2011 cdm updates day 2

HFMA Western NY Chapter

January 26, 2011 – Day 2

2011 OPPS UPDATES, CODING CHANGES

AND CHARGE MASTER APPROACHES

CY2011 HCPCS/CPT AND OPPS UPDATESCY2011 HCPCS/CPT AND OPPS UPDATES� Outline for remainder of work shop:

� Laboratory (inc. Blood Bank)

� Radiology (inc. Nuclear Medicine)

� Pain Management

� Interventional Radiology

� Cardiac Catheterization

� Electrophysiology

� Medical and Surgical Supplies

D

A

Y

1

2

� 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

1

D

A

Y

2

CY2011 HCPCS/CPT AND OPPS UPDATESCY2011 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

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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

CLINIC CLINIC AND EMERGENCY SERVICESAND EMERGENCY SERVICES� Separate HCPCS/CPT codes have yet to be established to describe E/M services

provided within a facility.

� Hospitals are permitted to utilize “physician” E/M to capture charges for services provided.

� Physicians – expertise

� Hospitals – overhead

� To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or already established.

4

necessary to first determine whether the patient is new or already established.

� New vs. Established

� Pertains to whether or not the patient already has a medical record

number

� If patient had use of that medical record number within the past 3 years,

the patient is considered an established patient to the hospital

� The same patient could be “new” to a physician or department, but

“established” to the hospital

CLINIC CLINIC AND EMERGENCY SERVICESAND EMERGENCY SERVICESCMS Standards for E/M Guidelines for Facilities

1. The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should

be designed to reasonably relate the intensity of hospital resources

2. The coding guidelines should be based on hospital facility resources, not physician

3. The coding guidelines should be clear to facilitate accurate payments and be usable for compliance

purposes and audits

4. The coding guidelines should meet the HIPAA requirements

5. The coding guidelines should only require documentation that is clinically necessary for patient care

5

6. The coding guidelines should not facilitate upcoding or gaming

7. The coding guidelines should be written or recorded, well-documented, and provide the basis for

selection of a specific code.

8. The coding guidelines should be applied consistently across patients in the clinic or emergency

department to which they apply.

9. The coding guidelines should not change with great frequency.

10. The coding guidelines should be readily available for fiscal intermediary (or if applicable MAC) review.

11. The coding guidelines should result in coding decisions that could be verified by other hospital staff, as

well as outside sources.

2008, Federal Register Vol. 72, p. 66805

EMERGENCY SERVICES

20.00%

25.00%

30.00%

35.00%

40.00%

% D

istr

ibu

tio

nCY2009 New York State ED Facility Levels

��

0.00%

5.00%

10.00%

15.00%

20.00%

1 2 3 4 5 6

New York 3.69% 13.12% 35.69% 34.59% 12.91% 1.00%

National 3.40% 12.52% 33.22% 33.00% 17.87% 2.00%

% D

istr

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n

CLINIC CLINIC AND EMERGENCY SERVICESAND EMERGENCY SERVICES� A visit should be charged only when the patient is being seen for such services

as to:

� be diagnosed;

� obtain a referral;

� obtain or renew prescriptions;

� discuss plans for therapy;

� have a dressing changed;

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� have a dressing changed;

� check vital signs, and/or

� obtain services where the reason for the visit is not for the sole purposes

of having a diagnostic test/procedure, injection, surgical procedure or

other service that is further defined by a CPT/HCPCS Code.

CLINIC CLINIC AND EMERGENCY SERVICESAND EMERGENCY SERVICESVISIT CHARGE WITH PROCEDURE

When the patient meets the visit criteria defined on the previous page, but

during the same visit the patient does have a diagnostic test/procedure,

injection, surgical procedure or other service, the visit level may still be

charged. A modifier -25 must be appended to the visit charge to indicate to

the payers that there were separate and distinct procedures performed.

Visit with -25 modifier and Procedure Charge Scenario

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Visit with -25 modifier and Procedure Charge Scenario

Mrs. Smith is being seen by the pain management specialist at the hospital for

her back pain. She is unsure of the origin of her pain and her treatment

options. She would like further evaluation. She is greeted in the pain

management clinic with a history taken by the hospital nurse before being

seen by the physician. The physician reviews her symptoms and history and

recommends an epidural injection. The physician performs the epidural

injection while the patient is still in the office.

CLINIC CLINIC AND EMERGENCY SERVICESAND EMERGENCY SERVICESPROCEDURE ONLY

When the patient’s reason for coming to the hospital is for a scheduled

diagnostic test/procedure, injection, surgical procedure or other service it is

not appropriate to also charge for a visit unless the patient presents a new

problem or there is some degree of medical decision. Time spent preparing

the patient, including any related evaluation prior, is included in the procedure

charge.

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Procedure Charge Only Scenario


her back pain. She has been scheduled for an epidural injection. The physician

performs the epidural injection in the clinic.

