NEWS | TRENDS | OUTCOMES
MAY 2011
Body System vs. Body Part
ICD-10-PCS Makes Them Different
DOC2DOC
Accountable Care Organizations: An Overview for Physicians
TALKING POINTS
Q2 Hospital OPPS Update: Something for Everyone
MODIFIERS CORNER
The Eyes Have It: Reporting Procedures on Eyelids
Q2 ANALYSIS
Q2 Updates: From MPFS to NCCIs, The Devil’s in the Details
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FEATURE ARTICLE
DOC2DOC
TALKING POINTS
MODIFIERS CORNER
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5
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9
Body System vs. Body Part: ICD10-PCS Makes Them Different
Accountable Care
Organizations: An Overview for
Physicians
Q2 Hospital OPPS Update:
Something for Everyone
The Eyes Have It: Reporting
Procedures on Eyelids
From the billing of drugs and biologicals to the one new HCPCS
codes and update payment rates
for the OPPS pricer, Renee Guilbeau, RHIA, CIRCC provides an
overview of Q2 changes.
It would seem that using the eyelid modifiers would be straightforward and easy, suggests Sandy
Palmer, RHIT. However, there are
only four options for the eyelids
based on upper and lower eyelids
and the right and left sides.
ICD-10-PCS characters have
different meanings in each
section. Character two (Body
System) and character 4 (Body
Part) appear to be the same but
are well-defined within ICD-10PCS, reports Darnacea Harris,
MHA, RHIT, CCS, in this month’s
feature article. Facilities can begin
now to familiarize themselves with
body systems, body parts and
the associated guidelines. Further
education in medical terminology,
and anatomy & physiology may
be needed to correctly apply and
interpret ICD-10-PCS codes, she
advises.
Accountable Care Organizations
(ACOs) are intended to assist
doctors, hospitals and other care
providers to better coordinate
the care provided to Medicare
patients, reports Denise Nash,
MD, CCS, CIM. The idea of an
ACO, she writes, is to create
incentives for healthcare providers
to work together (playing nice
in the same sandbox) to treat
an individual patient across
care settings (physician office,
hospitals, SNF, rehab, etc.)
Q2 ANALYSIS
10
Q2 Updates: From MPFS to NCCIs, The Devil’s in the Details
Editor’s Note: This article, as a collaborative effort by key
MedAssets analysts, summarizes and touches on key issues
reflective of the changes in the April 1, 2011 Q2 CMS updates.
MedAssets clients can look forward to this valuable information as
a quarterly feature of CCFN.
FEATURED ARTICLE
By Darnacea Harris MHA, RHIT, CCS
Body System vs. Body Part
ICD-10-PCS Makes Them Different
Character 1
Character 2
Character 3
Character 4
Character 5
Character 6
Character 7
SECTION
BODY SYSTEM
ROOT OPERATION
BODY PART
APPROACH
DEVICE
QUALIFIER
As
presented in previous articles in
CCFN, ICD-10-PCS characters
have different meanings in each section.
Character 2 (Body System) and character 4
(Body Part) appear to be the same but are
well-defined within ICD-10-PCS.
Body Systems
The second character, body system,
identifies the general anatomical region
involved in the procedure. In the ICD-10PCS classification system, there are 31 body
system values, ranging from 0–9, B–D, F–H,
J–N and P–Y. Body systems are categorized
into larger groups to make navigating tables
easier, and to obtain information about the
procedures quickly. The respiratory systems,
for example, represents a body system.
ICD-10-PCS uses non-traditional methods
to define “body systems.”
Examples of nontraditional body systems
include (P) upper bones, or (Q) lower
bones. The body systems and the
associated values are as follows:
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CCFN MAY 2011 MEDASSETS.COM
0 Central Nervous System
1 Peripheral Nervous System
2 Heart and Great Vessels
3 Upper Arteries
4 Lower Arteries
5 Upper Veins
6 Lower Veins
7 Lymphatic and Hemic System
8Eye
9 Ear, Nose, Sinus
B Respiratory System
C Mouth and Throat
D Gastrointestinal System
F Hepatobiliary System and Pancreas
G Endocrine System
H Skin and Breast
J Subcutaneous Tissue and Fascia
KMuscles
LTendons
M Bursae and Ligaments
N Head and Facial Bones
P Upper Bones
Q Lower Bones
R Upper Joints
S Lower Joints
T Urinary System
U Female Reproductive System
V Male Reproductive System
W Anatomic Region, General
X Anatomic Region, Upper Extremities
Y Anatomic Region, Lower Extremities
Guidelines associated with body systems
include the following:
B2.1 – Body systems contain body part
values that include contiguous body parts.
These values are used:
a.When a procedure is performed on the
general body part as a whole.
b.When the specific body part cannot be
determined.
c.In the root operations Change, Removal
and Revision, when the specific body
part value is not in the table.
Example: Body System value 7 is Upper
Joints, which is very general. The body part
“Wrist, Bursa, and Fascia, Right Hand” is
the more specific body part.
B2.2 – Body systems designated as upper
or lower contain body parts located above
or below the diaphragm.
Example: Upper Veins body parts are above
the diaphragm while Lower Veins are below
the diaphragm.
FEATURED ARTICLE
Body Parts
The fourth character of ICD-10-PCS
identifies the Body Part. The body part
values represent the more specific part
of the body system where the procedure
was performed. The body part differs from
the body system because body parts are
specific, where body systems are general.
Each body system includes 34 possible
body part values. Body parts may specify
laterality (right or left), but not all body parts
have a specific value. If there is no specific
value, use the whole body part value or
the body part value closest to the proximal
branch. Examples of general guidelines for
body parts include:
B4.1 If a procedure is performed on a
portion of a body part that does not have
a separate body part value, code the body
part value corresponding to the whole body
part.
B4.2 If the prefix “peri” is used with a body
part to identify the site of procedure, the
body part value is defined as the body part
named.
Example: A procedure site identified as
perirenal is coded to the kidney body part.
Bilateral Body Part Values
Bilateral Body Part Values exist in a
limited number of body parts based on
frequency and common practice. If identical
procedures are performed on contralateral
body parts, and bilateral body part values
exist for that body part, a single procedure
is coded using the bilateral body part
value. If no bilateral body part value exists,
code each procedure separately using the
appropriate body part value.
Example: The identical procedure performed
on both fallopian tubes is coded once using
the body part value Fallopian Tube, bilateral
knee joint procedures is coded twice using
the appropriate laterality (left knee joint and
right knee joint).
Body part guidelines exist for many
more body parts. ICD-10-PCS provides
an appendix that defines body parts
by anatomical term, and includes the
appropriate PCS description. Facilities
can begin now to familiarize themselves
with body systems, body parts and the
associated guidelines. Further education
in medical terminology, and anatomy &
physiology may be needed to correctly
apply and interpret ICD-10-PCS codes.
About the Author
Darnacea Harris MHA, RHIT, CCS, is an
AHIMA approved ICD-10-CM/PCS Trainer
with more than 20 years experience in the
coding, compliance and reimbursement
industry. Darnacea has previously held such
positions CCA Rules Manager, Assistant
Director HIM, HIM Manager, Coding
Manager and Consultant. She has also held
teaching positions at several colleges and
universities where she taught coding, billing,
HIM and supporting courses. n
REFERENCES
American Health Information Management Association:
ICD-10-CM/PCS, www.ahima.org/icd10
Centers for Medicare and Medicaid Services.
ICD-10 www.com.hhs.gov/ICD10
Centers for Medicare and Medicaid Services.
ICD-10-PCS 2011 Code Tables and Index 2011
ICD-10-PCS and GEMs ICD-10
Federal Register/Vol 74, No. 11 (2009). HIPAA
Administrative Simplification: Modifications to Medical
Data Code Set Standards to Adopt ICD-10-CM and
ICD-10-PCS. http://edocket.access.gpo.gov/2009/pdf/
E9-743.pdf
ICD-10-PCS The Complete Draft Code Set, (2010)
Ingenix,: UT
MedAssets Coding & Compliance Webinars
Laboratory Compliance, Coding and Billing Updates
Pharmacy Billing and Coding Best Practices
June 21, 2011, 2:00 p.m. (EST)
June 30, 2011, 11:00 a.m. (EST)
July 18, 2011, 11:00 a.m. (EST)
July 20, 2011, 2:00 p.m. (EST)
If you were unable to attend the ICD-10 PCS: Introduction to the Inpatient Coding Changes Webinar or the ICD-10: Introduction to
the Diagnosis Codes it is not too late. A recording of these ICD-10 MedAssets Compliance Webinars will be available on and after
June 1, 2011. The recording will be available for playback through Aug. 1, 2011. The recording will allow you view and listen to the
Webinars at your convenience.
