PEACE moments Andrew Lahiff 29 November 2004 10 January 2005 24 January 2005.
January 18, 2005 Handout
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Transcript of January 18, 2005 Handout
AAPC – Omaha ChapterJanuary 18, 2005
7:00 am
Presented by:Cynthia A. Swanson, RN, CPCPaula L. Smith, RN, CPC, CCS-P Seim, Johnson, Sestak & Quist, LLP8807 Indian Hills Drive, Suite 300 Omaha, NE 68114402.330.2660
CPT 2005 Changes and Medicare Update
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AGENDA
2005 CPT Overview of CPT Code Changes Category II Codes Category III Codes
Medicare 2005 Changes Other Issues/Discussion
DisclaimerA presentation can neither promise nor provide a complete review of the myriad of facts, issues, concerns and considerations that impact upon a particular topic. This presentation is general in scope, seeks to provide relevant background, and hopes to assist in the identification of pertinent issues and concerns. The information set forth in this outline is not intended to be, nor shall it be construed or relied upon, as legal advice. Recipients of this information are encouraged to contact their legal counsel for advice and direction on specific matters of concern to them.
CPT is a trademark of the American Medical Association. CPT codes, descriptions and modifiers are copyright 2004 CPT American Medical Association.
3
Overview of Changes for CPT 2005
Number of Annual CPT Coding Changes
1992 732
1993 1,467
1994 796
1995 410
1996 273
1997 162
1998 399
1999 686
2000 320
2001 408
2002 502
2003 428
2004 286
2005 277
4
Overview of Changes for CPT 2005
Code changes
o New Codes – 170o Revised – 61o Deleted – 46 o Hundreds of “other changes” related to guidelines,
introductory notes, explanatory text, headings, and cross-references
o Total codes for CPT 2005 = about 8,492 compared to 8,368 in 2004
5
Overview of Changes for CPT 2005 No longer a grace period for new codes – must be
used for services on or after January 1, 2005
National Standard Code Set/HIPAA
AMA Publication CPT™ Changes 2005–An Insider’s View
CPT Editing Marks The Symbols
6
Overview of Changes for CPT 2005
CPT Symbols● -________________________ -________________________+ -________________________ -________________________-________________________
Fill in the descriptions for these symbols Color coding scheme
7
Overview of Changes for CPT 2005
CPT Symbols A new symbol was added Conscious sedation “bulls-eye” symbol has
been added for 2005 Intended to indicate those procedures in
which the provision of conscious sedation services is considered to be inherent
Not separately reported by the same physician performing the primary service
Appendix G
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CPT 2005 Coding Manual
Appendix A – Modifiers Appendix B – Summary of Additions,
Deletions, and Revisions Appendix C – Clinical Examples Appendix D – Summary of CPT Add-on
Codes Appendix E – Summary of CPT Codes Exempt
from Modifier 51
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CPT 2005 Coding Manual FeaturesFour New Appendixes
Appendix F – Summary of CPT Codes Exempt from Modifier 63
Appendix G – Summary of CPT Codes which Include Conscious Sedation
Appendix H – Alphabetic Index of Performance Measures by Clinical Condition or Topic
Appendix I – Genetic Testing Code Modifiers
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Evaluation and Management (E/M) Services - continued
Excluding minor editorial modifications, revisions to the E/M section for CPT 2005 consist solely of clarification of the neonatal age
Consistency between diagnostic (ICD-9-CM) and procedural (CPT) code sets
11
Evaluation and Management (E/M) Services - continued
Editorial revision made to the neonatal and pediatric critical care codes 99293, 99294, 99295, 99296 Most commonly utilized definition of the neonatal
period is beginning at birth and lasting through the 28th day following birth
Formerly, CPT utilized 30 days of age or less A critically ill patient of 29 days of age was reported using
a neonatal CPT code and a non-neonatal ICD-9-CM code
Resolution of discrepancy
12
Evaluation and Management (E/M) Services - continued E/M Documentation Guidelines
Nothing new to report
The 1995 or 1997 E/M Documentation Guidelines are still in effect
Medicare – Can continue to use either set of guidelines
13
Anesthesia
Minimal revisions
Addition of a single code
●00561 – Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, under one year of age
(Do not report 00561 in conjunction with 99100, 99116 and 99135)
14
Anesthesia (continued)
Revision of the Anesthesia guidelines in tandem with the addition of Appendix G
Summary of CPT Codes Which Include Conscious Sedation
15
Surgery
Notable changes in the surgery section this year include: Six new transplant series of codes and
guidelines Conversion of Category III codes to
Category I codes Addition of 10 Category I codes
Guideline additions New codes for skin debridement for
necrotizing infections New codes for gastric restrictive
