Briefings on APCs MARCH 2016 P CPT update AMA updates genitourinary sections for new technology and terminology

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1 Briefings on APCs P4 P7 P10 Pay attention to the hierarchy when reporting drug administration services Codes for drug administration have not changed recently, but it still provides headaches for providers. Review the hierarchy to determine appropriate reporting. OPPS Advisor Jugna Shah, MPH, writes about the importance of accurate data for providers and CMS and how the agency can provide clarity to ensure better information. This month s coding Q&A Our experts answer questions about Composite APCs, modifier CT, and more. Volume 17 Issue No. 3 MARCH CPT update AMA updates genitourinary sections for new technology and terminology The 2016 CPT code update may have been relatively small compared to previous years, but the urinary and genital system sections did receive numerous changes to align them with other sections of the code book. Changes to codes for diagnostic nephrostograms and ureterograms are similar to those made for percutaneous biliary drainage catheters in the digestive system section (see February issue of Briefings on APCs for more information on those codes). The 2016 CPT Manual contains two new codes describing an injection procedure for antegrade nephrostograms and/or ureterograms. The codes include the complete diagnostic procedure, including imaging guidance and all associated radiological supervision and interpretation. One code is intended for new access (50430) and existing access (50431). The code for new access also includes accessing the collecting system and/or associated ureter with a needle and/or catheter. Coders should also make sure to see the parenthetical note associated with these codes to see which services should not be reported with them, said Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, the director of HIM and coding for HCPro, a division of BLR, in Danvers, Massachusetts, during the HCPro webcast Prepare for 2016 CPT Code Changes. The manual includes new codes for the placement of these catheters; one code is for placement of a nephrostomy catheter (50432) and the other is for placement of a nephroureteral catheter (50433). Each code is for a percutaneous placement and includes a diagnostic nephrostogram and/or ureterogram when performed, as well as imaging guidance and all associated radiological supervision and interpretation. Code (removal and replacement of externally accessible nephroureteral catheter [e.g., external/internal stent] requiring fluoroscopic guidance, including radiological supervision and interpretation) has been

2 Briefings on APCs March 2016 updated to reflect current terminology by noting use of a nephroureteral catheter. The AMA also added codes for the percutaneous conversion and exchange of nephrostomy catheters. Code should be reported when converting to a nephroureteral catheter via a preexisting nephrostomy tract. Code should be used when exchanging nephrostomy catheters. Both code including the diagnostic nephrostogram and/or ureterogram when performed, as well as imaging guidance and all associated radiological supervision and interpretation. If the removal of the catheter requires fluoroscopic guidance, use code (removal of nephrostomy tube, requiring fluoroscopic guidance [e.g., with concurrent indwelling ureteral stent]). Coders now have the option to report add-on code for an endoluminal biopsy of the ureter and/or renal pelvis. The code includes non-endoscopic imaging guidance and all associated radiological supervision and interpretation. The code may be reported once per ureter, per day. The biopsy may be performed through a new transrenal access, existing renal/ureteral access, transurethral access, an ileal conduit, or ureterostomy, according to McCall. New codes for placement of a ureteral stent are differentiated by the type of access, with the codes specifying a preexisting nephrostomy tract (50693), new access without a separate nephrostomy catheter (50694), and new access with a separate nephrostomy catheter (50695). Each code is for percutaneous placement, including a diagnostic nephrostogram and/or ureterogram when performed, imaging guidance, and all associated radiological supervision and interpretation. When a separate ureteral stent and nephrostomy catheter are placed into a ureter and its associated renal pelvis during the same session through a new percutaneous renal access, use code 50695, McCall said. This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. EDITORIAL ADVISORY BOARD Steven Andrews Editor sandrews@hcpro.com Questions? Comments? Ideas? Contact Editor Steven Andrews at sandrews@hcpro.com or , Ext Follow Us Follow and chat with us about all things healthcare compliance, management, and Kimberly Anderwood Hoy Baker, JD, CPC Director of Medicare and Compliance HCPro Danvers, Massachusetts Dave Fee, MBA Product Marketing Manager, Outpatient Products 3M Health Information Systems Murray, Utah Frank J. Freeze, LPN, CCS, CPC-H Principal The Wellington Group Valley View, Ohio Susan E. Garrison, CHCA, CHCAS, PCS, FCS, CPC, CPC-H, CCS-P, CHC, CPAR Executive Vice President of Healthcare Consulting Services Med Law Advisors, Inc. Atlanta, Georgia Diane R. Jepsky, RN, MHA, LNC CEO & President Jepsky Healthcare Associates Sammamish, Washington Lolita M. Jones, RHIA, CCS Lolita M. Jones Consulting Services Fort Washington, Maryland Jugna Shah, MPH President Nimitt Consulting Washington, D.C. Briefings on APCs (ISSN: [print]; [online]) is published monthly by HCPro, a division of BLR. Subscription rate: $285/year. Briefings on APCs, 100 Winners Circle, Suite 300, Brentwood, TN Copyright 2016 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, a division of BLR, or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro.com. Visit our website at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions ex pressed are not necessarily those of BAPCS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Current Procedural Terminology (CPT) is copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of American Medical Association; no fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. 2 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

