You must always match preventive medicine codes with a V code, even for Medicare patients.
A preventive medicine service is not a problem-oriented visit. Instead of signs and symptoms or other “problem” diagnoses, use an ICD-9 code that supports the services provided (e.g., V70.0 Routine general medical examination at a health care facility for adults; V72.31 Routine gynecological examination for gynecologic exams; or V20.2 Routine infant or child health check for well-child care). You may apply additional special screening codes (V73.0-V82.9), as appropriate.
December 2nd, 2013
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.
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
If two surgeons act as co-surgeons, they must likewise coordinate their documentation and billing to ensure that each receives proper reimbursement.
When two surgeons work together to perform distinct portions of a procedure identified by a single CPT® code, each surgeon will report the appropriate code with modifier 62 Two surgeons appended. Each surgeon must serve as the primary surgeon during some portion of the procedure. For example, per CPT® Assistant (February 2002), “In some cases, one surgeon may perform the approach procedure for anterior spine surgery, including making the incision and exposing the area requiring surgery, while another surgeon then performs the definitive procedure on the spine. Following completion of the definitive procedure, the first physician returns to perform the closure of the operative site. Therefore, two surgeons have performed the work included in one total procedure, reportable with a single code.”
Medicare (and many other payers) will recognize modifier 62 only with certain codes, as identified in the “CO-SURG” column of the National Physician Fee Scheduled Relative Value File.
- If the CO-SURG column includes a “1” indicator: You may append modifier 62, but documentation must show which special circumstances or skills required two surgeons to share responsibility.
- If the CO-SURG column includes a “2” indicator: You may append modifier 62 as long as each of the operating surgeons is of a different specialty.
- If the CO-SURG column includes a “0” or “9” indicator: Medicare does not allow modifier 62 with that code.
When submitting claims with modifier 62, each physician must document his or her own operative notes, detailing what portion of the procedure he or she performed, how much work was involved, how long the procedure took, etc. Each physician should identify the other as a co-surgeon; both surgeons should link the same diagnosis to the common procedure code; and each will submit his or her own claim.
Medicare and many other payers pay for codes appropriately submitted with modifier 62 at 125 percent of the usual fee schedule amount. The payer divides this between the two surgeons reporting the procedure, so each surgeon receives 62.5 percent of the regular fee. If the operating surgeons fail to coordinate their claims, however, one or both surgeons may not receive the earned reimbursement. For instance, if surgeon A sends his claim without a modifier appended, and his claim is the first to reach the payer, surgeon B (who acted as a co-surgeon) may have his or her claim rejected as a duplicate.
By Jim Strafford, CEDC, MCS-P
The Center for Medicare & Medicaid Services (CMS) has proposed a landmark change to emergency department (ED) and Clinic Facility coding methodology. If enacted, the proposal would mark an end to “levels” coding in the ED and hospital clinics.
In a letter dated July 18, CMS announced that, as part of the 2014 Outpatient Prospective Payment System Payment rules, it was “proposing to streamline the current five levels of outpatient visit codes. The proposal will replace them with a single Healthcare Common Procedure Coding System (HCPCS) for each unique type of outpatient hospital visit.” For example, CMS would reimburse a single emergency department (ED) HCPCS code, which would be based on an average of the five current APCs ($212.40 proposed).
CMS wants to collapse the current five levels (based on CPT® 99281-99285 for the ED, and 99201-99205/99211-99215 for hospital clinics) to a single level, “to maximize hospitals’ incentive to provide care in the most efficient manner.” Other stated goals are to discourage upcoding, to remove hospital incentives to provide medically unnecessary services, and to reduce administrative burden.
We have tracked the issue of ED Facility Coding for several years, and in our view there are additional reasons for the proposal:
• CMS has failed to create ED facility documentation guidelines similar to the 1995 or 1997 Guidelines for physician documentation. CMS continues to use AHIMA guidelines, which require only that ED levels be reasonable and that they relate to hospital cost.
• Due to the lack of documentation guidelines, government auditors and audit contractors (e.g., Recovery Audit Contractors, or RACs) have limited means to audit ED facility services, to determine whether assigned ED levels are correct.
• ED facility level acuity has been increasing for years—which translates into increased costs for CMS.
• Negative publicity over skyrocketing costs, from the NY Times to “60 Minutes” and more, laid the groundwork for the latest proposal. In response to criticisms, U.S. Secretary of Health and Human Services Kathleen Sebelius and U.S. Attorney General Eric Holder cited “overcoding” due to “EHR Abuse” (e.g., use of macros and templates to increase documentation and resulting coding levels) as one cause of rising expenditures.
The American Hospital Association, the American College of Emergency Physician, and other professional societies object to “one code fits all” on the grounds that it does not appropriately reflect the reality of ED and clinic medicine, and that one payment for all levels would unfairly penalize inner-city EDs that treat high acuity cases. Observers have also expressed concern that “one level” coding would result in additional “bundling” of services and payment reductions.
The Final Rule is due in late November. The general feeling among industry insiders is that the “one level” proposal will not be part of the Final Rule, but there’s no guarantee. Stay tuned.
Bio: Jim Strafford, CEDC, MCS-P has over thirty years experience as a consultant, manager, and educator in all phases of medical coding, billing, compliance, and reimbursement. Strafford is a published, nationally recognized expert on emergency department revenue cycle and coding issues.
November 12th, 2013
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