By G. John Verhovshek, MA, CPC

Certain circumstances call for practices to discard unused portions of drugs. For instance, Botox® (onabotulinumtoxin A) currently has a shelf life of only four hours when reconstituted. If the entire vial isn’t used within that time, the only option is to discard the remaining supply.

This waste is not necessarily money down the (proverbial) drain, however. You may report drug waste for those drugs the billing entity paid for and provides. For example, you wouldn’t bill waste for provider-administered drugs the patient purchased from a pharmacy. Nor would you report waste for drugs supplied by a facility. Read more »

By Jennifer Hritsco-Murray, CPC, CANPC

Under Medicare guidelines, pain management following surgery usually is included in the surgeon’s global fee and may not be billed separately. If another physician (such as an anesthesiologist) provides pain management at the surgeon’s request, however, it’s possible to report the service independently.

Specifically, according to the American Society of Anesthesiology (ASA), CPT® recommendations, Correct Coding Initiative (CCI) edits, and the Centers for Medicare & Medicaid Services (CMS) guidelines, when medically necessary a block performed for post operative pain only (which is not a part of the anesthesia service) may be billed separately with the proper modifier. The surgeon is responsible for documenting in the patient’s medical records why post-op care was given to the anesthesiologist. Read more »

By David Behinfar, JD, LLM, CHC, CIPP

It has been over seven years since the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule became effective for most covered entities. As public awareness of health care privacy issues has increased since 2003, efforts at privacy rule enforcement also have accelerated. One consequence is that it is much easier for health care workers—including coders—to find themselves in a privacy officer’s crosshairs.

Before I share my advice on how to avoid the wrath of your friendly local privacy officer, let’s discuss factors leading to greater awareness and enforcement of the HIPAA Privacy Rule. Read more »

By Denis Rodriguez, CPC, CCS, CIRCC, CASCC

Arthroscopy refers to less invasive procedures in which an endoscope is placed within the joint for the performance of diagnostic and therapeutic procedures. As technology advances, procedures previously performed through large incisions are now performed arthroscopically. To accommodate this emerging technology, new arthroscopy, CPT® Category III codes, and HCPCS Level II codes, have been added over the past few years.

There are three general principles of arthroscopic coding: Read more »

By John F. Bishop, PA-C, CPC, CGSC, CPRC

Abdominal wall reconstruction has become more common in the past 10 years. Such reconstructions may occur for blunt or penetrating abdominal trauma, abdominal compartment syndrome, wound dehiscence, intraperitoneal tumor resection, or complications of previous abdominal surgery (such as hernias and mesh infections).

Anatomy

The abdomen is comprised of several tissue layers, listed here by location from superficial to deep:

• Skin
• Subcutaneous tissues
• Superficial fascia (scarpa fascia)
• Anterior rectus fascia
• Rectus abdominus muscle
• Posterior rectus fascia
• Extraperitoneal adipose
• Peritoneum

The fascias are layers of elastic, fibrous tissue; adipose is fat; the peritoneum is a membrane that forms the lining of the abdominal cavity, which contains the stomach, intestines, liver, etc. Other abdominal wall structures located lateral to the rectus abdominus muscles are the external oblique fascia and muscle, internal oblique fascia and muscle, and transverses muscle and transversalis fascia. Distinguishing among the abdominal layers is important because the surgeon may close more than one layer of muscle or fascia during reconstruction, and each layer of closure sometimes calls for separate coding.

ICD-9-CM Coding

Diagnostic statements dictated by a surgeon for abdominal wall reconstruction may include:

• Acquired deformity of abdominal wall (738.8 Acquired deformity of other specified site)
• Congenital deformity of abdominal wall (756.70 Other congenital musculoskeletal anomalies; anomaly of abdominal wall, unspecified)
• Loss of upper domain (879.3 Open wound of abdominal wall, anterior, complicated) and/or lower domain (879.5 Open wound of abdominal wall, lateral, without mention of complication)
• Complicated open abdomen (879.3, 879.5, or 879.7 Open wound of other and unspecified parts of trunk, complicated)
• Large, complicated, incarcerated ventral hernia (553.20 Other hernia of abdominal cavity without mention of obstruction or gangrene; ventral hernia, unspecified)
• Large, complicated, incarcerated incisional hernia (553.21 Other hernia of abdominal cavity without mention of obstruction or gangrene; ventral hernia, incisional)
• Diastasis recti (728.84 Disorders of muscle, ligament, and fascia; diastasis of muscle)
• Disruption (dehiscence) of abdominal incision (998.31 Other complications of procedures, not elsewhere classified; disruption of internal operation wound)
• Complication of non-healing surgical wound (998.83 Other specified complications of procedures, not elsewhere classified; non-healing surgical wound)

Although these diagnoses are among the most common, they are not exclusive in prompting abdominal wall reconstruction: Other diagnoses may apply.