CLINIC CLINIC AND EMERGENCY SERVICESAND EMERGENCY SERVICESPROCEDURE ONLY

When the patient’s reason for coming to the hospital is for a scheduled

diagnostic test/procedure, injection, surgical procedure or other service it is

not appropriate to also charge for a visit unless the patient presents a new

problem or there is some degree of medical decision. Time spent preparing

the patient, including any related evaluation prior, is included in the procedure

charge.

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Procedure Charge Only Scenario


her back pain. She has been scheduled for an epidural injection. The physician

performs the epidural injection in the clinic.

CLINIC CLINIC AND EMERGENCY SERVICESAND EMERGENCY SERVICES

� CY2011 OPPS UPDATE

� CMS has not made revisions regarding the guidelines for clinic and

emergency services E/Ms. Continue to utilize internal guidelines.

� Critical Care in the Facility Setting

� CMS clarified in the final rule that, consistent with the 2011 CPT guidelines, hospitals may

begin reporting all of the ancillary services and their associated charges separately when

they are provided in conjunction with critical care.

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they are provided in conjunction with critical care.

� However, hospitals will not receive separate payment for these ancillary services.

� If code 99291 is present on the claim with any of the specified ancillary procedure codes,

the IOCE will change the status indicator of the ancillary procedure code from Q[#] to N

for packaging.

� There is an exception to the packaged payment status of ancillary services when they are

not provided in conjunction with critical care services. Hospitals may use modifier -59 to

indicate when an ancillary procedure or service is distinct or independent from critical

care when performed on the same day but in a different encounter. Payment for such

services will not be packaged into the payment for critical care.

CLINIC CLINIC AND EMERGENCY SERVICESAND EMERGENCY SERVICES

� CY2011 OPPS UPDATE

� Physician Supervision of Therapeutic Services

� CMS clarified in the final rule that therapeutic services performed in

hospitals must be done under direct physician supervision.

� The definition only requires that the supervising physician or NPP be

“immediately available to furnish assistance and direction throughout

the performance of the procedure.”

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the performance of the procedure.”

� Examples of Outpatient Therapeutic Services:

� Clinic/emergency department visits

� Observation services

� Drug infusions and blood transfusions

� Outpatient psychiatric services

� Wound debridement

� Cardiac and pulmonary rehabilitation

CLINIC CLINIC AND EMERGENCY SERVICESAND EMERGENCY SERVICES� CY2011 OPPS UPDATE

� Tobacco Cessation Counseling

� Starting January 1, 2011, hospitals will have two new HCPCS codes for

reporting covered tobacco cessation counseling services.

� HCPCS codes C9801 and C9802 will be deleted December 31, 2010, and

replaced with HCPCS codes G0436 and G0437.

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� G0436 - Smoking and tobacco cessation counseling visit for the

asymptomatic patient; intermediate, greater than 3 minutes, up to 10

minutes

� G0437 - Smoking and tobacco cessation counseling visit for the

asymptomatic patient; intensive, greater than 10 minutes

� Specific coverage and coding guidelines

� http://www.cms.gov/manuals/downloads/clm104c18.pdf

OUTPATIENT OBSERVATION SERVICESOUTPATIENT OBSERVATION SERVICES� “Observation care is a well-defined set of specific, clinically appropriate

services, which include ongoing short term treatment, assessment, and

reassessment, that are furnished while a decision is being made regarding

whether patients will require further treatment as hospital inpatients or if

they are able to be discharged from the hospital. “

– Medicare Claims Processing Manual

� Specific coding and billing requirements exist for payment:

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� Physician Order

� Documentation

� HCPCS/CPT requirements

� Calculation of Hours

OUTPATIENT OBSERVATION SERVICESOUTPATIENT OBSERVATION SERVICES� Physician Order

� The physician documentation should clearly differentiate an order for

outpatient observation from an order for inpatient admission. The

reason for observation must be stated in the orders for observation.

� Physicians should not use the term “admit” when placing the patient in

observation. This term could confuse staff responsible for indicating

the appropriate status in the bed tracking systems, request for

documentation requirements, internal flags for processing of

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documentation requirements, internal flags for processing of

laboratory and pharmacy orders, etc.

Inadequate Documentation:

“Place in observation due to a large amount of alcohol ingestion”.

Adequate Documentation:

“Place in observation due to large amount of alcohol ingestion and the risk of

hypoxia and aspiration”.

OUTPATIENT OBSERVATION SERVICESOUTPATIENT OBSERVATION SERVICES� Documentation

� Medical records will be expected to demonstrate the consistency

between the physician order (physician intent), the services actually

provided (inpatient or outpatient) and the medical necessity of those

services, including the medical appropriateness of the inpatient or

observation stay. The medical record must clearly support the medical

necessity for observation and should include a timed order to observe

which will support the number of hours billed.

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which will support the number of hours billed.

� Every page of the record must be legible and include appropriate

patient identification information (e.g., complete name, dates of

service(s)). The record must include the physician or non-physician

practitioner responsible for and providing the care of the patient.

