AAPC News Category
The American Medical Association (AMA) released, Nov. 11, errata and technical corrections updates for CPT® 2013 and 2014. To ensure accurate medical coding, you will need to update your codebooks with these changes.
CPT® 2013 Errata
There are a handful of corrections and revisions for CPT® 2013, which are effective Jan. 1, 2013. Among them are medium description revisions for Arterial Ligation code 37618 and Stereotactic Biopsy code 61751. There are also technical corrections for a parenthetical note following Cardiac Catheterization code 93463, guidelines preceding Chemodenervation code 64642, and transplantation and post-transplantation cellular infusion guidelines.
Click here to view the errata and technical corrections update for CPT® 2013.
CPT® 2014 Errata
There are several changes you’ll want to make note of in your CPT® 2014 codebook.
For starters, you’ll need to make technical corrections to guidelines preceding Chemodenervation code 64642, and revise the transplantation and post-transplantation cellular infusion guidelines preceding code 38241, which is also revised to add “transplantation.”
Further, AMA has clarified instructions for use of the CPT® codebook to say, “In selected instances, specific instructions may define a service as limited to professionals or limited to other entities (eg. Hospital or home health agency).” If no such specific instruction exists, “the use of terms such as “physician,” “qualified health care professional,” or “individual” is not intended to indicate that other entities may not report the service.
Also effective Jan. 1, 2014, code 43238 is revised to remove the term “esophagus;” and revisions have been made to the medium descriptors for codes 43238-43270, 64645, 64605, and 96119.
Parenthetical notes for Category III codes 0256T, 0257T, 0259T, and 0003T have been deleted; the exclusionary parenthetical note following 93656 has been revised to fix a transposed code; and the parenthetical note preceding 93000 has been revised to remove the reference to code 93799, replacing it with Category III codes 0178T-0180T.
Lastly, Category II code 1040F has been revised to reflect DSM-“5.”
Click here for complete details of the recent entries added to AMA’s Errata and Technical Corrections – CPT® 2014 document.
December 2nd, 2013
Working within a group practice can alleviate many of the financial headaches encountered in a private practice, but it also can create new challenges—such as keeping track of new versus established patients.
A “new patient” is one who hasn’t received any professional services, such as an evaluation and management (E/M) or other face-to-face service, from a physician or physician group practice of the same specialty within the previous three years.
For example: A physician in a radiology group practice provides an E/M service for a patient. The group practice provided diagnostic imaging one year prior, but no E/M or other face-to-face services have been provided to this patient with the past three years. This patient would be considered a new patient.
Per the Medicare Claims Processing Manual, chapter 12, section 30.6.5: “An interpretation of a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient, does not affect the designation of a new patient.” A beneficiary seeing a physician of a different specialty within the same group practice within a three-year period also would not affect his or her “new patient” status.
Many practices will soon find out just how costly a mistake it can be to claim a new patient E/M visit for an established patient. Effective Oct. 1, 2013, Medicare payers implemented a new edit for checking claims to make sure they aren’t paying for two new patient CPT® codes within a three-year period.
The new patient CPT® codes they will be checking in these edits include 99201-99205, 99324-99328, 99341-99345, 99381-99387, and 92004. The edits will also check to ensure that a claim with one of these new patient CPT® codes is not paid subsequent to payment of a claim with an established patient CPT® code (92012, 92014, 99211-99215, 99334-99337, 99347-99350, 99391-99397).
Payers will be treating such claims as improper payments and will take usual steps to recoup payment. If you haven’t received any such notices of repayment, don’t breath a sigh of relief just yet. Due to the government shutdown in September, payers are back-peddling a bit.
In an E/M general article published Oct. 22 on its website, Palmetto GBA, Part B Medicare administrative contractor for jurisdiction 11, advises providers to follow the usual protocol for appealing claims believed to be incorrectly adjudicated.
Source: MLN Matters® MM8165 Revised
The American Congress of Obstetricians and Gynecologists (ACOG) reports that some Medicare contractors are denying payment for routine pelvic and breast examinations reported with HCPCS Level II code G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination. “Specifically,” ACOG says, “payment has been denied when the documentation includes notation of surgically absent organs as part of the seven of eleven required exam components.”
