9497
J1322
J1439
J1446
CI
SI APC
Relative
Weight
Payment
Rate
Minimum
Unadjusted
Copayment
National
Unadjusted
Copayment
NI
G
G
G
G
G
G
G
1463
1664
1488
1489
1490
9132
1656
$240.00
$2,756.00
$54.06
$17.03
$45.75
$1.39
$2.10
$0.00
$0.00
.
.
.
.
.
$0.00
$0.00
$10.82
$3.41
$9.15
$0.28
$0.42
NI
NI
NI
NI
NI
NI
G
G
G
G
G
G
1657
1658
1659
1660
1662
1663
$109.18
$31.80
$31.59
$25.62
$1.25
$418.70
$0.00
.
.
.
.
.
$0.00
$6.36
$6.32
$5.13
$0.25
$83.74
Loxapine, inhalation powder
Elosulfase alfa, injection
NI
G 9497
G 1480
$153.70
$222.13
.
.
$30.74
$44.43
Inj ferric carboxymaltos 1mg
Inj, tbo-filgrastim, 5 mcg
NI G 9441
CH G 1477
$1.05
$3.99
.
.
$0.21
$0.80
CH
NI
NI
NI
Source: CMS Addendum B, effective January 1, 2015
34
Nonpass-Through Drugs
• Nonpass-through Drugs
– Nonimplantable biologicals as well as therapeutic
radiopharmaceuticals are included in the nonpassthrough drugs category. For 2015, CMS will
continue paying average sales price (ASP) + 6
percent for nonpass-through drugs and biologicals
that are payable separately under the OPPS.
– Nonpass-through drugs are assigned to an SI of
“K”* in Addendum B.
– For 2015, 289 drugs have been assigned to this
category.
* An excerpt from Addendum B of SI=K drugs appears on the next slide.
35
Nonpass-Through Drugs
HCPCS
Code
Short Descriptor
90676 Rabies vaccine id
90733
90735
A9517
A9530
A9543
A9563
A9564
A9600
A9604
A9606
C9121
C9248
C9257
C9293
J0120
J0129
Meningococcal vaccine sc
Encephalitis vaccine sc
I131 iodide cap, rx
I131 iodide sol, rx
Y90 ibritumomab, rx
P32 na phosphate
P32 chromic phosphate
Sr89 strontium
Sm 153 lexidronam
Radium ra223 dichloride
ther
Injection, argatroban
Inj, clevidipine butyrate
Bevacizumab injection
Injection, glucarpidase
Tetracyclin injection
Abatacept injection
Minimum
National
Relative
Unadjusted Unadjusted
CI SI APC Weight Payment Rate Copayment Copayment
K 9140
$172.30
.
$34.46
K
K
K
K
K
K
K
K
K
9143
9144
1064
1150
1643
1675
1676
0701
1295
$106.49
$108.29
$17.29
$10.28
$16,966.82
$213.56
$906.62
$1,345.01
$3,294.58
.
.
.
.
.
.
.
.
.
$21.30
$21.66
$3.46
$2.06
$3,393.37
$42.72
$181.33
$269.01
$658.92
NI K
K
CH K
K
CH K
CH K
K
1745
9121
9248
1281
9293
1666
9230
$120.65
$21.13
$4.22
$6.96
$223.85
$97.97
$32.25
.
.
.
.
.
.
.
$24.13
$4.23
$0.85
$1.40
$44.77
$19.60
$6.45
Source: CMS Addendum B, effective January 1, 2015
36
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S6-13
Self-Administered Drugs
• Self-administered Drugs (SADs)
– Medicare defines self-administered drugs as drugs that
the patient would take by mouth or normally administer
to themselves. Such drugs include, but are not limited
to: oral medications, insulin, eye drops, suppositories,
and topical treatments.
– Most MACs have policies pertaining to SADs. Refer to
Noridian’s policy at the link below:
https://med.noridianmedicare.com/web/
jeb/policies/sads
37
Self-Administered Drugs
• Self-administered Drugs (continued)
– CMS has instructed each MAC to “ . . . describe
the process they will use to determine whether a
drug is usually self-administered by the patient and
as such cannot be covered as ‘incident to’ a
physician’s service . . . [and] continue to assure
that not only is the drug medically reasonable and
necessary for any individual claim, but also that
the route of administration is medically reasonable
and necessary.”
