HFMA Western NY Chapter January 25, 2011 Day 1 2011 OPPS UPDATES, CODING CHANGES AND CHARGE MASTER APPROACHES
INTRODUCTIONS Caroline Rader, Associate Director Ms. Rader has approximately 15 years combined of industry and professional consulting experience related to charge integrity services; including but not limited to, charge description master maintenance, charge capture strategies, outpatient clinical documentation improvement, and billing compliance. She serves many of the top hospitals in the nation on related topics including Johns Hopkins Health System, Novant Health, University of Maryland Medical System, Caritas Christi and MedStar Health. Ms. Rader is also recognized as a state and national speaker for HCCA, HFMA, ACDIS and AHIMA. Deborah Zarick, Associate Director Ms. Zarick has both a clinical and coding compliance background. She has many credentials including R.N, B.S.N, CPC, CCS-P, CEMC, CPC-I, and CPMA. She leads NCI s physician coding services, providing consulting to such clients as University of Maryland Medical System, Lifebridge Health, Loyola and Stanford Medical Clinics. 2
OBJECTIVES OF THE WORKSHOP 2011 includes 400 CPT revisions, deletions, and additions. In order to avoid claim denials and coding errors as well as capture revenue for accurately documented services, it is critical that you keep current on relevant and significant updates to CPT as well as HCPCS codes. The workshop will address specific code changes, the rationale behind the change, and the impact these changes will have on your charge description master. The work shop will cover the items below by clinical department: 2011 CPT and HCPCS update Charge Capture Strategies Tips for Auditing and Monitoring Regulatory Update and Considerations CPT is registered trademark of the American Medical Association. All rights reserved. 3
OBJECTIVES OF THE WORKSHOP After attending this meeting, participants should be able to: Implement the new OPPS rules into day to day operations; Cite important HCPCS/CPT coding changes for 2011; Describe the use of new codes; Identify target areas for investigation; Analyze current use of the charge description master to identify opportunities for improvement in charge capture, and Implement office policies and procedures to ensure compliance with fraud and abuse regulations and statutes. 4
CHARGE DESCRIPTION MASTER The charge description master (CDM) is a file that contains a list of a provider s chargeable services. Hospital facilities can assess a patient charge for visits, procedures, medications and supplies. A current and accurate CDM is vital to any healthcare provider seeking proper reimbursement. Among the potential negative impacts that may result from an inaccurate charge master are overpayments, underpayments, claim rejections, civil monetary fines and penalties. 5
CHARGE DESCRIPTION MASTER In addition to the list of services, the CDM electronic file includes the following: unique reference identifier the procedure or service description the appropriate HCPCS/CPT code (if available) the UB-04 revenue code number unit of service and/or multiplier corresponding charge dollar amount. CDM Number CDM Service Description HCPCS/ CPT UB04 Rev Code UOS Charge Amount 4500100 ED VISIT LEVEL I 99281 450 1 $200.00 6
CHARGE DESCRIPTION MASTER Unique Reference Identifier - An internally assigned unique number that identifies each specific procedure or service listed on the charge master. Procedure or Service Description-This designation describes the procedure or service to be performed. HCPCS/CPT Code-The corresponding HCPCS/CPT code that identifies the specific line item service or procedure. Level I Category I -CPT Codes Level I Category II Quality Measurements Level I Category III New Technology Level II HCPCS National Codes 7
CHARGE DESCRIPTION MASTER UB-04 Revenue Code-A three-digit code number representing a specific accommodation, ancillary service, or billing calculation required for facility billing. Unit of Service/Multiplier In most cases the service unit of service will default to a unit of 1 and the line item is charged per each service. However, some instances will occur where the line item service or item is provided or dispensed in multiple units. Charge Dollar Amount-The specific amount charged by the facility for each procedure or service. This is not the actual amount that the facility will be reimbursed by a third party payer. Instead, the charge dollar amount represents the standard charge for that item. 8
CHARGE DESCRIPTION MASTER Services and/or items found in the CDM can either be hardcoded or soft-coded. To hard-code a service or item is to include the HCPCS/CPT in the CDM. The service or item is coded automatically and no human intervention is required. Hard-coding should be used only for the services that lack variability in their approach, performance, or situation such as EKGs, ED and clinic visits, radiology and laboratory services. To soft-code a service or item is to not include the HCPCS/CPT in the CDM. The service or item requires coding to be done manually by HIM or other means. Soft-coding is suitable for procedures that are variable in nature; such as surgical procedures (e.g. CPT codes 10000-69999). 9
CHARGE DESCRIPTION MASTER Current Procedural Terminology or CPT Codes (Level I/Category I CPT)) Maintained and updated annually by the American Medical Association. New updated code manuals provided in November of each year, with January 1 effective dates for changes. Focus on Appendix B of the CPT Coding Manual Summary of Additions, Deletions, and Revisions when evaluating the necessary changes to the charge master. CPT Code Categories: Evaluation and Management CPT Codes 99201 99499 Anesthesia CPT Codes 00100 01999 Surgery CPT Codes 10021 69990 Radiology CPT Codes 70010 79999 Pathology & Laboratory CPT Codes 80048 89399 Medicine CPT Codes 90281 99199 10
