Practices to be prepared for a 26.5% Drop in Medicare Pay in the coming year!

Some complex repair codes will face severe cuts in 2013.

As the New Year approaches practices wait anxiously to see if there are any chances of them losing money. This year The Centers for Medicare & Medicaid Services (CMS) has offered some relief in the 2013 MPFS including new transitional care management codes and associated payment but at the same time has included a 26.5 percent conversion factor cut that could impact practices across-the-board if Congress doesn’t act to reverse it before Jan. 1.

Since there was absence of Congressional action, an overall reduction of 26.5 percent will be imposed for the conversion factor that will be used to calculate payment for physicians’ services on or after January 1, 2013.

Some practices that will get affected is Neurology as neurologists will see a 7 percent cut to their total Medicare reimbursement in 2013, while pathologists will face 6 percent pay cuts. Independent laboratories will see a 14 percent combined impact due to the potentially misvalued care initiative, as has been revealed by The Centers for Medicare & Medicaid Services.

If Congress doesn’t act to increase the conversion factor there could be additional cuts. According to the final rule, practitioners of dermatology are projected to see a 0 percent combined impact to their reimbursements. According to the American Academy of Dermatology, the relative value units (RVUS) were maintained at almost the same payment levels for most of the codes in the complex repair code family. But the final 2013 fee schedule included a reduction to some Dermatology codes like CPT codes 13152 with the description: Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm by 13 percent, and CPT codes 13132 with the description: Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm by 16 percent – as a result of the cut in physician work Relative Value Units.

For CPT codes 13152, the physician work Relative Value Units was cut by 23.08 percent and the practice expense Relative Value Units was cut by 4.4 percent; whereas for CPT codes 13132 the physician work Relative Value Units was cut by 27.36 percent and the practice expense Relative Value Units was cut 7.59 percent respectively.

Amongst other specialties mostly primary care is expected to see pay rises under the proposal. CMS has finalized a seven percent increase for family practitioners, a four percent boost for internal medicine physicians, and a five percent raise for geriatricians thereby causing some relief to some practices.

Final Approval: Partial Freeze for ICD-9 CM and ICD-10

The coming year i.e. 2013 will not have new diagnosis code changes so providers can breathe a sigh of relief. There will be a partial freeze of the ICD-9 procedure codes and ICD-10 (ICD-10-CM and ICD-10-PCS) codes before the implementation of ICD-10 on October 1, 2014 by the ICD-9 CM Coordination and Maintenance Committee. There was also significant support for this partial freeze. The partial freeze on medical ICD codes is being implemented in the following ways:

• ·         On October 1, 2011 the last regular as well as annual update for both ICD-9 procedure codes and ICD-10 code sets was made.
• ·         There were partial code updates for both ICD-9 codes and ICD-10 code sets to capture new technologies and diseases as made essential by section 503(a) of Pub. L. 108-173 on October 1, 2012.
• ·         There will be only few code updates to ICD-10 code sets to capture new technologies and diagnoses as made mandate by section 503(a) of Pub. L. 108-173 on October 1, 2014. For ICD-9 codes there will be no updates as they will no longer be used for reporting.
• ·         ICD-10 codes will be regularly updated from October 1, 2014.

During this time of partial freeze the ICD-9-CM Coordination and Maintenance Committee will regularly meet twice a year. Also the public will be asked to participate in these meetings and their views will be taken on whether or not the requests for new diagnosis and ICD 9procedure codes need to be created based on the importance of the need to capture a new technology or disease. When the partial freeze finally ends, the code requests that did not meet the criteria will be taken into consideration to be implemented within ICD-10 on or after October 1, 2014.

The medical ICD codes discussed at the September 15^th and 16^th, 2010 and March 9^th and 10^th, 2011 by the ICD-9 CM Coordination and Maintenance Committee’s meeting were taken into consideration for implementation on 1^st October, 2011.