– While non-covered for Medicare outpatients under
most circumstances, self-administered drugs are
covered for inpatients and other payers.
38
Self-Administered Drugs
• Self-administered Drugs (continued)
– Neither the OPPS nor other Medicare payment
rules regulate the provision or billing by hospitals
of non-covered drugs to Medicare beneficiaries.
However, a hospital’s decision not to bill the
beneficiary for non-covered drugs potentially
implicates other statutory and regulatory
provisions, including the prohibition on
inducements to beneficiaries, section 1128A(a)(5)
of the Act, or the anti-kickback statute, section
1128B(b) of the Act (Medicare Program
Memorandum, A-02-129, Jan 3, 2003).
39
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S6-14
Supplies
• Medicare distinguishes supplies into two primary
categories:
– Routine
– Nonroutine
• In general, Medicare states that routine supplies
are not separately chargeable. Many facilities have
chargemaster issues related to supplies.
40
Supplies
• Over the years, Medicare bulletins and
newsletters* have emphasized that equipment
(e.g., humidifiers, IV pumps and ventilators),
educational materials, and other supplies (e.g.,
gowns, drapes and masks) should not be billed
separately.
• Chargemasters often reflect line items for many of
these, either improperly reported with a procedural
HCPCS or assigned to the UB-04 revenue code
that should be assigned to the procedure.
* Refer to the next slide for an example from Kansas BCBS.
41
Supplies
http://www.bcbsks.com/customerservice/providers/Publications/institution
al/manuals/pdf/NotSepChargeableItems.pdf
42
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S6-15
Routine vs. Nonroutine
• Routine vs. Nonroutine?
– A good rule of thumb is to determine whether
the supply item has been separately identified
in the patient’s chart.
– If not charted, then there is no way to verify that
item was utilized on that patient during that
encounter even if the item would “typically” be
utilized in such a circumstance.
43
Routine vs. Nonroutine
• Ask yourself:
– Is the item medically necessary and specifically ordered
by the patient’s physician?
– Is the item not ordinarily furnished to patients during the
course of the billed procedure or treatment?
– Is the item used specifically by the patient and not to
facilitate staff or equipment?
– Is the item not commonly available for use by patients
as needed in the billed setting (i.e., floor stock)?
– Is the item required to be billed under another UB-04
revenue code (i.e., radiology/other diagnostic supplies,
pacemakers, IOLs, implants, DMEPOS, etc.)?
44
Routine vs. Nonroutine
• Thus, basically:
– If you can answer yes to each of the five
conditions, then the item can be billed
separately as a non-routine item.
– However, if the answer is no to any of the five
conditions, then the item would be considered
routine and not separately billable.
45
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S6-16
DMEPOS vs. DME
• DMEPOS refers to:
– Non-implanted prosthetic and orthotic devices (typically
L-coded items with a Status Indicator of ‘A’ in Addendum
B) may be paid under the orthotics/ prosthetics fee
schedule*, and should be billed to the MAC under
revenue code 0274 and the appropriate HCPCS code
when provided for home use. DME items such as
crutches (typically E-coded items with a Status Indicator
of ‘Y’ or ‘E’ in Addendum B) are billed to the DME MAC,
and require a separate provider number (Medicare PM
A-03-035, May 2, 2003). Minimal cost take-home items
without specific HCPCS coding may be reported under
revenue code 0273.
* Note that for 2015, DMEPOS items provided in conjunction with a surgical or other procedure
46
will be packaged under the OPPS.
DMEPOS vs. DME
• DMEPOS (continued):
– Note that revisions were made to distinguish a
number of custom-fitted DMEPOS items from
Off-The-Shelf (OTS) ones in the 2014 OPPS
final rule. OTS items “require minimal selfadjustment for appropriate use and do not
require expertise in trimming, bending, molding,
assembling, or customizing to fit the individual”
(MLN Matters® MM8531, CR #8531).
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM8531.pdf
47
Thank you. Questions?
48
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S7-1
Revenue Cycle Institute
Session 7:
Chart to Bill Auditing
Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS
President/CEO and Principal Consultant
SLG, Inc. Consulting
Disclaimer
• Every reasonable effort has been taken to ensure
that the educational information provided in today’s
presentation is accurate and useful. Applying best
practice solutions and achieving results will vary in
each hospital/facility situation.