CHARGE DESCRIPTION MASTER Healthcare Common Procedure Coding System or HCPCS Codes (Level II) Maintained and revised throughout the year by CMS. New HCPCS codes are effective January1 of each year, with quarterly updates. HCPCS Code Categories: A Codes Transportation services B Codes Enteral and Parental Therapy C Codes Temporary codes for use with OPPS D Codes Dental procedures E Codes Durable Medical Equipment G Codes Procedures and Professional Services H Codes Alcohol & Drug Abuse Treatment Services J Codes Drugs Administered Other Than Oral K Codes DME Regional Carriers L Codes Orthotic and Prosthetic Procedures M Codes Other Medical Services P Codes Pathology and Laboratory Services Q Codes Temporary R Codes Diagnostic Radiology Services S Codes Nat l Codes (Non-Medicare) T Codes Nat l Codes for State Medicaid Agencies V Codes Vision and Hearing Services 11
CHARGE DESCRIPTION MASTER CPT Category III Codes Maintained and updated semiannually by the AMA. Temporary codes for emerging technologies, services, and procedures. Use Category III Code if available in lieu of Category I unlisted CPT Code. Codes have a alpha character as the fifth digit. Category Code III assignment does not imply coverage. 12
CHARGE DESCRIPTION MASTER CPT and HCPCS Level II Modifiers Modifiers provide a means by which a service can be altered without changing the procedure code. Required by CMS to be reported for outpatient services. The CPT modifiers currently approved for hospital reporting include: 25, 27, 50, 52, 58, 59, 73, 74, 76, 77, 78, 79 and 91. The HCPCS modifiers that are currently approved for hospital reporting are: CA, E1 through E4, FA through F9, BL, GN, GO, GP, GA, GY, GZ, GG, GH, LC, LD, RC, LT, RT, and TA through T9. 13
CHARGE DESCRIPTION MASTER CPT and HCPCS Level II Modifiers Varyingmethods of modifier assignment: Hard coded in the charge master Assigned by HIM Assigned during charge entry process Assigned through automated edits Assigned during pre-bill by PFS Assignment of correct modifiers can be critical to reimbursement Modifier 25 Modifier 50 Modifier 59 Modifier CA 14
CHARGE DESCRIPTION MASTER CPT and HCPCS Level II Modifiers Most common modifiers: 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. 27 Multiple outpatient hospital E/M encounters on the same date 50 Bilateral procedure 52 Reduced services 59 Distinct procedure 91 Repeat clinical diagnostic laboratory test LT Left side RT - Right side 15
CHARGE DESCRIPTION MASTER Hospital facilities also incorporate standard business rules around how their CDM is structured. Considerations can include the following: inclusion or use of statistical or other zero dollar line items Example: patient visit counters for productivity measures the determination of allowable items for charging Example: charging thresholds, routine supplies duplicate CPT codes across clinical departments Example: EKGs in the emergency department, clinics and diagnostic cardiology use of charge explosions use of miscellaneous CDMs decisions to standardize the CDM across a health system 16
CHARGE DESCRIPTION MASTER The CDM is one of the most complex master files within any hospital facility and is subject to continuous updates. Proper maintenance is essential to ensure proper charging for services and supplies within financial and regulatory parameters. Poor maintenance of the CDM can put the hospital at financial risk and may introduce risk of regulatory non-compliance. Because the Healthcare Common Procedure Coding System (HCPCS) codes and APCs are updated regularly, hospitals should pay particular attention to the task of updating the CDM to ensure the assignment of correct codes to outpatient claims. This should include timely updates, proper use of modifiers, and correct associations between procedure codes and revenue codes. - OIG Compliance Guidance for Hospitals 17
CHARGE DESCRIPTION MASTER Scenario Hospital bills and is reimbursed for services performed outside of the hospital. The staff performing the services did not indicate the patient location or type of service to charge entry staff. Similar services are provided within the hospital therefore billing staff do not question claims. The services are billed as if they were performed within the hospital walls. The hospital is reimbursed at a higher rate and benefit than would have been if the services were billed appropriately. Cause De-centralized CDM maintenance processes. Lack of charge capture knowledge within clinical department. Lack of participation of CDM Team in creation of new service line. Lack of regular CDM audit process. Consequences The hospital is fined over $1 million and is placed under a corporate integrity agreement with the OIG for 5 years. Required training and annual external review cost the hospital hundreds of thousands of dollars that are exempt from cost reporting. New positions are created and better controls in place as required under agreement. 18
CHARGE DESCRIPTION MASTER Hospitals can benefit from a formal process that routinely seeks to improve the maintenance and management of the CDM. Management of the CDM requires a coordinated team effort led by a senior manager ( CDM Coordinator ). CDM Coordinators create the need for a specific skill set: knowledge of the clinical terminology understanding of the various procedures performed in a given specialty area a solid understanding of coding and billing functions ability to work with stakeholders of the front, middle and back end of the revenue cycle 19
CHARGE DESCRIPTION MASTER Effective and efficient operation of the CDM requires close coordination and participation by various departments. Patient Financial Services Financial Reimbursement and Contract Management Patient Care Departments Compliance and Revenue Integrity Health Information Management Information Systems = CDM TEAM 20
CHARGE DESCRIPTION MASTER The primary purpose of the CDM team is to review the CDM policies and procedures and to improve the management and understanding of the CDM across the hospital users. The team should review all the new items and services it intends to add to the CDM. The team should be able to suggest changes to existing CDM items. CDM additions, revisions and deletions should be inventoried through the use of a change request form. The purpose of the form is to help the team evaluate the change request. 21