OUTPATIENT OBSERVATION SERVICESOUTPATIENT OBSERVATION SERVICES� Calculation of Hours

� Observation time begins at the clock time documented in the patient’s

medical record, which coincides with the time that observation care is

initiated in accordance with a physician’s order.

� Observation time ends when all medically necessary services related to

observation care are completed. For example, this could be before

discharge when the need for observation has ended, but other

medically necessary services not meeting the definition of observation

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care are provided (in which case, the additional medically necessary

services would be billed separately or included as part of the

emergency department or clinic visit)

� Hospitals should round to the nearest hour.


� Observation services should not be billed concurrently with diagnostic

or therapeutic services for which active monitoring is a part of the

procedure (e.g., colonoscopy, chemotherapy).

� In situations where such a procedure interrupts observation services,

hospitals would record for each period of observation services the

beginning and ending times during the hospital outpatient encounter

and add the length of time for the periods of observation services

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and add the length of time for the periods of observation services

together to reach the total number of units reported on the claim for

the hourly observation services HCPCS code G0378 (Hospital

observation service, per hour).



� Observation time ends when all medically necessary services related to

observation care are completed. For example, this could be before

discharge when the need for observation has ended, but other


care are provided (in which case, the additional medically necessary

services would be billed separately or included as part of the

emergency department or clinic visit).

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emergency department or clinic visit).

� Alternatively, the end time of observation services may coincide with

the time the patient is actually discharged from the hospital or

admitted as an inpatient.


OUTPATIENT OBSERVATION SERVICESOUTPATIENT OBSERVATION SERVICES� HCPCS/CPT requirements

� Hospitals should report G0378 when observation services are provided

to patients receiving outpatient observation services. The numbers of

units reported are equal to the number of hours in observation. If the

period of observation spans more than 1 calendar day, all of the hours

for the entire period of observation must be included on a single line

and the date of service for that line is the date that observation care

begins.

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begins.

� Hospitals should report G0379 when observation services are the

result of a direct admission into outpatient observation services

without an associated emergency room visit, hospital outpatient clinic

visit, or critical care service on the day of initiation of outpatient

observation services.

� Revenue Codes 0760 or 0762 may be used on the UB0413X bill type to

report observation services.

OUTPATIENT OBSERVATION SERVICESOUTPATIENT OBSERVATION SERVICES

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INFUSIONS AND INJECTIONSINFUSIONS AND INJECTIONS� Infusion therapy and injections can include both chemotherapeutic and non-

chemotherapeutic pharmaceuticals.

� To report, refer to CPT Codes 96360 – 96549

� UB-04 revenue codes are specific to the type of therapy (e.g. chemo – 0335)

� A hierarchy was created for facilities to report infusion therapy services.

� The initial code should be selected using a hierarchy whereby chemotherapy services are

primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration

services.

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services.

� Infusions are primary to pushes, which are primary to injections.

� Facilities are to follow this hierarchy and it supersedes

parenthetical instructions for add-on codes that suggest an

add-on of a higher hierarchical position may be reported in

conjunction with a base code of a lower position.

INFUSIONS AND INJECTIONSINFUSIONS AND INJECTIONS� Additional Coding Tips:

� If performed to facilitate the infusion or injection, the following services

are included and are not reported separately:

� Use of local anesthesia

� IV start

� Access to indwelling IV, subcutaneous catheter or port

� Flush at conclusion of infusion

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� Flush at conclusion of infusion

� Standard tubing, syringes, and supplies

� Preparation of chemotherapy agents

� When multiple drugs are administered, report the service(s) and the

specific materials or drugs for each.

� Don’t report infusion for fluids used to administer a drug.

� This also includes the administration of fluid to maintain IV line patency during

blood transfusions.


� When administering multiple infusions, injections or combinations, only

one “initial” service code should be reported, unless protocol requires that

two separate IV sites must be used.

� If an injection or infusion is of a subsequent or concurrent nature, even if it is

the first such service within that group of services then a subsequent or

concurrent code from the appropriate section should be reported, e.g., the

first IV push given subsequent to an initial one-hour infusion is reported using

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first IV push given subsequent to an initial one-hour infusion is reported using

a subsequent IV push code.

� It is important to remember that injections are coded per injection, not per

medication.

� When reporting codes based on infusion time, use the actual time over

which the infusion is administered.


� Length of time, calculated by the start and stop times, determines whether

a procedure is coded as an infusion or injection. To ensure accurate coding

and billing, providers must understand the start and stop documentation

requirement. Any infusion less than 15 minutes should be coded as an

intravenous push injection.

� In the absence of start and stop time, providers may only request

reimbursement at the IV push level.

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reimbursement at the IV push level.

� Fluid used to administer the drug(s) is considered incidental hydration and

is not separately reportable.