3 March 2016 Briefings on APCs The AMA added two add-on codes describing embolization (50705) and balloon dilation (50706) of the ureter using non-endoscopic imaging guidance. Each may also be reported once per ureter, per day. A diagnostic pyelography or ureterography may be reported separately, if performed, as can other interventions or catheter placements performed at the same site as the embolization or dilation. Coders should look at which procedures these addon codes can be used with, which include many of the new 2016 services, in the parenthetical listings, McCall said. In the male genital system section, coders will find two new options: 54437, repair of traumatic corporeal tear(s) 54438, replantation, penis, complete amputation including urethral repair If there s a tear that happens traumatically, these are going to be the codes we use, said McCall. Changes in other sections Updates to CPT codes in other surgical sections are even more minor than those made to the digestive and urinary sections. The integumentary system has two new codes, with no revisions or deletions. Very often, lesions in the body are marked with devices prior to therapy, said Peggy Blue, MPH, CPC, CEMC, CCS-P, a Medicare and coding Boot Camp instructor for HCPro, during the webcast. The goal of therapy is to shrink or eradicate the lesion and sometimes following therapy the lesion is no longer palpable or visible. Marking the problematic area prior to therapy is helpful for pinpointing that area for examination and possible resection following therapy, she said. While the CPT Manual already has site-specific codes to denote placement of these markers, two new codes for 2016 allow coders to report placement in other areas, such as the axilla or groin, that do not have specific codes: 10035, placement of soft tissue localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging, first lesion Add-on code 10036, placement of soft tissue localization device; each additional lesion The primary code should only be reported once per target site, regardless of how many markers are used. The add-on code should be used to report a second site. Coders should check to see if a site-specific code exists before reporting or 10036, Blue said. The AMA made minimal changes to codes for the respiratory system, deleting code (endobronchial ultrasound [EBUS] during bronchoscopic diagnostic or therapeutic interventions) and replacing it with three more specific codes. Very often, lesions in the body are marked with devices prior to therapy. Peggy Blue, MPH, CPC, CEMC, CCS-P The codes are: 31652, bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed; with EBUS guided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies], one or two mediastinal and/or hilar lymph node stations or structures 31653, bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed; three or more mediastinal and/or hilar lymph node stations or structures Add-on code bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed; with transendoscopic EBUS during diagnostic or therapeutic interventions for peripheral lesion(s) Endobronchial ultrasound is a relatively new, minimally invasive procedure that allows physicians to sample central lung masses and lymph nodes with the help of ultrasound guidance, without the need for conventional surgery, Blue said. It can be used for the diagnosis of lung cancer or other diseases that cause enlarged lymph nodes or masses in the chest. Each of these codes can only be reported once per session. H EDITOR S NOTE To learn more about the 2016 CPT changes, see the HCPro webcast Prepare for 2016 CPT Changes. To order an on-demand copy of the webcast, visit com HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 3

4 Briefings on APCs March 2016 Pay attention to the hierarchy when reporting drug administration services The CPT Manual divides drug administration services into three different categories: Hydration (CPT codes ) Therapeutic, prophylactic, and diagnostic injections and infusions ( ) Chemotherapy and other highly complex drug or highly complex biologic agent administration ( ) Each section of codes includes some that have the word initial as part of the code description, while others do not. Coding professionals will find add-on codes that may be used in conjunction with what is usually thought of as the parent code, usually the code that comes right before the add-on code in the CPT Manual. In the case of drug administration codes, these add-on codes may be used alongside other codes that are not necessarily the parent code. What is critical to note is that the IV injection and infusion drug administration CPT codes are subject to a coding hierarchy that is applicable to the facility setting and not the physician-office setting. According