HCPro.com - APCs Weekly Monitor

Q/A: Coding for telescopic intraocular lens

Fri, 10 Feb 2012 05:00:00 GMT

Q: An ophthalmologist implanted a telescopic intraocular lens (C1840) that is supposed to be separately payable. Our FI/MAC didn’t pay us and said it processed the claim correctly. Do you have any information about this situation?

A: CMS established new HCPCS code C9732 (insertion of ocular telescope prosthesis including removal of crystalline lens) for calendar year 2012.

According to Transmittal 2386 (January update to OPPS), HCPCS code C1840 (lens, intraocular [telescopic]) is a pass-through category and is separately payable only when reported with new HCPCS code C9732. Review the claim to ensure that you reported both codes. If you did, discuss this with your FI/MAC because there may be a problem in its claims processing system.

Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

Tip: ICD-10-CM simplifies meaning of excludes notes

Fri, 10 Feb 2012 05:00:00 GMT

ICD-9-CM contains one type of excludes note with two possible meanings. Nothing in the ICD-9-CM manual tells coders which mean applies, so they must apply logic to determine the meaning.

An excludes note in ICD-9-CM could mean that coders should not use a particular code for a particular condition. Instead coders should look in a different category because they can’t code the two conditions together.

It can also mean that a condition is not included in a particular code. In these cases, coders should assign both codes, if applicable, when patients have both conditions simultaneously.

When coders are looking at the excludes notes, they can become confused. ICD-10-CM will resolve this confusion by instituting two different excludes notes—Excludes1 and Excludes2—to differentiate the meanings.

An Excludes1 note is a pure excludes note. An Excludes1 note indicates that a coder should never use the excluded code with the code above the Excludes1 note. The two conditions cannot occur together.

An Excludes2 note means a condition is not included in the code. An Excludes2 note indicates that the excluded condition is not part of the condition the code represents, but a patient may have both conditions simultaneously. When an Excludes2 note appears under a code, coders may report both the code and the excluded code together when appropriate.

This tip is adapted from “Start preparing for ICD-10-CM: Note differences between ICD-9-CM and ICD-10-CM” on JustCoding.com.

Pay-per-view: Code and guideline changes spread throughout surgery subsections

Fri, 10 Feb 2012 05:00:00 GMT

In total, the AMA added 60 new codes throughout the surgery section of the 2012 CPT^® Manual, 18 of which appear in the cardiovascular and respiratory system subsections. The AMA also revised 86 codes and deleted 48 codes in the surgery section.

In addition, the AMA included significant guideline changes in certain subsections of the manual. Coders should note these changes as well as the code changes, says Peggy S. Blue, MPH, CPC, CCS-P, regulatory specialist for HCPro, Inc., in Danvers, MA, and an AHIMA-approved ICD-10 trainer.

Continue reading “Code and guideline changes spread throughout surgery subsections” on HCPro’s website. Subscribers to Briefings on APCs have free access to this article in the January issue.

Trivia

Fri, 10 Feb 2012 05:00:00 GMT

Mesa Verde National Park is located in which U.S. state?

a. Arizona
b. Colorado
c. New Mexico
d. Utah

Think you know the answer? E-mail Senior Managing Editor Michelle Leppert. If you are one of five randomly selected readers to answer correctly the day you receive your issue, you’ll receive a free three-month trial subscription to the HCPro newsletter of your choice.

Last week’s question
In the 115 years for which records are available, how many times has Punxsutawney Phil predicted an early spring?

a. 6
b. 11
c. 16
d. 29

The correct answer is C. Since the tradition began in 1887, Phil predicted an early spring only 16 times. The first official Groundhog Day celebration occurred February 2, 1887, in Punxsutawney, PA. It was the brainchild of local newspaper editor Clymer Freas, who sold a group of businessmen and groundhog hunters—known collectively as the Punxsutawney Groundhog Club—on the idea. The men trekked to a site called Gobbler’s Knob, where the inaugural groundhog became the bearer of bad news when he saw his shadow.

Q/A: New device pass-through categories

Fri, 03 Feb 2012 05:00:00 GMT

Q: Will CMS ever approve any new device pass-through categories?

A: CMS established one new device pass-through category for CY 2012, HCPCS code C1886 (catheter, extravascular tissue ablation, any modality [insertable]).