� If documentation supports a clinical condition that warrants hydration,

other than one brought about by the requirements of a procedure, the

hydration can be separately billable.


� Outpatient visits (E/M CPTs 99201- 99215) can be reported in the infusion

center setting when identified as a separate and distinct service.

� The basic assessment and monitoring of the patient pre and post

injection/infusion is inherent in the procedure and not considered to be

separate and distinct.

� When patients receive therapeutic treatment in the outpatient setting, the

first-listed code should represent the diagnosis, condition, problem or other

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first-listed code should represent the diagnosis, condition, problem or other

reason for the encounter/visit that is chiefly responsible for the outpatient

services provided.

� The only exception to this rule is that when the primary reason for the

encounter is chemotherapy, radiation therapy or rehabilitation, the

appropriate V-code for the service should be sequenced as the first-listed code

and the diagnosis or problem for which the service is provided is coded in

subsequent positions. - V58.11, “Encounter for antineoplastic chemotherapy”,

or V58.12, “Encounter for antineoplastic immunotherapy”

PHARMACEUTICALSPHARMACEUTICALS� Hospitals must report all appropriate HCPCS codes and charges for separately

payable drugs, in addition to reporting the applicable drug administration

codes.

� Hospitals should also report the HCPCS codes and charges for drugs that are

packaged into payments for the corresponding drug administration or other

separately payable services.

� Drugs are billed in multiples of the dosage specified in the HCPCS code long

descriptor.

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descriptor.

� If the drug dose used in the care of a patient is not a multiple of the HCPCS code

dosage descriptor, the provider rounds to the next highest unit based on the HCPCS

long descriptor for the code in order to report the dose provided.

� If the full dosage provided is less than the dosage for the HCPCS code descriptor

specifying the minimum dosage for the drug, the provider reports one unit of the

HCPCS code for the minimum dosage amount.

PHARMACEUTICALSPHARMACEUTICALS� Several outpatient drugs are classified as self-administrable and are not

covered by Medicare.

� The only ordinarily noncovered, self-administered outpatient drugs covered under

Medicare are insulin administered in an emergency situation to a patient in a

diabetic coma and antiemetics in limited situations.

� Oral radiopharmaceuticals can be captured and billed.

� Each line item billed as not covered or associated with an ABN must be identified

with a HCPCS code and associated modifier. This includes all OPPS packaged items

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with a HCPCS code and associated modifier. This includes all OPPS packaged items

and those items traditionally not billed with HCPCS codes in the past.

� Report the most specific HCPCS code available to describe the item or service. If no

specific HCPCS code exists, report HCPCS code A9270, “Non covered item/service”

with revenue code 0637.

� Outpatient claims submitted with a revenue code 0637 without a HCPCS will

be returned to the provider.

PHARMACEUTICALSPHARMACEUTICALS� CY2011 CMS OPPS Update

� Reporting Pharmaceuticals

� CMS continues to strongly urge hospitals to report charges for all

drugs, biologicals, and radiopharmaceuticals, regardless of whether the

items are paid separately or packaged, using the correct HCPCS codes

for the items used.

� CMS also restates that “It is also of great importance that hospitals

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� CMS also restates that “It is also of great importance that hospitals

billing for these products make certain that the reported units of service

of the reported HCPCS codes are consistent with the quantity of a drug,

biological, or radiopharmaceutical that was used in the care of the

patient.”


� Reporting Pharmaceuticals

� CMS reminded hospitals, “If two or more drugs or biologicals are mixed

together to facilitate administration, the correct HCPCS codes should be

reported separately for each product used in the care of the patient. The mixing

together of two or more products does not constitute a “new” drug as

regulated by the Food and Drug Administration (FDA) under the New Drug

Application (NDA) process. In these situations, hospitals are reminded that it is

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Application (NDA) process. In these situations, hospitals are reminded that it is

not appropriate to bill HCPCS code C9399. HCPCS code C9399, Unclassified drug

or biological, is for new drugs and biologicals that are approved by the FDA on

or after January 1, 2004, for which a HCPCS code has not been assigned. Unless

otherwise specified in the long description, HCPCS code descriptors refer to the

non-compounded, FDA-approved final product. If a product is compounded and

a specific HCPCS code does not exist for the compounded product, the hospital

should report an appropriate unlisted code such as J9999 or J3490.”