to the facility CPT coding hierarchy, chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services, which are primary to hydration services. Infusions are primary to pushes, which are primary to injections. Note that IV push injections are subject to the hierarchy. Subcutaneous (SQ) and intramuscular (IM) injections are not, as they do not contain the word initial in their descriptors nor are they IV services, which is what the facility coding hierarchy focuses on. IV infusion and injection facility coding drug administration hierarchy Remember, the hierarchy applies to all IV injection and infusion services. Chemotherapy services are primary and should be selected as initial when provided in conjunction with therapeutic, prophylactic, or diagnostic services. This hierarchy also supersedes parenthetical instructions for add-on codes that in some cases may suggest an add-on of a higher hierarchical position to be reported in conjunction with a base code of a lower position, according to the CPT Manual. In other cases, information may be missing from the parenthetical instructions. Use parenthetical notes in conjunction with the hierarchy, but allow the hierarchy to take precedence, as that will lead to correct coding each time. If you have questions, check with CPT, submit a question to the American Hospital Association, and reach out to your MAC. One code in each of the drug administration categories below, as directed by the CPT Manual, has been designated as the initial service: Chemotherapy and other highly complex drug or highly complex biologic agent administration Infusion (initial) IV push (initial) IM/SQ (no mention of initial) Others (many other codes exist in the section, but there is no use of the word initial since they are not IV services) Therapeutic/prophylactic/diagnostic injection and infusion Infusion (initial) IV push (initial) IM/SQ (no mention of initial) Hydration (initial) Services can be provided concurrently or sequentially. A concurrent service CPT code exists for an infusion service. Report this code when a new substance or drug is infused at the same time as another substance or drug. Concurrent infusions (CPT add-on code 96368) are only reported once per day regardless of whether the concurrent infusion lasts for multiple hours or whether additional drugs or substances are administered concurrently. Sequential services can be thought of as services that occur before or after another. They can be infusions or injections. Coding professionals need to know whether the same substance or drug is being administered because CPT includes different codes for reporting an infusion or injection of the same substance or drug versus a new substance or drug. 4 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

5 March 2016 Briefings on APCs Coding professionals also need to remember that the order of the service delivery does not determine what s initial. Even if a patient receives hydration first, followed by a therapeutic infusion, and then finally chemotherapy, the chemotherapy would be reported as the initial service according to the hierarchy. Typically, coding professionals will report only one initial service per visit, unless the patient has more than one access site. So if a patient receives hydration with IV pushes, with therapeutic infusions, or with chemotherapy, coding professionals can report hydration, but not as an initial service unless a separate IV line was started for it. Subsequent and sequential infusions The codes for subsequent and sequential infusions are add-on codes. Think of these infusions as ones occurring one after another or an infusion that comes before or after an initial service. Sequential infusions denote the administration of either a new drug or substance or the same drug or substance; knowing this is critical in selecting the correct code. Coding professionals can report these codes once per encounter for the same drug or infusate. If multiple different drugs or infusates are administered, then coding professionals can report multiple sequential infusion codes. Coding professionals can report (intravenous infusion, therapy, prophylaxis, or diagnosis; each additional hour) for additional hours of an initial infusion or additional hours of an infusion of a different substance or drug. This is an important concept because a single code is used to report two different things: additional hours as well as additional infusions. If the same drug is infused multiple times, CPT code must be used to report these infusions. This is not intuitive, since coding professionals usually think of this code as being used to report additional hours, yet is also used to report additional infusions of the same drug. In summary, use CPT to report each of the following: Additional hours of the initial service infusion Additional hours of a sequential infusion, which means additional hours of an infusion of a new drug Additional infusions of the same substance or drug therapy, prophylaxis, or diagnosis; additional sequential infusion, [list separately in addition to code for primary procedure] up to one hour), and for a chemotherapy sequential infusion, use Coding professionals can report codes that include subsequent/sequential in their descriptions even if those codes are the first service in a group of services (e.g., an IV push given in addition to an initial one-hour infusion must be reported with the subsequent IV push code even though there is no initial IV push code). It is not intuitive to report a subsequent