An Overview of Oncology Coding 2009 Bobbi Buell Version 5.0 January 2009 Disclaimer Payers differ on their guidelines. Please verify coding for each payer and claim. This is not legal or payment advice. This content is abbreviated for Medical Oncology. It does not substitute for a thorough review of code books, regulations, and Carrier guidance. This information is good for the date of the information and may contain typographical errors. CPT is the trademark for the American Medical Association. All Rights Reserved. Session Objectives Discuss Documentation Requirements Discuss ICD-9-CM Changes for 2009 Discuss CPT Changes for 2009 Discuss HCPCS Coding for 2009 Discuss Coding for PQRI 2009 Discuss Coding for E-Prescribing 2009 Review some E/M Changes for 2008 Review Consult Coding Review Who, What, Where, Why, and When of Audits Discuss the Implementation of ICD-10-CM General References Physician Payment Rule = http://www.cms.hhs.gov/PhysicianFeeSched/PFSFR N/list.asp#TopOfPage Hospital Outpatient Rule = http://www.cms.hhs.gov/HospitalOutpatientPPS/HO RD/list.asp#TopOfPage ICD-9-CM Codes = http://www.cms.hhs.gov/ICD9ProviderDiagnosticCod es/07_summarytables.asp#TopOfPage Documentation Guidelines General Principles (CMS) The medical record must be complete and legible. The documentation of the each patient encounter must include Reason for the encounter and relevant history, physical, and prior health examination results; Assessment, clinical impression, or diagnosis; Plan for care; and, Date and legible identity of the observer. CMS Documentation Guidelines (cont’d) If not documented, the rationale for ordering diagnostic and other ancillary services should easily be inferred. Past and present diagnoses should be accessible to the treating and/or consulting physician. Appropriate health risk factors should be identified. The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented. AND, the CPT and ICD-9-CM codes reported on the bill should be supported by the documentation in the medical record. DOCUMENTATION Documentation should paint a picture of: How patient is doing / what is new during higher code visit Need for unusual / atypical drugs, labs or unusual diagnostic tests - explain Need for frequent visits or higher e&m visits Any special problems with that individual patient Include observations and supportive data as needed Documentation need not be extensive Courtesy of Dr. Arthur Lurvey, CMD, PalmettoGBA, MAC for California, Nevada, and Hawaii • BUT MUST BE LEGIBLE 7 DOC: TRY TO PAINT A PICTURE CHOOSE A NORMAN ROCKWELL OR ANDREW WYETH PAINTING NOT A JACKSON POLLOCK OR VASILY KANDINSKY PICTURE Courtesy of Dr. Arthur Lurvey, CMD, PalmettoGBA, MAC for California, Nevada, and Hawaii 8 DOCUMENTATION POINTS Templates/forms are fine, but must be individualized for each patient and visit Patient name, date, time, and ID of who documented chart Computerized notes okay if individualized, but medical necessity still rules on review Note time when service is time related-e.G. Prolonged services, drug administration If poorly legible, send typed or printed copy with original 9 Coding Issues Cancer ICD-9-CM Codes 10/1/08 199.2 Malignant neoplasm associated with transplant organ 203.02 Multiple myeloma, in relapse 203.12 Plasma cell leukemia, in relapse 203.82 Other immunoproliferative neoplasms, in relapse 204.02 Acute lymphoid leukemia, in relapse 204.12 Chronic lymphoid leukemia, in relapse 204.22 Subacute lymphoid leukemia, in relapse 204.82 Other lymphoid leukemia, in relapse 204.92 Unspecified lymphoid leukemia, in relapse 205.02 Acute myeloid leukemia, in relapse 205.12 Chronic myeloid leukemia, in relapse 205.22 Subacute myeloid leukemia, in relapse 205.32 Myeloid sarcoma, in relapse 205.82 Other myeloid leukemia, in relapse 205.92 Unspecified myeloid leukemia, in relapse 206.02 Acute monocytic leukemia, in relapse 206.12 Chronic monocytic leukemia, in relapse 206.22 Subacute monocytic leukemia, in relapse 206.82 Other monocytic leukemia, in relapse 206.92 Unspecified monocytic leukemia Cancer ICD-9-CM Codes 10/1/08 207.02 Acute erythremia and erythroleukemia, in relapse 207.12 Chronic erythremia, in relapse 207.22 Megakaryocytic leukemia, in relapse 207.82 Other specified leukemia, in relapse 208.02 Acute leukemia of unspecified cell type, in relapse 208.12 Chronic leukemia of unspecified cell type, in relapse 208.22 Subacute leukemia of