According to a Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network product, G0101 is payable under the physician fee schedule when at least seven of the following 11 elements are included in the exam:
- Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge
- Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses
- External genitalia (for example, general appearance, hair distribution, or lesions)
- Urethral meatus (for example, size, location, lesions, or prolapse);
- Urethra (for example, masses, tenderness, or scarring)
- Bladder (for example, fullness, masses, or tenderness)
- Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele)
- Cervix (for example, general appearance, lesions or discharge)
- Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support)
- Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity)
- Anus and perineum
In reviewing this issue, the ACOG Health Economics and Coding Committee determined that G0101 should be covered if the documentation notes the absence of the breast(s), cervix, uterus, fallopian tube(s), and/or ovary(s).
Why the denials, then? If your claims for G0101 are being denied, it could be due to:
- Medical necessity; and/or
- Place of service.
Timing is Everything
Medicare Part B covers screening pelvic examinations for asymptomatic female beneficiaries every 24 months (i.e., at least 23 months after the most recent screening pelvic exam); or every 12 months (i.e., at least 11 months after the most recent screening pelvic exam) for women who are either at high risk for developing cervical/vaginal cancer, or are of childbearing age and have had a pelvic exam in the past three years that indicated the presence of cervical/vaginal cancer or other abnormality.
Diagnosis Indicates Medical Necessity
If timing isn’t an issue, then perhaps the problem is the diagnosis code you’re assigning to the procedure code.
There are a few ICD-9-CM diagnosis codes that support a screening pelvic exam for a low-risk patient, such as V72.31 Routine gynecological examination. But when documentation notes that the patient is without a cervix, the right code to report is V76.49 Special screening for malignant neoplasms, other sites.
Place of Service Matters
Remember also to include the appropriate place of service code on professional claims to indicate where the service was provided.
October 30th, 2013
Percutaneous image-guided lumbar decompression for lumbar spinal stenosis is a non-covered service for Medicare beneficiaries, and if the Centers for Medicare & Medicaid Services (CMS) has anything to say about it (and they do), it will stay that way. The agency issued a proposed decision memo on Oct. 17, stating as much.
PILD is a posterior decompression of the lumbar spine, used as treatment for symptomatic LSS unresponsive to conservative therapy. Generally considered a non-invasive procedure, PILD requires the use of specially designed instruments and X-ray guidance to percutaneously remove a portion of the lamina and debulk the ligamentum. The expected health outcome is relief from pain, numbness, or tingling in the lower back, legs, or buttocks that prohibits a person’s ability to stand or walk.
CMS initiated this national coverage analysis (NCA) on April 5 and accepted public comment through May 5 to use as part of their review of evidence for whether PILD for LSS provides improved health outcomes. The proprietary procedure mild® was included in this review.
Clinical evidence CMS considered in their review was generally favorable. The following are excerpts from a small sample of the many studies CMS actually reviewed:
- “In keeping with other reports, the procedure appears to offer a safe and effective alternative to patients suffering from LSS.”
- “As a less-invasive alternative to decompression surgery, mild Lumbar Decompression has demonstrated comparable patient outcomes to standard decompressive laminectomy, with shorter procedure times, less blood loss, shorter hospital stays, and significantly better safety.”
- “In this study, the mild procedure was shown to be safe, with properly diagnosed patents experiencing significant improvement in mobility and significant reduction of pain at one year after the procedure.”
- “This clinical outcome assessment demonstrates that, for this patient series, the mild procedure provided significant pain relief at 1-year post-treatment and increased mobility for patients with symptomatic LSS.”
- “The findings from this double-blind, randomized, prospective study of ESI vs. the mild procedure in the treatment of LSS patients suffering from symptomatic neurogenic claudication indicate that mild provides statistically significantly better pain reduction and improved functional mobility vs. treatment with ESI.”
During the initial 30-day comment period, CMS received 114 comments—99 of which advocated coverage.
Despite the outpouring of support for PILD, CMS is standing by its decision for non-coverage. CMS explains, “In reviewing the evidence on PILD we are confronted with weak studies, questions about missing information, questions about adverse events and conflicts of interest. After thoroughly reviewing the evidence for PILD for LSS, we have determined the evidence does not support a conclusion of improved health outcomes for our Medicare beneficiaries.”