service addon code from one drug administration section of the CPT Manual, such as in the example given about an IV push and a therapeutic infusion or in the case with hydration and other IV drug administration services. It is necessary in order to be compliant with the CPT coding hierarchy that facilities must follow. When a patient receives a chemotherapy infusion and prehydration, coding professionals should report hydration code 96361, essentially a subsequent service add-on code, even though they do not report what may be considered the parent code, In this case, the parent code is actually the chemotherapy infusion CPT code This may seem counterintuitive because it comes For a sequential infusion of a new nonchemotherapy drug or infusate, report (intravenous infusion, 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 5

6 Briefings on APCs March 2016 from the chemotherapy section of CPT rather than the hydration section. This is often not intuitive to those new to reporting facility drug administration services because it does not follow traditional CPT coding convention of add-on codes, but it is necessary to be compliant with the CPT coding hierarchy rules. For example, facilities may report a sequential IV push of the same drug using CPT code This code is used to report multiple IV pushes of the same substance or drug, only if 30 minutes elapse between the reported pushes. This code is also used to report an infusion and an injection of the same substance or drug. In other words, if a nonchemotherapy drug is infused and then the same drug is given by IV push, facilities would report for the injection and for the infusion. Note that is only for facility reporting of each additional sequential push of the same substance or drug. Coding professionals should hone in on the phrase new substance or drug. Various codes are available for reporting sequential infusion and injection services. Coding professionals will determine which code to use based on whether the drug is the same or different. For example, multiple infusions of the same substance or drug are reported with add-on code 96366, which may not be intuitive since this code is typically used to report additional hours of an infusion but can also be used to report additional infusions of the same substance or drug. If the provider is not infusing a new substance, coding professionals should not report the sequential infusion code, but instead should follow the CPT instruction that points to using the additional hours code to report additional infusions of the same substance or drug if the time requirements are met. Concurrent infusions Unlike subsequent infusions that can run before or after an initial infusion, concurrent infusions run at the same time as another infusion. The CPT code for a concurrent infusion is also an add-on code and should be reported when multiple infusions are running simultaneously through the same line. CPT includes only one concurrent code, and it is for nonchemotherapy infusion. If a patient receives concurrent chemotherapy infusions, coding professionals should report unlisted chemotherapy administration code Substances mixed together in one bag are considered one infusion not concurrent. In addition, there is no concurrent infusion code for hydration. In fact, if hydration is provided at the same time as another infusion, it cannot be reported separately with a CPT code. In other words, there is no separate payment available for hydration running concurrently to another infusion. Coding professionals can assign the concurrent code when a patient receives chemotherapy and a therapeutic infusion simultaneously into the same line. They can also report it when the patient receives two different nonchemotherapy drugs at the same time through the same line. Reporting the concurrent infusion code has raised many questions, including whether the infusions have to run for exactly the same time or whether a certain amount of overlap qualifies in reporting the concurrent infusion code. The CPT Manual doesn t provide guidance on this, but CPT Assistant archives (Fourth Quarter 1990 present) 2009 Coding Update: Infusion / Injection Services (February 2009, Volume 19, Issue 2, pages 17 21), provides some insight. The answer there indicates that if the majority of one of the infusions is sequential in nature, not running at the same time as the other infusion, then reporting the sequential infusion service code would be more appropriate. This essentially indicates that either the concurrent or the sequential code can be reported but that the sequential code may be more appropriate if the majority of the time is not concurrent. Coding professionals should recall that when the concurrent code is reported, it is reported with a unit of one, signifying that the service being reported is concurrent in nature. Remember that additional hours of a concurrent infusion cannot be reported. Hydration Hydration coding generates plenty of questions for coding professionals. Hydration cannot be reported when fluids are used solely to administer drug(s) or other substances, or to keep the line open. Incidental hydration can t be billed. Also remember that hydration that occurs concurrently with another infusion service cannot be reported 6 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