The Centers for Disease Control and Prevention (CDC) and CMS have not suggested any official changes to the ICD-9 codes and ICD-10 CM codes for the year 2013. The 2013 payment rule which has been proposed for hospital Inpatient Prospective Payment Systems (IPPS) as well as long-term care hospitals is the one where CMS has announced some changes for the diagnosis code set, which also includes, “that for the year 2013, due to the code freeze or for new technology no changes were made for ICD-9 codes or coding system. Similarly, we can come to the conclusion that there will be no new, revised or deleted diagnosis and procedure codes that are usually announced in Tables 6A (new diagnosis codes), 6B (new procedure codes), 6C (invalid diagnosis codes), 6D (invalid procedure codes), 6E (revised diagnosis code titles) and 6F (revised procedure codes).”

Modifier –PD One of the Biggest Changes of CPT 2012

2012’s biggest change did not come in the form of the addition or deletion of a CPT code, but rather initiation of a modifier. 

The CPT 2012 manual brought several CPT procedure codes and modifier changes. But on top of all the changes, the big news was inception of modifier PD. It was introduced to designate services furnished to a Medicare beneficiary in the three days prior to an inpatient admission in a facility wholly owned or wholly operated by the hospital. This is inclusive of the physician practices that self-designate ownership interest, as well as enable payment at the facility rate and identify that the service is subject to the three day payment window. 

The existing as well as new patient definitions in the Evaluation and  Management (E/M) guidelines was revised to add further clarifications to the words “ specialties” and “subspecialties”. According to this revision, even if the physician is of the same specialty, differences between the subspecialty would require a significant new patient work-up and would be considered a new visit, say for instance cardiologist vs. electrophysiologist.

CPT codes 2012 lookup for some specialties: 

CPT codes for Integumentary services related to surgery

There have been extensive changes for Integumentary services including the deletion of 24 codes, revision of six codes and the addition of eight new codes. The Skin Replacement codes (15271-15278) subheading was revised drastically. New skin replacement guidelines were added to state that skin replacement surgery now consists of the surgical preparation and topical placement of an autograft, which includes cultured tissue autograft, or skin substitute homograft, allograft and xenograft. 

CPT procedure codes  for Musculoskeletal services related to surgery

Two new codes for the treatment of Dupuytren's Contracture were added to the Musculoskeletal section of CPT 2012 which are code 20527 for the injection of an enzyme, such as collagenase, into the contracture and code 26341 is the follow up code for the manipulation of the Dupuytren Cord POST ENZYME injection. This code is to be used for subsequent visit(s) post the initial injection.

The phrase "bone biopsy included when performed" has been added to all vertebroplasty codes to be consistent with the kyphoplasty codes. You cannot report a separate bone biopsy in addition to a vertebroplasty. It’s not acceptable anymore.

CPT codes cardiology (for Cardiovascular services related to surgery)

CPT code 71090, insertion pacemaker, fluoroscopy, radiological supervision and interpretation was assessed and found to be used in combination with Pacemaker/ICD procedures more than 75% of the time and as such as has been deleted. If fluoroscopic guidance is used for diagnostic lead evaluation minus lead insertion, coders need to use 76000, fluoroscopy up to 1 hour physician time.

CPT codes for Digestive system services related to surgery

CPT codes 49080 and 49081 (abdominal paracentesis) have made way for codes 49082-abdominal paracentesis without imaging guidance, 49083-WITH imaging guidance, and 49084-Peritoneal lavage with imaging guidance.

This is just a glimpse of few of the CPT code and verbiage changes that was incorporated this year and that had a say in your practice’s coding.

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Get Answers to Your 4 Most Frequently Asked 86580 Questions

Coding experts help us help you code TB skin tests and injection codes successfully every time

Before you report any tuberculosis (TB) related procedures (86580) look for documentation details on the patient's course of treatment after the initial skin test who interpreted the test results to the patient and the level of supercoder.com E/Mservices the pulmonologist provided because this will make or break your reimbursement.

Looking at these four frequently asked questions will determine whether you know how to report TB readings accurately. Write down your responses before looking to the correct answers below.