Please note: we are not offering CEUs for the recorded Webinars. If you are interested in listening and viewing the recorded ICD-10
Webinars, please contact your MedAssets Account Manager or e-mail productsupport@medassets.com for additional information.
Registration online at https://medassets.webex.com.
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CCFN MAY 2011 MEDASSETS.COM
DOC2DOC
By Denise M. Nash MD, CCS, CIM
Accountable Care Organizations
An Overview for Physicians
So
we are all hearing about
Accountable Care Organizations
(ACOs) and, just recently, The Centers for
Medicare & Medicaid Services (CMS),
operating under the Affordable Care Act
(ACA), came out with their proposal, all
429 pages, on March 31 (the comment
period is set at 60 days with a closing day
of June 6, 2011).
The proposal centers around a comparison
to a three legged stool where care
delivery, payment methodology and health
information technology are dependent of
each other for success in the “Triple Aim” of
accomplishing the following:
• Cost reduction (decrease ER visits and IP
hospitalizations)
• Improving quality
• Improving overall population health
(preventative care, immunization)
These new proposed rules are intended
to assist doctors, hospitals and other care
providers to coordinate better the care
provided to Medicare patients through
ACOs. The idea of an ACO is to create
incentives for healthcare providers to work
together (playing nice in the same sandbox)
to treat an individual patient across care
settings (physician office, hospitals, SNF,
rehab, etc.)
Shared Savings Program
The intent of the Medicare Shared Savings
Program is to reward ACOs that not only
lower growth in healthcare costs, but also
meet performance standards on quality
of care.
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CCFN MAY 2011 MEDASSETS.COM
This is stated in section 3022 of the ACA,
which added a new section to the Social
Security Act that requires that the Shared
Saving Program be created by Jan. 1, 2012.
The proposed rule requires providers
participating in an ACO to “notify the
beneficiary of their participation and that
the provider will be eligible for additional
Medicare payments for improving the
quality of care the beneficiary receives
while reducing overall costs or may be
financially responsible to Medicare for
failing to provide efficient, cost effective
care. The beneficiary may then choose to
receive services from the provider or seek
care from another provider that is not part
of the ACO.” The new rule also proposes
that each provider notify the beneficiary
that claims data will be shared within the
realm of the ACO. The sharing of data
would make it easier to coordinate patient
care. This exchange allows for greater
transparency, which is the aim of modern
healthcare. So, as a provider you will need
to come out with yet another document
to issue to your Medicare patients or post
the document in your waiting room. As a
provider you also will be required to give
your Medicare patients the opportunity to
opt out of the data sharing arrangements.
The data sharing for the proposed Shared
Savings Program requires compliance with
all applicable privacy rules and regulations,
including HIPAA. So having a form that
patients can sign to opt in or opt out will be
necessary.
The ACO Model
What constitutes an ACO model?
The rules create two distinct programs
designed to accommodate both new and
experienced ACOs.
At the center is the Patient Centered
Medical Home (PCMH)
How many member lives are
necessary?
An ACO must agree to accept 5,000
Medicare patients. An ACO, if approved,
must sign an agreement with CMS to
participate in the Shared Savings Program
for three years.
What will the provider be required to do?
To participate in the Shared Savings
Program, you as the provider need to form
or join an ACO and apply to CMS. The
provider needs to adopt procedures and
processes to promote evidence-based
medicine and to engage the patient in her/
his care.
How many quality measures will
be used?
The proposed rule includes 65 quality
measures to assess the quality of care
furnished by an ACO. However, the
specifics will not be known until after the
comment period ends.
What is the CMS monitoring plan?
What funds will be used by CMS
to share back with the ACOs?
How will CMS share the data?
How will ACOs bear risk?
The monitoring plan includes analyzing
claims for both financial and quality data
with the issuance of both quarterly and
aggregated annual reports. Medicare
also intends to perform site visits and use
beneficiary surveys.
CMS will provide doctors with the whole
picture of medical services their patients
are receiving. Part A and B data elements
may include: beneficiary ID, date of birth,
gender, procedure codes, diagnosis codes,
dates of service, provider/supplier ID and
claim payment type. Part D data elements
may include beneficiary ID, prescriber ID,
drug service date, drug product service ID
and formulary identifier. This total view will
help reduce duplicating care for patients –
subjecting them to multiple unnecessary
tests – as well as reduce adverse events.
Will benchmarks be used?
If you become part of an ACO, you will
continue to receive fee-for-service (FFS) for
“specific items and services.”
The proposed rule requires Medicare to
develop a benchmark for savings achieved
by each ACO if the ACO is to receive
shared savings or be held liable for losses.
An ACO would be accountable for meeting
or exceeding quality performance measures
to be eligible to receive any shared savings.
The rule was created in the belief “that
establishing the benchmark based on
average beneficiary expenditures adjusted
for demographic characteristics would
result in the best estimate of the ACO’s
performance.”
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CCFN MAY 2011 MEDASSETS.COM
CMS is going to have a 25 percent
withholding on the current FFS, to be shared
back with the ACO meeting financial
performance. The proposal also states
that CMS would share back with the
ACO 50 to 60 percent of the savings.
Established ACOs that think they can handle
more risk could opt for potential bonuses of
up to 60 percent of savings, but they would
have to agree to repay Medicare for cost
overruns. At most, a badly performing ACO
would have to repay the government 10
percent of what Medicare would have spent
on those patients if they weren’t in the ACO.
ACOs that are less experienced or more risk
adverse could choose an alternative path
to avoid any financial risk for the first two
years. They would be eligible for smaller
bonuses of up to 50 percent of savings they
achieved for Medicare. These ACOs would
still face potential penalties in the third year
of up to 7.5 percent of what CMS estimated
their patients should have cost.
What is the savings threshold?
Medicare is establishing a threshold
because of the annual fluctuation in health
spending (often accounted by seasonality).
Often the greater fluctuation is found within
smaller provider groups. Therefore the
higher threshold of 3.9 percent has been
established for smaller participating groups.
The larger groups will have a threshold
of 2 percent.
The Shared Savings Program will commence
operations on Jan. 1, 2012.
If you would like to see the Notice of
Proposed Rule Making (NPRM) release
which was published on April 7, 2011 /
Vol. 76, No. 67 / issue of the Federal
Register go to: http://edocket.access.gpo.
gov/2011/pdf/2011-7880.pdf
About the Author
Denise M. Nash, MD, CCS, CIM, is
the Medical Director and Lead Product
Manager for Episodes of Care. Denise
has more than 20 years experience in the
healthcare industry. She has worked for
CMS in hospital auditing and has expertise
in negotiation and implementation of
risk contracting for managed care plans.
Denise has also worked with individuals
as well as physician groups on utilization
improvements to improve financial
performance for the risk-based contracts.
She has worked with both hospitals and
physician practices on the legal aspects
of adding new services to the respective
facilities. Denise is a consultant on
compliance/HIPAA at physician practices,
hospitals, and insurance plans and has
worked for the OIG of New Hampshire for
its Fraud and Abuse Division. n
TALKING POINTS
By Renee Guilbeau, RHIA, CIRCC
Q2 Hospital OPPS Update
Something for Everyone
Editor’s. Note: The following sources are referenced to provide an overview of OPPS changes for the Q2, 2011: Transmittal R2174CP & MLN Matters
MM7342 – April 2011 Update of the Hospital Outpatient Prospective Payment System (OPPS) and R2172CP & MLN Matters MM7344 – April 2011 Integrated Outpatient Code Editor (I/OCE) Specifications Version 12.1. Below is an overview that provides details of Q2 changes.