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CHARGE DESCRIPTION MASTER The CDM team should establish a charge-audit process to ensure that all new charges and planned changes to existing charges are properly captured, reported, and documented. The focus of this audit is to examine not only the accuracy of the billing statement but also the supporting medical record documentation to prevent the charge from being denied. The CDM policies and procedures should also include a schedule for performing routine audits of the CDM. Limited reviews are recommended at least annually, with comprehensive reviews at a three-year interval. 23
CHARGE DESCRIPTION MASTER Review Step Limited CDM Review Comprehensive CDM Review Review CDM for Deleted Codes Review CDM for Accurate Assignment in HCPCS/CPT, based on CDM Procedure or Service Description Review CDM for Accuracy in UB04 Revenue Code Assignment Review CDM for Accuracy in Unit of Service/Multiplier Assignment Review CDM for Missing HCPCS/CPT Review CDM for Zero Usage Line Items Review CDM Pricing Review CDM for Duplicate HCPCS/CPTs Review CDM Line Item Usage Against Expected Usage Patterns Review Departmental CDM, Charge Capture and Documentation Practices including review of charge capture tools and medical record documentation to charge capture Review Clinical Subsystem to CDM Linkage(aka Order Entry Mapping) 24
CHARGE DESCRIPTION MASTER The CDM is a critical piece of effective revenue management. Hospital organizations of all sizes and capabilities are using tools to support daily CDM maintenance. NOTE: this is a tool and not a complete solution Optimal software packages include the following: online reference tools have a complete and active code book feature include a browser-based, cross-reference toolkit have the ability to analyze prospective and retrospective claims for potential charge capture and/or compliance issues 25
OUTPATIENT REIMBURSEMENT With the implementation of APCs in 2000, the CDM has had a more important role in the charge capture, coding and billing processes of services rendered. Payment is defined by the HCPCS/CPT codes reported, which in many cases is hard-coded in the CDM. The importance of capturing and reporting the correct HCPCS/CPTs continues as Medicaid contractors, such as New York State Medicaid, adopt other reimbursement methodologies such as Ambulatory Payment Groups (APGs) and as health care reform moves to bundled payment methodologies. 26
OUTPATIENT REIMBURSEMENT APC system was implemented by Medicare in 2000. Annual and quarterly update process. Payment for services is calculated based on APC grouping logic. Services within an APC are similar clinically and require similar resources. APC payments include certain packaged items, such as anesthesia, supplies, certain drugs, and the use of recovery rooms. Packaged services are considered to be included in the primary APC payment and can also include ancillary services Payment logic is further defined by the use of NCCI edits, MUEs and status indicators. 27
OUTPATIENT REIMBURSEMENT National Correct Coding Initiative (NCCI) CMS developed the NCCI to promote national correct coding methodologies. The NCCI was developed by the Centers for Medicare and Medicare Services (CMS) to: Prevent payments from being made due to inappropriate CPT and HCPCS code assignment; Eliminate unbundling of services; Detect incorrect or inappropriate reporting of combinations of CPT and HCPCS codes; and Curtail improper coding practices that lead to inappropriate increased payment. NCCI edits are reviewed for every possible pairing of CPT and HCPCS codes. They continue to be enhanced utilizing the following: Coding conventions defined in the American Medical Association's CPT code manual; National and local policies and edits; Coding guidelines developed by national societies; Analysis of standard medical and surgical practice; and Review of current coding practice. 28
OUTPATIENT REIMBURSEMENT Medically Unlikely Edits (MUEs) CMS developed (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. Payment for Part B services is limited by HCPCS/CPT as defined by the MUEs. Not all HCPCS/CPT codes have an MUE. Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors' use only. Those that have been published are available online on CMS website. http://www.cms.gov/nationalcorrectcodinited/08_mue.asp#topofpage 29
OUTPATIENT REIMBURSEMENT CMS Status Indicators Indicator Definition Explanation A B Indicates services that are paid under some other method: Durable medical equipment, prosthetics and orthotics are paid under the DMEPOS fee schedule Physical, occupational, and speech therapy are paid under the physician fee schedule Ambulance services are paid under the ambulance fee schedule Erythropoietin (EPO) for end-stage renal disease (ESRD) is paid under a national rate Physician services for ESRD patients are billed to the Medicare carrier Clinical diagnostic laboratory services are paid under the laboratory fee schedule Screening mammography is paid by either the lower charge or national rate structure Codes not recognized by OPPS when submitted on an Outpatient Hospital Part B bill type (12x,13x, and 14x) Not paid under OPPS. Paid by Medicare contractors under the appropriate fee schedule or another payment system. Should not be used for OPPS billing since they are not payable under OPPS. Services may be payable when submitted on a different bill type (e.g., 075X CORF). Some codes may have an alternate code that should be used for OPPS billing. C Inpatient only Not paid under OPPS unless specific circumstances have been met. Admit patient; bill as inpatient. 30