Question 1: Should I bill 99211 for tuberculosis (PPD) reading?

Question 2: We are trying to link the purified protein derivative (PPD) tuberculosis (TB) test to the correct ICD-9 code. We have been using V03.2 but we think that diagnosis is incorrect because V03.2 is a vaccination code. Which ICD-9 code should we report?

Question 3: Should I bill for an injection administration in addition to a tuberculosis (TB) skin test?

Question 4: When someone has a positive Mantoux (PPD) test and a negative chest x-ray and comes in for a visit to initiate INH (isonicotinic acid hydrazide called isoniazid) therapy what should we code? We code a moderate level office visit but what diagnosis should we use? We can't use tuberculosis because the chest x-ray was negative and if we use a V code we probably won't get paid.


Answer 1: You should report the initial purified protein derivative (PPD) tuberculosis test with 86580 (Skin test; tuberculosis intradermal).

Code 86580 does not cover any follow-up care. Therefore if the patient returns to the office to have the nurse evaluate the test's results you may report 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...typically 5 minutes are spent performing or supervising these services).

Most plans will usually pay for the nurse visit with the screening diagnosis. If the payer denies 99211 you may appeal the claim or charge the patient.

Remember: Don't forget to collect a copayment for the 99211 services the pulmonologist provides at the follow-up visit.

Answer 2: You should report V74.1 (Special screening examination for bacterial and spirochetal diseases; pulmonary tuberculosis) with 86580 (Skin test; tuberculosis intradermal) for pulmonary tuberculosis says Denae M. Merrill CPC coding specialist with NEM Pulmonary Associates in Saginaw Mich.

When a nurse or other individual in your office administers a PPD TB test she gives an inoculation screening test not a vaccination.

The TB screen test detects the disease's presence by inoculating the skin with the TB antigen. The TB screen doesn't vaccinate the person. Instead the screen is an inoculation to confer disease immunity. Therefore you should link the test code to…..

A Surefire Strategy for Male Mammogram Claims

Hint: Don't rely on your diagnosis codes
While Medicare often covers diagnostic mammography for male patients with symptoms of breast cancer screening mammograms are another story. Your best bet is to have male patients sign an ABN before you perform a screening mammogram.

TV announcer Rod Roddy the famous voice of "The Price Is Right " died in October of colon and breast cancer prompting many men to wonder whether breast cancer could happen to them. Because Roddy's death publicized the fact that 1 500 men each year are diagnosed with breast cancer your radiology clinic may soon begin fielding calls from men interested in getting screened for the disease.
Screening Mammos Are Male-Exempt
Most local medical review policies (LMRPs) recommend V76.12 (Other screening mammogram) for screening mammograms (76092 Screening mammography bilateral [two view film study of each breast]). The carrier may or may not pay for this service however because CMS covers annual screening mammography for "All women age 40 and over and one baseline screening mammography for women between the ages of 35 and 39."
 
"Medicare does not cover screening mammography on males by statute " says Jeff Fulkerson BA CPC CMC certified coder for the department of radiology at The Emory Clinic in Atlanta.

If you perform a mammogram on a male patient in the future you should ask him to sign an advance beneficiary notice (ABN) and append modifier -GA (Waiver of liability statement on file) to 76092 Fulkerson says.

If you do not obtain an ABN he says you should append modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to 76092. "By adding modifier -GY you are telling the carrier that you know that the service is not covered by statute and do not expect reimbursement " Fulkerson says. "How your local carrier wants the provider to handle claim filing for this type of exam may vary."
You Can Collect for Diagnostic Mammos
If you perform a diagnostic mammogram on a male patient (76090 Mammography; unilateral) or 76091      (... bilateral) your practice should document a meticulous patient history because most male patients referred for diagnostic mammography actually have signs and/or symptoms that support the performance of a diagnostic mammogram (for example mass nipple discharge or pain with or without swelling). "History of a mother with breast cancer usually is not sufficient " says Candace Ryan coding supervisor at Radiology Consultants in Denver. "You need a more comprehensive reason for the mammogram than that."

