An IMS Institute for Healthcare Informatics survey released April 4 shows a drop in physician office visits and prescription use. As patients struggle with high deductibles, co-pays, and general economic issues they are more likely to ask their physician about cheaper alternatives for tests and prescriptions, or to find other alternatives rather than seeing their doctor.
IMS’ report findings are similar to reports from the Kaiser Family Foundation and Chase health industry analyst John Rex. Their reports also found a decline in office visits. Another survey report, released November 2011 by Commonwealth Fund, said 42 percent of “sicker” adults had more cost-related access problems than in the previous year.
IMS’ report found that from 2010 to 2011:
- Retail pharmacy prescription spending declined 1.1 percent.
- Prescription spending by insured patients ages 19-25 went up 2 percent.
- Patients 65 and older spent 3.1 percent less out-of-pocket for prescriptions.
- Ages 65-69 had the biggest prescription decline, with a 4.3 percent drop.
- The biggest prescription decline was for those treating hypertension.
- Non-emergency hospital admissions declined 0.1 percent.
- Emergency admissions went up 7.4 percent.
The increase in emergency admissions is an indicator that patients are reluctant to seek medical treatment from their physician office or to take medications because of financial concerns. Larry Levitt, senior vice president of the Kaiser Family Foundation said, “It suggests people are putting off care, and they’re showing up sicker.”
According to the survey, here are the statistics showing the number of office visit changes from prior years:
2002 – 1,503,225,000: 2.7%
2003 – 1,589,694,000: 5.8%
2004 – 1,565,978,000: -1.5%
2005 – 1,654,375,000: 5.6%
2006 – 1,670,502,000: 1.0%
2007 – 1,624,189,000: -2.8%
2008 – 1,627,786,000: 0.2%
2009 – 1,602,354,000: -1.6%
2010 – 1,535,506,000: -4.2%
2011 – 1,468,265,000: -4.7%
Advice for Physicians Who are Seeing a Decline
According to an amednews.com article, here’s what physicians can do to make it more likely that financially strapped patients will follow advice for prevention and treatment:
- Explain the value of the recommended medication, test, or procedure even if the patient doesn’t ask. Barry Make, MD, a pulmonologist with National Jewish Health in Denver, said, “Patients will only do something if they understand what it is for, but patients are often reluctant or ashamed or embarrassed to ask.”
- Make it clear that some negotiation is possible if cost is a significant concern. For example, see a patient every four months rather than every three.
- Steer patients to lower-cost prescription resources and write prescriptions for drugs to be filled cheaper at big pharmacies.
- Guide patients to drug assistance programs or discount programs.
Source: IMS Institute for Healthcare Informatics “The Use of Medicines in the United States: Review of 2011“
April 27th, 2012
From bronchoscopy to tongue excision and dizziness to drooling, here’s what’s new for ENT.
By Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CHCC, CENTC
CPT® 2011 brings more than a dozen code changes of particular relevance to ear, nose, and throat (ENT) practices. Among the most prominent is the addition of three codes to report endoscopic dilation of the sinus ostia:
31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium
(eg, balloon dilation), transnasal or via canine fossa
31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium
(eg, balloon dilation)
31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation)
Sinus ostia are narrow corridors connecting the sinuses to the nasal cavity. These pathways can become blocked, allowing sinus secretions to collect, which can lead to sinusitis and other problems. Codes 31295-31297 describe a relatively new technique, in which the surgeon inflates a balloon catheter in the affected ostium (maxillary, frontal, or sphenoid). The expanding balloon forcibly dilates the surrounding tissue. When the balloon is deflated and withdrawn, the ostium remains open. Fluoroscopy, when performed, is included in the dilation.
Like the sinuses, the ostia are paired structures (for instance, there is both a left and a right sphenoid sinus ostia); but per CPT® guidelines, 31295-31297 report unilateral procedures. If the surgeon dilates both the left and right sphenoid sinus ostia, for example, append modifier 50 Bilateral procedure to 31297. By contrast, if the surgeon dilates the left sphenoid sinus ostium and the right frontal sinus ostium, proper coding is 31296, 31297. Modifier 50 isn’t required because different (rather than paired) ostia were targeted.