OUTPATIENT REIMBURSEMENT Indicator Definition Explanation D Deleted Code or Discontinued Code Codes deleted or discontinued effective January 1, 2011. E Items, codes, and services that meet one of the following conditions: Are not covered by Medicare based on statutory exclusion Are not covered by Medicare for reasons other than statutory exclusion Are not recognized by Medicare but for which an alternate code for the same item or service may be available Separate payment is not provided by Medicare Not paid under OPPS or any other Medicare payment system. F Corneal Tissue Acquisition Cost; Certain CRNA Services Not paid under OPPS. Paid at reasonable cost. G Drug/Biological Pass-Through Paid under OPPS. Separate APC payment made. H Device Category Pass-Through, Therapeutic Radiophamaceuticals Paid under OPPS. Separate cost-based passthrough payment made. 31
OUTPATIENT REIMBURSEMENT Indicator Definition Explanation K Non Pass-through Drug/Biological; Separate APC Payment Paid under OPPS. Separate APC payment. L InfluenzaVaccine;PneumumoccalPneumoniaVaccine Not paid under OPPS. Paid at reasonable cost and not subject to deductible or coinsurance. M Service not billable to FI and not payable under OPPS Not paid under OPPS. N ServiceIsPackagedintoAPCRate Paid under OPPS. However, payment is packaged into payment for other services. No separate APC payment made. P Partial Hospitalization Paid under OPPS; per diem APC payment. Q1 STVX Packaged Paid under OPPS. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator S, T, V, or X. (2) In all other circumstances, payment is made through the separate APC as listed in the table. 32
OUTPATIENT REIMBURSEMENT Indicator Definition Explanation Q2 T Packaged Paid under OPPS. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator T. (2) In all other circumstances, payment is made throughtheseparateapcaslistedinthetable. Q3 Composite Paid under OPPS. (1) Composite APC payment based on OPPS composite-specific payment criteria. Payment is packaged into a single payment for specific combinations of service. (2) In all other circumstances, payment is made through a separate APC payment or packaged into payment for other services. 33
OUTPATIENT REIMBURSEMENT Indicator Definition Explanation R Blood and Blood Products Paid under OPPS; separate APC payment. S Significant Procedure, Not Discounted When Multiple Paid under OPPS; separate APC payment. T Procedure, Discounted When Multiple T Procedures Performed Paid under OPPS; separate APC payment. U Brachytherapy Sources Paid under OPPS; separate APC payment. V Visit to Clinic or Emergency department Paid under OPPS; separate APC payment. X Ancillary Service; Separate APC Payment Paid under OPPS; separate APC payment. Y Non-Implantable Durable Medical Equipment:; Not paid under OPPS Not paid under OPPS. All institutional providers other than home health agencies bill to durable medical equipment regional carrier. 34
OUTPATIENT REIMBURSEMENT Payment is driven at an encounter level and requires the use of HCPCS/CPT codes. All items and services should be captured per encounter to collect valuable cost and clinical information for future rate setting. Fifty percent of the full OPPS amount is paid if a procedure for which anesthesia is planned is discontinued. Multiple surgical procedures furnished during the same operative session are discounted. Other items/services may qualify as pass-through items and receive an additional payment. These items/services are identified by status indicators G and H. 35
OUTPATIENT REIMBURSEMENT Composite APCs are reimbursed for services that can span an episode of care and package services into a single payment for services such as the following: Outpatient Observation Services Low Dose Radiation Prostate Brachytherapy Electrophysiology Studies Mental Health Services Multiple Imaging Studies 36
OUTPATIENT REIMBURSEMENT Composite APC Composite APC Title Criteria for Composite Payment 8000 Cardiac Electrophysiologic Evaluation and Ablation Composite At least one unit of CPT code 93619 or 93620 and at least one unit of CPT code 93650, 93651 or 93652 on the same date of service. One or more units of CPT codes 55875 and 77778 on the same date of service. 1) Eight or more units of HCPCS code G0378 are billed-- On the same day as HCPCS code G0379*; or On the same day or the day after CPT codes 99205 or 99215; and 2) There is no service with SI=T on the claim on the same date of service or 1 day earlier 8001 Low Dose Rate Prostate Brachytherapy Composite 8002 Level I Extended Assessment and 1) Eight or more units of HCPCS code Management Composite 37
OUTPATIENT REIMBURSEMENT Ambulatory Payment Groups (APGs) were created in the mid- 1990 s as a methodology to reimburse outpatient services. The APGs were designed to clearly describe and define each ambulatory visit for both clinical and financial purposes. The overriding goals of APGs are to create a medical home for patients, promote and ensure continuity of care, and promote efficiencies in a payment model. Several state Medicaid programs and third-party payers continue to operate under an OPPS developed using APGs as the classification system. 38
OUTPATIENT REIMBURSEMENT Many similarities still exist between APGs and APCs, including the use of HCPCS/CPT codes to assign payment groups, and packaging logic to bundle ancillaries into final payment. The methodology is further defined by the consideration of ICD-9-CM diagnoses and significant procedure consolidation. As with APCs, HCPCS/CPTs are grouped to APGs. From the grouping additional factors, such as weights and packaging discounts, are considered before final payment is determined. 39
OUTPATIENT REIMBURSEMENT There are three primary types of APGs: Significant Procedure-A procedure which constitutes the reason for the visit and dominates the time and resources expended during the visit. Examples include: excision of skin lesion, stress test, treating fractured limb. Medical Visit A visit during which a patient receives medical treatment (normally denoted by an E&M code), but did not have a significant procedure performed. E&M codes are assigned to one of the 181 medical visit APGs based on the diagnoses shown on the claim (usually the primary diagnosis). Ancillary Tests and Procedures- Ordered by the primary physician to assist in patient diagnosis or treatment. Examples include: immunizations, plain films, laboratory tests. 40