unspecified cell type, in relapse 208.82 Other leukemia of unspecified cell type, in relapse 208.92 Unspecified leukemia, in relapse Cancer ICD-9-CM Codes 10/1/2008 209.00 Malignant carcinoid tumor of the small intestine, unspecified portion 209.01 Malignant carcinoid tumor of the duodenum 209.02 Malignant carcinoid tumor of the jejunum 209.03 Malignant carcinoid tumor of the ileum 209.10 Malignant carcinoid tumor of the large intestine, unspecified portion 209.11 Malignant carcinoid tumor of the appendix 209.12 Malignant carcinoid tumor of the cecum 209.13 Malignant carcinoid tumor of the ascending colon 209.14 Malignant carcinoid tumor of the transverse colon 209.15 Malignant carcinoid tumor of the descending colon 209.16 Malignant carcinoid tumor of the sigmoid colon 209.17 Malignant carcinoid tumor of the rectum 209.20 Malignant carcinoid tumor of unknown primary site 209.21 Malignant carcinoid tumor of the bronchus and lung 209.22 Malignant carcinoid tumor of the thymus 209.23 Malignant carcinoid tumor of the stomach 209.24 Malignant carcinoid tumor of the kidney 209.25 Malignant carcinoid tumor of foregut, not otherwise specified 209.26 Malignant carcinoid tumor of midgut, not otherwise specified 209.27 Malignant carcinoid tumor of hindgut, not otherwise specified 209.29 Malignant carcinoid tumor of other sites New Cancer ICD-9 Codes 10/1/2008 209.30 Malignant poorly differentiated neuroendocrine carcinoma, any site 238.77 Post-transplant lymphoproliferative disorder (PTLD) 289.84 Heparin-induced thrombocytopenia (HIT) 999.81 Extravasation of vesicant chemotherapy 999.82 Extravasation of other vesicant agent 999.88 Other infusion reaction 999.89 Other transfusion reaction V07.51 Prophylactic use of selective estrogen receptor modulators (SERMs) V07.52 Prophylactic use of aromatase inhibitors V07.59 Prophylactic use of other agents affecting estrogen receptors and estrogen levels V13.51 Personal history of pathologic fracture V87.41 Personal history of antineoplastic chemotherapy V87.42 Personal history of monoclonal drug therapy V87.49 Personal history of other drug therapy Changed Codes of Note 203.00 Multiple myeloma, without mention of having achieved remission 203.10 Plasma cell leukemia, without mention of having achieved remission 203.80 Other immunoproliferative neoplasms, without mention of having achieved remission 204.00 Acute lymphoid leukemia, without mention of having achieved remission 204.10 Chronic lymphoid leukemia, without mention of having achieved remission 204.20 Subacute lymphoid leukemia, without mention of having achieved remission 204.80 Other lymphoid leukemia, without mention of having achieved remission 204.90 Unspecified lymphoid leukemia, without mention of having achieved remission 205.00 Acute myeloid leukemia, without mention of having achieved remission 205.10 Chronic myeloid leukemia, without mention of having achieved remission 205.20 Subacute myeloid leukemia, without mention of having achieved remission 205.30 Myeloid sarcoma, without mention of having achieved remission 205.80 Other myeloid leukemia, without mention of having achieved remission 205.90 Unspecified myeloid leukemia, without mention of having achieved remission Changed Codes of Note (2009) 206.00 Acute monocytic leukemia, without mention of having achieved remission 206.10 Chronic monocytic leukemia, without mention of having achieved remission 206.20 Subacute monocytic leukemia, without mention of having achieved remission 206.80 Other monocytic leukemia, without mention of having achieved remission 206.90 Unspecified monocytic leukemia, without mention of having achieved remission 207.00 Acute erythremia and erythroleukemia, without mention of having achieved remission 207.10 Chronic erythremia, without mention of having achieved remission 207.20 Megakaryocytic leukemia, without mention of having achieved remission 207.80 Other specified leukemia, without mention of having achieved remission 207.20 Megakaryocytic leukemia, without mention of having achieved remission 207.80 Other specified leukemia, without mention of having achieved remission \ 208.00 Acute leukemia of unspecified cell type, without mention of having achieved remission 208.10 Chronic leukemia of unspecified cell type, without mention of having achieved remission 208.20 Subacute leukemia of unspecified cell type, without mention of having achieved remission 208.80 Other leukemia of unspecified cell type, without mention of having achieved remission 208.90 Unspecified leukemia, without mention of having achieved remission V45.71 Acquired absence of breast and nipple CPT Changes 2009 CPT decided to ‘go green this year and changed the numbering for the Hydration and Therapeutic codes so they are in the same section as the Chemo codes. All Hydration and Therapeutic codes will be “963” codes instead of “907” codes. 