CPT® Coding

The various procedures now designed to assist with abdominal wall reconstruction may include a component separation utilizing longitudinal release of the rectus abdominus muscles (15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk).

This release is designed to help relieve the tension in closure of the peritoneum. Most frequently, it is done bilaterally.

The National Correct Coding Initiative (NCCI) and Medicare Physician Fee Schedule (MPFS) Relative Value File do not allow the use of modifiers 50 Bilateral procedure with 15734. Instead, a bilateral procedure may be reported using two units of 15734. Some payers may further require you to append modifier 59 Distinct procedural service to the second unit on a second line entry to indicate a separate anatomic location. Check with your payer for details. There are several appropriate procedures:

• Separate release(s) of the external oblique fascia and muscle (15734; bilateral 15734 x 2—note that second unit may require modifier 59).
• Separate release(s) of the internal oblique fascia and muscle (15734; bilateral 15734 x 2—note that second unit may require modifier 59).
• Separate release(s) of the transverses muscle and transversalis fascia muscle (15734; bilateral 15734 x 2—note that second unit may require modifier 59).
• Application of acellular dermal allograft (such as Alloderm®, Tissuemend®).

The insertion of these allograft materials usually acts as an overlay to strengthen the closure of the rectus and/or fascia. This is reported using 15330 Acellular dermal allograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children for the first 100 sq cm and +15331 Acellular dermal allograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) for each additional 100 sq cm or part.

For example, you would report placement of 351 sq cm of allograft 15330 for the first 100 sq cm, and 15331 x 3 for the additional 251 sq cm.

• Repair of a reducible ventral or incisional hernia (initial 49560 Repair initial incisional or ventral hernia; reducible or recurrent 49565 Repair recurrent incisional or ventral hernia; reducible)
• Implantation of mesh or other prosthesis for open incisional or ventral hernia repair (+49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair))
• Adjacent tissue transfer or tissue rearrangement for the closure of the deep subcutaneous tissues and superficial fascia (scarpa fascia) (14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm and +14302 Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure))
• Following surgery, the skin and subcutaneous tissues may require a complex closure (13100-13102)

Op Report Coding Example

In this procedure, a general surgeon and plastic surgeon work as co-surgeons to repair an incisional hernia and reconstruct the abdominal wall. Each co-surgeon must dictate his or her own operative (op) note. We will be coding for the plastic surgeon’s portion of the procedure only, as represented in the following op note.

Pre-op dx: 1. Incisional hernia 2. Acquired deformity of anterior abdominal wall

Post-op dx: 1. Incisional hernia 2. Acquired deformity of anterior abdominal wall

Procedure: 1. Repair of incisional hernia. 2. Components separation of anterior abdominal wall. 3. Bilateral rectus muscle advancement flaps for anterior abdominal wall reconstruction. 4. Insertion of BioA tissue matrix for reinforcement of anterior abdominal wall reconstruction. 5. Adjacent tissue transfer closure of anterior abdominal wall (20 cm x 30 cm).

Procedure in Detail: The patient was brought to the OR … The abdominal scar was excised. We then elevated anterior abdominal flaps from costal margin to costal margin and down to the pubis. This allowed us to expose the hernia sac.

The operation was then turned over to [general surgeon] for reduction of the hernia and lysis of adhesions and small bowel exploration. After the general surgery team had freed the fascial edges, the plastic surgery team scrubbed back in and began the components release portion of the operation.

Incision was made in the anterior rectus fascial sheath, and we then dissected external oblique muscles bilaterally. We were then able to slide the rectus muscle along with the internal oblique muscles medially … This allowed for tension-free closure of the abdomen along the midline … we plicated and closed the anterior abdominal wall along the midline … [and] implanted a BioA tissue matrix … We used 2 sheets of 15 x 9 and quilted them together … We sutured the BioA in with 2-0 Vicryl along the anterior rectus fascia sheath, along the edges where the incisions then were made for the components separation. This spanned the entire area.

We inserted #19French Blake drains … [and] advanced the skin flaps, trimmed off the excess tissue and the additional scar tissue, and closed in multiple layers … The deep layer was closed with 2-0 Vicryl in simple interrupted fashion. The deep dermis was closed with 3-0 Vicryl in simple inverted interrupted fashion. The skin then was approximated with 4-0 monocryl in a subcuticular fashion. The wound was dressed …

The coding template below represents the aforementioned well-documented, summary op report. Not all op reports are this complex, or use the same number or specific CPT® codes and units. I encourage all coders and surgeons to review the CPT® verbiage and make sure each tissue layer (peritoneum, fascia, muscle, subcutaneous, and skin) is well documented to support appropriate and legal reimbursement.

The plastic surgeon acts as co-surgeon for the hernia repair, performing the approach (including excision of the abdominal scar and exposure of the hernia sack). This would be reported using 49560 with modifier 62 Two surgeons appended, and a primary diagnosis of incisional hernia (553.21). A tissue matrix also is placed to strengthen the repair and may be reported separately using add-on code 49568.