Under OPPS payment methodology, a pass-through payment for a device includes an offset of the APC payment. When a pass-through code is reported and reimbursed, CMS deducts amount for the procedure the APC payment because payment for devices without pass-through has been included in the calculation of the APC payment.

Finance and billing departments should monitor these payment amounts to ensure appropriate application of this methodology.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

Tip: Note physician supervision changes

Fri, 03 Feb 2012 05:00:00 GMT

CMS finalized two significant changes to the physician supervision requirements as part of the 2012 OPPS Final Rule.

First, CMS agreed to delay enforcement of physician supervision rules for critical access hospitals (CAH) as well as small and rural hospitals with 100 or fewer beds.

Second, CMS will use the Federal Advisory Panel on Ambulatory Payment Classification Groups (APC Panel) to review supervision levels for outpatient services. These reviews could begin as soon as the winter 2012 APC Panel meeting.

CMS' decision to apply the supervision requirements in 76 Federal Register 74580 §410.27 to all OPPS therapeutic services and all CAH services is particularly interesting. Services to which the requirements will apply include physical, occupational, and speech therapy.

The tip is adapted from “CMS finalizes numerous provider-friendly OPPS changes for CY 2012” in the January issue of Briefings on APCs.

Pay-per-view: Note major updates to pathology and laboratory section

Fri, 03 Feb 2012 05:00:00 GMT

Coders can find the largest number of new codes in the pathology and laboratory section of the 2012 CPT^® Manual. The AMA added a total of 103 new codes, 101 of which denote Tier 1 and Tier 2 molecular pathology procedures.

The AMA also deleted two codes and revised five additional codes.

Continue reading “Note major updates to pathology and laboratory section” on HCPro’s website. Subscribers to Briefings on APCs have free access to this article in the January issue.

Trivia

Fri, 03 Feb 2012 05:00:00 GMT

In the 115 years for which records are available, how many times has Punxsutawney Phil predicted an early spring?

a. 6
b. 11
c. 16
d. 29

Last week’s question
The oldest known valentine still in existence today was sent in which year?

a. 1315
b. 1415
c. 1515
d.1615

The oldest known valentine still in existence today is a poem written in 1415 by the jailed Charles, Duke of Orleans, to his wife, according to History.com. Charles spent time in the Tower of London after being captured during the Battle of Agincourt. The greeting is part of the manuscript collection of the British Library in London, England.

Q/A: Reporting negative pressure therapy

Fri, 27 Jan 2012 05:00:00 GMT

Q: The new guidelines for the integumentary system section state that CPT^® codes 15002–15005 are noted to be reportable for surgical preparation of the site, including for negative pressure wound therapy. Please explain how to use these codes when reporting negative pressure wound therapy? This may affect how we report certain wound care services that we provide.

A: The 2012 CPT^® Manual includes a new subheading, “Skin Replacement Surgery” that includes definitions for surgical preparation codes 15002–15005.

The AMA expanded the instructions in 2011 to include negative pressure wound therapy and further defined the instructions for 2012. The 15002–15005 code range denotes the initial preparation of a wound site to create a clean and viable surface for skin graft placement or for negative pressure wound therapy.

CPT codes 15002–15005 may be reported in addition to the codes for skin grafting and negative wound therapy when the intent is for the wound to heal by primary intention. Do not report these codes if a wound is left to heal by secondary intention.

Negative pressure wound therapy, also known as a wound vac, plays an important role in treating wounds. The wound vacuum applies subatmospheric pressure, either continuously or intermittently, to the surface of a wound to promote healing.

CPT code 97605 (negative pressure wound therapy) and CPT code 15002 (preparation of the wound bed) do not trigger a National Correct Coding Initiative (NCCI) Edit triggers. No NCCI instructions prevent reporting the codes together.

The keys to appropriate reporting are to ensure:

Medical necessity is met relative to NCDs or LCDs
Documentation is complete, includes the correct dimensions of the wound, and supports the need for wound preparation
Wound is meant to heal by primary intention

Providers should review the “Skin Replacement Surgery” codes in the 2012 CPT® Manual carefully and ensure that documentation clearly supports the service before assigning any codes in the 15002–15278 range.

Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

Tip: Set rates that reflect intent of new codes

Fri, 27 Jan 2012 05:00:00 GMT

CMS expects hospital charges to reflect the relative resources that are required to provide a particular service. Therefore, someone at each hospital must understand new and replaced code changes, determine the intent of the new codes, and work with the appropriate individuals to develop an accurate charge.

Inputting a code in the chargemaster and calling it a day isn’t enough because new codes often represent new combinations even if they don't always represent new services.
If a new code is similar to an existing service, determine how similar (or dissimilar) it is with respect to time, resources, billing units, dosage, and other factors, and then move forward to develop the charge.

Increasingly more new codes represent a combination of existing codes and services. For example, in 2011, the AMA introduced three new combination codes for CT of the abdomen and pelvis. The codes were new, but they did not represent new services; instead they combined two existing services into single codes.

In this example, if the individual who updates the chargemaster simply replaces the old single-service code with a new combination code without reviewing and changing the dollar charge associated with the new code the hospital will continue to bill as if it rendered only a single service, even though the new code represents two services.

The tip is adapted from “Reevaluate charge setting in light of 2012 OPPS final rule” in the January issue of Briefings on APCs.

Pay-per-view: Code and guideline changes spread throughout surgery subsections

Fri, 27 Jan 2012 05:00:00 GMT

In total, the AMA added 60 new codes throughout the surgery section of the 2012 CPT® Manual, 18 of which appear in the cardiovascular and respiratory system subsections. The AMA also revised 86 codes and deleted 48 codes in the surgery section.

The AMA also included significant guideline changes in certain subsections of the manual. Coders should note these changes as well as the code changes, says Peggy S. Blue, MPH, CPC, CCS-P, regulatory specialist at HCPro, Inc., in Danvers, MA, and an AHIMA-approved ICD-10 trainer.

Trivia

Fri, 27 Jan 2012 05:00:00 GMT

The oldest known valentine still in existence today was sent in which year?

a. 1315
b. 1415
c. 1515
d.1615

Last week’s question
Which U.S. state’s motto is Sic semper tyrannis (Thus always to tyrants)?

a. Massachusetts
b. Vermont
c. Virginia
d. West Virginia

The correct answer is C. Sic semper tyrannis appears on the state seal of Virginia as the state’s motto. After fatally shooting President Abraham Lincoln, actor John Wilkes Booth jumped to the stage of Ford’s Theater and shouted “Sic semper tyrannis” before fleeing the scene. The phrase is also the motto of the United States Navy attack submarine USS Virginia and Allentown, the third largest city in Pennsylvania. It is referenced in the official state song of Maryland.

As a side note, Virginia, along with Pennsylvania, Massachusetts, and Kentucky, is actually called a Commonwealth, but in the United States a commonwealth and a state are the same.

Q/A: Reporting molecular pathology codes

Fri, 20 Jan 2012 05:00:00 GMT

Q: Addendum B of the APC updates for 2012 lists the new molecular pathology codes as status indicator E (noncovered service, not paid under OPPS). Our laboratory director has heard that we should report the new codes in addition to the codes that are payable. Can you explain why?

A: Providers use molecular pathology tests to detect the presence of specific genes. Currently, coders report these tests with multiple CPT^® codes to describe the specific testing being performed. Reporting in this manner is sometimes referred to as “stacked” codes.

The AMA created new CPT codes for these tests to reflect the service with a single code for CY 2012, Claims data reflects the stacked codes that historically have been reported for these services. No one-to-one relationship maps the old codes to new codes, so no easy crosswalk between them exists.

Multiple current CPT codes will map to one new code, and one current CPT code will map to several new codes because they are reported for several types of testing. The result is multiple-to-one and multiple-to-multiple mapping that must be considered before payment rates can be determined.

CMS is depending on providers to report both sets of codes to facilitate mapping the new CPT codes to the current cost/pricing information. Assignment of status indicator E should allow this line item to pass through the Integrated Outpatient Code Editor without delaying claims. CMS will not reimburse for the new codes, but reporting in this manner will put the new code on the same claim with current codes for the service. This will allow CMS to analyze the claims with the individual codes and the combination of codes that were reported for future rate-setting under the Clinical Diagnostic Laboratory Fee Schedule. Transmittal 2386 provides the following guidance:

Effective January 1, 2012, under the hospital OPPS, hospitals are advised to report both the existing CPT “stacked” test codes that are required for payment and the new single CPT test code that would be used for payment purposes if the new CPT test codes were active.