90761 = 96361 90767 = 96367 90772 = 96372 ETC. Source: CPT 2009 Crosswalk available at http://www.asco.org CPT Changes 2009 The Chemotherapy Section name has changed to “Chemotherapy or Highly Complex Drug or Highly Complex Biologic Agent” Administration The word “highly complex” used with frequency Will payers change admin codes on some drugs? CMS leaves this up to the MACs and Carriers. Other payers may be more strict with drug administration, but let’s wait and see what the AMA says. Descriptor Source: CPT 2009 HCPCS Changes 2009 (1/1/2009) New Codes: J0641 J1267 J1453 J1459 INJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MG INJECTION, DORIPENEM, 10 MG INJECTION, FOSAPREPITANT, 1 MG INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G. HCPCS Changes New Codes J8705 TOPOTECAN, ORAL, 0.25 MG J9033 INJECTION, BENDAMUSTINE HCL, 1 MG J9207 INJECTION, IXABEPILONE, 1 MG J9330 INJECTION, TEMSIROLIMUS, 1 MG HCPCS Changes Changed Descriptors J1572 INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, J2788 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROGRAMS (250 I.U.) J2790 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.) HCPCS Deleted Codes Q4097 INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NONLYOPHILIZED (E.G. Q4098 INJECTION, IRON DEXTRAN, 50 MG • They reinstated J1750 INJECTION, IRON DEXTRAN, 50 MG MIPPA Legislation - PQRI The Medicare Improvements for Patients and Providers Act (MIPPA), passed in July 2008, contained several new authorities and requirements for quality reporting and PQRI for 2009 and beyond. Section 131 directly impacts PQRI Section 132 contains the new electronic prescribing incentive provisions. What Do You Need to Code for PQRI?? Step 1: Decide how often you must report Once per reporting period versus Once per treatment versus Every time you see the patient Step 2: Determine the patient population in the denominator Hint: Do not look at the title of the measure! Age Diagnosis Combined with the procedure codes, e.g visits, radiation, etc. What Do You Need to Code for PQRI?? Step 3: What combination of codes or single codes do you report at least 80% of the time? CPT II HCPCS Not reported if patient is not in the denominator. Report on the same claim with the denominator information, if at all possible. Foot CDQ (Numerator) codes with the diagnosis code for the measure. PQRI Measure #71 Changes for 2009 Coding Changes Different instructions Deleted: 3302F, 3303F, 3305F, 3306F, 3307F, 3309F, 3310F, 3311F, 3312F Added (Not in CPT) 3370F = AJCC Breast Cancer Stage 0 documented 3372F = AJCC Breast Cancer Stage I: T1 mic, T1a, or T1b documented 3374F = AJCC Breast Cancer Stage I: TIC, Tumor Size >1 cm2cm 3376F = AJCC Breast Cancer Stage II documented 3378F = AJCC Breast Cancer Stage III documented 3380F = AJCC Breast Cancer Stage IV documented http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp PQRI Coding 2009 Coding Example--Measure #71 Hormonal Therapy for Stage IC-III. ER/PR + Breast CA Report once per reporting period for all females 18 and over having breast cancer seen during the reporting period. Numerator Coding for patients receiving tamoxifen and AIs and have Stage 1C-III, ER/PR+; coding now depends upon the submission of one to three numerator codes in some cases. Tamoxifen/AI Prescribed (Three CPT II Codes [4179F & 3374F or 3376F or 3378F & 3315F] are required to report) Tamoxifen/ AI Not Prescribed for Medical, Patient, or System Reasons (Three CPT II Codes [4179F-1-3P & 33xxF & 3315F ] Tamoxifen/ AI Not Prescribed due to Stage or ER/PR Negative [3370F or 3372F or 3380F or 3316F]--ONE CODE ONLY Tamoxifen/ AI Not Prescribed; Reason Not Specified (Three CPT II Codes [4179F-8P & 33xxF & 3315F] are required to report) No documentation of cancer stage or ER/PR status [3370F-8P or 3316F-8P ONLY] Denominator Coding Patient is 18 years old or older Breast Cancer Dx Codes (174.0-174.6, 174.8, 174.9) E/M codes (99201-99205, 