Billing for Drugs, Biologicals,
and Radiopharmaceuticals
Drugs and Biologicals with Payments
Based on Average Sales Price (ASP)
Effective April 1, 2011
Payment for nonpass-through drugs, biological and therapeutic radiopharmaceuticals
is made at a single rate of ASP plus five
percent.
Payment for pass-through drugs, biological and therapeutic radiopharmaceuticals
is made at a single rate of ASP plus six
percent.
CMS states that these rates provide
payment for both the acquisition cost and
pharmacy overhead costs associated
with the drug, biological or therapeutic
radiopharmaceutical.
Updated payment rates, effective April 1,
2011, can be found in the April 2011
update of the OPPS Addendum A and
Addendum B on the CMS Website at:
www.cms.gov/HospitalOutpatientPPS/AU/
list.asp#TopOfPage
Drugs and Biologicals with OPPS
Pass-Through Status
The following three new drug and biological codes have been granted OPPS passthrough status effective April 1, 2011.
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CCFN MAY 2011 MEDASSETS.COM
C9280 Injection, eribulin mesylate, 1 mg
(SI G, APC 9280)
C9281 Injection, pegloticase, 1 mg
(SI G, APC 9281)
C9282 Injection, ceftaroline fosamil, 10 mg
(SI G, APC 9282)
New HCPCS Code
For April 1, 2011, one new HCPCS code
has been created for reporting drugs and
biological in the hospital outpatient setting.
This new HCPCS code (Q2040) will replace
HCPCS code C9278.
Q2040Injection, incobotulinumtoxin A,
1 unit (SI G, APC 9278)
Updated Payment Rates
Incorrect payment rates for the following
nine codes in Q4 of 2010, effective Oct. 1,
2010 through Dec. 31, 2010, are corrected
in the April 2011 OPPS Pricer. Corrected
payment rates and minimum unadjusted
copayments are listed below:
J0833 ­­– Cosyntropin
injection NOS
$51.32 / $10.26
(SI K, APC 0835)
J1451 ­­– Fomepizole,
15 mg
$7.14 / $1.43
(SI K, APC 1689)
J3030 ­­– Sumatriptan
succinate / 6
$45.71 / $9.14
(SI K, APC 3030)
J7502 ­­– Cyclosporine
oral 100 mg
$3.04 / $0.61
(SI K , APC 1292)
J7507­­– Tacrolimus oral $3.18 / $0.64
per 1 MG
(SI K, APC 0891)
J9185 ­­– Fludarabine
phosphate inj
$162.67 / $32.53
(SI K, APC 0842)
J9206 ­­– Irinotecan
injection
$7.45 / $1.49
(SI K, APC 0830)
J9218 ­­– Leuprolide
acetate injection
$4.50 / $0.90
(SI K, APC 0861)
J9263 ­­– Oxaliplatin
$4.52 / $0.90
(SI K, APC 1738)
Incorrect payment rates for one HCPCS
code in Q1 of 2011, effective Jan. 1,
2011 through March 31, 2011, has been
corrected in the April 2011 OPPS Pricer.
The corrected payment rate and minimum
unadjusted copayment is listed below:
Q4118 Matristem micromatrix $3.19 / $0.64 (SI K, APC 1342)
Remember, as stated in previous quarterly
updates, CMS has instructed FI/MACs to
adjust claims only as appropriate when
brought to its attention for the codes listed
above. MedAssets advises you to review
these codes and determine if your facility
meets the criteria for rebilling.
Adjustment to Status Indicator
Effective Jan. 1, 2011, CMS is changing
the SI for HCPCS code Q4119 – Matristem
wound matrix, per square centimeter, to “K”
which means that separate payment is now
available for this product. APC 1351 –
Matristem wound matrix, per square
centimeter – with a payment rate of $5.62
and a minimum unadjusted copayment rate
of $1.12.
Category I H1N1 Vaccine Codes
Effective Jan. 1, 2011, both CPT codes
90663 – Flu vacc pandemic H1N1 –
and 90470 – Immune admin H1N1 im/
nasal – have been assigned SI “D,” which
indicates that these two codes are no longer
paid under OPPS or any other Medicare
payment system.
Correct Reporting of Biologicals When Used
As Implantable Devices
If a HCPCS code describes a product
that may either be surgically implanted or
inserted or otherwise applied in the care
of a patient, hospitals should not report
separately the biological HCPCS code.
Medicare states that this is due to the
fact that under the OPPS, hospitals are
reimbursed by a packaged APC payment
for surgical procedures that includes
implantable devices without pass-through
status.
CMS goes on to describe how hospitals
may include charges for these items in their
charge for the procedure.
Correct Reporting of Units for Drugs
CMS states yet again that units should be
reported in multiples of the units included
in the HCPCS descriptor and provides the
agency with an example of this. Medicare
cautions providers that before submitting a
claim it is extremely important to review the
complete long descriptors for the applicable
HCPCS code(s).
Reporting of Outpatient Diagnostic Nuclear
Medicine Procedures
CMS states that when a diagnostic radiopharmaceutical product is administered by
a hospital or a non-hospital for a different
hospital providing the nuclear medicine
scan, hospitals should comply with OPPS
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CCFN MAY 2011 MEDASSETS.COM
policy which requires the radiolabeled products be reported and billed with the nuclear
medicine scan(s). In this scenario, Medicare
does allow the hospital or nonhospital to
enter into an arrangement, as defined by
CMS, with the hospital that actually performs the nuclear medicine scan(s).
with the use of an endoscope when
performed, single or multiple levels,
unilateral or bilateral
The payment rate.................$3,535.92
The minimum unadjusted
copayment............................. $707.19
SI T, APC................................... 0208
CMS considers the radiopharmaceutical
product and the nuclear medicine scan to
be part of one procedure. CMS expects
both services to be performed and reported
together.
Adjustment to Status Indicator for G0010
Effective Jan. 1, 2011, CMS erroneously
assigned status indicator “B” to HCPCS
code G0010 – Administration of hepatitis B
vaccine. Therefore, CMS will retroactively
adjust the SI for HCPCS code G0010 from
“B” to “S” and assign G0010 to APC 0436.
HCPCS Code C9399
Once again CMS reminds us that it is
not appropriate to report HCPCS code
C9399 – Unclassified drugs or biological
– for drugs and biological that are defined
as usually self-administered drugs by the
patient.
HCPCS code C9399 is to be used solely for
the following purposes:
(1) new outpatient drugs or biologicals
that are approved by the FDA on or
after Jan. 1, 2004 and (2) furnished as
part of covered outpatient department
services for which a product-specific
code has not been assigned.
Changes to Device Edits for April 2011
Many years ago CMS determined
that certain procedural HCPCS codes
accompany a particular device code and
vice versa. Each quarter, CMS updates this
list. The most recent edits for procedureto-device and device-to-procedure
edits can be found at www.cms.gov/
HospitalOutpatientPPS.
Remember, if claims fail to pass these edits,
the claim will be returned to the provider.
New Service
Effective April 1, 2011, CMS has established
a new HCPCS code:
C9729Percutaneous laminotomy/laminectomy (intralaminar approach) for
decompression of neural elements,
(with ligamentous resection, discectomy, facetectomy and/or foraminotomy, when performed) any method
under indirect image guidance,
For services performed after Jan. 1, 2011,
CMS also states that to ensure the correct
waiver of coinsurance and deductible
for the administration of the hepatitis B
vaccines, providers should report HCPCS
code G0010 for OPPS billing rather
than CPT code 90471 – Immunization
administration (includes percutaneous,
intradermal, subcutaneous, or intramuscular
injections); one vaccine (single or
combination vaccine/toxoid ­– or CPT code
90472 – Immunization administration
(includes percutaneous, intradermal,
subcutaneous, or intramuscular injections);
each additional vaccine (single or
combination vaccine/toxoid) (list separately
in addition to code for primary procedure).
HCPCS Code Q1003
Effective April 1, 2011, CMS will delete
HCPCS code Q1003 – New technology
intraocular lens category 3. Currently it is
packaged under the OPPS.
Note: The definitions of status indicators (SI)
mentioned throughout this article:
G –Pass-Through Drugs and Biologicals.
Paid under OPPS; Separate APC
payment
K – Nonpass-Through Drugs and
Nonimplantable Biologicals, including
Therapeutic Radiopharmaceuticals.