Although we are not coding for the general surgeon, the lysis of adhesions is bundled to the repair—unless it is documented as unusually difficult or time-consuming, in which case modifier 22 Increased procedural services may be appended to the primary procedure code. Similarly, exploration of the small bowel is not reported separately in this case.

The rectus muscle advancement should be coded 15734 and, because this was a bilateral procedure, may be reported twice. Remember that some payers may require modifier 59 on the second unit. A diagnosis of muscle separation (728.84 Diastasis of muscle) is primary to the hernia diagnosis.

The adjacent tissue transfer used in closing measures a total of 600 sq cm (20 cm x 30 cm). Report 14301 for the first 60 sq cm, and 18 units of 14302 for the remaining 540 sq cm (each unit of 14302 specifies 30 sq cm; 30 sq cm x 18 units = 540 sq cm). Here, the reason for the procedure is the open wound (879.3 Open wound of abdominal wall, anterior, complicated).

Tip: Note the use of modifier 51 on 14301 and 14302: Some payers may not require you to append modifier 51 because the payer’s billing software will recognize multiple procedures and order them accordingly. If you don’t already know your payers’ policy, ask for it in writing.

Although not documented here, if the abdomen is open already, or is a difficult case to close, each separate layer may need individual closure. The coder should read the op note carefully to search for the distinction between each separate layer, and what materials and methods are used for final closure. Even if the surgeon states he used a local tissue advancements flap to close the abdomen, he also may dictate something like, “the deep subcutaneous layers were closed with 0-Vicryl, the superficial sub-Q layer closed with 2-0 Vicryl, the subdermal was closed with 3-0 Vicryl, and the subcuticular layer closed with 4-0 Nylon.” This type of dictation may warrant the use of complex closure codes 13100-13132, as appropriate to the length of the wound.

John F. Bishop, PA-C, CPC, CGSC, CPRC, has 36 years experience as a physician assistant, and is a multi-specialty surgical coder with over 25 years in coding, compliance, auditing, and provider/coder education. He is president of Bishop & Associates, Inc., and senior coder/auditor for The Coding Network, LLC.

By Terri Brame, MBA, CHC, CPC, CPC-H, CGSC, CPC-I

Surgical wound closure can be confusing and vague, but you can sew up your wound closure knowledge by returning to the basics. CPT® foundation concepts always apply and can help you navigate wound closure and delayed closure procedures.

Define Your Terms

Keep the definitions of primary, delayed primary, and secondary in mind when you code for wound closures:

• Primary closure – Actively closing a wound immediately after completing the procedure with sutures, Steri-Strips, or another active binding mechanism.
• Delayed primary closure – Actively closing a wound, but at a later operative session beyond the procedure.
• Secondary closure – Usually means allowing the wound to close without intervention (without suture or other closure); however, when active wound closure is described as “secondary,” the term is used in place of delayed primary closure.

Primary Closure – What’s Included?

The wound closure portion of a global surgical package involves smaller procedures. Any typical procedure required to close the surgical wound is bundled with the primary procedure.

Some repair level—simple, intermediate, or complex—always is included as part of the wound closure. For laparotomies and sternal thoracotomies, the code assumes the surgeon will close this major incision, and with rather complex closure.

For example, because ventral/incisional hernia repair (49560-49566) principally is the closing of an opening in the abdominal wall, these repairs are included as part of a larger procedure unless they are noted to be in a separate anatomic location. If some debridement is necessary to reapproximate the skin for a good result, the debridement is bundled into the primary procedure, as well.

Primary Closure – Additional Procedures

When wound closure is more extensive than typical, additional procedures may be reported. For example, flaps may be necessary to close a large wound. When this occurs, a variety of flaps may be used, and you may separately report the flap. Common flaps for a laparotomy include 15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk and 15756 Free muscle or myocutaneous flap with microvascular anastomosis.

If the surgeon determines additional material is required to close the wound properly, recall CPT® coding basics before selecting a code. When laparotomy requires additional material, it might be tempting to choose +49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair). Notice, however, the parenthetical comment below 49568—you may add this code to 11004-11006 and 49560-49566 only.

When the material used is a bioprosthetic, such as Alloderm®, you might think a code from the 15002-15431 series is correct, but those codes don’t apply to this procedure. CPT® is an organ system-based coding system. This code series is for skin replacement surgery and skin substitution. CPT® codes are procedure-based, not product-based. When the surgeon closes a wound and uses a bioprosthetic as a fascial graft, the graft is not intended to replace skin, so these codes are incorrect.

There is not an exact code to report when the surgeon uses additional material to close the myofascial layers of a wound so CPT® basics apply. Some codes may bundle these grafts into the primary procedure surgical package. This is likely when the graft is a typical part of the closure and is common practice. Otherwise, report the graft with an unlisted procedure code, such as 20999 Unlisted procedure, musculoskeletal system, general.