99212-99215) http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp Hematology-Oncology Measures 2009 MDS And Acute Leukemias Cytogenetic Testing (ICD-9 codes changed for 2009) MDS Documentation of Iron Stores Multiple Myeloma: Treatment With Bisphosphonates (Minor language and ICD-9 changes for 2009) CLL Baseline Flow Cytometry (ICD-9 codes changed for 2009) Hormonal Therapy for Stage IC-III ER/PR + Breast Cancer (CPT II codes changed; language change) Chemotherapy for Stage III Colon Cancer Patients (Updated language, CPT II codes changed, language changes) Breast Cancer Patients Who Have pT and pN category and histological grade for their cancer (Language changes, minor coding changes) Colorectal Cancer Patients Who Have pT and pN category and histological grade for their cancer (Language changes, minor coding changes) Inappropriate use of bone scan for staging low risk cancer patients (Denominator code change, language change) Adjuvant hormonal therapy for high-risk prostate cancer patients (Language, Instruction changes, minor coding changes) Three-dimensional radiotherapy for patients with prostate cancer (CPT II changes, language changes, reporting frequency) Melanoma: Follow Up Aspects of Care (2009) Melanoma: Continuity of Care (2009) Melanoma: Coordination of Care (2009) Oncology Med/Rad: Plan of Care for Pain (2009) goes with Oncology Med/Rad: Pain Quantified (2009) Oncology: Radiation Dose Limits to Normal Tissues (2009) Oncology Recording of Clinical Stage for Lung and Esophageal Cancer (2009) Notice #73 #74 #101 and #103 are gone PQRI Errors Errors from 2007 1,711,975 (12.15%) of QDC submission attempts had a missing NPI. 2,662,023 (18.89%) of QDC submission attempts occurred with an incorrect HCPCS code. 1,963,196 (13.93%) of QDC submission attempts occurred with an incorrect Dx code. 1,019,422 (7.24%) of QDC submissions had an incorrect HCPCS and Dx code. 700,201 (4.97%) had only the QDC code and no other line items were billed. “Physician Quality Reporting Initiative 2007 Reporting Experience” available at http://www.cms.hhs.gov/pqri/ Oncology-Specific Errors Measure % OK HCPCS Wrong Dx Wrong QDC Only NPI Problem #71 Breast Cancer with drug tx 83.70% 5.61% 4.04% 5.87% 13.38% #73 Plan of Chemotherapy 25.16% 52.70% 12.40% 8.00% 5.68% #72 Stage III Colon Cancer 56.25% 7.38% 12.00% 4.68% 9.31% “Physician Quality Reporting Initiative 2007 Reporting Experience” available at http://www.cms.hhs.gov/pqri/ Hem-Onc Specific Errors Measure % OK HCPCS Wrong Dx Wrong QDC Only NPI Problem #70 Baseline Flow in CLL 77.31% 7.13% 10.35% 3.28% 12.50% #67 MDS Baseline Cytogenetic Testing 66.63% 9.05% 9.47% 3.67% 10.31% #69 Multiple Myeloma Tx With Biphosphonates 73.02% 12.21% 8.28% 4.46% 12.40% #74 RT Recommended Breast Ca 15.45% 58.15% 1.03% 7.47% 7.31% “Physician Quality Reporting Initiative 2007 Reporting Experience” available at http://www.cms.hhs.gov/pqri/ PQRI Things to Remember Patient must have the proper age, diagnosis and that must be linked to the PQRI codes. Codes must be arrayed per measure specifications. Patient must meet the age requirement. Codes must be reported with the denominator CPT or HCPCS codes. Claims must have an NPI. 80% is calculated by NPI. Get forms at http://www.amaassn.org/ama/pub/category/17432.html MIPPA Legislation – Successful Electronic Prescriber, Section 132 The MIPPA provides for a 2% incentive payment to eligible professionals who successfully prescribe (as defined by the statute) their patient’s medications electronically beginning in 2009. The legislation specifically refers to the electronic prescribing measure currently in 2008 PQRI (measure #125). E-Prescribing measure will be removed from PQRI for 2009 and added to the E-Prescribing incentive program as a stand-alone benefit. The Secretary has the authority to update the specifications of the electronic prescribing measure in the future. Qualified Electronic Prescribing Systems – 2009 The measure assesses eligible professional’s use of electronic prescribing using a qualified system. As a qualified system, the program must be able to perform the following tasks: Communicate with the patient’s pharmacy; Help the physician identify appropriate drugs and provide information on lower cost alternatives for the patient; Provide information on formulary and tiered formulary medications; and Generate alerts about possible adverse events, such as improper dosing, drug-to-drug