� New Codes

� For 2011, fourteen new HCPCS codes that are eligible for separate

payment have been created for reporting drugs and biologicals in the

hospital outpatient setting:

� C9274 Crotalidae Polyvalent Immune Fab (Ovine), 1 vial

� C9275 Injection, hexaminolevulinate hydrochloride, 100 mg, per study

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� C9275 Injection, hexaminolevulinate hydrochloride, 100 mg, per study

dose

� C9276 Injection, cabazitaxel, 1 mg

� C9277 Injection, alglucosidase alfa (Lumizyme), 1 mg

� C9278 Injection, incobotulinumtoxin A, 1 unit

� C9279 Injection, ibuprofen, 100 mg

� J0638 Injection, canakinumab, 1 mg

� J1559 Injection, immune globulin (Hizentra), 100 mg


� New Codes

� J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g.,

liquid), not otherwise specified, 500 mg

� J2358 Injection, olanzapine, long-acting, 1 mg

� J7196 Injection, antithrombin recombinant, 50 IU

� J7309 Methyl aminolevulinate (mal) for topical administration, 16.8%, 10

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mg

� Q4118 Matristem micromatrix, 1 mg

� Q4121 Theraskin, per square centimeter


� New Codes

� J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g.,

liquid), not otherwise specified, 500 mg

� J2358 Injection, olanzapine, long-acting, 1 mg

� J7196 Injection, antithrombin recombinant, 50 IU


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mg

� Q4118 Matristem micromatrix, 1 mg

� Q4121 Theraskin, per square centimeter

DIAGNOSTIC CARDIOLOGYDIAGNOSTIC CARDIOLOGY� Diagnostic cardiology includes diagnostic non-invasive testing; such as,

electrocardiograms and echocardiograms.

� CPT Coding is fairly straightforward for each test.

� Report the technical service only, “without interpretation and report”

� The units of service are “1” per test.

� Routine electrocardiographic monitoring during surgery does not constitute a

separate charge.

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� A specific order must be present in documentation, along with a separate, signed,

written, and retrievable report.

� Reviewing strips from a telemetry monitoring system is not enough

� – “I saw a blip!”, Nurse Sally

� The UB revenue code required for reporting comes from 48X. Most providers

default to the general classification of 0480.

DIAGNOSTIC CARDIOLOGYDIAGNOSTIC CARDIOLOGY� CY2011 CPT Updates

� Deleted Codes

� 93012, “Telephonic transmission of post-symptom electrocardiogram

rhythm strip(s), 24 hour attended monitoring, per 30 day period of

time; tracing only”

� 93014 – physician review with interpretation and report only

� To report telephonic transmission of post-symptom electrocardiogram

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� To report telephonic transmission of post-symptom electrocardiogram

rhythm strips, see 93268-93272


� Revised Codes

� 93224, “External electrocardiographic recording up to 48 hours by

continuous rhythm recording and storage; includes recording, scanning

analysis with report, physician review and interpretation”

� 93225 – recording (includes connection, recording and

disconnection)

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disconnection)

� 93226 – scanning analysis with report

� 93227 – physician review and interpretation

� Revised to describe external electrocardiographic recording for up to

48 hours

� The term “wearable” has been replaced with “external” for

consistency with other codes.


� Revised Codes

� 93228, “External mobile cardiovascular telemetry with

electrocardiographic recording, concurrent computerized real time

data analysis and greater than 24 hours of accessible ECG data storage

(retrievable with query) with ECG triggered and patient selected events

transmitted to a remote attended surveillance center for up to 30 days;

physician review and interpretation with report”

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physician review and interpretation with report”

� 93229 – technical support for connection and patient instructions

for use, attended surveillance, analysis and physician prescribed

transmission of daily and emergent data reports

� The term “wearable” has been replaced with “external” for consistency

with other codes.


� Deleted Codes

� 93230, “Wearable electrocardiographic rhythm derived monitoring for

24 hours by continuous original waveform recording and storage

without superimposition scanning utilizing a device capable of

producing a full miniaturized printout; includes recording,

microprocessor-based analysis with report, physician review and

interpretation”

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interpretation”

� 93231 – recording (includes connection, recording, and

disconnection)

� 93232 – microprocessor-based analysis with report


� To report external electrocardiographic rhythm derived monitoring for

up to 48 hours, see 93224-93227


� Deleted Codes

� 93235, “Wearable electrocardiographic rhythm derived monitoring for

24 hours by continuous computerized monitoring and non-continuous

recording, and real-time data analysis utilizing a device capable of

producing intermittent full-sized waveform tracings, possibly patient

activated; includes monitoring and real-time data analysis with report,

physician review and interpretation”

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physician review and interpretation”

� 93236 – monitoring and real-time data analysis report


� To report external electrocardiographic rhythm derived monitoring for

up to 48 hours, see 93224-93227


� Revised Codes

� 93268, “External patient and, when performed, auto activated

electrocardiographic rhythm derived event recording with symptom-

related memory loop with remote download capability up to 30 days,

24 hours attended monitoring; includes transmission, physician review

and interpretation”

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� 93270 – recording (includes connection, recording, and

disconnection)

� 93271 – transmission download and analysis


� The term “wearable” has been replaced with “external” for consistency

with other codes.

RESPIRATORY/PULMONARYRESPIRATORY/PULMONARY

� Respiratory and pulmonary services are found in CPT range 94010–94799.

� Services include laboratory procedure(s) and interpretation of test results.

� If a separate identifiable evaluation and management (E/M) service is

performed, the appropriate E/M service code should be reported in addition

these services.