OUTPATIENT REIMBURSEMENT Source: New York State Office of Health Insurance Programs, APG Implementation Ambulatory Patient Groups (APGs) and Ancillary Lab/Radiology Services, September 2009. 41
OUTPATIENT REIMBURSEMENT Other payers may reimburse based on a fee-for-service system or a prepaid system. The prepaid system includes managed care plans or capitation plans that pay in advance of any services for each of its members. Usually, the medical provider receives a fixed dollar amount each month for each member in return for medical services when they are needed. The focus of the chargemaster changes from one of charges to that of resource management and costs in order to determine the actual cost of services versus the reimbursement. 42
OUTPATIENT REIMBURSEMENT The future methodology for outpatient reimbursement will focus on bundled payments. Seen as a measure to control health care costs and provide higher quality of care. Under bundled care models, the payment model highly incentivizes providers to care for complicated patients with high severity of illness. Any reduction of cost based on expected complications will be pure profit potential. Evidence driven medicine 43
REGULATORY CONSIDERATIONS Maintaining a CDM to stay current on ever changing regulations, payer expectations and clinical practice can be daunting. Lack of controls and an effective maintenance process can lead to regulator scrutiny. Regulators are beginning to focus more and more on outpatient services in their auditing and monitoring of payment compliance. With the CDM as the backbone of the HCPCS/CPT coding and charge capture of outpatient services, the maintenance of the CDM should be at the forefront of any hospital revenue integrity program. 44
REGULATORY CONSIDERATIONS Why the shift in focus to outpatient services? Outpatient services are : provided in greater quantity, in a short span of time can occur simultaneously with other services involve different coding guidelines and different coding systems rely heavily on documentation from non-physician staff utilize a higher degree of computerization for documentation utilize automated processes for code selection that may not involve certified and/or experienced coding professionals 45
REGULATORY CONSIDERATIONS There are many regulatory contractors and initiatives to be aware of in today s outpatient environment: Comprehensive Error Rate Testing (CERT) Medicare Administrative Contractors (MACs) Medicaid Fraud Control Unit (MFCU) Medicaid Integrity Contractors (MIC) Payment Error Rate Measurement (PERM) Recovery Audit Contractor (RAC) Zone Program Integrity Contractors (ZPIC) The approach to reviews and issues targeted are very similar, if not the same. 46
REGULATORY CONSIDERATIONS Target Areas/Identified Issues Medical Necessity Infusion Therapy ICDs and Pacers Coronary Artery Stents Frequency Limitations Screening and Preventive Services Presence of Complete Provider Orders Laboratory and Radiology Complete and Legible Documentation Accuracy in Units of Service Reporting Pharmaceuticals Time-Based Codes 47
REGULATORY CONSIDERATIONS How are hospitals reacting? Revenue Integrity Programs Primary objective is to prevent recurrence of issues that can cause revenue leakage and/or compliance risk Activities under Revenue Integrity are expected to focus more on process improvement Taking a holistic approach 48
REGULATORY CONSIDERATIONS Revenue Integrity Programs A successful revenue integrity program will provide for a holistic view of the revenue cycle, with support from leadership and technology. Ultimately the program will provide for the following: Identification and correction to the processes and systems that lead to lost revenue opportunities through the creation of processes to ensure the accurate capture and reporting of data, translation of data into useful information and use of data to support strategic initiatives; Assurance that every chargeable procedure, item or service is coded, documented, captured, billed and paid according to the terms of government guidelines and payer contracts, and Serve as a resource for other staff members on questions or issues related to documentation, coding, charge capture and billing to create, or better foster, an organization-wide understanding of the importance of revenue integrity. 49
REGULATORY CONSIDERATIONS The Holistic View of Revenue Integrity MedAssets. (n.d.). Securing Revenue with Improved Data Use.Retrieved December 2010, from Healthcare Financial Management Association: www.hfma.org 50
CY2011 HCPCS/CPT AND OPPS UPDATES CPT Updates 109 deleted codes 213 new codes 365 revised codes Revisions can include those that did not change the intent of the service, but rather included a grammatical or formatting change HCPCS Updates 287 deleted codes 140 new codes 43 revised codes OPPS Updates Published Federal Register Final Rule, November 24, 2010 51
CY2011 HCPCS/CPT AND OPPS UPDATES Outline for remainder of work shop: D A Y 1 D A Y 2 Laboratory (inc. Blood Bank) Radiology (inc. Nuclear Medicine) Pain Management Interventional Radiology Cardiac Catheterization Electrophysiology Medical and Surgical Supplies Outpatient Facility E/M Services; Clinic and Emergency Services Outpatient Observation Services Infusions and Injections Pharmaceuticals Diagnostic Cardiology Respiratory/Pulmonary Cardiac and Pulmonary Rehabilitation Radiation Oncology 52
CY2011 HCPCS/CPT AND OPPS UPDATES Hospital Facility Chargemaster Reference Guide Includes additional detail for topics discussed today HCPCS/CPT Code to UB04 crosswalk Modifier definitions Greater narrative detail The companion guide provides for quick access to important payment tables and references UB04 claim form UB04 revenue code descriptions CMS Medically Unlikely Edits (MUEs) CY2011 CPT Code Changes CMS OPPS status indicator definitions CMS OPPS comment indicator definitions CY2011 CMS OPPS Final Rule Addendum B 53