procedures Revisions and additions to the
bronchoscopy codes
16
Surgery/Integumentary System
- Codes ●11004 – ●11006 were added to identify extensive debridement procedures
- High risk patients, soft tissue infections such as Fournier’s gangrene
- In addition to the risk and extensiveness involved in the performance of debridement procedure, transplantation or removal of organs, hernia and/or intestinal repair, or fistula repair may be necessary
17
Surgery/Integumentary (continued)
Add-on code ●11008 has been established to identify concurrent removal of a mesh or prosthetic device
Includes parenthetical notes to identify procedures that should be separately reported and a list of exclusionary codes
18
Surgery/Integumentary System (continued)
o Three codes added to the Breast Introduction Section
●19296
●19297
●19298
o Describe catheter placement and subsequent catheter removal for interstitial radioelement application in the breast following partial mastectomy
19
Surgery/Integumentary System (continued)
Clarify reporting of spinal procedures related to:
- Exploration of spinal fusion - Revision of previously placed instrumentation
Introductory language has been revised and expanded
20
Surgery – Musculoskeletal
Clarify reporting of spinal procedures related to:
Exploration of spinal fusion
Revision of previously placed instrumentation
Introductory language of the Spinal Arthrodesis and Spinal Instrumentation subsections has been revised and expanded
21
Surgery – Musculoskeletal (continued)Exploration Subsection
- Instructs the appropriate method of reporting arthrodesis procedures which would be performed at the same session as the definitive spinal procedure
- Clarifies the use of 51 modifier
22
Surgery – Musculoskeletal(continued)
Deletion of Category III codes 0012T, 0013T, 0014T
Five codes and nine cross-references were established to report techniques to provide hyaline or hyaline-like repair for articular knee defects
New codes●27412 – Autologous chondrocyte implantation,
knee●27415 – Osteochondral allograft, knee, open
23
Surgery/Respiratory System
Codes ●31545 & ●31546 were added to describe direct operative laryngoscopy with removal of non-neoplastic lesion(s) of the vocal cord
Revisions to the bronchoscopy section to distinguish airway stents placed in the trachea versus the bronchus or bronchi
24
Surgery – Transplantation Services
Transplantation Background
Transplantation Procedures
Donor Backbench Codes
Rationale for Changes
25
Surgery/Respiratory System
Lung Transplantation
Three distinct components of physician work
1) Cadaver donor pneumonectomy(s)2) Backbench work3) Recipient lung allotransplantation
Two new codes (●32855 and ●32856) for backbench preparation of cadaver donor lung allograft prior to transplant
26
Surgery/Cardiovascular System
Heart/Lung Transplantation
Codes ●33933 and ●33944 were added to describe backbench preparation of cadaver donor heart/lung allograft prior to transplantation
27
Surgery/Cardiovascular System (continued)
o Four new codes added to report endovenous ablation therapy for incompetent veins
o ●36475, ●36476, ●36478 and ●36479
o Add-on code to each of the initial codes intended to report performance of ablation for each additional vein after the first vein
28
Surgery/Digestive Systemo Several new gastric restrictive surgery codes were
added to reflect the rapidly expanding field of bariatric surgery
●43644 and ●43645 – laparoscopic techniques
●43845 – added to describe biliopancreatic diversion with duodenal switch
43846 – editorial revision to existing open Roux-en-Y gastric bypass for morbid obesity (150 cm or less)
For greater than 150 cm, use 43847
29
Surgery/Digestive System
o New codes for backbench worko Intestine Transplant
New codes (●44715 – ●44721)
o Liver Transplant New codes (●47143 – ●47147)
o Pancreas Transplant New codes (●48551 – ●48552)
o Kidney Transplant New codes (●50323 – ●50329)
30
Surgery/Nervous System
Two new codes have been added to describe laminoplasty procedures ●63050
●63051 Laminoplasty is an alternative approach
for posterior decompression of the cervical spinal cord
31
Radiology
New Coding Tool
Clinical Examples in Radiology Newsletter
Authors: American Medical Association, American College of Radiology
Quarterly case-orientated format
32
Radiology
o Guideline additions to the Radiology Section
o Provide greater clarity in coding
o Guidelines for reporting diagnostic angiographies in the Aorta and Arteries, Veins and Lymphatics, and Transcatheter Procedures subsections of Radiology
o Guidelines for ultrasound imaging services in the Abdomen and Peritoneum and Non-Obstetrical subsections of Radiology
33
Radiology (continued)
o New codes for fetal ultrasound services ●76820
●76821
o Revisions in the Therapeutic Nuclear Medicine subsectiono Tumor Imaging
34
Radiology (continued)
Six new (●78811 – ●78816) codes for reporting tumor imaging by positron emission tomography (PET) and computed tomography (CT) procedures have been added to the Nuclear Medicine Diagnostic subsection of CPT.