When dilation occurs in the same sinus as another surgical, functional endoscopic service, the dilation in some cases may not be separately reportable. Per CPT® parenthetical instructions:
- Do not report 31295 in addition to 31233 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture), 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy, or 31267 Nasal/sinus endoscopy, surgical, with removal of tissue from maxillary sinus when performed on the same sinus.
- Do not report 31296 in addition to 31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus when performed on the same sinus.
- Do not report 31297 in addition to 31235 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium, 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy, or 31288 Nasal/sinus endoscopy, surgical, with removal of tissue from the sphenoid sinus when performed on the same sinus.
As an example, if the surgeon dilates the left maxillary sinus and performs maxillary antrostomy with removal of tissue in the same sinus, claim 31267 only; the dilation (31295) should not be reported separately. If the dilation and antrostomy occurred at different locations, report each procedure separately, appending modifier 59 Distinct procedural service on the dilation code to represent a separate site.
Endoscopic Bronchopleural Fistula Occlusion Calls for 31634
Added code 31634 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, with assessment of air leak, with administration of occlusive substance (eg, fibrin glue), if performed also describes an endoscopic procedure using a balloon. In this case, the balloon is placed and inflated to occlude (block) a bronchopleural fistula (BPF)—an abnormal passageway between the lungs and pleura that allows inhaled air to escape the lungs into the pleural space. An occlusive substance, such as fibrin glue, may be administered to seal the fistula after the balloon has been removed. The procedure includes assessment of air leak, fluoroscopic guidance (to guide placement of the balloon), when performed, and moderate sedation.
BPFs occur most frequently due to infection or prior surgery. According to CPT® Changes 2011: An Insider’s Guide, endoscopic balloon occlusion “has been performed in the past as part of a last effort to resolve persistent bronchopleural fistulas. It is becoming more common as an earlier therapy for this disease.” Prior to 2011, the procedure was reported using an unlisted code.
Stereotactic Code Recognizes Extradural Procedures
Image-guided surgery allows for navigation and localization around high-risk anatomical structures. Code 61795, which previously described image-guided surgery, is deleted for 2011 and is replaced by three codes that describe the navigational procedure by location.
New code +61782 Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure) now describes image-guided surgery outside the cranium. In previous years, there was no way to differentiate extradural procedures from intradural procedures (now reported using +61781 Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure)) or spinal procedures (now reported using +61783 Stereotactic computer-assisted (navigational) procedure; spinal (list separately in addition to code for primary procedure)), which generally are limited to neurosurgical specialists.
Navigation is an add-on procedure reported in addition to a primary surgical procedure in the same area. For example, 61782 might accompany nasal surgical endoscopy with optic nerve decompression (31294).
Injection for Sialorrhea — 64611
Sialorrhea (drooling) may be a serious problem for some patients. Selective chemodenervation with botulinum toxin A may reduce saliva production. Code 64611 Chemodenervation of parotid and submandibular salivary glands, bilateral describes such an injection into the parotid and submandibular salivary glands. This is a bilateral code; if fewer than four salivary glands are injected, CPT® instructs you to append modifier 52 Reduced services to 64611.
Revised Labyrinthotomy No Longer Includes Subsequent Perfusions
Labryinthotomy may be performed to treat Ménière’s disease and/or vertigo. The descriptors for 69801 Labyrinthotomy, with perfusion of vestibuloactive drug(s); transcanal and 69802 Labyrinthotomy, with perfusion of vestibuloactive drug(s); with mastoidectomy have been revised to remove references to cryosurgery. According to CPT® Changes 2011: An Insider’s View, “Cryosurgery is no longer utilized, and the only type of nonexcisional destruction performed currently is the perfusion of vestibuloactive drugs.” For example, the physician makes an incision in the tympanic membrane (ear drum), inserts the needle, and perfuses gentimycin (among other vestibulactive drugs) into the middle ear. The perfused drug deadens the hair-like fibers that transmit balance information to the brain. Initially, the procedure may cause dizziness for several days or weeks. This eventually dissipates and the vertigo disappears.
Several treatments may be required. You may report 69801 only once per day; however, for 2011 the global period for 69801 has been changed from 90 days to zero days. As a result, you may report subsequent perfusions on different dates of service separately, along with the drug supply code.