7 March 2016 Briefings on APCs separately with the hydration CPT code, per CPT rules. Typically, hydration is reported as an initial service only when it s provided with no other drug administration services, or when it s provided with non-iv injection and infusion drug administration services. To report a hydration CPT code, the hydration must last for a minimum of 31 minutes. A parenthetical note under code instructs coding professionals not to report an IV infusion for hydration of 30 minutes or less. Per CPT, there are no limiting requirements around patients needing a specific diagnosis code, such as dehydration, or a specific flow rate, in order to bill for hydration. Some MACs have begun including diagnosis codes in their local coverage policies as well as guidance on flow rates that they believe to be appropriate in order to report hydration, while others have not. The CPT Manual does not state anything specific, so coding professionals need to check their MAC as well as local payers policies to know if there are any restrictions or stipulations on reporting hydration. Short hydration times cannot be added together to report a unit of hydration. For example, a patient may receive medically necessary hydration from 1p.m. to 1:15 p.m. and again from 2:10 p.m. to 2:30 p.m. These two separate hydration intervals cannot be added together to reach the more-than-30-minute time requirement for reporting hydration. In this case, no CPT code can be reported to reflect the two separate hydration services. Instead, a revenue code and dollar charge can be reported to reflect that facility resources were expended. Hydration provided before and/or after chemotherapy is appropriate to charge, if medically necessary and if it meets the time reporting requirement, but the time hydration runs during chemotherapy or concurrently with another infusion cannot be billed. Fluids include prepackaged solutions, normal saline, D5W, and lactated ringers. Hydration solution may include a combination of sugar and carbohydrates (for energy), electrolytes, and trace elements, or common crystalloid fluid. The December 2011 CPT Assistant indicates the reason for administration is important in reporting hydration or a therapeutic infusion. Reporting hydration versus a therapeutic infusion is based on the primary reason for the encounter, and whether any other infusion/injection services are performed. If the infusion is for rehydration and the patient received no other IV infusion service that day, report hydration as the initial service. If the patient receives an infusion to address a low potassium level for which 20 meq of KCI was added to an IV fluid, report the therapeutic infusion code. H EDITOR S NOTE This is an excerpt from the HCPro publication JustCoding s Injections and Infusions Coding Handbook, reviewed by Jugna Shah, MPH. For more information or to order, see OPPS ADVISOR by Jugna Shah, MPH Data accuracy is key for CMS to set payment rates, but guidance must be standardized Editor s note: Jugna Shah, MPH, president and founder of Nimitt Consulting, writes a bimonthly column for Briefings on APCs, commenting on the latest policies and regulations and analyzing their impact on providers. This month s column is all about data the importance of providers reporting accurate and complete data, as well as CMS having complete, accurate, and consistent data to compute future payment rates. Data has become an increasingly important part of healthcare as providers are required to collect, store, re- port, and analyze more of it. Payers are using data more and more to make coverage payments and business decisions. Data is used to refine clinical treatment plans, facilitate the creation of efficient internal processes, and data underlies most quality improvement and valuebased purchasing initiatives, among many other uses. Annual coding and billing changes, different Medicare Administrative Contractor interpretations and guidance, and Medicare moving toward more bundled payments can all result in incomplete, missing, and/or erroneous data being used by CMS in future rate-setting HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 7

8 Briefings on APCs March 2016 Data is so vital to CMS development of future payment policies and regulations that it s critical for providers to be able to report accurately and completely, but much of that depends on CMS and its MACs. For example, we re all familiar with the annual release of new diagnosis and procedure codes, as well as OPPS regulations, that need to be updated and put into place by January 1. Providers are almost never given a grace period and must be ready with all coding and billing changes for the upcoming year. But when CMS doesn t release new codes in a timely fashion, or its systems aren t ready to accept new codes or implement new policies, real-time problems can arise for providers, and future rate-setting can become compromised. We saw this last year with CMS not being ready with new codes to support the release of its February 5, 2015, national coverage determination (NCD) for lung cancer screening and the low-dose CT scan. Providers were forced to hold claims until January 1, 2016, when CMS finally released and recognized HCPCS codes G0296 (counseling visit to discuss need for lung cancer screening using low-dose CT scan) and G0297 (low-dose CT scan for lung cancer screening). This year, providers are facing problems reporting the following HCPCS laboratory test G codes: G0477, drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service G0478, drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service G0479, drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service G0480, drug test(s), definitive; qualitative