35
Pathology and Laboratory
Codes and cross-references added to report Helicobacter pylori testing/interpretation
Additions and revisions made to the morphometric analysis codes in the Surgical Pathology subsection
Guidelines added to the Molecular Diagnostics and Cytogenetics subsections
36
Medicine
Revisions to: Vaccine administration procedure codes Gastric testing codes Acupuncture codes Neurostimulator codes Echocardiography guidelines
37
Medicine (continued)
Immunization Administration for Vaccines/Toxoids
Series of new codes (●90465 – ●90468) for immunization administration which incorporates the work of physician immunization counseling for young children (under 8 yrs. of age)
38
Medicine (continued)
Gastroenterology
Five new codes (●91034 – ●91040) to report esophagus reflux testing, esophageal function testing and esophageal balloon distension provocation study
New testing methods in recent years
39
Medicine (continued)
Active Wound Care Management
Updated section includes revised introductory guidelines
Revised codes to report selective debridement based on total surface area of wound(s) size
New procedures to describe negative pressure wound therapy techniques based on total surface area wound(s) size
40
Medicine (continued)
Acupuncture Codes 97780 and 97781 were deleted Codes ●97810 – ●97814 were established
to more clearly describe acupuncture and electroacupuncture services
Codes based on 15 minute increments of personal contact with the patient
41
Category II Codes
A new section of Category II (Performance Measurement) CPT codes and introductory notes was added to CPT 2004
All of the 2004 Category II codes have been deleted and renumbered
Four new codes have been added to represent Maternity Care Management
Eight new categories added for future expansion
42
Category III Codes
Emerging Technology, Services and Procedures
CPT Codes – Alphanumeric identifier with a letter (T) in last field
27 new codes added
Many Category III codes have been converted to Category I codes for 2005
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Category III Codes
Series of codes added for reporting
Percutaneous transcatheter placement of extracranial vertebral or intrathoracic carotid artery stents
Ultrasound ablation of uterine leiomyomata
Acoustic heart sound recording and computer analysis
Computed tomographic colonoscopy
Percutaneous intradiscal annuloplasty
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MMA 2003
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
Largest change to the Medicare program since its inception
Huge social debate
Medicare 1964 – Disease Specific benefit
Movement to preventive medicine benefit with a co-pay
45
MMA 2003 (continued)
Other Changes
- Regulation
- Managed Care
- Fee Schedule Changes
- Demonstration Projects
46
2005 Medicare Changes
MMA provision replaced a 4.5% reduction with a 1.5% increase for 2004 and a 3.3% reduction with a 1.5% increase for 2005
47
2005 Medicare Changes (continued) Medicare Physician Fee Schedule
Conversion Factor
2004 - Conversion Factor $37.3374 2005 - Conversion Factor $37.8975
Anesthesia Conversion Factor
2004 - Conversion Factor $17.4969 2005 - Conversion Factor $17.7594
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Medicare Changes 2005 (continued) Venipuncture HCPCS Code G0001 is deleted
for 2005 Report venipuncture service with CPT code
36415 In the final rule, the status indicator for CPT
code 36415 reflects “I” – Invalid for Medicare. This is an error and it should be a “C” – Carrier priced.