CPT® additionally instructs that you may not report 69801 with 69420 Myringotomy including aspiration and/or eustachian tube inflation, 69421 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia, 69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia, or 64636 Tympanostomy (requiring insertion of ventilating tube), general anesthesia when performed on the same ear.
Code 69802 describes labyrinthotomy, as above, along with mastoidectomy (excision to remove an infected portion of the mastoid bone). This procedure is reported rarely (13 cases in 2008, according to Charles Koopman, Jr., MD, who presented at the American Medical Association’s (AMA’s) CPT® and RBRVS 2011 Annual Symposium this past November).
Turn to Category III Codes for Automated Audiometry
CPT® 2011 adds five Category III codes to describe automated audiometry tests (e.g, Tympany Otogram™). Such automated exams diagnose hearing defects using various parameters as defined within the codes.
0208T Pure tone audiometry (threshold), automated; air only
0209T Pure tone audiometry (threshold), automated; air and bone
0210T Speech audiometry threshold, automated
0211T Speech audiometry threshold, automated; with speech recognition
0212T Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated
For audiometric testing using audiometers performed manually by a qualified health care professional, see 92551-92557.
CPT® 2011 Clarifies Vestibular Function Test Combo Confusion
Vestibular evaluations are used to diagnose the origin of symptoms such as dizziness and vertigo, and specifically to determine if something is wrong with the vestibular portion of the inner ear. If dizziness is not caused by the inner ear, it might be caused by brain disorders, another medical condition (e.g., low blood pressure), or even psychological issues (e.g., anxiety).
A basic vestibular evaluation includes four components:
- A spontaneous nystagmus test
- A positional nystagmus test
- An optokinetic nystagmus test
- An oscillating tracking test
CPT® includes codes to report each of these component tests individually; however, if all components are performed together, you would report them using a single code, 92540 Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording.
In past years, there was confusion about how to report the individual components of the vestibular evaluation if a complete evaluation was not performed. Parenthetic instructions within CPT® now clarify that if three or fewer of the above component tests are performed, in any combination, you may report each test separately, as follows:
92541 Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording
92542 Positional nystagmus test, minimum of 4 positions, with recording
92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording
92545 Oscillating tracking test, with recording
For instance, for spontaneous nystagmus test and optokinetic nystagmus test, report 92541 and 92544. If these tests occurred along with positional nystagmus and oscillating tracking tests, report 92540 to describe all four components. Don’t report any single component (92541, 92542, 92544, or 92545) in addition to 92540.
Note, however, that codes describing caloric vestibular test (92543 Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4 tests), with recording), vertical axis rotational testing (92546 Sinusoidal vertical axis rotational testing), and use of vertical electrodes (+92547 Use of vertical electrodes (List separately in addition to code for primary procedure) may be separately reported with 92540 or any legitimate combination (three or fewer) of 92541, 92542, 92544, and 92545.
Watch out for Tongue Excision/Flap Bundle
A revised parenthetical note in CPT® 2011 now disallows separate reporting of 41114 Excision of lesion of tongue with closure; anterior with local tongue flap with 41112 Excision of lesion of tongue with closure; anterior two-thirds or 41113 Excision of lesion of tongue with closure; posterior one-third. This is in direct opposition to earlier editions of CPT®, which instructed “List 41114 in addition to code 41112 or 41113.”
Be sure to update your coding. If flap repair (41114) occurs with excision (41112 or 41113), report only the excision.
Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, is president CRN Healthcare Solutions and senior coder and auditor for The Coding Network. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and health care related topics nationally.
March 1st, 2011
By Denise Williams, RN, CPC, CPC-H
For the 2011 Outpatient Prospective Payment System (OPPS) Final Rule, the Centers for Medicare & Medicaid Services (CMS) based payments on claims data submitted by hospital providers during 2009. Let’s highlight some of the rule to prepare you for the changes in the year ahead.
You can download the CMS display copy of the rule and all preamble tables and addenda at: www.cms.hhs.gov/HospitalOutpatientPPS/HORD. Select CMS-1504-FC to access the Final Changes to the Hospital Outpatient Prospective Payment System and CY 2011 Payment Rates files and final rule documents.