Use of the word “advised” suggests this reporting is voluntary. However, providers must carefully consider the future impact if they don’t report both sets of codes. Incomplete and insufficient claims data will be used to determine the payment amount for these services. These molecular pathology tests are complex; if providers don’t report both sets of codes, the resulting payment determination could be insufficient for the services provided. Providers should read the entire section of the transmittal pertaining to reporting these codes.

Note that Transmittal 2386, which was published January 13, replaces Transmittal 2376.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairperson, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

Tip: Corrrectly code image-guided lumbar decompression

Fri, 20 Jan 2012 05:00:00 GMT

Percutaneous image-guided, minimally invasive lumbar decompression witha specially designed toolkit (mild^tm) has been proposed as an ultra-minimally invasive treatment for central lumbar spinal stenosis.

During this procedure, physicians fill the epidural space with contrast medium under fluoroscopic guidance. Using a 6-gauge cannula clamped in place with aback plate, physicians employ single-use tools (e.g., portal cannula, surgical guide, bone rongeur, tissue sculpter, and trocar) to resect thickened ligamentum flavum and small pieces of lamina. Tissue and bone sculpting occurs entirely under fluoroscopic guidance, with additional contrast media added throughout the procedure to aid visualization of the decompression. The process is repeated on the opposite side for bilateral decompression of the central canal.

Report CPT^® category III code 0275T (percutaneous laminotomy/laminectomy [intralaminar approach] for decompression of neural elements) that became effective July 1, 2011, to denote this procedure. This code maps to APC 0280 with a national payment of $3,535.92. Note, however, that automatic CMS coverage is not implied simply because a CPT code with payment exists under OPPS.

The tip is adapted from “This month’s coding Q&A” in the January issue of Briefings on APCs.

CMS finalizes numerous provider-friendly OPPS changes for CY 2012

Fri, 20 Jan 2012 05:00:00 GMT

Fortunately for providers, CMS decided not to cap outpatient payment rates for cardiac resynchronization therapy defibrillator (CRT-D) procedures at the standardized inpatient rate. The agency announced its decision as part of the CY 2012 OPPS final rule released November 1, 2011.

CMS also finalized several changes regarding payments for 11 cancer centers, drug payment calculations, and physician supervision.

Continue reading “CMS finalizes numerous provider-friendly OPPS changes for CY 2012” on HCPro’s website. Subscribers to Briefings on APCs have free access to this article in the January issue.

Trivia

Fri, 20 Jan 2012 05:00:00 GMT

Which U.S. state’s motto is Sic semper tyrannis (Thus always to tyrants)?

a. Massachusetts
b. Vermont
c. Virginia
d. West Virginia

Last week’s question
What is fear of Friday the 13th called?

a. Anthropophobia
b. Batrachophobia
c. Eisoptrophobia
d. Friggatriskaidekaphobia

The correct answer is D. Friggatriskaidekaphobia is a morbid, irrational fear of Friday the 13th. Anthropophobia is a fear of people, while batrachophobia is a fear of amphibians, frogs, newts, and salamanders. Eisoptrophobia is an abnormal and persistent fear of mirrors.

Q/A: Correct use of modifier -FB and -FC

Fri, 13 Jan 2012 05:00:00 GMT

Q: Our billing office is concerned about reports that the OIG is auditing for appropriate use of the following modifiers:

-FB (Item provided without cost to provider, supplier or practitioner, or credit received for replacement device [examples, but not limited to covered under warranty, replaced due to defect, free samples])
-FC (Partial credit received for replaced device)

We know this is related to pacemaker recalls, but the billing office doesn’t know whether a replacement was due to a recall or the battery simply needed replacement. No one seems to know at the time of the procedure that the cost is discounted and that modifier -FC will be applicable. Billing office staff members say they know only when the invoice arrives.
Can you help us sort this out?

A: CMS has required use of modifiers -FB and -FC since 2007 and 2008, respectively, to reflect the reporting of a device that the provider obtained at no cost (modifier -FB) or at a discounted cost (modifier -FC).

The modifiers are appropriate for reporting devices related to a recall situation, but their use is not limited to this circumstance. Append modifier -FB when a facility incurs no cost or receives full credit for the cost of a device. Append modifier -FC when a facility received a manufacturer credit of 50% or more of the cost of a device.