2
Agenda
• Overview of Facility Outpatient Auditing
• Outpatient Chart-to-Bill Audit Review
– Purpose
– Key Elements
– Forms Utilized
• Surgery
– Auditing Tips
– Examples
• Discussion
3
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S7-2
Learning Objectives
• Participant will understand the common types of
outpatient facility audits.
• Participant will be able to identify forms and
concepts used in auditing.
• Participant will understand some key elements in
performing chart-to-bill audits for surgical services.
4
Facility Outpatient Auditing
• There are a number of types of audits that can be
performed in the facility outpatient setting. These
include:
– Coding validation (i.e., ICD-9-CM, HCPCS, and
occurrence/value/condition codes)
• These can involve a review of a single codeset or
combination of codesets on a claim to ensure they are
accurate and supported by documentation.
– Medical necessity reviews
• These are performed to determine whether services
rendered are appropriate, essential and supported by
the diagnosis.
5
Facility Outpatient Auditing
• Types of facility outpatient audits (continued):
– Reimbursement audits (e.g., APC, MPFS, etc.)
• These require comparing the Explanation of Benefits
(EOB) to the payment that was expected.
– Charge capture analyses
• These entail a review of charge encounter forms, order
entry screens, ancillary system interfaces and/or staff
charging practices to ensure charges are entered
timely and accurately.
– Chart-to-Bill (a.k.a. Chart-to-Charge) audits
• These will be described in more detail on the next
several slides.
6
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S7-3
Chart-to-Bill Audits - Purpose
• What is the purpose of a Chart-to-Bill audit, i.e.,
why would a hospital want to perform one?
– The answer is simple – to ensure billing
compliance and appropriate charge capture!
• A Chart-to-Bill audit, also sometimes referred to as
a Chart-to-Charge audit, is a review to ensure that
all items (i.e., HCPCS, ICD-9-CM, payer type,
provider name, etc.) reported on the UB-04, CMS1500 and/or detail bill have been properly
documented in the chart and vice-versa, and that
such services do not elicit NCCI, device-toprocedure, and other payer edits.
7
Chart-to-Bill Audits – Key Elements
• What are some key elements that one should one look
out for when performing a hospital chart-to-bill audit?
– Charges for medications/supplies or tests/services
that were not ordered or that were not performed or
provided
– Charges for certain services that were performed by
nurses or technicians, such as equipment
monitoring, that should be included in the
accommodation, surgery time, procedure or visit
8
Chart-to-Bill Audits – Key Elements
• Key elements of a hospital chart-to-bill audit
(continued):
– Separate charges for tests that together
comprise a panel for which there should be a
single charge, i.e., unbundling
– Duplicate charges, i.e., more than one charge
for the same item or service
– Likely to happen when same/similar services
are performed by multiple departments, e.g.,
venipunctures, CPR, and EKGs
9
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S7-4
Chart-to-Bill Audits – Key Elements
• Key elements of a hospital chart-to-bill audit
(continued):
– Separate charges for services and supplies that
should be included in the charge for another item,
e.g., NCCI edit issues
– Charges for routine supplies and equipment such
as surgical gloves, drapes, urinals, bedpans,
irrigation solutions, ice bags, IV tubing, pillows,
towels, gauze, oxygen masks, oxygen supplies,
syringes, blood pressure cuffs, heating pads, and
monitors
10
Chart-to-Bill Audits – Key Elements
• Key elements of a hospital chart-to-bill audit
(continued):
– Incorrect dates of service
– Charges for tests and services that had to be
repeated because they were performed
incorrectly the first time, the results were lost,
mislaid, or not properly documented, etc.
11
Chart-to-Bill Audits – Key Elements
• Key elements of a hospital chart-to-bill audit
(continued):
– Documented items and services that were not
charged, but are separately billable
– Units of service match what is charted
– Appropriate use of modifiers
– Rounding of timed charges is accurate when
applicable
12
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S7-5
Chart-to-Bill Audits – Key Elements
• Key elements of a hospital chart-to-bill audit
(continued):
– Orders and results present for all billed services
• Physician orders must be:
– Legible
– Complete, i.e., identify the patient, support the
diagnosis/ condition, etc.