2X Rule Violation Exceptions Increase
As in the past couple of years, CMS made changes to the ambulatory payment classification (APC) assignment this year based on the “2X rule violation.” Prospective payment involves an inherent grouping of services requiring comparable resource usage. A 2X rule violation happens when the highest cost item’s median cost is twice that of the lowest cost item within the same APC. The secretary of Health and Human Services (HHS) has the discretion to allow exceptions to this rule (such as for low-volume procedures and services), and has approved 22 APCs as exceptions to the 2X rule for 2011 (seven more than in 2010). These are listed in Table 22 in the Final Rule.
Composite APCs Remain the Same
CMS made no changes to existing composite APCs, nor did they create new composite APCs for 2011. The Multiple Imaging composites were implemented in 2009, and the first claims data for monitoring the impact were available for this year’s rate setting. The APC panel and rule commenters recommended additional composites that could be created in the future. CMS continues to “consider the development and implementation of larger payment bundles, such as composite APCs (a long-term policy objective for the OPPS), and continues to explore other areas” where this model could be utilized, according to the Final Rule.
Outlier Fixed-Dollar Thresholds Updated
CMS annually updates the formula for calculating outlier payments. Just like in 2010, an outlier payment is triggered in 2011 when costs for providing a service or procedure exceed both:
- 1.75 times the APC payment amount
- The APC payment plus $2,025 fixed-dollar threshold (decreased by $150 from 2010)
CMS made no changes to the outlier reconciliation policy for outpatient services provided based on cost reporting periods beginning in 2009.
Pass-through Payment Changes
There is one device that became eligible for pass-through payment in October 2010. Described by HCPCS Level II code C1749 Endoscope, retrograde imaging/illumination colonoscope device (implantable), this item will continue with pass-through status for 2011. There are additional applications for pass-through items under consideration. Drugs and biologicals with pass-through status that expired Dec. 31, 2010 are listed in Table 27 of the Final Rule. The cost of 13 of these drugs is above the packaging threshold, which is $70 for 2011, and separate payment will continue.
Payment for separately-payable drugs without pass-through status will increase for 2011 to average sale price (ASP) plus 5 percent. For the 42 drugs and biologicals having pass-through status for 2011, payment is ASP plus 6 percent. These drugs are listed in Table 28. There are HCPCS Level II code changes for several of these drugs.
New vs. Established Definitions Continue
CMS notes that 2009 claims data continues to reflect a cost difference between new and established patient visits. The agency continues to define “new” and “established” patients based on whether the patient was an inpatient or outpatient of the hospital within the past three years.
E/M Guidelines Are Passed By
No new national evaluation and management (E/M) guidelines are established for 2011. Claims data continues to reflect stable distribution of billed visits. CMS instructs hospitals to keep using their individual internal guidelines, being sure that the guidelines meet the 11 criteria specified in the 2008 Final Rule. Fiscal intermediaries (FIs) and Medicare administrative contractors (MACs) are encouraged to use the individual hospital’s internal E/M guidelines when an audit occurs.
New CPT® Instruction, New Edit
CMS instructs facilities to follow CPT® guidelines. Beginning in 2009, this included the introductory guidelines for services contained in critical care services (CPT® 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and +99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (list separately in addition to code for primary service). For 2011, the American Medical Association (AMA) has added language to the Critical Care instructions noting that, “Facilities may report the above services separately.” CMS has provided packaged payment for critical care services based on the CPT® definition for the past two years. CMS notes, “Beginning in CY 2011, hospitals that report in accordance with the CPT® guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care.”
In response to this change, CMS will institute a new Outpatient Code Editor (OCE) edit that will package the services for the separately-reported procedures into the payment for critical care services. Instituting “automatic packaging” via the OCE will ease a huge operational burden on facilities who have had to use an internal, usually manual, process to remove the HCPCS Level II codes from the claim and roll the charges into one line item for critical care services.