interactions, or allergy concerns. Successful Reporting of the eRx Measure for 2009 The measure is intended to be reported on for EVERY patient visit in the denominator. Successful reporting is defined as reporting the measure on at least 50% of eligible patients or an amount of electronic submission of claims under Part D. Limitation: CPT codes that make up the denominator MUST account for at least 10% of the provider’s total allowed charges for Medicare Part B covered services OR a parameter of claims NOT submitted to Part D (not in 2009). Reporting of E-Rx in 2009 To get paid the incentive, you must have an eprescribing system, report a visit and choose a code (not out yet) to state that the patient: They did not prescribe any medications during the visit; They used e-prescribing for any medications prescribed during the visit; or They did not use e-prescribing for a prescription because the law prohibits electronic prescribing for the specific type of drug, such as a controlled substance. Coding for E-Prescribing 2009 You must use a QUALIFIED E-prescribing system AND Have an encounter with one of these codes 90801, 90802, 90803, 90804, 90805, 90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, G101, G0108, G0109. Notice some from original guidelines were removed. Coding for E-prescribing 2009 Report on all eligible patients: G8443--All prescriptions created during the encounter were generated using an e-prescribing system. G8445--No prescriptions were generated during the encounter. Provider does have access to a qualified e-prescribing system. G8446--Provider does have access to a qualified e-prescribing system. Some or all prescriptions generated were printed or phoned in as required by state regulation, patient request, or pharmacy being able to receive electronic transmission. Future Penalties for Not Electronically Prescribing Eligible professionals who are not successfully using electronic prescribing by 2012 will be penalized 1% of their covered Medicare Part B charges. This means that these providers will be paid at 99% for their covered Medicare Part B fee schedule services. Limitation applies as for incentives Fee reduction is prospective, providers will have to electronically prescribe by a date to be determined to be sure their fees are not reduced in 2012. This date will not be before 2010. Hardship exemption on a case-by-case basis for small practices. Future Penalties for Not Electronically Prescribing In 2013 - 1.5% deducted from their covered Medicare Part B services. Professionals will be paid at 98.5% of the physician fee schedule for covered services. In 2014 and beyond penalty will increase to 2%. Professionals will receive 98% of the physician fee schedule for the covered services they provide. Part D Information The Secretary has the authority to change the requirements for successful E-Prescribing in the future. The MIPPA legislation allows for future use of Part D data in lieu of claims-based reporting by eligible professionals. Info Sources for ESAs… View the policy itself at View CMS FAQs http://www.ascofoundation.org/portal/site/ASCO/menuitem.5d1b 4bae73a9104ce277e89a320041a0/?vgnextoid=24be6e750752 3110VgnVCM100000ed730ad1RCRD View CMS Transmittals R1412, R1413, R80NCD at http://www.cms.hhs.gov/mcd/ncpc_view_document.asp?id=12 View ASCO FAQs http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=203 http://www.cms.hhs.gov/Transmittals/2008Trans/list.asp View American Society of Hematology Guidelines (ASH) at http://www.hematology.org/policy/practice/01242008.cfm ESA/Anemia Billing Summary If the patient has cancer and is on chemotherapy, submit the “most recent” hemoglobin must be <10 (or Hct < 30%). Bill the H or H results and use -EA. Follow Carrier guidelines for diagnosis coding. If the patient is on Radiotherapy, submit the latest H or H result, use -EB, and get denied. If the patient does not have chemotherapy-induced anemia (or ESRD), submit the latest H or H, use -EC, and follow your Carrier’s guidelines for coding and billing. If the patient has cancer and is on an anemia drug which is not selfadministered, submit the latest H or H result. All other guidelines are at Carrier discretion. Medicare: Hospital Discharge Day Transmittal #1460, CR #5794, effective 4/1/2008 A Hospital Discharge Day service (99238-99239) is a face-toface service between the attending physician and the patient. Only