Paid under OPPS; separate APC
payment
D – Discontinued Codes. Not paid under
OPPS or any other Medicare payment
system.
Continued on Page 16
MODIFIERS CORNER
By Sandy Palmer, RHIT
The Eyes Have It
Reporting Procedures on Eyelids
Modifiers E1–E4 became effective for
reporting procedures performed on eyelids
under the Medicare Outpatient Perspective
Payment System (OPPS) 2002.
Just as many of the other Current Procedural
Terminology ® (CPT) Level II modifiers that
are used to report procedures performed
on specific anatomical sites, it would seem
that using the eyelid modifiers would be
straightforward and easy. There are only
four options for the eyelids based on
upper and lower eyelids and the right and
left sides. The four anatomical modifiers
assigned to the eyelids are described below:
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
Before deciding to append one of the eyelid
modifiers, providers need to make sure
they understand the published description
of the CPT or HPCPCS code used to report
the procedure. When the procedure code
description clearly states that a procedure is
specific to one eyelid it may be appropriate
to use one of the eyelid modifiers.
Another thing providers need to be aware of
is whether the payor being billed bases the
reimbursement for the eyelid procedure per
eyelid, eye, patient, procedure or encounter.
Medicare guidance for modifier use in the
Claims Processing Manual states that the
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CCFN MAY 2011 MEDASSETS.COM
anatomical group of modifiers should be
utilized to “add specificity to the reporting
of procedures performed on eyelids.”
Moreover, the most specific modifier
available should be used. When the eyelid
Modifiers E1–E4 are appropriate they
should be reported rather than modifiers
LT (Left Side), RT (Right Side) or 59 (Distinct
Procedural Service) since they are more
specific to the individual eyelids.
Modifiers E1–E4, however, should NOT
be used if the procedure code description
indicates multiple occurrences or multiple
eyelids.
Example: 67875 – Temporary closure of
eyelids by suture (eg, Frost suture)
During the Frost suture procedure the
upper and lower eyelids are sutured
together to prevent opening and closing
of the eyelids. Medicare considers this
to be a unilateral procedure and allows
modifiers LT, RT and 50 to be appended
when reporting CPT 67875.
When a procedure specific to an eyelid is
performed, it is most appropriate to report
one of the eyelid modifiers (E1–E4) to
indicate on which eyelid the procedure was
performed. However, sometimes Modifiers
50 (Bilateral Procedure), LT (Left side) or RT
(Right Side) are preferred or required by the
payor rather than one or more of the eyelid
modifiers. Medicare Medically Unlikely Edits
(MUEs) may be checked for a procedure
code to see Medicare’s expectation of the
maximum number of service units that would
be expected to be reported per day for a
single beneficiary. If the MUE edit is “4”
for an eyelid procedure code it is probable
that the code is considered appropriate to
report for each of the four eyelids and that
the eyelid modifiers would be acceptable for
reporting with that code.
Example: 68761 – Closure of the lacrimal
punctum; by plug, each
CPT 68761 has a MUE edit of 4 units per
day.
The E1–E4 modifiers should also NOT be
used if the code indicates that the procedure
may apply to different body parts.
Example: CPT 11640, Excision, malignant
lesion including margins, face, ears,
eyelids, nose, lips; lesion diameter 0.5 cm
or less
Even though CPT 11640 could be
performed on a right upper and a right
lower eyelid during a patient encounter,
codes in the 116XX range are reported
by lesion and size rather than anatomical
location. The eyelid modifiers are
generally not appropriate for reporting the
CPT codes in the integumentary system,
with the exception of the blepharoplasty
codes (15820 - 15823).
Continued on Page 15
Q2 ANALYSIS
By Bev Hillinger, RHIA, CPC
Q2 Updates
From MPFS to NCCIs, The Devil’s in the Details
Editor’s Note: This article is a collaborative effort by key MedAssets analysts and
will summarize key issues reflective of the
changes in the April 1, 2011 Q2 CMS updates. MedAssets clients can look forward
to this valuable information as a quarterly
feature of CCFN.
Medicare Physician Fee Schedule
(MPFS) – April 1, 2011 Q2
New Code Addition Effective April 1, 2011
HCPCS Q2040 – Injection, incobotulinumtoxin A, 1 unit
• Beginning April 1, 2011, new HCPCS
code Q2040 replaced deleted HCPCS
code C9278
• MPFS Status Indicator is set at “X” which
indicates under statutory exclusion there is
no payment made under the Physician Fee
Schedule (PFS)
• Payment allowance limit is based on
Average Sales Price (ASP) Methodology –
effective April 1, 2011, payment limit for
one unit is set at 5.565 (ASP Drug Pricing
Files April 2011 Update is located at
www.cms.gov/McrPartBDrugAvgSalesPric
e/01a18_2011ASPFiles.asp#TopOfPage)
HCPCS Code...................................Q2040
Short Description...........Incobotulinumtoxin A
HCPCS Code Dosage........................... 1 UNIT.
Payment Limit................................. 5.565
• Medicare will accept HCPCS Q2040
as a valid HCPCS code using Type of
10 CCFN MAY 2011 MEDASSETS.COM
Service(s) (TOS) 1, 9 – TOS 1 Medical
Care or TOS 9 Other medical items or
services–official guidance may be found
in Transmittal R2147CP www.cms.gov/
Transmittals/downloads/R2147CP.pdf
Code Deletions Retroactive to Jan. 1, 2011
CPT/HCPCS 90470 – H1N1 immunization
administration (intramuscular, intranasal),
including counseling when performed
CPT/HCPCS 90663 – Influenza virus vaccine, pandemic formulation, H1N1
• As reflected in the CMS 2011 Q2 MPFS
Data Files, the American Medical Association (AMA) discontinued CPT/HCPCS
codes 90470 and 90663 effective as of
Dec. 31, 2010; therefore beginning Jan.
1, 2011, the codes were no longer valid
for reporting
• Based on CMS regulatory guidance,
Part B claims already paid by Medicare
contractors after Jan. 1, 2011, and before
April 4, 2011, will not be retracted or rereviewed unless it is specifically requested
by the provider; in which case claims may
be reviewed or adjusted
• There will not be retroactive payment
reviews made by Medicare Contractors
for Part B claims submitted or paid prior
to April 4, 2011, based on CMS Transmittal R2180CP www.cms.gov/transmittals/
downloads/R2180CP.pdf
• HCPCS code G9141 Influenza A (H1N1)
immunization administration (includes the
physician counseling the patient/family)
may be reported and is reimbursable for
Medicare beneficiaries. Since the vaccine
is provided at no cost to the provider,
HCPCS G9142 Influenza A (H1N1)
vaccine, any route of administration
is not separately payable.
Other Code Deletions Effective April 1, 2011
HCPCS codes Q1003, S2270, S2344, and
S3905 are no longer valid
Indicator Changes Beginning April 1, 2011
Global Days Indicator Changes From
XXX to 000
• Global surgery guidelines now will apply
and be included for pre-op and post-op
services performed on the same day of the
procedure (generally including E/M services)
• Validate services performed on the same
day with CCI edits for verification
31579 – Diagnostic laryngoscopy
92511 – Nasopharyngoscopy with endoscope (separate procedure)
Co-surgery Indicator Changes From 0 to 2
• Indicator “2” allows reimbursement for
two physicians of separate specialties
to be paid at 62.5 percent of the fee
schedule amount
• Modifier 62 is reported with the CPT
code to identify co-surgeons performing
the procedure
57155 – Insertion of uterine tandem and/or
vaginal ovoids for clinical brachytherapy
Medically Unlikely Edits (MUEs) –
April 1, 2011 Q2
Bilateral Surgery Indicator Changes
from 1 to 2
• Relative value units (RVUs) and Medicare
payment is based on the procedure being
performed bilaterally, 150 percent payment adjustment does not apply
• The CPT code is reported once and modifier 50 is generally not required
CMS developed Medically Unlikely Edits
(MUEs) to reduce the paid claims error rate
for Part B claims. An MUE for a HCPCS/CPT
code is the maximum units of service that a
provider would report under most circumstances for a single beneficiary on a single date of
service. Not all HCPCS/CPT codes have an
MUE and some defined MUEs are confidential
and therefore not published by CMS.