or quantitative, all source(s), includes specimen validity testing, per day, 1 7 drug class(es), including metabolite(s) if performed G0481, drug test(s), definitive; qualitative or quantitative, all source(s), includes specimen validity testing, per day, 8 14 drug class(es), including metabolite(s) if performed G0482, drug test(s), definitive; qualitative or quantitative, all source(s), includes specimen validity testing, per day, drug class(es), including metabolite(s) if performed G0483, drug test(s); qualitative or quantitative, all source(s), includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed Because these codes were finalized late in 2015 by CMS Clinical Laboratory Fee Schedule (CLFS) group, it was too late for the Hospital Outpatient Department group to build these into the first quarter 2016 Integrated Outpatient Code Editor (I/OCE) files. Software vendors also may not be recognizing these codes at this time, but will likely do so by April Providers began noticing this and raised questions to CMS via and during the January 26, 2016 Hospital Open Door Forum (ODF) call. Without CMS recognizing these codes in its I/OCE, software vendors haven t included them in their products, leading many providers to wonder why seemingly official codes are not being recognized. In response to provider questions about whether they would have to hold claims, as they ve had to do in the past, face the burden of refiling, or simply leave these codes off claims, CMS did instruct its MACs to post some information in late January on their websites. For example, in late January, Palmetto GBA s site stated: CMS discovered systems errors affecting claims with new drug testing laboratory codes (HCPCS codes G0477 through G0483) with dates of service on or after January 1, No provider action is required. This means MACs will correct any claims previously returned to providers in error with these codes and reason code W7006. CMS will hold these claims until April 4, These codes are likely to be assigned status indicator Q4 for conditionally packaged 8 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

9 March 2016 Briefings on APCs laboratory services, which means more than likely there will be no separate reimbursement for providers. This has led to many providers wondering if they should just leave these codes off their claims, such as ED claims where these G codes occur in high volume, simply to get their claims submitted and paid. While understandable from a cash flow perspective, this practice raises two questions: would CMS see this as a compliance problems and won t this compromise future APC rates, since the dollars associated with these packaged labs will not be present on claims to package into other services? During the January ODF, call CMS staff indicated that they were aware of this and that it was a timing issue for CMS to get the new codes into the January I/OCE release. Staff also indicated that it would be OK for providers to remove these codes from their claims between January and April. If true, hopefully CMS will release this in official guidance to ensure that providers do not face any compliance backlash later. And even if providers are allowed to remove codes from claims in order to have them processed promptly and get paid in a timely manner, this sets a bad precedent for future rate setting, as future APC rates will become compromised if more and more codes are left off of claims simply because they are packaged. Other changes in the file, available at the CMS website titled 2016 Corrections to the Alpha-Numeric HCPCS File, include code deletions and slight edits to other codes. As CMS increases packaging, including conditional packaging, there is a danger that providers will not report all of their services, since there may be no separate payment. Additionally, with respect to comprehensive APCs (C-APCs), since CMS makes the assumption that all services reported on the same claim are related, there is again a risk that providers may stop reporting all of their services, in which case future C-APC payment rates could decline. The above issues, combined with data and analysis issues CMS may have, can all lead to future payment inaccuracies. The best thing providers can do is continue submitting all of their data in a timely and complete manner for all services, regardless of whether CMS has data issues and/or whether separate payment is generated. MACs offer conflicting guidance A separate but related issue involving CMS receiving inconsistent data has arisen regarding differing MAC guidance on whether providers should report a nonchemotherapy vs. chemotherapy injection code when injecting monoclonal antibodies and/or biologic response modifiers. CMS should clear up this question and release guidance that supersedes existing MAC guidance so that consistent data is received from providers. The two CPT codes in question are: 96372, therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 96401, chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic The code is for a more complex service that requires skilled staff and resources, and pays more than CPT code The CPT book states that code is to be used for certain monoclonal antibody agents and other biologic response modifiers, but the manual doesn t specify which drugs those could be. The Medicare Claims Processing Manual provides examples of some drugs that are allowed to be reported with the code, but then states: The drugs cited are not intended to be a complete list of drugs that may