the attending physician of record shall report 99238-99239. Other providers shall report subsequent hospital services (9923199233), if they perform concurrent services. Reporting of the service is on the calendar day of the visit, even if it differs from the discharge date. Report only one discharge service (99238-99239) per patient per stay. Do NOT report discharge services and subsequent services the same date. Discharge services may be billed for pronouncement of death on the date of death. Medicare: Inpatient/ Observation Transmittal #1466, CR 5791 Initial Hospital Observation Services (CPT codes 99218-99220) and Observation Care Discharge Services (99217) When the observation care is less than 8 hours on the same calendar date report an Initial Observation Care code. Do not report an Observation Care Discharge Service. When the patient is admitted for observation care and discharged on a different calendar date report an Initial Observation Care and an Observation Care Discharge. In those rare instances when a patient is held in observation care status for more than two calendar dates report an Office or Other Outpatient Visit (CPT 9921199215) for a visit before the discharge date. The medical record must include documentation that: Satisfies E/M guidelines for admission to and discharge from observation care to inpatient hospital care. Identifies the billing physician/NPP was present and personally performed the services Indicates the number of hours that the patient remained in the observation care status Identifies the admission and discharge notes were written by the billing physician/NPP Medicare Inpatient/ Observation Observation or Inpatient Care Services (including Admission and Discharge Services) (CPT codes 99234-99236) When a patient is admitted to observation or inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date report an Observation or Inpatient Hospital Care Services code (Including Admission and Discharge Services). Do not report an additional discharge service. The medical record must include documentation that: States the stay for hospital treatment or observation care status involves 8 hours but less than 24 hours. Identifies the billing physician/NPP was present and personally performed the services. Identifies the admission and discharge notes were written by the billing physician/NPP. Transmittal #1466, CR 5791 Medicare: Prolonged Services On April 14, 2008, CMS issued Transmittal 1490CP, Change Request 5972, Effective Date is June 2, 2008(meaning that’s when you are responsible for it) with an Implementation Date of July 7, 2008 These services (99354-99355) are payable when billed on the same day (and, on the same claim) as the companion evaluation and management codes. Again, the time for the service refers to the typical/average time units associated with the companion evaluation and management service as noted in the CPT code. Each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services may be reported by CPT code 99355. Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes. So, using our 99213 example, you would not report anything of less than 45 minutes, as that time frame is 30 minutes past the average visit time per CPT. Medicare Prolonged Services Code 99355 or 99357 may be used to report each additional 30 minutes beyond the first hour of prolonged services, based on the place of service. These codes may be used to report the final 15 – 30 minutes of prolonged service on a given date, if not otherwise billed. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. Companion Codes must be correct in terms of pairing with Prolonged Services or claims for these codes will not be paid… The companion evaluation and management codes for 99354-99355 are the Office or Other Outpatient visit codes (99201 - 99205, 99212 –99215), the Office or Other Outpatient Consultation codes (99241 – 99245), the Domiciliary, Rest Home, or Custodial Care Services codes (99324 – 99328, 99334 – 99337), the Home Services codes (99341 - 99345, 99347 – 99350); and/or The companion evaluation and management codes for 99356-99357 are the Initial Hospital Care codes (99221 - 99223, 99231 – 99233), the Inpatient Consultation codes (99251 – 99255); Nursing Facility Services codes (99304 -99318). There is a requirement for physician (or NPP) presence. Physicians may count only the duration of direct face-toface contact between the