– Dated and timed
– Authenticated in written or electronic form
– Retained in the chart and available for audit
purposes
https://www.cms.gov/Regulations-and
Guidance/Guidance/Transmittals/downloads/R47SOMA.pdf
13
Forms Utilized
• In addition to analyzing elements in the chart, a
chart-to-bill audit entails a review of the UB-04 (or
in some cases, the CMS-1500) and a comparison
to the itemized bill.
• The UB-04 is maintained by the National Uniform
Billing Committee (NUBC) and the CMS-1500, by
the National Uniform Claim Committee (NUCC).
14
UB-04
http://www.nubc.org/
15
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S7-6
UB-04 – Pertinent Fields
• UB-04 Form Locators (FL 42-48)
42
Revenue Code
Required
44
HCPCS / Rate / HIPPS Code
Conditional
46
Service Units
Required
47
Total Charges
Required
48
Non-Covered Charges
Conditional
This field contains applicable
revenue code(s), i.e., 4-digit for the
services rendered. There are 22
lines available and should include
the total line for revenue code 0001.
This field is used to report the
appropriate HCPCS codes for
ancillary services, the
accommodation rate for bills for
inpatient services, and the Health
Insurance Prospective Payment
System (HIPPS) rate codes for
specific patient groups.
This field is used to report units such
as pharmaceutical base-dosage
dispensed, pints of blood used,
miles traveled, or the number of
inpatient days utilized.
This field reports the total charges—
covered and non-covered—related
to the current billing period.
This field indicates charges that are
non-covered by the payer as related
to the revenue code.
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/837I-FormCMS-1450-ICN006926.pdf
16
UB-04 – Example
17
CMS-1500
http://nucc.org/
18
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S7-7
CMS-1500 – Pertinent Fields
• CMS-1500 Fields (selected)
21
Diagnosis or nature of illness or
injury
Required
23
Prior authorization number
Required if
applicable
24D
Procedures, services or supplies
Required
24E
Diagnosis pointer
Required
24J
Rendering provider ID
Required if
applicable
This field is used to list up to four
ICD-9-CM diagnosis codes. Relate
lines 1,2,3,4 to lines of service in 24E
by line number. Use the highest level
of specificity. Do not provide
narrative description in this box.
This field is used to enter the prior
authorization or service agreement
number as assigned by the payer for
the current service.
This field is used to enter HCPCS
Level I codes (CPT), Level II codes
and modifiers. Up to four modifiers
may be submitted.
This field is used to enter diagnosis
pointer(s) referenced in field 21 to
indicate which diagnosis code(s)
apply to the related HCPCS code.
Do not enter ICD-9-CM codes or
narrative descriptions in this field. Do
not use slashes, dashes, or commas
between reference numbers.
This field is used to enter the tendigit NPI.
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/form_cms-1500_fact_sheet.pdf
19
Detail (Itemized) Bill
20
Surgery – Auditing Tips
• What should one look for when auditing for
Surgical services?
– Correct date(s) of service
– Orders and results for services rendered
21
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S7-8
Surgery – Auditing Tips
• What should one look for when auditing for
Surgical services?
– Appropriate HCPCS, ICD-9-CM and revenue code
assignment
22
Surgery – Auditing Tips
• What should one look for when auditing for
Surgical services?
– Correct use of modifiers, e.g, 59 (Distinct
Procedural Service), the new X{EPSU}
modifiers, etc.
• Be wary of using modifiers simply for bypassing
edits – always go back to the documentation
• Responsibility for appending varies significantly from
hospital to hospital
• So much misuse and confusion exists that the OIG
has published guidance on its use:
http://oig.hhs.gov/oei/reports/oei-03-02-00771.pdf
23
Surgery – Auditing Tips
• What should one look for when auditing for
Surgical services? (continued)
– Documentation for procedures, e.g., surgery,
anesthesia and recovery start/stop times, etc.
24
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S7-9
Surgery – Auditing Tips
• What should one look for when auditing for
Surgical services? (continued)
– Legibility
25
Surgery – Auditing Tips
• What should one look for when auditing for
Surgical services? (continued)
– Proper reporting of supplies, DMEPOS items and
pharmaceuticals dispensed by department, including
review of device-dependent edits
26
Surgery – Examples
• Note that under the OPPS 2015 final rule, CMS
will still require facilities to report a device code for
procedures currently assigned to a devicedependent APC. However, providers may report
any medical device C-code listed among the
device codes, rather than a particular device Ccode in order to meet this requirement.