LABORATORY Laboratory services are included in CPT code 80,000 range and include HCPCS for screening services (G-codes) and blood products (P-codes). The laboratory section of the CPT code manual includes subheadings and subsections that separate types of testing. UB04 revenue codes are specific to the type of testing being performed. CDM service or procedure descriptions often do not mirror the CPT manual description. Units of service in the CDM will default as 1 but it is common for a multiplier to be utilized due to the nature of the test to be resulted per specimen, analyte or other means. 54
LABORATORY CMS does not pay for laboratory services as part of APCs. Laboratory services are reimbursed from the laboratory fee schedule. There are essential coding guidelines to consider when capturing laboratory services: Diagnosis Coding Code Selection Modifier Use Date of Service Reporting Reference Laboratory Testing 55
LABORATORY Diagnosis Coding The diagnosis documented by the pathologist is the condition representing the highest degree of certainty for that visit. When the physician interpretation of a test performed in the outpatient setting establishes a definitive diagnosis, this definitive diagnosis should be coded. Any presenting symptoms that are integral to this diagnosis should not be coded. Any documented symptoms or conditions not routinely associated with the definitive diagnosis should be assigned additional codes. Abnormal findings in test results not interpreted by a physician, such as CBC or urinalysis, should not be coded unless confirmation of a definitive diagnosis is obtained from the physician. In these cases, the presenting symptoms, conditions, or other reasons for the test should be coded. 56
LABORATORY Code Selection Only those services ordered by a qualified provider should be provided and billed. Providers may not perform additional laboratory services based on internal standard or implied protocols. The following sample protocols are not covered Medicare services and may be subject to a regulatory contractor for corrective action. Physician s written order for a hemoglobin and hematocrit prompts the lab to perform a CBC Physician s written order for a CBC prompts the lab to perform a CBC with differential White cells or bacteria discovered in a physician ordered urine test prompts the lab to perform a urine culture without a physicians order 57
LABORATORY Modifier Use Modifier 91 should be appended to laboratory procedure(s) or service(s) to indicate a repeat test or procedure on the same day. This modifier should not be used to report repeat laboratory testing due to laboratory errors, quality control, or confirmation of results. Modifier 59 should be used to report procedures that are distinct or independent, such as performing the same procedure (which uses the same procedure code) for a different specimen. Modifier BL must be reported with blood products (P-codes) and blood processing HCPCS/CPT codes by OPPS providers that purchase blood or blood products from a community blood bank or assesses a charge for blood or blood products collected in its own blood bank. 58
LABORATORY Date of Service Reporting As a general rule the date the specimen was collected is the date of service to be reported. In the case where the specimen collection spans over two days, the date the collection ended is the reported date of service. Where a specimen is an archived specimen (stored >30 days), the date of service should reflect the date of the test. Reference Laboratory Testing Only one laboratory may bill for a referred laboratory service. It is the responsibility of the referring laboratory to ensure that the reference laboratory does not bill for the referred service when the referring laboratory does so (or intends to do so). In the event the reference laboratory bills or intends to bill, the referring laboratory may not do so. 59
LABORATORY Common Errors in Laboratory Billing per Comprehensive Error Rate Testing (CERT) Results Physician order for billed labs not submitted. Report date and date of order do not match. General coding errors Venipuncture Panels Urinalysis Blood Counts 60
LABORATORY Venipuncture CPT 36415 A specimen must be extracted in order to be paid. Only one collection fee is allowed for each type of specimen. If a series of specimens is required to complete a single test; treated as a single encounter. If the test resulted is deemed not medically necessary, the venipuncture to obtain the specimen is also considered to not be medically necessary. 61
LABORATORY Panels CPTs 80048, 80053 and 80061 (cited specifically) Individual tests that duplicate a test in a panel and should not be ordered. All of the tests in the definition of the panel should be documented as performed. Urinalysis with Microscope CPT 81001 Documentation must support the use of a microscope. Microscopic testing performed as part of a reflex test should be documented. Unable to read dipstick reactions due to color/chemical interference. The microscopic testing will be performed. 62
LABORATORY Blood Counts CPTs 85025 and 85027 The physician order must indicate CBC with differential to bill for 85025; otherwise CPT 85027 should be billed. Submit CPT code 85027 to report a CBC to measure hemoglobin, hematocrit, red blood cell, white blood cell and platelet levels Submit CPT code 85025 to report a CBC and differential white blood cell (WBC) count to measure the percentages of white blood cell types If the provider orders an automated hemogram (CPT 85027) and a manual differential WBC (CPT 85007), both codes can be reported. CPT 85007 cannot be reported with CPT 85025, as the WBC would be considered duplicative. 63
LABORATORY CMS Special Coverage and Billing Considerations Blood and Blood Products The act of transfusing blood or blood products is paid once per day, per CMS guidelines. The transfusion CPT should correspond to the type of product transfused Laboratory testing including blood typing, screening or matching should also be captured. Testing is reported separately whether the hospital received the product from a community blood bank or its own blood bank. Blood products must be reported with the transfusion service, and vice versa. If either is missing the claim may be returned to the provider. Report the unit(s) of blood transfused, applicable HCPCS with modifier BL, and UB04 revenue code 0380 0389 Albumin is reported with UB04 revenue code 0636 64