physician and the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed to determine whether prolonged services can/cannot be billed and to determine the prolonged services codes that are allowable. Documentation is required in the medical record regarding the duration and content of the medically necessary evaluation and management service and prolonged services billed. According to the Transmittal “the start and end times of the visit shall be documented in the medical record along with the date of service.)” Counseling/coordination of care can necessitate use of Prolonged Services---but you must use the highest level of the code set involved first, e.g. 99215, 99245. Medicare will not pay prolonged services codes 99358 and 99359, which do not require any direct patient face-toface contact (e.g., telephone calls). Medicare Consultations (Medicare) Transmittal 788, CR #4215, December 2005 No shared visits for consultations in either office or hospital. Either the NPP or MD should charge for the consult. This is black and white in the transmittal. 3 R’s have been more formalized and one has been added… REQUEST from another physician for consultant’s opinion must be clearly documented in BOTH the receiving and referring physician charts. Referring MDs must have it in their plan of care, but there is no need for you to check every record. The REASON for the consult must be clearly documented in the medical record. Opinion RENDERED by the consultant with RECOMMENDATIONS for treatment. REPORT goes back to the referring physician. 99211 may not be used for a consult. Consultations Consultations (Cont’d) Consultations may be billed based on time for counseling/coordination of care, but an opinion must be rendered. Also, if care is continuous before the consult for the same/original problem, an additional consult may not be billed. Only ONE consultation may be billed per inpatient stay. Consultations Transfer of Care A transfer of care occurs when a physician or NPP requests that another physician or NPP take over the responsibility for managing the patient’s complete care for the condition, and does not expect to continue treating or caring for the patient for that condition. When this transfer is arranged, the requesting provider is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or NPP shall document this transfer of the patient’s care in the patient’s medical record or plan of care. If a transfer of care occurs, report the appropriate new or established patient visit code should be billed based on place of service. 51 Specialty Societies have objected to this language (including the AMA, ASCO, and ASH), but this Transmittal is still in effect and has been the Medicare rule since 1/1/2006. Consult vs. Referral Referral Consult Diagnosis and/or treatment known at the time of the referral for a new or existing problem. Referring physician wants to ascertain differential diagnoses and/or treatments for the patient for a new problem. Documents the consultation request as part of their treatment plan. Treatment known at the time of the referral with or without report by consultant. Treatment plan to be communicated by report by consultant to the referring physician. Referring physician does not expect to further treat the patient for this particular diagnosis. Referring physician will continue to treat the patient after the consultation. Referring physician out of the picture. Consultant generates a report with their opinion and plan for treatment and may update the referring physician periodically . CERT AND MEDICAL INTEGRITY CONTRACTORS CERT Contractors Ask for only a single chart or case Purpose to review the reviewers If denied money must be returned Appeals possible if you disagree MIP Contractors CalBisc and TrustSolutions in Calif. Potential fraud or abuse cases Respond promptly, get all info, may be misunderstanding with patient Courtesy of Dr. Arthur Lurvey, CMD, PalmettoGBA, MAC for California, Nevada, and Hawaii 53 RAC-RECOVERY AUDIT CONTRACTOR Contractor named and challenged by other RAC Reviews old claims (up to 3 years from date of claims-start 10/07) Initial demonstration in 3 states Paid a percent of what it brings in Vast majority of claims are hospital Look at medical necessity and incorrect coding for over and underpayment Can appeal denials several levels Courtesy of Dr. Arthur Lurvey, CMD, PalmettoGBA, MAC for California, Nevada, and