64613 – Chemodenervation of muscle(s);
neck muscle(s) (e.g., for spasmodic torticollis, spasmodic dysphonia
64614 – Chemodenervation of muscle(s);
extremity(s) and/or trunk muscle(s) (e.g., for
dystonia, cerebral palsy, multiple sclerosis
77071 – Manual application of stress performed by physician for joint radiography,
including contralateral joint if indicated
Practice Expense Relative Value Changes
CPT Code Code Description
Practice Expense
Change
On a quarterly basis CMS publishes three
separate MUE files:
• Outpatient Facility files for the services
provided in a hospital or clinic
• Practitioner files for services provided
by physicians
• DME files (includes HCPCS A, B, D–H,
K–V) for supplies/devices provided for the
care of the beneficiary
For Q2 2011 CMS made additions or
changes to 294 MUEs
Outpatient
Facility
Services
Practitioner
Services
DME Supplier
Services
Additions
127
147
11
Revisions
0
1
0
Deletions
4
4
0
MUE Q2 2011
93224 External electrocardiographic
recording up to 48 hours by
continuous rhythm recording and
storage; includes recording, scanning analysis with report, physician
review and interpretation
PE RVU
increased from
2.3 to 2.53 –
Total work, PE,
MP =3.08
93225 External electrocardiographic
recording up to 48 hours by
continuous rhythm recording and
storage; recording (includes connection, recording, and disconnection)
PE RVU
increased from
0.82 to 0.91 –
Total work, PE,
MP =0.92
Additions
The majority of additions to the MUEs are a
result of the CPT/HCPCS and Category III
codes that became effective Jan. 1, 2011.
93226 External electrocardiographic
recording up to 48 hours by
continuous rhythm recording and
storage; scanning analysis with
report
PE RVU
increased from
1.21 to 1.35 –
Total work, PE,
MP =1.36
• MUEs were added to nearly 40 Category
III CPT codes. Services reported with these
new MUE edits are rib fracture treatment,
injections for paravetebral facet joints and
esophageal motility procedures.
93503 Insertion and placement of flow
PE RVU
directed catheter (e.g., Swan-Ganz) decreased from
0.77 to 0.73 –
for monitoring purposes
Total work, PE,
MP =3.91
• CMS added MUEs for CPT codes
reported for both Outpatient Facility Services and Practitioner Services to include
debridement, arthroscopy, gastric tube
placement, neurostimulator services, ophthalmic procedures, heart catheterization
procedures and subsequent observation
services.
• Distinct to Outpatient Facility Services
only, CMS added MUEs for endoscope,
11 CCFN MAY 2011 MEDASSETS.COM
retrograde imaging/illumination colonoscope device, magnetic resonance
angiography procedures of the spinal
canal and upper extremities, and dermal
injections for facial lipodystrophy syndrome (LDS).
• Distinct to Practitioner Services only, CMS
added MUEs for repair of paraesophageal hiatal hernia, placement of interstitial
device open for radiotherapy, MRI breast
and influenza vaccines.
Eleven MUEs were newly assigned to DME
HCPCS codes. These include combination
oral/nasal masks, gastrostomy/jejunostomy
tubes and skin protection wheel chair seat
cushions. All of the assigned MUEs for these
DME supplies are also listed in both the
Outpatient Facility Services and Practitioner
Services files.
• Of particular note for facilities and practitioners are new MUE edits with 20 units
associated with Rabies Immune globulin
CPT codes 90375 and 90376. The long
descriptions of these CPT codes do not
include a dosage amount, however, CMS
defines the strength of the HCPCS dosage in the ASP Pricing Files as 150 IU.
Therefore for each 150 IU administered
one billable unit may be captured. There
are various rabies protocols established
for single or multiple injections within one
day and multiple days. For example if on
day one a total of 1500 IU was administered then it would be appropriate to
capture 10 billable units of either 90375
or 90376. MedAssets recommends that
you review your current protocols and
ensure the correct capture of billable units
associated with rabies administration.
Revisions
In the Q2 of 2011, CMS made only one revision: CPT code 34900 (Endovascular repair
of iliac artery) was assigned an MUE of two
and it was reduced to an MUE of one.
Deletions
CMS deleted four MUEs for both Outpatient
Facility Services and Practitioner Services.
These deletions include the CPT code range
of 11010 – 11012 and 97598, all of which
are related to debridement services.
Addendum A and B – April 2011, Q2
CMS has made some significant changes
for the Q2 2011. Though they may be small
in number the impact has the potential to be
significant.
Summary of Changes:
• Make HCPCS/APC/SI changes as
specified by CMS
• Implement version 17.0 of the NCCI
• Remove CPT code 88177 from the
female-only procedures list
• Add new modifier 33 to the valid
modifier list
APC Changes
Added APCs
The following APC(s) were added to
Integrated Outpatient Code Editor (IOCE)
effective Jan. 1, 2011.
APC
APC Description
01351
Matristem wound
matrix
Status Indicator
HCPCS
K
Q4119
Status Indicator K indicates that the associated HCPCS–Q4119 Matristem wound
matrix, per square centimeter – is now
payable. A facility that offers Matristem
should ensure this is now available on its
chargemaster. Status Indicator K describes
Nonpass-Through Drugs and Pharmaceuticals that are paid under OPPS and deliver
a separate APC payment. The National
Payment Rate for Q4119 is $6.10.
Reporting biologicals may be puzzling, and
care must be taken to report the item accurately. CMS Transmittal R2130CP, “January
2011 Update of the Hospital Outpatient Prospective Payment System (OPPS),” provides
current guidance on reporting biologicals in
item 9. “Billing for Drugs, Biologicals, and
Radiopharmaceuticals e.g. Correct Reporting of Biologicals When Used As Implantable Devices.” The guidance states that
hospitals should report HCPCS codes for
biologicals based on the way the product is
described by how the HCPCS code is used.
Based on R2130CP item 9, MedAssets
12 CCFN MAY 2011 MEDASSETS.COM
recommends that hospitals should always
report the HCPCS code for biologicals with
one exception, when the following is true
for the biological product:
• The HCPCS codes describes a product
that may either be surgically implanted or
inserted or otherwise applied in the care
of a patient
• The HCPCS code does not have passthrough status
• When the hospital has provided a biological device (that may either be
surgically implanted or inserted or otherwise applied, e.g. skin substitute, during
a surgical procedure) they should not
report the HCPCS code for the biological,
however, they may report the charges for
the product one of three ways:
1. Include the charges for these items in
their charge for the procedure
2. Report the charge on an uncoded
revenue center line
3. Report the charge under a device
HCPCS code (if one exists)
HCPCS/CPT Procedure Code Changes
Added HCPCS/CPT Procedure Codes
The following new HCPCS/CPT codes were
added to the IOCE effective April 1, 2011.
APC codes 09280, 09281 and 09282 are
also new and effective for April 1, 2011.
HCPCS
Code Description
SI
APC
C9280 Injection eribulin mesylate 1 mg
G
09280
C9281 Injection pegloticase 1 mg
G
09281
C9282 Injection ceftaroline fosamil 10 mg
G
09282
C9729 Percutaneous laminotomy/laminectomy T
(intralaminar approach) for decompression of neural elements (with ligamentous resection discectomy facetectomy
and/or foraminotomy when performed)
any method under indirect image
guidance with the use of an endoscope
when performed single or multiple levels
unilateral or bilateral; lumbar
00208
Q2040 Injection incobotulinumtoxin A 1 unit
09278
G
Deleted HCPCS/CPT Procedure Codes
The following HCPCS/CPT codes were deleted from the IOCE effective Jan. 1, 2011.
HCPCS
Code Description
90470
H1N1 immunization administration (intramuscular
intranasal) including counseling when performed
im/nasal
90663
Influenza virus vaccine pandemic formulation H1N1
Code 90470 H1N1 immunization administration was created by an urgent request
due to the avian flu pandemic. The code
was released simultaneously with a descriptor update to code 90663. The updates
became effective Sept. 29, 2009, which
was too late for publish action in the 2010
CPT Manual. According to policy, the updates were first published in the 2011 CPT
Manual. Additional confusion ensued as the
codes were discontinued, effective Dec. 31,
2010. The CPT parenthetical notes detailing the terminations will not be visible until
the 2012 CPT Manuals are published. The
termination date was published by CMS in
transmittal R2167CP.