27
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S7-10
Surgery – Auditing Tips
• When it comes to billable supplies, consider
whether the items would be noted by name, size,
type, use, etc., in the chart. If not, then they are
routine and should not be charged separately.
Implantable devices, DMEPOS and those items
assigned to HCPCS C-code categories should be
captured when appropriately documented.
28
Surgery – Auditing Tips
• Non-routine items and services may be reported
separately to Medicare when they are:
– directly identifiable items and services provided
to individual patients
– furnished under the direction of a physician
because of specific medical needs
– not reusable or represent a cost for each
preparation
29
Surgery – Examples
• Routine Supplies Example
30
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S7-11
Surgery – Auditing Tips
• DMEPOS refers to:
– Non-implanted prosthetic and orthotic devices (typically
L-coded items with a Status Indicator of ‘A’ in Addendum
B) may be paid under the orthotics/ prosthetics fee
schedule*, and should be billed to the MAC under
revenue code 0274 and the appropriate HCPCS code
when provided for home use. DME items such as
crutches (typically E-coded items with a Status Indicator
of ‘Y’ or ‘E’ in Addendum B) are billed to the DME MAC,
and require a separate provider number (Medicare PM
A-03-035, May 2, 2003). Minimal cost take-home items
without specific HCPCS coding may be reported under
revenue code 0273.
* Note that for 2015, DMEPOS items provided in conjunction with a surgical or other procedure
31
will be packaged under the OPPS.
Surgery – Auditing Tips
• DMEPOS (continued):
– Note that revisions were made to distinguish a
number of custom-fitted DMEPOS items from
Off-The-Shelf (OTS) ones in the 2014 OPPS
final rule. OTS items “require minimal selfadjustment for appropriate use and do not
require expertise in trimming, bending, molding,
assembling, or customizing to fit the individual”
(MLN Matters® MM8531, CR #8531).
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM8531.pdf
32
Surgery – Auditing Tips
• Observation is often billed in conjunction
with surgical services. However,
observation should not be reported:
– for routine post-operative monitoring during a
normal (4-6 hours) recovery period
– as a substitution for a medically appropriate
inpatient admission
– when not medically necessary for diagnosis or
treatment
– for routine recovery procedures and services
provided prior to outpatient diagnostic testing
– via standing orders following outpatient surgery
33
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S7-12
Surgery – Examples
• The physician orders on the next slide were written
and timed prior to the procedure. Unless the
patient ultimately had an adverse event, charging
for observation is not warranted.
34
Surgery – Examples
• Order for 23-hour Observation Written in Advance
of Surgery Example
35
Surgery – Examples
• On the next slide, we have an example of provider
progress notes that are virtually unreadable. How
many words you can decipher?
36
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S7-13
Surgery – Examples
• Multidisciplinary Progress Notes Example
37
Surgery – Examples
• On the next slide, there are time charges for
surgery, recovery, general anesthesia and
desflurane anesthesia gas. In the facility setting,
anesthesia charges represent the supplies,
equipment and gases utilized by the
anesthesiologist or CRNA. What seems awry
here?
38
Surgery – Examples
• Time Charges Detail Bill Example
39
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S7-14
Surgery – Examples
• This next slide is supposedly the documentation to
support the anesthesia time charges reported on
the previous detail bill example; however, it is
totally illegible.
40
Surgery – Examples
• Illegible Anesthesia Record Example
41
Surgery – Examples
• Of the supplies on the next slide, how many do
you think are separately billable?
42
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S7-15
Surgery – Examples
• Surgery Supplies Detail Bill Example
43
Surgery – Examples
• Now we have a very complex surgery case
reflected on a UB-04. The patient had bilateral
breast implant rupture and cancer of her left breast
with removal and implant replacement. What do
you observe?
44
Surgery – Examples
• UB-04 Coding Example
45
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S7-16
Surgery – Examples
• The correct codes that should have been reported
per the documentation are:
– 38500
– 38792-LT
– 19301-LT
– 19371-50
– 19340-50
– 15777
• None of the 59 modifiers reported were needed.
46
Thank you. Questions?
47
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