LABORATORY CMS Special Coverage and Billing Considerations PSA Screening Screening prostate antigen testing is covered once every 12 months for men age 50 years and older. Eleven months must elapse between exams. Specific coding requirements exist for payment consideration HCPCS code G0103 PSA screening, is payable by the Medicare laboratory fee schedule. Non-Medicare payers may not recognize the G-code and prefer a CPT code from range 84152-84154. Submit diagnosis code V76.44, Special screening for malignant neoplasm prostate, when billing for screening prostate specific antigen blood tests. 65
LABORATORY CMS Special Coverage and Billing Considerations Pap Smear Screening Screening Pap smears are covered once every two years for patients who are not at high risk. Screening Pap smears are covered annually, 11 months must elapse, for high-risk patients. Specific coding requirements exist for payment consideration HCPCS P3000 is payable under the Medicare Laboratory Fee Schedule Submit diagnosis code V76.2, routine cervical PAP 66
LABORATORY CMS Special Coverage and Billing Considerations Fecal Occult Blood Fecal occult blood and fecal immunoassays tests are covered annually by CMS, 11 months must elapse for patients age 50 years and older. Diagnosis codes appropriate to the risk factor should be submitted on the claim. Specific coding requirements exist for payment consideration HCPCS G0103 is payable under the Medicare Laboratory Fee Schedule - error CORRECTION: HCPCS G0328 (ifobt, or immunoassay-based). CPT 82270 non-medicare 67
LABORATORY CMS Special Coverage and Billing Considerations Diabetic Disease Screening Medicare covers diabetes screening tests for patients at risk for diabetes once every six months for patients who have been diagnosed with prediabetes, and once a year for those patient who have not received prediabetes diagnosis, or who have never been tested A fasting glucose (CPT code 82947) A post glucose challenge test (82950), or A glucose tolerance test (82951) is covered once every six months for patients who have been diagnosed with prediabetes and once a year for those patients who have not received a prediabetes diagnosis or who have never been tested. Report ICD-9-CM diagnosis code V77.1, Special screening for diabetes mellitus 68
LABORATORY CMS Special Coverage and Billing Considerations Cardiovascular Disease Screening Medicare covers cardiovascular disease screening. These are screening laboratory tests for cholesterol and triglyceride levels that can indicate the presence or risk of cardiovascular conditions. A lipid panel (CPT code 80061) is covered once every 60 months. Note that if the individual tests (82465, 83718, 84478) included in the panel are individually billed, the benefit limit will still apply. When billing for cardiovascular screening, one of the following ICD-9- CM diagnosis codes should be reported: V81.0, Special screening for ischemic heart disease V81.1, Special screening for hypertension V81.2, Special screening for other and unspecified cardiovascular conditions 69
LABORATORY Charge Capture Tips for Laboratory Services Understand the relationship between the clinical subsystem and the CDM. If charge explosions are utilized, review the parent to children relationships annually for in-house tests and quarterly for reference laboratory testing. When pricing individual CDM line items, be sure to compare the per test charge to the Medicare Laboratory Fee Schedule. The fee schedule pays at the fee schedule amount or lesser of charges for most tests. Ensure there is a formal process for verifying that a complete physician order is present before drawing a specimen and or performing a laboratory test. Front office staff should have the ability to question orders, contact providers or obtain additional information from the patient in the absence of contact with the ordering physician (i.e. signs/symptoms). Understand the relationship of HCPCS/CPT codes to clinical practice to understand how to analyze usage statistics. 70
LABORATORY Analyzing the laboratory CDM line item usage can identify potential areas of financial and/or compliance risk. Examples Urinalysis with Microscope It is not expected that the volume of urinalysis with microscopy (81000 81001) be at the same volume level or exceed the number of total urinalyses. If this is found, further review including a review of charge capture practice and the review of actual encounters should be performed. CBC and Manual Differential It is not expected that the volume of manual differentials (85007) will be at the same volume level or exceed the number of total complete blood count (CBC) (85025/7). If this is found, further review including a review of charge capture practice and the review of actual encounters should be performed. 71
LABORATORY Examples (continued) Crossmatch It is not expected that the volume of crossmatch CPT Codes (86920 86923) will exceed the total volume units of blood captured. It is expected that the volumes would be equal, or close to equal. A crossmatch is expected for each unit of blood. Antibody Screen The volume for antibody screen CPT Code 86850 should not exceed the total volume of crossmatch CPT codes (86920-86923). It is expected that one antibody screen will be captured with each crossmatch. 72
LABORATORY CY2011 CPT Updates Drug Testing New CPT Code 80104 80104, Multiple drug classes other than chromatographic method, each procedure. Created to report a specific drug screen, qualitative analysis by multiplexed method for 2 15 drugs or drug classes (eg, multidrug screening kit) and to eliminate confusion created by the HCPCS level II codes for drug testing. 73