Medicare reimbursement remains at $3.00 for 2005
49
Medicare Changes 2005 (continued)New Medicare Preventive Services
1) Initial preventive physical examination (HCPCS “G” codes)
2) Cardiovascular screening blood tests
3) Diabetes screening tests
Specific coverage provisions apply for each of these new benefits
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Medicare Changes 2005 (continued) Preventive Physical Examination
Eligible beneficiary An initial preventive physical examination
Medical history Physician Qualified NPP Social History Review of individual’s functional ability and level
of safety Performance and interpretation of ECG
51
Medicare Changes 2005 (continued) Initial Preventive Physical Examination (IPPE)
G Codes G0344 IPPE; face to face visit services limited to
new beneficiary during the first six months of Medicare enrollment
G0366 EKG, routine EKG with at least 12 leads with interpretation and report, performed as a component of the IPPE
Report IPPE and the applicable EKG (G code)
52
Medicare Changes 2005 (continued)
G0367 tracing only, without interpretation and report, performed as a
component of the IPPE
G0368 interpretation and report only, performed as a component
of the IPPE
53
Medicare Changes 2005 (continued) Diabetes Screening
The term “diabetes screening tests” is defined in Section 613 of the MMA as testing furnished to an individual at risk for diabetes and includes a fasting blood glucose test and other tests
Not a benefit if previously diagnosed diabetic
54
Medicare Changes 2005 (continued) Diabetes Screening
Individual at risk Hypertension Dyslipidemia Obesity, BMI < or = to 30 kg/m2 Previous elevated fasting glucose Two out of four risk factors
Overweight, as defined Family history of diabetes History of gestational diabetes mellitus or
delivery of a baby weighing greater than 9 lbs 65 years of age or older
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Medicare Changes 2005 (continued) Diabetes Screening
Pre diabetic twice per 12 month period V77.1 diagnosis code CPT codes 82947, 82950, 82951
Watch for additional Medicare instructions regarding applicable coding and billing of these services
56
Medicare Changes 2005 (continued) Cardiovascular Screening
Ordered as panel or individually 80061 82465 Cholesterol – total 83718 HDL – cholesterol 84478 Triglycerides
Once every five years Labs must offer lipid panel without doing LDL
above certain parameters V81.0, V81.1 and V81.2
Watch for additional Medicare instructions regarding applicable coding and billing of these services
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2005 Medicare Changes (continued) Chemotherapy Drug Demonstration Project
Goals and Objectives
Review and analyze pain control management
Minimization of nausea and vomiting Assess lack of energy Assess quality of life Assess patient symptoms and complaints
58
2005 Medicare Changes (continued) Chemotherapy Drug Demonstration Project
Calendar Year 2005 Chemotherapy encounter 12 new G codes for assessment
Not at all A little Quite a bit Very much
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2005 Medicare Changes (continued)
Chemotherapy Assessment
G0921 – G0924 Assessment of nausea and vomiting
G0925 – G0928 Assessment of pain G0929 – G0932 Assessment of lack
of energy (fatigue)
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2005 Medicare Changes (continued) Chemotherapy Assessment
Participating physicians must bill the applicable G-codes for each patient status factor assessed in each of the three categories during a chemotherapy encounter
A G-code for each patient status factor must appear on the claim for payment to be made
61
2005 Medicare Changes (continued)
A patient chemotherapy encounter is defined as chemotherapy administered through intravenous infusion or push, limited to once per day
An additional payment of $130 per encounter will be paid to participating providers for submitting the patient assessment data as described, during the demonstration project
62
Medicare Changes 2005 (continued) MMA – Drugs Paid by Average Selling
Price Beginning January 1, 2005, the payment limit
for Part B drugs and biologicals, not paid on a cost or prospective payment basis, will be paid based on the Average Sales Price (ASP) plus 6 percent.
Drugs will be paid based on the date of service and the lower of:
The submitted charge; or The ASP plus 6 percent
Quarterly pricing updates
63
Medicare Changes 2005 (continued) Medicare Incentive Payment
5% incentive payment to physicians furnishing services in physician scarcity areas (PSA)
Primary care and specialty physicians MMA defines a primary care physician as a
general practitioner, family practice practitioner, general internist, obstetrician, or gynecologist
Applies to the professional services including E/M, surgery, consultation, and home, office and institutional visits (technical services are not eligible)
Dentists, Optometrists, Podiatrists and Chiropractors are not eligible
64
Medicare Changes 2005 (continued) Clinical Psychologists
Supervision of Diagnostic Tests
CP may supervise the performance of diagnostic psychological and neuropsychological testing services in addition to performing them
65
Medicare Changes 2005 (continued) Other Provisions
ESRD Care Plan Oversite (CPO) Hospice Consultation CMS Replacement Drug Demonstration
“G” Codes Vaccinations
Increase in allowances Others that may be applicable to your practice
66
Other 2005 Changes
CPT 2005 Erratawww.ama-assn.org
2005 Medicare Physician Fee Schedule
HCPCS 2005 Additions, Revisions, and Deletions
2005 ICD-9-CM Diagnosis Codes Effective Oct. 1 your practice should already be using
Office of Inspector General (OIG) Work Plan Fiscal Year 2005www.oig.hhs.gov
67
OIG Work Plan Fiscal Year 2005
Medicare Physicians and Other Health Professionals Billing Service Companies Medicare Payments to VA Physicians Care Plan Oversight Ordering Physicians Excluded from Medicare Physician Services at Skilled Nursing Facilities
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OIG Work Plan Fiscal Year 2005 (continued)
Physician Pathology Services performed in the physician office
Cardiography and Echocardiography Services
Physical and Occupational Therapy Services
Part B Mental Health Services
69
OIG Work Plan Fiscal Year 2005 (continued)
Wound Care Services
Coding of E/M Services
Use of Modifier 25
“Long Distance” Physician Claims
Provider-Based Entities
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Considerations
Practitioner/staff education on changes
Available tools/resources
Update of office and out of office encounter forms
Fee analysis/updates
Computer updates/changes
71
Other Issues/Concern
Questions
Discussion