� The respiratory therapy/pulmonary function chargemaster may include

procedures, therapies and supplies.

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procedures, therapies and supplies.

� Services have great potential to be confusing and lend to errors in coding and

charge capture.

� Common issues are found across facilities nationwide.

RESPIRATORY/PULMONARYRESPIRATORY/PULMONARY

� General Coding Tips:

� Spirometry and flow loop should not be reported together.

� When spirometry is performed, this includes vital capacity and/or

maximum voluntary ventilation.

� Spirometry with bronchodilator includes a pre and post spirometry.

� The demonstration and/or evaluation of patient utilization of an aerosol

generator, nebulizer, metered dose inhaler or intermittent positive

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generator, nebulizer, metered dose inhaler or intermittent positive

pressure breathing (IPPB) device can only be reported once per day.

CARDIAC AND PULMONARY REHABILITATIONCARDIAC AND PULMONARY REHABILITATION

� Cardiac and pulmonary rehabilitation are covered services under CMS, with

specific requirements for HCPCS/CPT coding,, diagnoses and frequency

limitations.

Element Cardiac Rehabilitation Pulmonary Rehabilitation

HCPCS/CPT 93797, 93798 G0424

Diagnoses Acute MI, CABG, Stable

Angina, Heart Valve

Moderate to Severe COPD

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� Services are required to be provided under direct physician supervision.

http://www.cms.gov/manuals/downloads/clm104c32.pdf

Angina, Heart Valve

Repair/Replacement, PTCA,

Heart or Heart/Lung

Transplant

2-1 hour sessions/day 2-1 hour sessions/day

36 sessions up to 36 weeks 36 sessions

Frequency

SURGICALSURGICAL SERVICESSERVICES

� Surgical services are found in the range of CPTs 10000 – 69990

� some Category III

� G-codes

� HIM often will not “code per payer”

� Typically captured through use of time-based codes, but no standard

methodology is found.

Involves soft-coding processes

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� Involves soft-coding processes

� Exception may exist with minor surgical procedures performed in ED, Clinic

or Radiology procedures

� Examples: breast biopsies, wound care, intubation, gastric lavage

� Pricing includes routine costs ,equipment, overhead, etc.

SURGICALSURGICAL SERVICESSERVICES

� CY2011 CMS Updates

� Number of updates made including additions, revisions and deletions.

� Minimal number of the changes are found ton include procedures that can

either be found hard-coded in the CDM

� All CPT updates can be provided in a separate presentation to the group.

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SURGERY - INTEGUMENTARY

� Extensive revisions to the integumentary system by removing the term

“excisional debridement” and replacing with only the term “debridement”

� Guidelines have been expanded to define wound debridement and

surface area related to debridement of the subcutaneous tissue,

biofilm, epidermis, dermis, muscle, &/or fascia.

��

DEBRIDEMENT

� Revision Example – Integumentary:

� Editorially revised for standardization of the nomenclature describing

debridement including removal of foreign material at the site of an open

fracture &/or an open dislocation

� 11010 – Debridement including removal of foreign material at the site of

an open fracture &/or an open dislocation (eg, excisional debridement); an open fracture &/or an open dislocation (eg, excisional debridement);

skin and subcutaneous tissues

� Old – Debridement including removal of foreign material associated

with open fracture(s) &/or dislocation(s); skin and subcutaneous tissues

� 11011 – skin, subcutaneous tissue, muscle fascia, and muscle

� 11012 – skin, subcutaneous tissue, muscle fascia, muscle, and bone

��

DEBRIDEMENT

� Deleted codes:

� 11040 – Debridement; skin partial thickness

� 11041 skin, full thickness

� For debridement of skin, ie epidermis &/or dermis only, see 97597, 97598

� Revised codes:

11042, 11043, 11044 - Revised by surface area and depth, and the depth � 11042, 11043, 11044 - Revised by surface area and depth, and the depth

was further split into 4 levels of wound surface. Also uniformly include a

20 sq cm with add-on codes for additional services.

� New codes:

� 11045, 11046, 11047 - Add-on codes to report each additional 20 sq cm, or

part thereof

��

SURGERY-MUSCULOSKELETAL

� Deleted code:

� 20000 – incision of soft tissue abscess; superficial

� Deleted due to overlap and intent of the cutaneous/subcutaneous

codes

� To report incision and drainage procedures, cutaneous/subcutaneous,

see 10060, 10061see 10060, 10061

� Revised code:

� 20005 – Incision and drainage of soft tissue abscess, subfascial (ie, involved

the soft tissue below the deep fascia)

� Editorially revised to define the depth of the incision and drainage as

“subfascial” instead of “deep”

��

RESPIRATORY

� New code:

� Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when

performed, diagnostic, with cell washing, when performed

� 31634 – with balloon occlusion, with assessment of air leak, with

administration of occlusive substance (eg, fibrin glue), if performed

� New code to describe a bronchoscopic technique that has been � New code to describe a bronchoscopic technique that has been

performed in the past as part of a last effort to resolve persistent

broncho-pleural fistulas. It is becoming more common as an earlier

therapy for the disease.