LABORATORY CY2011 CPT Updates Chemistry Replaced CPT Codes 82926 and 82928 The gastric acid codes had low-volume utilization and were deleted and replaced by a simplified CPT code 82930. Deleted CPT Codes: 82926, Gastric acid, free and total, each specimen 82928, Gastric acid, free or total, each specimen New CPT Code 82930, Gastric acid analysis, includes ph if performed, each specimen 74
LABORATORY CY2011 CPT Updates Chemistry Revised CPT Code 82952 82952, Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) Revised to add-on status New CPT Code 83861 83861, Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity Created to report tear analysis by direct microfluidic specimen collection and tear film osmolarity Use code 83861 twice for tear analysis of both eyes 75
LABORATORY CY2011 CPT Updates Chemistry New CPT Code 84112 84112, Placental alpha microglobulin-1 (PAMG-1), cervicovaginal secretion, qualitative PAMG-1 is an immunoassay that represents a new approach as a chemical marker specific for detecting amniotic fluid from vaginal discharge. This biochemical marker can accurately and sensitively indicate fetal membrane rupture. Revised CPT Code 85597 85597, Phosphoid neutralization; platelet CPT Code 85597 has been updated to include phospholipid neutralization and platelet phospholipid neutralization. 76
LABORATORY CY2011 CPT Updates Chemistry New CPT Code 85598 85598, Phospholipid neutralization; hexagonal phospholipid New CPT Code 85598 was created to report hexagonal phospholipid neutralization CPT Code 85598 is a child code to 85597 77
LABORATORY CY2011 CPT Updates Immunology Revised CPT Codes 86480 86480, Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon CPT Code 86480 was revised to report TB testing by cell mediated immunity antigen response measurement New CPT Code 86481 86481, Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T-cells in cell suspension CPT Code 86481 was created to report TB testing by enumeration of gamma interferon-producing T cells. 78
LABORATORY CY2011 CPT Updates Transfusion New CPT Code 86902 86902, Blood typing; antigen testing of donor blood using reagent serum, each antigen test Deleted Codes 86903, Blood typing; antigen screening for compatible blood unit using reagent serum, per unit screened Use CPT Code 86902 79
LABORATORY CY2011 CPT Updates Microbiology New CPT Codes 87501, 87502 and 87503 Due to the volume of influenza molecular testing, more specific codes for detection of influenza virus were required. 87501, Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, reverse transcription and amplified probe technique, each type or subtype 87502, Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, reverse transcription and amplified probe technique, first 2 types or sub-types 87503, Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, multiplex reverse transcription and amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to primary procedure) 80
LABORATORY CY2011 CPT Updates Microbiology Revised CPT Code 87901 87901, Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase and protease regions HIV clinicians use resistance testing to select the appropriate drugs to optimize a patient s treatment regimen. The DHHS recommends resistance testing be utilized. CPT Code 87901 was revised to provide clarity and terminology consistency. CPT Code 87906 was also created. New CPT Code 87906 87906, Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (eg, integrase, fusion) 81
LABORATORY CY2011 CPT Updates Cytopathology New CPT Codes 88120 and 88121 Created to allow more specific reporting for multiple probe kits 88120, Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual 88121, Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computer-assisted technology Revised CPT Code 88172 88172, Cytopathology, evaluation of fine needle aspirate; immediate cytohistiologic study to determine adequacy for diagnosis, first evaluation episode, each site Revised to specify the units of service 82
LABORATORY CY2011 CPT Updates Cytopathology New CPT Code 88177 88177, Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure) Created to report each additional evaluation of a fine needle aspiration at the same site 83
LABORATORY CY2011 CPT Updates Surgical Pathology Revised CPT Codes 88332 and 88334 88332, Pathology consultation during surgery; each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure) 88334, Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site (List separately in addition to code for primary procedure) Revised to add-on code status New CPT Code 88363 88363, Examination and selection of retrieved archival (i.e., previously diagnosed) tissue(s) for molecular analysis (eg, KRAS mutational analysis) Created to report the pathologist s identification and selection of appropriate tumor tissue from a surgical specimen 84
LABORATORY CY2011 CPT Updates Lab Procedures New CPT Code 88749 88749, Unlisted in vivo (eg, transcutaneous) laboratory service Created to report unlisted in vivo tests because no unlisted service code was available Deleted CPT Codes With the creation of CPT Codes 43754-43755 (gastric intubation and aspiration) and to reflect current clinical practice, codes below have been deleted. 89100, Duodenal intubation and aspiration; single specimen (eg, simple bile study or afferent loop culture) plus appropriate test procedure 85
LABORATORY CY2011 CPT Updates Lab Procedures Deleted CPT Codes 89105, Duodenal intubation and aspiration; collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube 89130, Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology; 89132, Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology; after stimulation 89135, Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 1 hour 89136, Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 2 hours 86
LABORATORY CY2011 CPT Updates Lab Procedures Deleted CPT Codes 89140, Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 2 hours including gastric stimulation (eg, histalog, pentagastrin) 89141, Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 3 hours, including gastric stimulation 89225, Starch granules, feces 89235, Water load test 87