be administered using the chemotherapy administration codes. Local carriers may provide additional guidance as to which drugs may be considered to be chemotherapy drugs under Medicare. This has resulted in a situation where MACs have created their own guidance on whether providers should report or for the administration of certain biologic response modifiers, which essentially contradicts what the CPT Manual states, yet it s being allowed. As a result of MACs being allowed this discretion, despite the CPT book being clear, the data CMS receives won t consistently reflect the drug administration resources providers expend when providing biologic response modifiers or monoclonal antibodies. Two different drug administration codes with varying charges and payment rates can be reported for the administration of the exact same drug, depending on the MAC. Hopefully, CMS will address this and other anomalous data situations in the coming year. H 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 9

10 Briefings on APCs March 2016 Payments for Composite APCs Q Did something change with the observation services Composite APC in 2016? The director of patient financial services says we no longer receive payment for it. A The observation services Composite APC (APC 8009) was replaced with a single comprehensive APC (C-APC 8011) for CY 2016t. Along with the new C-APC comes new status indicator J2. Services assigned to J2 are considered to be adjunctive services and components of C-APC 8011, and this will result in a single payment for these services reported as part of the comprehensive observation services APC. The J2 designation and the payment are based at the claims level and not per date of service. The good news is that the requirements to meet the observation services C-APC are the same as for the Composite APC (e.g., clinic/ed visit, 8 or more units of G0378, etc.). Even more good news is that the ED visit level requirement now includes all Type A and Type B ED levels and critical care; the level is no longer limited to the higher ED visit levels. Be sure that all services provided continue to be reported to ensure that all costs pertaining to the individual patient s scenario are included in your claims data. CMS will continue to expect and rely on the claims data for rate setting under the OPPS. For more information, see the Medicare Claims Processing Manual, Chapter 4, sections , , 10.4, , , and new section How do we apply modifier CT? Q Our radiology department is requesting that we add a new modifier to their charge description master (CDM), modifier CT (computed tomography [CT] services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association [NEMA] XR standard). They want this added to the CT scan line items, but they are not sure if it is for all of the items or only certain ones. Can you provide more information that might help us know how to proceed? A Each facility needs to have a discussion before you hardcode the modifier to the CDM. Modifier CT is a new modifier for 2016 and the NEMA standard has to do with dose optimization and management. For CT scans that are performed on equipment that is noncompliant with this standard, the modifier must be reported on specific codes. The specific CPT codes are listed in Transmittal 3425 and the Medicare Claims Processing Manual, Chapter 4, section A discussion is warranted if you have more than one CT scanner in use at your facility. This modifier is only applicable to scanners that don t meet the requirement, and a payment reduction is involved when the modifier is reported. For CY 2016, CMS instituted a 5% reduction in payment when the modifier is reported, but the percentage increases for CY 2017 and beyond. So, if you have multiple scanners in use, you want to be sure that the modifier is only applied to those services provided on the noncompliant scanner/equipment. Noting pregnant patient admission without delivery Q If patient is admitted to the hospital for a complication in the second trimester, how do we indicate this is not a delivery? When the patient delivers, we want to ensure we are not denied for it being already paid as part of the global package. A When you are billing for your complication in the second or third trimesters and the patient is still pregnant (undelivered), the appended ICD- 10-CM codes document this. If and when the patient actually delivers, you will append the outcome of delivery codes to the claim, as per the ICD-10-CM coding guidelines. The guidelines state: Outcome of delivery: A code from category Z37, Outcome of delivery, should be included on every 10 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

11 March 2016 Briefings on APCs maternal record when a delivery has occurred. These codes are not to be used on subsequent records or on the newborn record. Codes in this category to consider are: Z37.0, single live birth Z37.1, single stillbirth Z37.2, twins, both liveborn Z37.3, twins, one liveborn and one stillborn Z37.4, twins, both stillborn Z37.5-, other multiple births, all liveborn Z37.50, multiple births, unspecified, all liveborn Z37.51, triplets, all liveborn Z37.52, quadruplets, all liveborn Z37.53, quintuplets, all liveborn Z37.54, sextuplets, all liveborn Z37.59, other multiple births, all liveborn Z37.6-, other multiple births, some liveborn Z37.60, multiple births, unspecified, some liveborn Z37.61, triplets, some liveborn Z37.62, quadruplets, some liveborn Z37.63, quintuplets, some liveborn Z37.64, sextuplets, some liveborn Z37.69, other