Delayed Primary (Secondary) Closure

It is easy to be confused by the term “secondary.” You may think a secondary closure requires a previous closure to be performed. Secondary does not necessarily mean second with regard to wound closure, however. In this context, secondary denotes either delayed primary closure or a subsequent closure following an initial closure procedure.

If the surgeon performs a procedure that typically includes wound closure, but decides not to perform closure during the primary procedure, report the primary procedure code with modifier 52 Reduced services. The modifier is necessary because the surgeon did not complete the entire intra-operative portion of the surgical package. When the surgeon finally performs the closure, report the closure with modifier 58 Staged or related procedure or service by the same physician during the postoperative period appended because the surgeon planned to close the wound.

Before selecting a secondary wound closure CPT® code, be sure a more comprehensive code is not correct.

For example, a laparotomy has been packed open to allow for lavage due to peritoneal infection. During the fifth washout, the surgeon unpacks the wound, explores the peritoneal cavity, completes lavage, and determines the infection has cleared. The wound is closed with layered sutures. The intra-operative portion of the surgical package for 49002 Reopening of recent laparotomy includes exploration and lavage. In this instance, rather than reporting a closure-only code, 49002 is appropriate.

If a more comprehensive code does not apply, consider using 13160 Secondary closure of surgical wound or dehiscence, extensive or complicated. Although some reference materials only apply this code for infection or dehiscence, secondary closure of surgical wound is the first part of the code’s long description. The short description for this code is “Late closure of a wound.” The long description of 13160 is an instance where “secondary closure” is a replacement term for “delayed primary closure.”

Closure for a Reopened Wound

Report 13160 also for wound dehiscence closure. If, however, the surgical wound is a laparotomy that has dehisced (split open), you should consider 49900 Suture, secondary, of abdominal wall for evisceration or dehiscence.

Code 13160 includes closing a wound in multiple layers without reopening the wound. Code 49900 includes reopening the entire wound, removing any remaining sutures, and completely resuturing the wound. The latter code also includes replacing any structures that moved through the opening back into the abdominal cavity. If the surgeon completes any additional work within the abdominal cavity, such as exploration, lavage, or repair, consider whether 49002 or another abdominal code is more appropriate.

Codes 12020-12021 are for much simpler wounds that have dehisced and may not be infected. Code 12020 Treatment of superficial wound dehiscence; simple closure only includes single layer closure. If the repair includes layered closure, 12020 is not correct.

Capture All Reportable Services

Never rule out using an unlisted code to report the procedure performed. Remember the CPT® axiom is to select only a code that represents the exact procedure performed. Many surgeons complete extremely large wound closures and reclosures after significant trauma or infection. These closures may include grafts and bioprosthetic materials that you may not separately report with the codes available. Consider whether CPT® includes a code that accurately represents the procedure, or whether an unlisted code is more appropriate.

For example, consider a patient who had multiple incisional hernias and a necrotizing soft tissue infection following a laparotomy, including a strangulated hernia that required extensive mesh for closure. The patient’s infection was so great that it resulted in loss of significant anterior abdominal fascia, subcutaneous tissue, and superficial fascia. One of the defects was 20 x 20 cm, which is just less than 8 inches per side—nearly the size of a typical dinner plate.

The closure required massive flap mobilization from both flanks, which were each 50 x 30 cm (20 x 12 in). The procedure also included reinforcing the repair’s muscle layer with porcine biologic mesh.

The surgeon placed an additional piece of biologic mesh, 20 x 16 cm, under one set of hernias, and another 20 x 25 cm sheet under another area. Essentially, the patient’s entire anterior abdominal wall required reconstruction with mesh.

Coding for closure can be challenging, but if you follow the CPT® basics, they should guide you to the right decision. As a quick review:

• Know your terms: Keep in mind that “secondary closure” does not necessarily mean a second closure, and the term is often used to mean delayed secondary closure.
• Approach matters: A code may seem to describe the closure performed but, if the approach is not correct, the code does not apply.
• Be aware of bundles: You should not bill separately for included procedures, but also do not leave separate procedures unbilled. If you are unsure of bundling issues, check with the payer or seek out additional information regarding the coding you selected.

Terri Brame is the director of reimbursement and compliance for Coopersmith Health Law Group in Seattle, Wash. You may contact Terri at terri@coopersmithlaw.com.

By G. John Verhovshek, MA, CPC

The Centers for Medicare & Medicaid Services (CMS) will reimburse providers for screening cardiovascular blood tests, but only for those beneficiaries and services meeting strictly-defined requirements, and only for those claims documented and coded appropriately.

Screening blood tests determine a patient’s cholesterol and other blood lipid levels, and may indicate whether he or she is at high risk for cardiovascular disease. Citing the risks and health care costs associated with heart disease, Congress established the cardiovascular blood test screening benefit as part of the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003. Coverage is provided as a Medicare Part B benefit. The beneficiary pays nothing for the blood test; there is no coinsurance, copayment, or deductible.