When CMS packaged the cost of devices into the APC payment for the procedures, it created a situation for many procedures in which the total APC payment is largely due to the cost of the device. CMS noted in the OPPS final rules for 2007 and 2008 that it believes payment should be decreased when a facility obtains a device at a decreased cost. CMS does not believe that the Medicare program or a beneficiary should pay for something that a facility received at a substantially discounted cost. As a result, CMS created these modifiers for use in these instances. Report the appropriate modifier with the HCPCS code for the procedure, not the device; this triggers a reduced APC payment.

Establishing a communication process to ensure that the appropriate parties are informed about situations in which one of these modifiers is applicable. The individual responsible for appending the modifier varies by facility, depending on internal processes, and may not be the individual who reports the HCPCS code.

CMS realized that information about partial discounts may not be known when a procedure is performed, so it published instructions in the January 2008 update to OPPS in Transmittal 1417:

Because hospitals may not know at the time the device replacement procedure takes place whether or how much credit the manufacturer will provide for the device, hospitals have the option of either: (1) submitting the claims immediately without the FC modifier and submitting a claim adjustment with the -FC modifier at a later date once the credit determination is made; or (2) holding the claim until a determination is made on the level of credit.

The good news is that the modifiers do not apply to every possible scenario in which a facility receives an item at a discounted cost. In 2009, CMS created a specific list of devices and APCs for which the cost of a device accounts for the majority of the APC payment and for which these modifiers are applicable based on the percentage of payment related to the device. Select the Final Rule and then the file titled “OPPS Final Without Cost of With Credit Device Information.”

CMS provides further instructions in the Medicare Claims Processing Manual, Chapter 4, §§20.6.9, 20.6.10 and §61.3 for reporting the modifiers and charges.

Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

Tip: Take note of inpatient-only list revisions

Fri, 13 Jan 2012 05:00:00 GMT

CMS removed 10 codes from the inpatient-only list as part of the 2012 OPPS Final Rule. For CY 2012, CMS removed the following CPT^® and HCPCS codes from the inpatient-only list:

0184T, Excision of rectal tumor, transanal endoscopic microsurgical approach (i.e., TEMS), including muscularis propria (i.e., full thickness)
20930, Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)
21346, Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local fixation
22551, Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
22552, Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)
22554, Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2
35045, Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudo-aneurysm, and associated occlusive disease, radial or ulnar artery
43281, Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh
43770, Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components)
54650, Orchiopexy, abdominal approach, for intraabdominal testis (e.g., Fowler-Stephens)

The tip is adapted from “CMS finalizes numerousprovider-friendly OPPS changes for CY 2012” in the January issue of Briefings on APCs.

Pay-per-view: Reevaluate charge setting in light of 2012 OPPS final rule

Fri, 13 Jan 2012 05:00:00 GMT

Hospitals received a timely reminder about the importance of properly setting charges in CMS' 2012 OPPS final rule.

In the final rule, CMS finalized its plan to move CPT® code 77338 (Multi-leaf collimator [MLC] device[s] for intensity modulated radiation therapy [IMRT], design and construction per IMRT plan) to APC 0305 (Level II therapeutic radiation treatment preparation), which has a median cost of approximately $264.

Continue reading “Reevaluate charge setting in light of 2012 OPPS final rule” on HCPro’s website. Subscribers to Briefings on APCs have free access to this article in the Janaury issue.

Trivia

Fri, 13 Jan 2012 05:00:00 GMT

What is fear of Friday the 13th called?

a. Anthropophobia
b. Batrachophobia
c. Eisoptrophobia
d. Friggatriskaidekaphobia

Last week’s question
In Greek mythology, who is the god of fire?

a. Dionysus
b. Hades
c. Hephaestus
d. Vulcan

The correct answer is C. Hephaestus is the Greek god of fire and according to Homer is the son of Zeus and Hera. He was either born lame or became lame after Zeus threw him down from Olympus when Hephaestus took Hera's side in a dispute. Hephaestus was represented as bearded, with mighty shoulders, but crippled legs. At huge furnaces worked by Cyclopes, he fashioned ornaments, weapons, and magical contrivances for the gods and heroes (e.g., Achilles' shield). Vulcan is the Roman god of fire. Dionysus is the Greek god of wine, and Hades is the ruler of the underworld.