CMS is now seeking comments on their proposed decision that PILD for LSS is non-covered by Medicare. Comments can be made on the Medicare Coverage Database website and will be accepted through Nov. 16.
 Lingreen R, Grider S. Retrospective review of patient self-reported improvement and post-procedure findings for mild® (minimally invasive lumbar decompression). Pain Physician 2010; 13:555-560
 Schomer DF, Solsberg D, Wong W, Chopko BW. mild® Lumbar decompression for the treatment of lumbar spinal stenosis. The Neuroradiology Journal 2011; 24:620-626
 Deer TR, Kim C K, Bowman II RG, Ranson MT, Yee BS. Study of percutaneous lumbar decompression and treatment algorithm for patients suffering from neurogenic claudication. Pain Physician 2012; 15:451-460
 Wong W. mild interlaminar decompression for the treatment of lumbar spinal stenosis, procedure description and case series with 1-year follow-up. Clin J Pain 2012; 28:534-538
 Brown LL. A double-blind, randomized, prospective study of epidural steroid injection vs. the mild® procedure in patients with symptomatic lumbar spinal stenosis. Pain Practice 2012, 12:333-341.
Medicare payers may require you to report discarded amounts of single-use drugs or biologicals as separate line items with modifier JW Drug or biological amount discarded/not administered to any patient appended. In every case, however, practitioners must document unused portions in the patient record. If a recent Office of Inspector (OIG) review is any indication, however, practitioners may need to be informed of this requirement.
According to the OIG report, which reviewed some 2010 Medicare Part B claims for Xolair (omalizumab) paid by NHIC, Corp.—the Medicare administrative contractor (MAC) for jurisdiction 14—practitioners are generally unaware of this documentation requirement. This may be due to the fact that nowhere in the Medicare Claims Processing Manual, under the section for discarded drugs and biologicals, does it say anything about documenting discarded drug amounts.
Regardless, Medicare pays for the entire single-use vial/package (up to the amount indicated on the vial or package label); therefore, MACs expect practitioners to document in the patient record the drug/biological product, date, time, and number of units that were administered and that were discarded.
Documentation is required—that much is clear—but what is the protocol for billing unused portions of a single-use drug/biological?
The Centers for Medicare & Medicaid Services (CMS) provides this example in the Medicare Claims Processing Manual, chapter 17, section 40:
“For example, a single use vial that is labeled to contain 100 units of a drug has 95 units administered to the patient and 5 units discarded. The 95 unit dose is billed on one line, while the discarded 5 units may be billed on another line by using the JW modifier. Both line items would be processed for payment.”
Discarded units “may be” billed on another line by using the JW modifier. That’s rather ambiguous. What would happen if you didn’t report discarded units on a separate line with modifier JW? The answer is: It depends on the MAC.
NHIC, Corp. for example, doesn’t require the use of modifier JW. “Providers who wish to voluntarily use the JW modifier to report wastage may do so on a separate line (both lines will be paid),” according to a Sept. 30 provider education article posted on the MAC’s website.
WPS Medicare doesn’t require providers to use modifier JW modifier either. This Part B MAC for jurisdiction 5 gives providers an option: “They can bill separately, identifying the discarded portion with the JW modifier or bill both the administered and discarded portions combined without the JW modifier.”
CGS Administrators, LLC, has a different stance. Effective Jan. 1, 2012, this A/B MAC for jurisdiction 15 requires providers seeking drug waste reimbursement to report the wasted portion of the drug on a separate claim line with modifier JW appended.
Clearly, to get a definitive answer for how you should submit claims for drug waste, you’ll need to speak to the payer directly.
As a rule, though, if you choose to use modifier JW, apply it only to the line item reporting the wasted amount of drug/biological. And do not use modifier JW at all if the actual dose of the drug/biological is less than the billing unit.
“For example,” CMS offers in Pub. 104, chapter 17, section 40, “one billing unit for a drug is equal to 10 mg of the drug in a single use vial. A 7 mg dose is administered to a patient while 3 mg of the remaining drug is discarded. The 7 mg dose is billed using one billing unit that represents 10 mg on a single line item. The single line item of 1 unit would be processed for payment of the total 10 mg of drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3 mg of drug is not permitted because it would result in overpayment.”
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