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December 2010 EditionHot Topics:AMA Coding Guidance:Code Set Updates:General Coding News:Hot Topics:What in the World is Endovascular Revascularization?By Lynn Kuehn, MS, RHIA, CCS-P, FAHIMAEndovascular revascularization is a surgical procedure to provide new, additional or augmented blood supply to a vessel. Not only is endovascular revascularization a challenge to say, it’s a challenge to code. Codes 37220 to 37235 are new in 2011 and attempt to make these procedures easier to code. While they are easier, there are still some rules that need to be observed when coding these interventions. These new codes for 2011 represent revascularization of the lower extremity arteries and bundle the procedures commonly performed together. The codes include:
In addition, this new series of codes describe vascular access gained through either the percutaneous approach or through an open surgical exposure. These new codes treat the arteries as “territories,” or regions. The iliac territory contains three vessels; the common, external and internal iliacs and are found as the aorta branches into the groin area. The femoropopliteal territory has only one vessel, although it has three names that help define the exact location in the vessel. They are the common, deep and superficial femoral and popliteal and are located in the thigh area. The tibial/peroneal territory again has three vessels including the anterior tibial, the posterior tibial and the peroneal, branching just below the knee. To assign codes to the interventions performed in these territories, the coder should observe the hierarchy of procedures. From least intensive to most intensive, the interventions are:
The coder should code one code per vessel treated and select the code based on the highest intensity of treatment provided, using this hierarchy. The codes for revascularization are combination codes that describe the catheterization, the imaging and the interventions listed above. These codes are unilateral and the CPT coding notes direct the coder to use a modifier 59 when different legs are being treated, even if the intervention is different in each leg. For example, within the tibial/peroneal territory, a primary code is assigned for the first intervention performed in the vessel (37228 through 37231) and an add-on code is assigned for an additional intervention performed in the 2nd vessel in the territory (code chosen based on the hierarchy from 37232 through 37235). If a 3rd vessel is treated in the territory, another add-on code is assigned and a modifier 59 is appended to that add-on code. If the contralateral (opposite) leg is also treated with an intervention, another primary code is assigned for the territory that was treated and a modifier 59 is appended to the primary code. As you might expect, several codes in the Radiology Section of CPT have been revised to exclude separate coding for the radiological supervision and interpretation that is now included in this code series. Take the Pain out of Transforminal Injections for 2011By Jana Gill, MA, CPCBack in September 2008, the Office of Inspector General (OIG) finalized a nationwide audit to review the 84 million dollar increase in Medicare payments for transforaminal epidurals between 2003 and 2007. Transforminal epidurals have been used in a pain management setting to treat acute and chronic leg and back pain caused by conditions such as a herniated discs and similar nerve compression diagnoses. As a part of the procedure and to reduce the risk of spinal cord damage, radiologic guidance is used (fluoroscopy, x-ray, CT) to accurately place the needle into the foramen area. The OIG review had two goals in mind:
2. To determine what safeguards existed to ensure Medicare part B payments for transforminal epidural injections met Medicare requirements. The findings of the report revealed that in 2007 alone, approximately $45 million dollars were paid out in improper payments and that although CMS contractors had LCD published, both the safeguards and edits were lacking technical enforcement. Since the final report was issued, CMS in cooperation with the AMA has made several code and policy changes to prevent program overpayments for future years. The focused review targeted four specific CPT codes (64479, 64480, 64483, 64484) along with the associated radiologic guidance (77003) to facilitate the procedure. In 2010, the code description was revised to include both fluoroscopy and CT as integral part of the overall procedure. For 2011, the code descriptor added cross reference note to guide the coder to Category II HCPCS codes if ultrasound was used for visualization. HCPCS code 0229T may be coded in addition to the injection at the cervical or thoracic level and code 0230T at the lumbar and sacral level. From an auditor’s prospective, and based on the many changes to these codes since 2008, the following is a list of recommendations to help build internal controls when coding and billing transforminal injections:
As a final compliance measure, periodically review all injection claims using an experienced inside or outside resource to ensure coding, billing and documentation support government regulations along with AMA coding guidelines. AMA Coding Guidance:November 2010 CPT AssistantBy Jennifer Ridell, CPC Coding Consultation: Fluoroscopy – 76000, 76001, 77001, 77002, and 77003 In an attempt to clarify fluoroscopic coding, a compilation of questions and answers has been published on the subject. The information covers CPT codes 76000, 76001, 77001, 77002, and 77003. Additional information is included in the July 2008 CPT Assistant. Coding Brief: Minimally Invasive Lumbar Spinal Decompression (MILD) Procedure New techniques and technology in spine surgery has caused confusion on when it is appropriate to report existing spine surgery codes when a procedure involves an open surgical technique and a combination of open/endoscopic techniques. Clarifying information on this topic has been provided in a question and answer format that covers CPT codes 22899, 63030, 63047 and 64999. Using Stereotactic Template Guided Saturation Biopsy for the Prostate (Code 55706) Using Stereotactic Template Guided Saturation Biopsy for the Prostate (Code 55706) CPT code 55706 covers transperineal, template guided saturation biopsies that have been performed under anesthesia. If a standard sextant biopsy is performed under local anesthesia then CPT code 55700 should be reported. The main difference between these two procedures is the approach used during the biopsy and the level of anesthesia. The procedure associated with 55706 can only be performed in the hospital inpatient and outpatient setting or ASC setting. Pathologists have a sequence of G-codes that CMS developed to report the examination of specimens from a saturation biopsy. These codes are G0416-G0419. The appropriate G-code should be chosen based on the number of specimens taken during the saturation biopsy. Coding Brief: EEG Epileptic Spike Reporting Information on using electroencephalography (EEG) is provided in a question and answer format. The information covered includes clarification on CPT codes 95957 and 95951. Coding Consultation: Questions and Answers An article by the CPT Editorial Panel answers questions posed to the panel regarding the subjects of Medicine/neurology and neuromuscular procedure, ophthalmology and physician medicine and rehabilitation, surgery/nervous system, auditory system, digestive system, cardiovascular system and eye and ocular adnexa and pathology and laboratory/chemistry. The responses answer multiple questions including: Is it appropriate to report CPT code 95980 for a temporary insertion of a gastric lead for gastroparesis and is it appropriate to report CPT code 69424 for removal of a ventilating tube without general anesthetic? To view these articles via CCH Coding Comply, search from the Search Code Sets tab in Coding Comply for any of the codes listed above, view the Related Documents by clicking on the paper icon next to the code, then select the article. To view these articles in The Coding Suite, go to the CPT Assistant Archives folder and in the Search field within this folder and enter “October 2010.” Code Set UpdatesJanuary 1, 2011 OPPS and Physician Fee UpdatesBy Jennifer Ridell, CPC The end of the year is always busy for OPPS and the Medicare Physician Fee Schedule, and this year has been no exception. As of December 29, 2010 CMS had released an emergency update to the Physician Fee RVU file on their website. We are currently working with CMS to determine what this update includes but it will likely be the updated payment rates resulting from the passage, on December 15, 2010, of the Medicare and Medicaid Extenders Act of 2010. The RVU file that CMS initially posted in the fall for January 1, 2011 contained payment rates reflecting the proposed reduction in Medicare physician payments for 2011 that the Medicare and Medicaid Extenders Act has since reversed. CMS has also posted the OPPS Addendum B file for January 1, 2011. This file does not include any updated information for HCPCS "J" codes. CCH has previously analyzed the Addendum B data and determined that CMS releases an updated Addendum B file in mid-January with updated "J" code data. This occurs because the deadline to get ASP drug pricing information to CMS is too late in 2010 to be included in the initial posting of the Addendum B file for January 1. It is recommended that you keep a close eye on the CCH and MediRegs Coding Suite throughout January for further information on these two important updates. 2011 Clinical Lab Fee Schedule updateThe 2011 Clinical Lab Fee Schedule annual update has been released and is now reflected in Coding Comply. The update, effective January 1, 2011, includes 16 new codes, including HCPCS codes G0432-G0435 and CPT codes 87501-87503, and 1188 modified codes. To view this update in CCH Coding Comply, go to the Search Code Sets tab in Coding Comply, select the Clinical Lab code set, in the Refine Search box, de-select the Return active codes effective as of: box, then select Added, Modified, and Deleted for Filter Actions, in the Start Date enter 01/01/2011 and click Search. General Coding NewsEnd stage renal disease home dialysis monthly capitation paymentEffective January 1, 2011, the End Stage Renal Disease (ESRD) monthly capitation payment (MCP) physician (or practitioner) must furnish at least one face-to-face patient visit per month for the home dialysis MCP service as described by CPT codes 90963, 90964, 90965, and 90966. Documentation by the MCP physician (or practitioner) should support at least one face-to-face encounter per month with the home dialysis patient. However, Medicare contractors may waive the requirement for a monthly face-to-face visit for the home dialysis MCP service on a case by case basis. Chapter 8, section 140.1.1 of the Medicare Claims Processing Manual was revised to reflect this change. Additionally, references to the ESRD MCP "G codes" were removed from chapter 8, section 140.1.2 of the manual. Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1999, July 9, 2010. This transmittal can be viewed at ¶159,367 in the December 6, 2010, CCH Coding Comply What’s New newsletter; or on Rex via The Coding Suite in the CMS Manuals section under the title “R1999CP ESDR Home Dialysis MCP.” Updated coverage policy for annual wellness visitsSection 4103 of the Affordable Care Act amended the list of routine physical examinations excluded from coverage, effective January 1, 2011. Beginning January 1, 2011, Medicare Part B beneficiaries will be eligible for a routine annual wellness visit (AWV), including a personalized prevention plan, as long as it has occurred 12 months or more after their previous AWV. To support this new coverage policy, two new HCPCS codes will be implemented January 1, 2011, G0438 and G0439. Both new codes are for an AWV with a personalized prevention plan but G0438 covers the initial AWV and G0439 covers subsequent visits. Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 2109, Dec. 3, 2010 and Medicare Benefit Policy Manual, Pub. 100-02, Transmittal No. 134, Dec. 3, 2010. These transmittals can be viewed at ¶159,376 and ¶159,378 in the December 13, 2010, CCH Coding Comply What’s New newsletter; or on Rex via The Coding Suite in the CMS Manuals section under the titles “R134BP Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS)” and “R2109CP Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS).” Additions and revisions of HCPCS G-codes used for reporting skilled nursing and therapy services in the Home Health or Hospice settingThe Medicare Advisory Payment Commission (MedPAC) reported to CMS in 2009 and 2010 that improvements were needed within the Home Health prospective payment system (HH PPS) to reduce vulnerabilities. CMS determined that to address MedPAC's findings, they need to collect more specific data on their HH claims. CMS is now requiring HH agencies to report more specific data for therapy and nursing visits beginning January 1, 2011. Additions and revisions are being made to the HCPCS G-codes utilized for HH claims. These codes contain references to the hospice setting as well, but hospices are not yet required to use the new codes due to limitations in the Medicare systems for hospice claims. G-codes G0151 - G0153 have been revised to specifically state that services were performed by a qualified physical or occupation therapist of speech language pathologist. Two new G-codes were also added (G0157 and G0158) to report services provided by qualified therapy assistants. Three more new G-codes have been created to report the establishment or delivery of therapy maintenance programs by qualified therapists. G-code G0154 has been revised to better describe direct skilled nursing services for a beneficiary; indirect skilled nursing involvement (training of patient, family or caregiver, management and evaluation of a care plan, and observation and assessment of a patient's condition) can now be reported using new G-codes G0162, G0163 and G0164. HH agencies must remember that more than one G-code cannot be reported for a single nurse visit or therapist visit. The code that should be reported is the code that represents what the qualified professional spent the majority of their time working on. One-Time Notification Manual, Pub. 100-20, Transmittal No. 824, Dec. 17, 2010. This transmittal can be viewed at ¶159,406 in the December 27, 2010, CCH Coding Comply What’s New newsletter; or on Rex via The Coding Suite in the CMS Manuals section under the title "R824OTN Additions To and Revisions of Existing G-Codes for the Reporting of Skilled Nursing Services and Skilled Therapy Services in the Home Health or Hospice Setting." NOTE: To follow the MediRegs links above, you will need to be a subscriber to the Coding Suite of products and if prompted, enter your username and password. If you cannot remember your user name or password go to: http://wk.mediregs.com/login_fs.html and the system will let you request a reminder. For the Internet Research Network or IntelliConnect links, you will need to be a subscriber to the CCH Coding Comply. Requests for information about article submission and comments from readers are welcome and should be directed to at Nicole Stone at Nicole.Stone@wolterskluwer.com, Fax 847-267-2514. Customer service inquiries should be directed to 800-449-9525. CCH Coding Compliance Advisor is published monthly by CCH, a Wolters Kluwer business. ©2010 CCH. All rights reserved. No claim is made to original government works; however, the gathering, compilation, and arrangement of such materials, the historical, statutory and other notes and references, as well as commentary and materials in this Publication are subject to CCH copyright. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the publisher is not engaged in rendering legal, accounting or other professional service. If legal advice or other expert assistance is required, the services of a competent professional should be sought. For more information about the The Coding Suite or CCH Health Care Portfolio, please visit our online store at http://mediregs.com or http://health.cch.com. 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