The following HCPCS/CPT code(s)
were deleted from the IOCE effective
April 1, 2011.
HCPCS
Code Description
C9278
Injection incobotulinumtoxin a 1 unit
Q1003
New technology intraocular lens Category 3
(reduced spherical aberration)
S2270
Insertion of vaginal cylinder for application
of radiation source or clinical brachytherapy
(report separately in addition to radiation source
delivery)
S2344
Nasal/sinus endoscopy surgical; with enlargement of sinus ostium opening using inflatable
device (i.e. balloon sinuplasty)
S3905
Non-invasive electrodiagnostic testing with
automatic computerized hand-held device to
stimulate and measure neuromuscular signals in
diagnosing and evaluating systemic and entrapment neuropathies
Update your chargemaster, fee slips, superbills, etc., as necessary to avoid any claim
returns or compliance issues to provide the
most accurate charging and billing.
HCPCS Description Changes
The following code description was
changed effective Oct. 1, 2010.
HCPCS Old Description
New Description
G0435 Rapid immunoassay HIV-1 2
Oral HIV-1/HIV-2 screen
The following code description was
changed effective Jan. 1, 2011.
HCPCS Old Description
New Description
G0431 Drug screen multiple class
Drug screen multiple class
Updating your HCPCS descriptions will
aid your accuracy of charges for claim
submission.
HCPCS Edit Changes
The following code(s) were removed from
the list of female procedures effective
Jan. 1, 2011.
HCPCS 88177
This update corrects the gender edit placed
on this add-on code.
Edit Assignments
The following code(s) were added to
the conditional bilateral list-effective
Jan. 1, 2011.
0245T 0246T 0247T 0248T 29914
29915 29916 31295 31296 31297
37220 37221 37222 37223 37224
37225 37226 37227 37228 37229
37230 37231 37232 37233 37234
37235 38900 64568 64569 64570
65778 65779 66174 66175
CPT/HCPCS codes having a CMS “conditional bilateral” designation represent
procedures/services for which it is appropriate to append Modifier 50, such as certain
surgical procedures (e.g., 15822 – Revision
of upper eyelid, 25505 – Treat fracture of
radius).
13 CCFN MAY 2011 MEDASSETS.COM
The following code(s) were added to the
inherently bilateral list effective Jan. 1, 2011.
HCPCS 64611, 92132, 92133, 92134,
92227, 92228
CPT codes with a CMS “inherent bilateral”
designation represent procedures/services
for which it is not appropriate to append
the Modifier 50.
For these codes, the procedures/services
are actually being performed as a bilateral
procedure, since the technique may inherently involve physiology or anatomy on both
the left and right side of the body.
Added Modifiers
The following modifier(s) were added to the
list of valid modifiers effective Jan. 1, 2011.
Modifier 33 Preventative Service
When the primary purpose of this service is
the delivery of an evidence-based service in
accordance with a U.S. Preventive Services
Task Force A or B rating in effect and other
preventive services identified in preventive
services mandates (legislative or regulatory), the service may be identified by
appending Modifier 33 Preventive Service
to the service. For separately reported
services specifically identified as preventive
the modifier should not be used.
One of the most significant changes in this
auarterly update is the new Modifier 33.
Modifier 33 identifies screening/preventive
services. This was developed by the American Medical Association (AMA) to comply
with a requisite of the Affordable Care Act.
To accommodate PPACA, Modifier 33 will
permit providers to identify and notify payers about those services that were preventative and that cost-sharing does not apply.
In practice, Modifier 33 can show when a
procedure originally began as preventative but changed to a therapeutic action is
befitting to waive the deductible (copays
or coinsurance). The AMA’s example is a
screening colonoscopy (45378 or G0121)
resulting in a polypectomy (45383).
Summary
Armed with this new information, providers
should ensure that coders, billers and CDM
coordinators are aware of Q2 changes by
taking the following actions:
• Initiating discussions on new, revised and
deleted codes
• Determining revenue impact from new
payable APCs
• Applying new bilateral surgery rules
• Establish guidelines for the use of
Modifier 33
National Correct Coding Initiative (NCCI)
Edits – April 1, 2011 Q2
National Correct Coding Initiative Edits
(CCI) may account for a large percentage
of claim rejection issues. As part of a
preventative claim denial process, providers
should be aware of quarterly CCI edit
changes that may impact their services.
Effective April 1, 2011, were CCI Edit
Version 17.1 for Professional services,
and Version 17.0, incorporated into IOCE
version 13.0, for Facility services. Providers
can directly access the NCCI edit files at
www.cms.gov/NationalCorrectCodInitEd.
The NCCI edits are available in the
MedAssets KnowledgeSource product.
For Version 17.1 Professional 11,831 new
column 1/column 2 or Comprehensive/
Component edit pairs have been added,
346 pairs have been deleted and 13 pairs
have a modifier indicator change. For
Version 17.0 Facility, 19,347 new column
1/column 2 or Comprehensive/Component
edit pairs have been added, 65 pairs have
been deleted and 26 pairs have a modifier
indicator change.
17.1 PRO
ADDITIONS, DELETIONS & CHANGES BY NCCI SERVICE TYPE & CODE RANGE
17.0 FACILITY
ADDITIONS
DELETIONS
CHANGE TO
MODIFIER
INDICATOR
96
18
10
ANESTHESIA 00100–01999
0
271
2971
0
INTEGUMENT 10000–19999
78
2
27
0
NCCI SERVICE TYPE/CODE RANGE
CATEGORY III CODES 0001T–9999T
ADDITIONS
DELETIONS
2702
17
CHANGE TO
MODIFIER
INDICATOR
MUSCULOSKELETAL 20000–29999
3494
1
1730
1
RESPIRATORY, CARDIOVASCULAR, HEMIC & LYMPH 30000–39999
1376
51
2596
28
1
DIGESTIVE CPT 40000–49999
3416
1
2128
4
1
URINARY, MALE GENITAL, FEMALE GENITAL, MATERNITY CARE/DELIVERY 50000–59999
100
0
942
0
ENDOCRINE, NERVOUS, EYE, AUDITORY 60000–69999
561
0
1385
1
RADIOLOGY 70010–79999
207
0
601
0
PATH/LAB 80000–89999
E/M, MED/OTHER 90000–99999
SUPPLEMENTAL SERVICES A0000–V9999
TOTAL
0
0
100
0
1887
2
4063
12
616
0
102
2
11831
346
19347
65
ADDITIONS, DELETIONS AND CHANGES BY NCCI EDIT CATEGORY
NCCI EDIT CATEGORY
1
1
57
11
8
8
12
0
4680
5
More Extensive Procedure
28
4
Mutually Exclusive Procedure
14
15
CPT Manual and CMS coding manual instructions
HCPCS/CPT procedure code definition
Misuse of column2/with column 1 code
Standards of med/surgical practice
24
26
17.0 FACILITY
DELETIONS
CPT "separate procedure" definition
13
17.1 PRO
ADDITIONS
Anesthesia Service Included in Surgical Procedure
3
7031
24
Sequential Procedure
0
7
Standard preparation/monitoring services for anesthesia
0
271
CHANGE TO
MODIFIER
INDICATOR
ADDITIONS
DELETIONS
19190
39
157
26
CHANGE TO
MODIFIER
INDICATOR
From Modifier indicator 0 to 1
3
1
From Modifier indicator 1 to 0
10
25
TOTAL
HIGHLIGHTS 17.0 FACILITY
• Fluoroscopy guidance has been added as
a component code to multiple comprehensive procedure codes in the surgical code
range, radiology code range and the new
2011 cardiac catheterization code range.
As a misuse of column 2/column 1, rule
modifier usage may be allowed for some
of the new code pairs with the exception of
some of the cardiac catheterization codes.
• 0253T has been added as an edit for
“Standard preparation/monitoring
services for anesthesia” and will be a
14 CCFN MAY 2011 MEDASSETS.COM
11831
346
component to the majority of anesthesia
services.