Hawaii 54 OTHER REVIEWS OR POSSIBLE DENIALS Medicare bundling edits: “Correct Coding Initiative” Some procedure codes part of other codes and not split apart If bill separately you may be paid lesser code Medicare unbelievable edits (MUE) Occurs when frequency of services extremely unusual Usually coding error not medical necessity error Private insurance edits or audits also are in effect Courtesy of Dr. Arthur Lurvey, CMD, PalmettoGBA, MAC for California, Nevada, and Hawaii 55 NPRMs Issued To Change HIPAA Standards Nachimson Advisors, LLC On August 22, 2008 CMS published 2 NPRMs One proposed upgrading X12 and NCPDP HIPAA administrative transactions, with an April 1, 2010 compliance date One proposed replacing ICD-9-CM with ICD-10-CM for diagnoses ICD-10-PCS for inpatient hospital procedures With an implementation date of Oct. 1, 2011 for the change (services provided on or after that date) 56 57 Industry Response to NPRMs Panic Hospital codes must change; ICD-9-CM procedure codes running out of room… Concerns with Timing Cost Impact on other initiatives So What Is the Deal with ICD10? Codes change every year anyway Transaction version changes (X12 version 5010) will be in place to handle the codes Why not business as usual? 58 59 Major changes from ICD-9-CM Nachimson Advisors, LLC Not just the usual annual update ICD-10 markedly different from ICD-9 Requires changes to almost all clinical and administrative systems. Requires changes to business processes. Changes to reimbursement and coverage. Why? 60 Specific Changes Diagnosis Codes (ICD-9 to ICD-10-CM) Goes from 5 positions (first one alphanumeric, others numeric) to 7 positions, all alphanumeric From 13,000 existing codes to 68,000 existing codes Much greater specificity 61 Structure of ICD-10 Nachimson Advisors, LLC Examples of ICD-10-CM Specificity Nachimson Advisors, LLC Diabetes mellitus codes are expanded to include the classification of the diabetes and the manifestation. The category for diabetes mellitus has been updated to reflect the current clinical classification of diabetes and is no longer classified as controlled/uncontrolled: E08.22, Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease E09.52, Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.11, Type 1 diabetes mellitus with ketoacidosis with coma E11.41, Type 2 diabetes mellitus with diabetic mononeuropathy1 62 Examples of ICD-10-CM Specificity Nachimson Advisors, LLC ICD-9-CM 599.7 Hematuria (blood in urine) ICD-10-CM R31.0 Gross hematuria R31.1 Benign essential microscopic hematuria R31.2 Other microscopic hematuria R31.9 Hematuria, unspecified 63 64 Examples of ICD-10 Specificity W21.00 Struck by hit or thrown ball, unspecified type W21.01 Struck by football W21.02 Struck by soccer ball W21.03 Struck by baseball W21.04 Struck by golf ball W21.05 Struck by basketball W21.06 Struck by volleyball W21.07 Struck by softball W21.09 Struck by other hit or thrown ball W21.31 Struck by shoe cleats Stepped on by shoe cleats W21.32 Struck by skate blades Skated over by skate blades W21.39 Struck by other sports foot wear W21.4 Striking against diving board •W21.11 Struck by baseball bat •W21.12 Struck by tennis racquet •W21.13 Struck by golf club •W21.19 Struck by other bat, racquet or club •W21.210 Struck by ice hockey stick •W21.211 Struck by field hockey stick •W21.220 Struck by ice hockey puck •W21.221 Struck by field hockey puck •W21.81 Striking against or struck by football helmet •W21.89 Striking against or struck by other sports equipment •W21.9 Striking against or struck by unspecified sports equipment Strategies for Success Look at your denials…any red flags there??? Really consider doing PQRI and e-prescribing---4% is nothing to sneeze at. E-prescribing is a ‘no brainer’. Audit chemo prospectively; peer review E&M. Physicians must review consults before it is too late! Transmittal 788, CR 4215 (2005). Know what your documentation looks like and know how you would respond to an audit. Look back and see if you have off-label denials. Try to appeal based on the new transmittal. Look at your billing profiles. Give $$ back before the RACs collect it for you! Start at 10/1/2007. Do not get too upset about ICD-10, until the final rules and system are believable for physician practices. Participate in the struggle! Contact Info Contact [email protected] [email protected] 800-795-2633 Newsletter is free! Thank You!