Inpatient-only Procedures Shrink
The “Inpatient Only” list specifies procedures typically provided in an inpatient setting due to the invasive nature of the procedure; the need for at least 24 hours of post-procedure monitoring before the patient can be safely discharged; or the underlying physical condition of the beneficiary; and therefore, these procedures are not reimbursable under the OPPS. For 2011, CMS removed three procedures from the inpatient-only list, which allows hospitals to be reimbursed when these procedures are performed on an outpatient basis.
21193 Reconstruction of mandibular rami; horizontal, vertical, C, or L osteotomy; without bone graft
21395 Open treatment of orbital floor blowout fracture; periorbital approach with bone graft (includes obtaining graft)
25909 Amputation, forearm, through radius and ulna; reamputation
These procedures, their corresponding CPT® codes, and APC assignments are found in Table 46.
Direct Supervision for Outpatient Therapeutic Services
In 2010, there was a lot of discussion regarding the requirements under the conditions of participation versus the definition requirements of direct physician supervision. CMS delayed enforcement of direct supervision for therapeutic services provided in critical access hospitals (CAHs) as of March 2010. In the Final Rule, CMS extended this non-enforcement period through 2011 and extended the exception to small rural hospitals with 100 beds or fewer located in a rural area or paid under OPPS with a rural wage index.
CMS listened to providers during the year and made some changes to the definition of direct supervision. The updated definition requires the practitioner to be “immediately available” and “interruptible,” but specific references to where the practitioner must be physically located are removed. The removal of reference to geographical location is applicable for both on-campus and off-campus provider-based departments and applies to cardiac rehab, pulmonary rehab, and intensive cardiac rehab.
The agency created a list of 16 services, called “non-surgical extended duration services,” for which direct supervision is required at the initiation of the service. Once the patient is stable, general supervision may be provided for the duration of the service. These services are identified in Table 48a. The included services must meet four criteria:
1. May last a significant time
2. Have a low risk of requiring direct supervision once initiated
3. Have a significant monitoring component typically provided by nursing/auxiliary staff
4. Are not surgical services that include recovery time
Initiation of these services requires direct supervision; once the treating practitioner deems the patient to be medically stable, general supervision is acceptable. CMS expects the transition from direct to general supervision to be documented in the medical record, but does not specify what this documentation must look like.
The agency acknowledges that “the statute does not explicitly mandate direct supervision,” but believes that direct supervision is the most appropriate level for services provided incident-to a physician service. CMS proposes to establish a committee and independent review process to assess the appropriate supervision level for hospital outpatient therapeutic procedures. For the 2012 rule-making cycle, CMS most likely will establish a timeframe for receiving requests, develop criteria for evaluation of each service, and create or designate a committee. CMS has requested public comment on this proposal.
Additional Notable Changes
The Patient Protection and Affordable Care Act (PPACA) waives the Part B deductible and coinsurance for certain preventive services payable under the OPPS. Based on classification by the U.S. Preventive Services Task Force (USPSTF), covered preventive services graded as A or B mean the beneficiary coinsurance is waived and, for many of the services, the Part B deductible also is waived. Table 48b contains specific information regarding these services.
Changes to the 2011 Medicare Physician Fee Schedule (MPFS) (CMS-1503-FC, found at: www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp) also impact OPPS facilities related to laboratory requisitions and rehabilitation services with payment based on the fee schedule. Beginning in 2011, requisitions for clinical laboratory services paid under the laboratory fee schedule must be signed/authenticated by the physician/non-physician practitioner (NPP). CMS discussed the history of lab requisitions vs. orders in the MPFS proposed rule.
CMS also is instituting a “multiple procedure payment reduction” for outpatient therapy services paid under the MPFS. The reduction is 25 percent of the second and subsequent “always therapy” services’ practice expense component. The first unit of the highest valued service is payable at 100 percent; all additional units of the same service or different service are paid at 75 percent. The payment reduction is based on services provided on a single date of service, even if the services are provided by different therapy disciplines. Table 21 in the 2011 MPFS Final Rule lists the services subject to this policy.
Denise Williams, RN, CPC, CPC-H, is the director of revenue integrity services for Health Revenue Assurance Associates, Inc. She has been involved with APCs since their initiation. She has worked as corporate chargemaster manager for two health care systems, heavily involved in compliance and coding/billing edits and issues.
January 1st, 2011