• Therapeutic, diagnostic or anesthetic
agent injections into nervous system locations will now be considered a component
and a misuse of column 2/column 1 when
used in conjunction with a limited number
of comprehensive surgical procedure
codes. Addition of a modifier will not be
allowed.
• Services such as venipuncture, infusions,
injections, transfusion and EKGs will be
considered a component under the Stan-
13
19347
65
26
dards of medical/surgical practice rule
to a limited range of surgical procedure
codes; in particular codes which were
new for 2011. However, modifier usage
will be allowed under appropriate
circumstances.
• Added as a component is code 74176 –
Computed tomography, abdomen and
pelvis; without contrast material. This
code will edit when used in conjunction
with comprehensive code(s) 74177 –
Computed tomography, abdomen and
pelvis; with contrast material(s) or 74178
– Computed tomography, abdomen and
pelvis; without contrast material in one or
both body regions, followed by contrast
material(s) and further sections in one or
both body regions. No modifier usage
will be allowed.
HIGHLIGHTS 17.1 PROFESSIONAL
• Therapeutic, diagnostic or anesthetic
agent injections into nervous system locations will now be considered a component and a misuse of column 2/column
1 when used in conjunction with a wide
range of comprehensive surgical procedure codes. Addition of a modifier will
not be allowed.
• Conscious sedation will be edited as a
component to a new limited number of
comprehensive codes in the integumentary, musculoskeletal, digestive and nervous
system code ranges. Modifier usage
will not be allowed under the misuse of
column 2/column 1 edit. As a deleted
edit, Conscious sedation will no longer be
considered a component edit for procedure 0253T – Insertion of anterior segment aqueous drainage device, without
extraocular reservoir; internal approach,
The Eyes Have It
Continued from page 9
According to the Medicare National Correct
Coding Initiative (NCCI) manual, modifiers
E1–E4 are included in the list of anatomical
modifiers that may be used to bypass an
NCCI edit when the appropriate clinical circumstances exist and are documented in the
facility medical record. The E1–E4 modifiers
may allow two codes of a code pair with an
NCCI edit to be reported if the two or more
procedures are performed on separate or
contralateral organs or structures.
Example:
Column 1 code (comprehensive): 67930 –
Suture of recent wound, eyelid, involving
lid margin, tarsus, and/or palpebral conjunctiva direct closure; partial thickness
Column 2 code (component): 7938 – Removal of embedded foreign body, eyelid
Code 67938 is a component of column 1
code 67930 but a modifier is allowed in
15 CCFN MAY 2011 MEDASSETS.COM
into the suprachoroidal space. Code
0253T has also been deleted as an edit
for “Standard preparation/monitoring services for anesthesia” and will no longer
be considered a column 2 or component
code integral to the majority of anesthesia
services.
• Services such as venipuncture, infusions,
injections, transfusion and EKGs will be
considered a component under the Standards of medical/surgical practice rule to
wide range of surgical procedure codes.
However, modifier usage will be allowed
under appropriate circumstances.
• Component CPT code(s) 38760 for
iInguinal lymphadectomy or code(s)
55500, 55520, 55530 for varicoceles,
hydroceles and spermatoceles will be
edited as new code pairs as a CPT
“separate procedure” definition edit when
used in conjunction with comprehensive
procedure codes for inguinal hernia
repairs. Modifier usage will be allowed if
appropriate.
• Multiple new code pair additions of radiological vascular procedures for supervision and interpretation as components
codes and misuse of column 2/column
order to differentiate between the services
provided. When these procedures are
performed on separate eyelids the appropriate eyelid modifier may be appended
to add site specificity for the procedures
and eliminate the appearance of duplicate billing.
Common code ranges where the E1–E4
eyelids modifiers are often reported include
many of the codes in the CPT Surgery
subsections for Eye and Ocular Adnexa:
Eyelids 67700–67999 and Conjunctiva
68020–68999.
Summary
Review the code descriptions, payor policies
and medical record documentation carefully in order to use the appropriate eyelid
Modifiers E1, E2, E3 and E4 when reporting
eyelid procedures. Procedures performed
and reported for multiple eyelids should also
have the medical necessity for performing
those multiple specific procedures documented as well.
1 to comprehensive cardiovascular and
transcatheter procedure codes. Modifier
usage will be allowed under appropriate
circumstances.
• Insertion, removal or repair of certain
pacemakers will no longer be mutually
exclusive as a component of CPT 33226
– Repositioning of previously implanted
cardiac venous system (left ventricular)
electrode (including removal, insertion
and/or replacement of generator).
• Alcohol and/or substance abuse screening and intervention codes 99408–
99409 will be a new component for
comprehensive Evaluation & Management (E/M) codes and no modifier usage
will be allowed. Alcohol and/or substance abuse assessment codes G0396
and G0397 will be a new component
for comprehensive Evaluation & Management codes, however, a modifier may be
used under appropriate circumstances.
These edits fall under the misuse of column 2/column 1 rule.
• Deleted as an edit under the more extensive procedure rule are code pairs 97597
and add-on code 97598 for debridement
services. n
About the Author
Sandy Palmer, RHIT, is a Coding and CDM
Analyst for MedAssets Integrity Services.
Her expertise includes inpatient and
outpatient facility coding with a specific
emphasis on the Outpatient Prospective
Payment System (OPPS). She has more than
12 years experience in Health Information
Management and is currently responsible
for researching and responding to complex
facility coding inquiries as well as database
maintenance and management. n
REFERENCES
Medicare CPM | Chapter 4 | 20.6 – Use of Modifiers –
Level II (HCPCS) Modifiers
www.cms.gov/manuals/downloads/clm104c04.pdf
Medicare Program Memorandum A-02-026 |
Date: MARCH 28, 2002
www.cms.gov/hospitaloutpatientpps/downloads/
a02026.pdf
Medicare NCCI Manual | Chapters 1 and 8
https://www.cms.gov/NationalCorrectCodInitEd/
Downloads/NCCI_Policy_Manual.zip
FEATURED ARTICLE
Q2 Hospital OPPS Update
Trade Shows & Events
Continued from page 8
MAY 23 – 24
JUNE 5 – 7
The World Congress 2 Annual
Leadership Summit on Accountable
Care Organizations
2011 Catholic Health Assembly
Washington, D.C. • Booth: TBD • View
Website
JUNE 27 – 28
ND
T – Significant Procedure, Multiple
Procedure Reduction Applies. Paid
under OPPS; Separate APC payment.
B – Not recognized by OPPS when
submitted on an outpatient hospital Part
B bill type (12x and 13x)
S – Significant Procedure, Not Discounted
When Multiple
About the Author
Renee Guilbeau, RHIA, CIRCC, has been
a MedAssets employee for more than five
years. Prior to this position she was an
APC Coordinator & Outpatient Coding
Supervisor for five years. Renee has an
additional credential in Interventional
Radiology Cardiovascular Coding (CIRCC).