To meet benefit requirements under the MMA, all of the following conditions must be met:

•  The screening must be “for the purpose of early detection of cardiovascular disease,” according to the Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Healthcare Professionals (www.cms.gov/mlnproducts/downloads/psguid.pdf). CMS recommends all eligible beneficiaries to take advantage of the coverage.
• The patient must be asymptomatic. The beneficiary “must have no apparent signs or symptoms of cardiovascular disease,” the Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Healthcare Professionals explains.

Although the patient must have no apparent signs or symptoms of cardiovascular disease to qualify for the screening, he or she may exhibit one or more risk factors for cardiovascular disease, such as:

• Diabetes
• Family history of cardiovascular disease
• High-fat diet
• History of previous heart disease
• Hypercholesterolemia (high cholesterol)
• Hypertension
• Lack of exercise
• Obesity
• Smoking
• Stress
• The screening may take place no more often than once every five years (more precisely, at least 59 months after the last covered screening tests). To stress this point, the Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Healthcare Professionals offers two examples of when Medicare may deny coverage of cardiovascular screening blood tests:
  • The beneficiary received a covered Lipid Panel during the past 5 years.
  • The beneficiary received the same individual cardiovascular screening blood test during the past five years.
•  The documentation must show that the screening tests were ordered by a physician or non-physician practitioner (NPP). Under CMS guidelines as they pertain to these screenings, a physician is defined as “a doctor of medicine or osteopathy,” while a qualified NPP is defined as “a physician assistant, nurse practitioner, or clinical nurse specialist.”
•  The beneficiary must fast for 12 hours prior to the test. This is required because the foods we eat and drink can affect the values obtained.
• An appropriate HCPCS/CPT® procedure code must be reported.

Cardiovascular screening blood tests covered under the benefit include:

• total cholesterol test (82465 Cholesterol, serum or whole blood, total)
• cholesterol test for high-density lipoproteins (83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol))
• triglycerides test (84478 Triglycerides)

All other cardiovascular screening blood tests are non-covered, stresses the Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Healthcare Professionals.

Although any of these three tests may be ordered separately, more commonly they are ordered at the same time as part of a full lipid panel (80061 Lipid panel). Note that 80061 bundles 82465, 83718, and 84478; the individual tests are not reported in addition to 80061.

Under CMS guidelines, “laboratories must offer the ability to order a lipid panel without the low-density lipoprotein (LDL) measurement.” If the screening lipid panel shows results that require a further direct LDL measurement, the physician may order the test to arrive at a diagnosis and treatment plan.

Be aware also the five-year frequency limit, mentioned earlier, applies for each test regardless of whether the physician ordered the tests individually or in a panel.

• An appropriate diagnosis code must be reported.

A screening diagnosis “V” code should be linked to the claim. ICD-9-CM codes specifically covered under the Medicare screening benefit for cardiovascular blood tests include:

V81.0       Special screening for ischemic heart disease

V81.1       Special screening for hypertension

V81.2       Special screening for other and unspecified cardiovascular conditions

You may report more than a single V code, but always list the primary reason for the screening first. Because patients obtaining the screening are by definition asymptomatic, physicians must indicate in the medical record the primary reason for the test(s).

Individual payers may accept diagnoses not listed above. For example, some payers may accept diabetes (250.x) as a covered diagnosis under the benefit. Check with your payer(s) for details.

• All of the above requirements must be documented in the medical record.

Always remember: You can’t code or bill what hasn’t been documented.

When in doubt, consider an ABN

Occasionally, a patient may request or agree to a screening that does not meet the aforementioned requirements. For instance, the service may exceed frequency limitations as defined by the screening benefit (for example, two screenings within a five-year period). In such a case, the provider should ask the patient to sign an Advance Beneficiary Notice (ABN) to ensure reimbursement.

Under CMS rules, as explained in the Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Healthcare Professionals:

If the item or service meets the definition of the Medicare-covered benefit, Medicare still may not pay for the item or service if the item or service was “not reasonable and necessary” for the beneficiary on the occasion in question or if the item or service exceeds the frequency limitation for the particular benefit or falls outside the applicable time frame for receipt of the covered benefit.

In these instances, an ABN may be used to shift liability for the cost of the item or service to the beneficiary.

If an ABN is not issued properly in such a case, the provider may be held liable for the cost of the screening unless the provider “is able to demonstrate that they did not know and could not reasonably have been expected to know that Medicare would not pay for the item or service.”

For more information on the ABN and its proper use, visit the CMS website at: www.cms.hhs.gov/BNI/02_ABNGABNL.asp.