multiple births, some liveborn Z37.7, other multiple births, all stillborn Z37.9, outcome of delivery, unspecified Determine reimbursement for corneal tissue Q I have a question about reimbursement for the cost of corneal tissue. I previously read This line item should reflect the costs associated with the corneal tissue. We have just started providing this service and are having a debate on what this statement means. I think we can apply our usual markup, but our cost accounting person thinks this means we can only pass along our invoice cost. What does it mean in regard to setting our price? A The statement means that you should use the cost associated with the processing, preserving, and transporting of the tissue when you set your charge. Medicare pays this service based on reasonable cost basis, which means that it applies the cost-to-charge ratio to the line item in order to determine what your cost for the service was. Contributors We would like to thank the following contributors for answering the questions that appear on pages 10 12: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS Director of coding and HIM HCPro Danvers, Massachusetts Laurie L. Prescott, RN, MSN, CCDS, CDIP AHIMA-approved ICD-10 trainer CDI education specialist HCPro Danvers, Massachusetts Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC AHIMA-approved ICD-10 trainer President Webb Services Boise, Idaho Denise Williams, RN, CPC-H Director of revenue integrity services Health Revenue Assurance Associates, Inc. Plantation, Florida Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA AHIMA-approved ICD-10 trainer Safian Communications Services Orlando, Florida 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 11

12 Briefings on APCs March 2016 The standard markup can be used, but you want to be sure you use only the cost related to the corneal tissue and nothing else on that line item. This will ensure not only that you receive appropriate reimbursement, but that you also report the correct cost to the Medicare program. Reporting IMRT services accurately Q Our radiation oncology department is having some angst about some updated guidance provided by CMS regarding reporting of planning services. These services are provided prior to the actual intensity-modulated radiation therapy (IMRT) service in order to know how to deliver the IMRT. We are not sure if we have been reporting this correctly. A This subject came up during the comment period for the OPPS rule. A commenter asked for some clarification regarding the reporting of planning services and simulation codes for IMRT based on some guidance instructions that had been published by the American Society for Therapeutic Radiation Oncology. These instructions included a statement that if IMRT is the chosen treatment modality, a simulation code (e.g., CPT code 77290) cannot be reported separately prior to completion of the IMRT treatment plan, even if the two services are performed on separate days. CMS response was that this has been long-standing guidance in the NCCI Manual (see Chapter 9) and in the Medicare Claims Processing Manual instructions (Chapter 4, section ). The NCCI Manual notes that IMRT planning includes the simulation codes ( ) and these codes should not be reported with the planning. NCCI goes on to note that there are procedure pair edits in place for reporting the code pairs on the same date of service, and these edits should not be circumvented by performing the two procedures described by a code pair edit on different dates of service. There is no applicability of adding a modifier for this service. CMS went on to state that they believe hospitals have been reporting the services correctly, that the payment for the simulation codes is included in the planning code (77301), and that if separate claims have been submitted, CMS would consider this to be unbundling. CMS is updating the Medicare Claims Processing Manual language to be very specific: Payment for the services identified by CPT codes 77014, through 77295, through 77321, 77331, and is included in the APC payment for CPT code (IMRT planning). These codes should not be reported in addition to CPT code (on either the same or a different date of service) unless these services are being performed in support of a separate and distinct non-imrt radiation therapy for a different tumor. The important exercise here is to review your claims and reporting procedures to ascertain how the services are being reported, and ensure that the services are not being unbundled, even if they are performed/provided on different dates of service. If you have been reporting them separately and receiving separate payment, a conversation with your compliance officer is warranted. H Stay Connected BAPCs in Your Inbox Sign up for any of our 17 newsletters, covering a variety of healthcare compliance, management, and reimbursement topics, at Don t miss your next issue If it s been more than six months since you purchased or renewed your subscription to Briefings on APCs, be sure to check your envelope for your renewal notice or call customer service at Renew your subscription early to lock in the current price. Relocating? Taking a new job? If you re relocating or taking a new job and would like to continue receiving Briefings on APCs, you are eligible for a free trial subscription. Contact customer serv ice with your moving information at At the time of your call, please share with us the name of your replacement. 12 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or