She is a graduate of University of Louisiana
at Lafayette. n
REFERENCES
www.cms.hhs.gov/transmittals/downloads/R2172CP.pdf
www.cms.gov/MLNMattersArticles/downloads/MM7344.pdf
www.cms.hhs.gov/transmittals/downloads/R2174CP.pdf
www.cms.gov/MLNMattersArticles/downloads/MM7342.pdf
MAY 24 – 27
NAHAM 37TH Annual National
Conference and Exposition
San Antonio, TX • Booth: 501 • View Website
No Excuses! Removing the Barriers and
Enabling POS Collections presented by Paul
Manganiello, Director, Admitting, Valley
Presbyterian Hospital and Julie Waddell, Vice
President, Revenue Cycle Solutions Strategy,
MedAssets
Assembling a Revenue Cycle Team presented
by Tammy Stone, CHAM, Director of Business
and Admission Services, Presbyterian Hospital
of Denton and Julie Waddell, Vice President,
Revenue Cycle Solutions Strategy, MedAssets
MAY 24 – 25
HFMA Region 1 – 10TH Annual
Conference
Uncasville, CT • Booth: TBD • View Website
MAY 26
Associated Purchasing Services (APS)
Annual Meeting
Overland Park, KS • View Website
Healthcare Reform Forcing Extreme Makeover
in Expense Management presented by
Gina Thomas, RN, MBA, CMRP, FAHRMM,
Regional Vice President, Spend Management,
MedAssets
Atlanta, GA • Booth: TBD • View Website
2011 ANI: The Healthcare Finance
Conference
Orlando, FL • Booth: 1003 • View Website
Preserving Net Revenue: Using Technology to
Re-engineer Processes, Simplify Reimbursement
and Reduce Denials presented Kristy Waters,
Vice President, Finance Operations, Tenet
Healthcare Corporation and Denny Roberge,
Executive Director, Solution Strategy,
MedAssets
Atlantic Health Uses Service Line Management
to Drive Strategic Decisions presented by
Joseph DiPaolo, Chief Supply Chain Officer
and Director of Pharmacy and Orthopedic
Services, Atlantic Health and Morgan
McGrady, Consultant, Service Line Analytics,
MedAssets
JULY 17 – 19
Health Forum and the American
Hospital Association Leadership
Summit
San Diego, CA • View Website
How to Have a Margin Discussion With Your
Doctors presented by Nick Sears, M.D., Chief
Medical Officer, MedAssets
JULY 18 - 21
Alabama HFMA 2011 Annual Institute
Destin, FL • View Website
Migration from Fee-for-Service to Episode of
Care Payments and Contracting Challenges
presented by Doug Emery, Program Leader,
Health Care Incentives Improvement Institute,
Inc. (HCI3) and Blane Schilling, M.D., Senior
Vice President, Pharmacy, Aspen Healthcare
Metrics, a MedAssets Company
16 CCFN MAY 2011 MEDASSETS.COM
Trade Shows & Events
TITLE
FREQUENTLY ASKED QUESTIONS
In this section, MedAssets has reviewed and analyzed the questions that are received via our compliance help desk.
We offer some of the most frequently asked questions and the MedAssets response for your convenience.
Q
In the hospital outpatient setting, if a DME item is not on the
list billable to the FI, ie., A7523, can the item be billed to the
patient, or is it considered routine and not chargeable?
MedAssets Response
A7523, Tracheostomy Shower Protector, each, is a Status Indicator
(SI) A [Not paid under OPPS. Paid by intermediaries/MACS under
a fee schedule or payment system other than OPPS].
According to Transmittal R1702, “When medical and surgical supplies (other than prosthetic and orthotic devices, as described in
the Medicare Benefit Policy manual, Pub. 100-02, Chapter 15, 120
and 130, and take-home surgical dressings) described by HCPCS
Codes with status indicator other than “H” or “N”, are provided incident to a physician’s service by a hospital outpatient department,
the HCPCS codes for these items should not be reported because
these items represent supplies.”
Based on this guidance, tracheostomy supplies (e.g. A7523) in the
outpatient hospital settings are considered supplies and should be
billed without a HCPCS Code with the appropriate revenue code.
Tracheostomy items are generally listed on Addendum B with Status
Indicator A (paid by fee schedule). We recommend reporting the
tracheostomy items with 271 for unsterile items and 272 for sterile
items since these items are not listed.
Resources: Transmittal R1702 April 2009 OPPS
(viewable in KnowledgeBase)
Help Us Help You!
MedAssets Tests ANSI 5010 Compliance
MedAssets is on target to help customers meet ANSI 5010
compliance. We are now in the testing registration phase for
those MedAssets products that require customer testing (NOTE:
Some products may only require MedAssets certification). If you
regularly use a product impacted by ANSI 5010, please complete
the registration form to schedule your testing. Following submission
of the registration form, you will be contacted within five business
days to initiate the testing scheduling process. You will be provided
specific information at that time about the data necessary to
complete the testing. Timing of the actual testing is partially based
upon your registration date so don’t hesitate! Register today.
MedAssets will work closely with you to obtain all necessary files
and guide you through the ANSI 5010 testing process.
17 CCFN MAY 2011 MEDASSETS.COM
Q
What is meant by “payment offset policy?”
MedAssets Response
CMS utilizes the “payment offset policy” for contrast media and radiopharmaceuticals as described in the 2011 OPPS Final Rule. CMS
considers contrast media and diagnostic radiopharmaceuticals as
“policy packaged” drugs because they are inherent to the procedures performed, and therefore these drugs are always packaged
unless they are considered to be pass-through drugs. Since these
drugs are primarily packaged, the cost of the radiopharmaceutical
or the contrast media is identified and packaged into the APC for
the primary procedure. For example, CPT 70460 CT Brain with contrast is assigned to APC 0283 and built within the reimbursement
for the procedure since it is the cost of the contrast media. Contrast
media and diagnostic radiopharmaceuticals that are assigned passthrough status are the exception as these pass-through drugs are
reimbursed at the average sales price plus six percent in addition to
the APC payment for the procedure.
In order to reimburse correctly for the pass-through drug, CMS has
created the “payment offset policy.” CMS will deduct from the payment for the pass-through drug an amount that reflects the portion
of the APC payment associated with drug costs already included
in the APC payment. In this way there is no duplication of payment
for the pass-through drug. As a hypothetical example if APC 0283
included a cost of $25 for contrast media and a packaged contrast
media was reported, there would not be a separate payment for
the contrast media as the reimbursement amount of $25 is already
included in the APC payment. However, should the same procedure
be performed that utilizes a pass-through contrast media, this may
be separately reimbursed. If it were determined that the reimbursement amount for the pass-through drug was $50, then CMS would
utilize the “payment offset policy” by deducting the already included amount of $25 from the $50 pass-through amount providing
a pass-through reimbursement amount of $25 which would be paid
in addition to the APC payment.
Payment offset policies are utilized for contrast media, diagnostic
radiopharmaceuticals and devices. The APC Offset File can be
viewed on CMS Website under the 2011 OPPS Final Rule.
2011 OPPS Final Rule and Files: http://www.cms.gov/HospitalOutpatientPPS/HORD/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=
3&sortOrder=descending&itemID=CMS1240960&intNumPerPage=10
CCFN CROSSWORD MAY 2011
By Toueria Morris, CPC-H
Across
1. One example of a nontraditional body
system would be upper ___.
1
2
3
5. Body systems are ___ and body parts
are specific.
6. Which character, of ICD-10-PCS,
identifies the body part?
7. An ___ that defines body parts by
anatomical term, and includes the
appropriate PCS description, is provided
in ICD-10-PCS.
4
5
Down
1. Based on frequency and common
practice, ___ body part values exist in a
limited number of body parts.
2. When identical procedures are
performed on contralateral body parts,
and bilateral body part values exist for
that body part a ___ procedure is coded
using the body part value.
6
3. There are 34 possible body part ___ for
each body system.
4.Each ___ would be coded separately
using the appropriate body part value,
when no bilateral body part value exists.
7
ACROSS 1. BONES 5. GENERAL 6. FOURTH 7. APPENDIX
DOWN 1. BILATERAL 2. SINGLE 3. VALUES 4. PROCEDURE
ANSWERS
Tell Us What You Think
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What subjects would you like us to cover? Send us an e-mail (compliance2@medassets.com) and tell us what you think.
CCFN STAFF CREDITS
Q. Warner
VP, Integrity Services
Shelley V. Nave, RHIA, CPC-H
MedAssets Integrity Services
Coding and Chargemaster Analyst
Kelly Randall
Communications Manager
Tara O’Neill
Art Director
Chuck Buck
Creative Consultant
KEEP YOUR SUBSCRIPTION COMING.
CONTRIBUTING WRITERS
Renee Guilbeau, RHIA, CIRCC
Darnacea Harris, MHA, RHIT, CCS
CCFN is a free monthly e-magazine discussing the latest information in the world of coding and compliance.
To register for your free subscription, visit www.medassets.com/ResourceCenter/Pages/CFN.aspx.
CCFN provides a discussion of coding practices for educational purposes only. MedAssets has made every effort
to ensure the accuracy of the contents herein. Official coding guidelines are maintained by the Central Office on
ICD-9-CM of the American Hospital Association.
Toueria Morris, CPC-H
Denise Nash, MD, CCS, CIM
Sandy Palmer, RHIT
18 CCFN MAY 2011 MEDASSETS.COM
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