G. John Verhovshek, MA, CPC, is AAPC’s director of editorial development/education.

By Janice G. Jacobs, CPA, CPC, CCS, ROCC, and G. John Verhovshek, MA, CPC

The Centers for Medicare & Medicaid Services’ (CMS’) 2010 Outpatient Prospective Payment System (OPPS) Final Rule revised guidelines that define physician supervision of services performed in a hospital outpatient department, while leaving rules for services performed in free-standing centers/physician offices unchanged. The new guidelines, “Policies for Direct Supervision of Hospital and CAH Outpatient Therapeutic Services,” begin on page 264 of the final rule.

Resource Tip: View the 2010 OPPS Final Rule online at: http://edocket.access.gpo.gov/2009/pdf/E9-26499.pdf.

Midlevel Providers May Supervise Therapeutic Procedures

Under the 2010 OPPS Final Rule, CMS has broadened the rules for supervision of therapeutic procedures in the hospital outpatient setting to permit direct supervision by non-physician practitioners (NPPs), to include the following health care professionals:

• physician assistants (PAs)
• nurse practitioners (NPs)
• clinical nurse specialists (CNS)
• certified nurse-midwives (CNMs)
• licensed clinical social workers (LCSWs)

Eligible NPPs may supervise only those therapeutic services “that they may perform themselves under their state license and scope of practice and hospital-granted or CAH-granted privileges.” In other words, an NPP may supervise only those services he or she can perform personally under the applicable guidelines.

Therapeutic services falling under the new rules are those such as outpatient psychiatric group therapy, physical therapy (PT), speech therapy, and occupational therapy (OT).

For example, a LCSW may now supervise outpatient psychiatric group therapy sessions because he or she is qualified and trained to perform that service. That same LCSW may not prescribe medications or perform other services for which only the attending or other psychiatrist is qualified.

CMS guidelines define direct supervision to mean the supervising provider must be “immediately available to furnish assistance and direction throughout the performance of the procedure.” Specifically, “immediate availability” requires that:

The supervising provider must not be “performing another procedure or service that he or she could not interrupt.”

• The supervising provider must not be “so physically far away on the main campus from the location where hospital outpatient services are being furnished that he or she could not intervene right away.”
• • For therapeutic procedures performed on a hospital’s main campus, the supervising physician or practitioner must be present “on the same campus.” The supervisor may be located anywhere on the campus, including a physician’s office, an on-campus skilled nursing facility (SNF), or other nonhospital space.
  • For therapeutic procedures performed in an off-campus provider-based department (PBD), the supervising physician or practitioner must be present in the PBD during the procedure.
  • In addition to being able to provide the service/procedure under his or her state license, scope of practice, and hospital-granted or critical access hospital (CAH)-granted privileges, the supervising provider “must be prepared to step in and perform the service, not just respond to an emergency.”

A coding example of interactive group therapy provided by a LCSW would be CPT® code 90857 Interactive group psychotherapy billed on the CMS-1500 form under the LCSW’s own provider identification number (PIN).

Pay attention to payer requirements: Although these supervision guidelines apply specifically to Medicare patients/services, contractual ‘non-discrimination clauses’ with private payers may require hospitals (and participating physicians) to apply the same rules for all patients.

Diagnostic Services Specify Different Requirements

Supervision requirements for diagnostic services—such as computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, positron emission tomography (PET), ultrasound, and X-rays—differ from those for therapeutic services, as described above. NPPs may not supervise diagnostic tests provided to hospital outpatients. The required supervision can be provided only by a physician (MD or DO).

CMS guidelines specify, “All hospital outpatient diagnostic services provided directly or under arrangement, whether provided in the hospital, in a PBD of a hospital, or at a nonhospital location, follow the physician supervision requirements for individual tests as listed in the [Medicare Physician Fee Schedule] MPFS Relative Value File.”

In the Relative Value File, in the “Physician Supervision of Diagnostic Procedures” column, CMS assigns a physician supervision indicator to each CPT®/HCPCS Level II code representing a diagnostic service.

Resource Tip: The Relative Value File is available online at: www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp?listpage=4.

The indicators and definitions are:

CMS defines “general,” “direct,” and “personal” supervision requirements in the Medicare Benefit Policy Manual, chapter 15, section 80:

General Supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the non-physician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

Direct Supervision (in the office setting) means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure (for example, the physician must not be performing another procedure that cannot be interrupted, and must not be so physically far away that he or she could not provide timely assistance). This does not require that the physician must be present in the room when the procedure is performed, however.

Personal Supervision means a physician must be in attendance in the room during the performance of the procedure.

For example: The MPFS relative value unit (RVU) file assigns the technical portion of CPT® 77014 Computed tomography guidance for placement of radiation therapy fields a “2” physician supervision indicator. This means the service requires direct physician supervision when performed in the hospital radiology department, in a hospital-owned imaging center that is defined as a PBD, or in a physician office under arrangements with the hospital (that is, an outside imaging facility bills the hospital for exams it performs on hospital patients).

Go to the source and find out how the new rules pertain to you.

By Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC

On Jan. 1, the Centers for Medicare & Medicaid Services (CMS) adopted revised standards regarding Medicare anesthesia teaching programs. These changes result from the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), as announced in the 2010 Medicare Physician Fee Schedule (MPFS) final rule, subsequently implemented by CMS Transmittal 1859, Change Request (CR) 6706, and clarified by MLN Matters MM6706 Revised.

As outlined in MM6706 Revised, these new standards:

• Establish a special payment rule for teaching anesthesiologists;
• Specify the periods during which the teaching anesthesiologist must be present during the procedure to qualify for payment based on the regular anesthesia fee schedule amount; and
• Provide the Secretary of Health and Human Services (HHS) with a directive addressing payments for the anesthesia services of teaching certified registered nurse anesthetists (CRNA).

Teaching Anesthesiologists May Oversee Up to Two Cases

In previous years, when a teaching anesthesiologist was involved in a single case with an anesthesia resident, payment was the same as if the anesthesiologist performed the anesthesia case alone. If the anesthesiologist medically directed the provision of anesthesia services in two, three, or four concurrent cases, and any of the concurrent cases involved residents, the physician’s involvement in the resident case(s) was paid under the medical direction payment policy. Under medical direction, payment for the anesthesiologist service was based on 50 percent of the anesthesia fee schedule that applied if the anesthesiologist performed the case alone.

The new rules specify that a teaching anesthesiologist may receive payment under the MPFS, at the regular fee schedule level, if he or she is involved in the training of residents in:

• A single anesthesia case;
• Two concurrent cases; or
• In a single case that is concurrent to another case paid under the medical direction rules.

The last of these provisions applies specifically when the concurrent case involves a CRNA, an anesthesia assistant (AA), or a student nurse anesthetist.

In other words, according to the Medicare Claims Processing Manual, chapter 12, section 50.C, “For services furnished on or after January 1, 2010, the medical direction rules do not apply to a single resident case that is concurrent to another anesthesia case paid under the medical direction rules or to two concurrent anesthesia cases involving residents.”

For the teaching anesthesiologist payment exception to apply, two conditions must be met.

1) The teaching anesthesiologist (or other anesthesiologists in the same physician group) must be present during all critical or key portions of the anesthesia service.

If different teaching anesthesiologists in the anesthesia group are present during the key or critical periods, the performing physician, for purposes of claims reporting, is the teaching anesthesiologist who started the case. The National Provider Identifier (NPI) of the teaching anesthesiologist who started the case must be indicated in field No. 24 of the CMS claim form. The NPI of the group would be indicated in field No. 33.

2) The teaching anesthesiologist (or another anesthesiologist with whom the teaching anesthesiologist has entered into an arrangement) must be immediately available to furnish anesthesia services during the entire procedure.

Documentation should substantiate that the previously stated conditions have been met. The teaching anesthesiologist should use modifier AA Anesthesia services performed personally by anesthesiologist and certification modifier GC The Teaching Physician was present during the key portion of the service and was immediately available during other parts of the service when reporting his or her services (note that Medicare Part B does not pay residents for anesthesia services).

For example, if an anesthesiologist was involved in two concurrent cases (a total knee replacement, 01402 Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty, and a laparoscopic cholecystectomy, 00790 Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified) which both involved resident teaching, and documented requirements of the new rule were met, you would code the services: knee replacement, 01402-AA-GC; and laparoscopic cholecystectomy, 00790-AA-GC.

New Rules Also Refine CRNA Payment

As revised by CR 6706, Claims Processing Manual, chapter 12, section 140.5, “Payment for Anesthesia Services Furnished by a Teaching CRNA,” provides additional language to address payment for teaching CRNAs.

As in past years, a teaching CRNA (not under the medical direction of a physician) was paid under Medicare Part B, at the regular fee schedule rate, when he or she was present continuously and supervising a single case involving a student nurse anesthetist. In such a case, the CRNA would report the service using modifier QZ CRNA service: without medical direction by a physician. No payment could be made under Part B for the service provided by a student nurse anesthetist.

Under the new rules, however, a teaching CRNA can be paid at the regular fee schedule rate for each case when involved with two concurrent cases. Once again, the CRNA should append modifier QZ to each claim to indicate he or she is not medically directed by an anesthesiologist.

Medicare specifies that to bill the anesthesia base units, the CRNA involved with two concurrent cases must be present with the student nurse anesthetist during the pre- and post-anesthesia care for each of the two cases (ibid).

To bill anesthesia time for each case, the teaching CRNA must continue to devote his or her time to the two concurrent cases and not be involved in other activities. MM6706 Revised allows, however, for the teaching CRNA to “decide how to allocate time to optimize patient care in the two cases based on the complexity of the anesthesia case, the experience and skills of the student nurse anesthetist, the patient’s health status and other factors.”

The teaching CRNA must document his or her involvement in the cases with the student nurse anesthetists. MM6706 Revised reminds specifically “that the teaching CRNA’s medical record documentation in these cases must be sufficient to support the payment of the fee and be available for review upon request.”