��

RESPIRATORY

� New codes:

� 31295 – Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus

ostium (eg, balloon dilation), transnasal or via canine fossa)

� 31296 – with dilation of frontal sinus ostium (eg, balloon dilation)

� 31297 – with dilation of sphenoid sinus ostium (eg, balloon dilation)

Created to describe the dilation of sinus ostia by displacement of tissue � Created to describe the dilation of sinus ostia by displacement of tissue

utilizing any method

��

RADIATION ONCOLOGYRADIATION ONCOLOGY

� The process of treating a patient with radiation involves five basic steps:

� Consult or new patient exam

� Treatment planning

� Simulation and Dosimetry

� Treatment delivery and management

� Follow up

52

� Documentation to support the medical necessity of all procedures and

complementary services must be maintained in the patient’s medical record.

� Planned course of therapy

� Type and delivery of treatment

� Level of clinical management involved

� Ongoing documentation of any changes in the course of treatment.


� Examples of documentation include, but are not limited to:

� Treatment plan for course of therapy

� Type and method of delivery of therapy

� Clinical management notes

� Simulation – request, level, devices, medical necessity, and location

performed

Physics/Dosimetry – calculations and signatures, isodose plans, special

53

� Physics/Dosimetry – calculations and signatures, isodose plans, special

dosimetry, special consults, etc.

� Treatments

� Procedure notes

� Treatment devices


� General Coding and Billing Tips

� Date of Service

� Since a number of services are considered to be components of major

services performed for treatment planning and delivery, it is necessary

that all services billed include the date of service documented in the

medical record.

� Treatment Planning

54

� Treatment Planning

� Treatment planning is generally only reported once for a given course

of treatment since it is directly tied to the course of therapy and to the

site(s) where the therapy will be provided.

� A different problem necessitating a new course of radiation therapy

will justify the charge for another treatment planning code.

� If additional plans are done, the specific reason for the additional plan

must be documented.



� Simulation

� Documentation of simulation requires a written record of the

procedure and hardcopy of electronic images and evidence of image

review by physicians including signature or initials and data review.

� Dosimetry

The typical course of radiation therapy may require from one to six

55

� The typical course of radiation therapy may require from one to six

dosimetry calculations, depending upon the complexity of the patient's

problem.

� Medicare would expect to see documentation in the patient's medical

record that would include any changes in dosimetry calculations and

change in radiation treatment and frequency.



� Teletherapy Isodose Plan

� The typical course of radiation therapy will require from one to three

isodose plans.

� Usually only one plan per volume of interest will be sufficient,

though some patients may require multiple teletherapy plans

during the course of therapy.

56

during the course of therapy.

� Situations that may require an extra teletherapy plan include the

need to change the machine or the volume of interest.

� Toward the end of treatment, due to clinical variations of the

patient, another plan may be required.



� Teletherapy Isodose Plan

� While multiple plan calculations may be required for a given

condition, the one chosen for optimal therapy is the only one that

can be charged.

� Only one isodose plan may be reported for a given course of

therapy to a specific treatment area; however, additional

57

therapy to a specific treatment area; however, additional

isodose plans may be reported if fields or equipment are

changed for medically necessary conditions.

� The addition of a boost, requiring a separate isodose plan, is

separately coded and billed.



� Special Teletherapy Port Plan

� This service is considered medically necessary only when a plan for a

special beam consideration is required.

� Only one plan should be billed per treatment course.

� Special Dosimetry

This service is considered medically necessary once per port when the

58

� This service is considered medically necessary once per port when the

physician determines that it is necessary to have a measurement of the

amount of radiation that a patient has actually received at a given

point with the final results being utilized to accept or modify the

current treatment plan.

� When special dosimetry is employed, the usual frequency will vary

from one to four times during the radiation course.



� Treatment Devices

� If devices of two separate levels of complexity are used for the same

treatment port, only the device of the highest complexity will be

billable – unless each device has been custom designed for that port.

An individual treatment device may be reported and charged only one

time for the entire course of therapy.

59

time for the entire course of therapy.

� Items that are not billable as treatment devices include sandbags,

pulleys, passive restraints, sponges and pads, armrests, pillows, T-bar,

leg immobilizers.



� Physics Planning

� Procedure code 77336 can be billed if detailed documentation in the

medical record reflects that all aspects of the patient’s care has been

reviewed and appropriate recommendations have been made as a

result of that review.

� A "week" consists of five treatments. The date of service billed for

60

� A "week" consists of five treatments. The date of service billed for

77336 must be the same date as the last treatment for that week.



� Special Physics Consultation

� Capture for consultative purposes when a problem or special situation arises

during radiation therapy. The procedure requires a detailed written report by

the physicist to the radiation oncologist with reference to the problem being

addressed.