Go to the source: You can find more information about payment for teaching anesthesiologists and CRNAs in CR 6706, available at www.cms.hhs.gov/Transmittals/downloads/R1859CP.pdf. This change request includes updated portions of the Claims Processing Manual, chapter 12, sections 50 and 100.1.4, as well as new section 140.5. MM6706 Revised also may be found on the CMS website at: www.cms.hhs.gov/MLNMattersArticles/downloads/MM6706.pdf.

IPPE changes reflect an increased focus on primary care, health promotion, and disease prevention.

By Torrey Kim, MA, CPC

Among many noteworthy items contained within the 2010 Medicare Physician Fee Schedule (MPFS) Final Rule is an increase in value for the so-called “Welcome to Medicare” benefit—known formally as the Initial Preventative Physical Examination (IPPE).

Section 611 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) established the IPPE benefit. The benefit subsequently was revised by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), for services beginning Jan. 1, 2009.

Under Part B, Medicare will cover an initial preventive physical examination for a new beneficiary (one IPPE per beneficiary, per lifetime). Initially, the eligibility period for receiving an IPPE was within six months of the beneficiary’s Part B enrollment date. MIPPA extended this eligibility period to within 12 months of an individual’s enrollment in Medicare Part B.

Tip: When scheduling a beneficiary’s IPPE, practices should check the patients’ eligibility with Medicare to make sure he or she doesn’t have Medicare managed care. Check the patients’ Medicare cards, as well, to confirm his or her eligibility dates, and to make sure he or she is within the IPPE eligibility period. You should also double-check with the patient to confirm he or she has not already had an IPPE with another physician.

The service may be performed by a doctor of medicine or osteopathy, or by a qualified non-physician practitioner (NPP) (i.e., nurse practitioner (NP), physician assistant (PA), and clinical nurse specialist (CNS)). The IPPE encompasses a broad array of components and focuses on primary care, health promotion, and disease prevention, according to the Centers for Medicare & Medicaid Services (CMS). As defined in chapter 12, section 30.6.1.1 of the Medicare Claims Processing Manual, the IPPE includes:

• A review of the individual’s medical and social history with attention to modifiable risk factors for disease detection.
• A review of the individual’s potential (risk factors) for depression or other mood disorders.
• A review of the individual’s functional ability and safety level.
• A physical examination to include measurement of the individual’s height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate by the examining physician or qualified NPP.
• Education, counseling, and referral, as deemed appropriate based on the results of the review and evaluation services described in the previous elements.
• Education, counseling, and referral including a brief written plan (for instance, a checklist or alternative) provided to the individual for obtaining the appropriate screening and other preventive services.

Under MIPPA, the IPPE also must include measurement of the beneficiary’s body mass index (BMI), and (upon an individual’s consent) end-of-life planning.

The appropriate code to report an IPPE is G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment. The Medicare deductible does not apply to IPPEs (code G0402) performed on or after Jan. 1, 2009. Coinsurance, however, does apply.

Prior to MIPPA, screening electrocardiogram (EKG) was a mandatory component of an IPPE. Since MIPPA (beginning Jan. 1, 2009), screening EKG is optional and is permitted as a one-time screening service as a result of a referral arising out of the IPPE. Screening EKG, if performed, is reported separately from G0402 using, as appropriate:

G0403     Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

G0404     Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

G0405     Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Note that G0403 describes the global EKG (including tracing with interpretation and report), while G0404 and G0405 describe the tracing only, and interpretation and report only, respectively. Note also that the waived deductible for the IPPE does not apply to the screening EKG service, irrespective of the codes used or service date.

This instruction, along with additional, complete content and coding guidelines for the IPPE, are outlined in the CMS Transmittal 1615, Change Request 6223, dated Oct. 17, 2008 (www.cms.hhs.gov/transmittals/downloads/R1615CP.pdf).

For 2010, the reporting requirements for the IPPE do not change; however, code G0402 is revalued. According to the MPFS Final Rule, upon review, CMS felt “the services, in the context of work and intensity, contained in HCPCS code G0402 are most equivalent to those services contained in CPT code 99204 Evaluation and management new patient, office or other outpatient visit.” As such, CMS has increased the work relative value units (RVUs) for HCPCS Level II code G0402 to 2.30—up from 1.34 in 2009—effective for services furnished beginning on Jan. 1. At current rates, this will increase provider payment for the service by roughly $30.

Resource tip: See 42 CFR Parts 410, 411, 414 et al. Medicare Program; Payment Policies, Under the Physician Fee Schedule and Other Revisions to Part B for 2010; Final Rule (2010 Medicare Physician Fee Schedule Final Rule) in the Nov. 25, 2009 Federal Register at: http://edocket.access.gpo.gov/2009/pdf/E9-26502.pdf. The information on IPPE begins on page 61766 (page 30 of the viewable .pdf file).