� This is not routinely assigned for complex services, such as all 3D services or for

61

This is not routinely assigned for complex services, such as all 3D services or for

IMRT planning.

� Some examples of cases where a special physics consult would be requested

are:

� analysis of customized beam modification devices and special blocking

procedures to protect critical organs during treatment

� plan development for multiple primary cancers, treated simultaneously

� analysis and recommendations for transplanted organ protection



� Port Films

� CPT code 77417 is a technical service only. No modifier is required.

� Documentation in the medical record must verify that the port films were done

as per the physician order.

� The date, location and views of the films along with the name of the radiology

technician who performed the imaging must be documented in the medical

62

technician who performed the imaging must be documented in the medical

record

� Port films should be reported as one charge per five fractions of therapy per

portal regardless of the number of films required. Additional films may be

necessary if the patient’s clinical status changes.



� Stereotactic Radiosurgery

� For non-Medicare claims CPT codes 77371–77373, and 77432 may be

used to report stereotactic radiosurgery (SRS).

� For Medicare claims, report SRS planning with the available CPT

treatment planning codes that most accurately reflect the services

provided, regardless of the mode of treatment delivery planned.

63

provided, regardless of the mode of treatment delivery planned.

� For Medicare claims, the reporting of SRS delivery depends on the

mode of treatment.

� Report CPT code 77371 for multisource photon (cobalt-60) SRS, delivery including

collimator changes and custom plugging, complete course of treatment, all lesions

� HCPCS code G0173 is used to report linear accelerator based SRS, delivery including

collimator changes and custom plugging, complete course of treatment in one

session, all lesions.



� Stereotactic Radiosurgery

� Report HCPCS code G0339 for image-guided robotic linear accelerator

based SRS, including collimator changes and custom plugging, complete

course of treatment in one session or first session of a fractionated

treatment.

� HCPCS code G0251 is used to report linear accelerator based SRS, delivery

64

HCPCS code G0251 is used to report linear accelerator based SRS, delivery

including collimator changes and custom plugging, fractionated

treatment, all lesions, per session, maximum of five sessions per course of

treatment.

� Report HCPCS code G0340 for image-guided robotic linear accelerator

based SRS, including collimator changes and custom plugging, second

through fifth sessions, maximum of five sessions per course of treatment.



� Intensity modulation radiation therapy (IMRT)

� Hospitals should report CPT code 77301 for IMRT planning. IMRT

treatment delivery is reported using CPT code 0073T or 77418.

� Hospitals should bill CPT code 77418 for multileaf collimator-based

IMRT delivery and category III CPT code 0073T for compensator-based

IMRT delivery.

65

IMRT delivery.

� Payment for IMRT planning does not include payment for CPT codes

77332–77334 when furnished on the same day.

� When services described by CPT codes 77332–77334 are furnished on

the same date of service with 77301, these services should be billed in

addition to the CPT IMRT planning code 77301.




� Hospitals billing for both IMRT treatment planning, CPT code 77301,

and design and construction of complex treatment devices, CPT code

77334, on the same day should append modifier 59 to CPT code 77334.

� Hospitals may report other services, CPT codes from range 77401–

77416, or 77418, if they are performed at different treatment sessions

66


on the same day as IMRT. Append modifier 59 to the appropriate

codes.


� CY2011 OPPS Update


� Hospitals billing for both IMRT treatment planning, CPT code 77301,

and design and construction of complex treatment devices, CPT code

77334, on the same day should append modifier 59 to CPT code 77334.

� Hospitals may report other services, CPT codes from range 77401–


67


on the same day as IMRT. Append modifier 59 to the appropriate

codes.

REFERENCESREFERENCES� Federal Register Final Rule for CY2011

� http://edocket.access.gpo.gov/2010/pdf/2010-27926.pdf

� CMS Addendum A and B Updates

� http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage

� CMS Internet Only Manuals

� http://www.cms.gov/Manuals/IOM/list.asp

� CMS Transmittals

68

� http://www.cms.gov/Transmittals/2011Trans/list.asp

� CMS Frequently Asked Questions

� http://questions.cms.hhs.gov/

� CMS HCPCS File

� http://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage

REFERENCESREFERENCES� CMS Device to Procedure & Radiopharmaceutical Edits

� http://www.cms.gov/HospitalOutpatientPPS/02_device_procedure.asp#TopOfPage

� CMS Integrated Outpatient Code Editor

� http://www.cms.gov/OutpatientCodeEdit/

69

THANK YOU!

PRESENTER INFORMATIONPRESENTER INFORMATION

Caroline Rader, MBA, MSHCA, CHC

Associate Director, Navigant Consulting

[email protected]

410-463-9867

Deborah S. Zarick, R.N., BSN, CPC, CCS-P, CEMC, CPC-I, CPMA

Associate Director, Navigant Consulting

[email protected]

484-764-6688

2011 cdm updates day 2

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