In such cases you should report the appropriate ICD-9 code(s) for the signs and symptoms. "Most carriers cover diagnostic mammograms for males using the same symptoms conditions and diagnoses that are........

Code Most GERD Tests With 91034, 91010

Make sure you document other treatments on manometry, pH study claims

When your gastroenterologist suspects that a patient may have gastroesophageal reflux disease (GERD), a trial of reflux medication or an endoscopy will usually confirm the condition.

If normal methods don't work, the gastroenterologist may choose to perform an esophageal manometry and/or a pH monitoring to check for GERD in the patient, says Ann M. Plansky, CCS-P, MBS, of Woodland Clinic in Manitowoc, Wisc.

Coding for these advanced GERD tests not only requires CPT knowledge; you also have to know who owns the equipment you're using and whether your payer will want a modifier on the claim.

Follow us for some expert advice on coding in several GERD-testing scenarios.

Manometry Only? Use 91010 - Usually

If a patient reports to your office with symptoms that could indicate GERD but doesn't have typical endoscopy findings or improvement with acid-suppression medication, the gastroenterologist may try other testing methods to determine the patient's condition, says Margaret Fisher, CCS-P, of Tacoma Digestive Disease Center/Tacoma Endoscopy Center in Washington.

Exceptions: You'll report most manometric studies with 91010, but there are separate CPT codes for special manometries. If your physician performs a manometry:

• with a stimulant, report 91011 (... with mecholyl or similar stimulant) instead of 91010 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study).
  
• with acid perfusion, report 91012 (... with acid perfusion studies) instead of 91010.

Choose 91034 for pH Monitoring

Your gastroenterologist may not choose a manometric study to check for GERD; in some instances, the physician opts for pH monitoring instead.

Heads-up: Anyone who has yet to code for a pH study this year should remember: There is a whole new way to report the procedures. Regardless of how long the study
takes, you should code all catheter pH monitoring sessions with new code 91034 (Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation), Plansky says.

Last year, you would have reported pH studies with 91032 (Esophagus, acid reflux test, with intraluminal pH electrode for detection of gastroesophageal reflux) and 91033 (... prolonged reading), depending on the encounter. These codes are not in CPT 2005, however, so do not use them at all.

For example, a patient reports for a pH study to identify the cause of acute esophagitis. The gastroenterologist performs a seven-hour pH monitoring session. On the claim, you should:

• report 91034 for the pH testing.
• attach ICD-9 code 530.12 (Acute esophagitis) to 91034 to represent the patient's symptoms.
• document any previous treatments or tests the gastroenterologist performed on the patient for the condition.

Both Tests in Same Session Possible

In certain instances, performing a manometry and pH study during the same patient encounter makes sense, Plansky says. When her gastroenterologist performs both tests in the same session, Plansky reports 91010 for the manometry and 91034 for the pH monitoring.

We have billed [91010 and 91034 together] to our local Medicare carrier and other commercial insurance companies" and have not had any problems with payment " Plansky says.

Fisher also reports 91010 and 91034 without any modifiers but she offers this tip: "Report 91010 on the date of service and 91034 the next day or whenever the probe is removed " she says.

That way you can avoid problems that can befall claims featuring two CPT codes with the same date of service.

Observe Modifier -26 -TC Exceptions

When reporting either 91010 or 91034 you must remember that you cannot get paid for the entire code unless your office owns the equipment. If your gastroenterologist is using another facility's equipment to perform the manometry you should attach modifier -26 (Professional component) to the CPT code.

For example the physicians at Fisher's practice have their own equipment set up in an ambulatory surgery center. When they perform esophageal manometries or pH studies in that ASC Fisher reports the encounters without any modifiers.

However when the physicians treat Medicare and Medicaid patients at local hospitals Fisher reports the encounters with modifier -26 attached to indicate that her practice only deserves payment for the professional service. These payers do not reimburse her practice for the facility fee she says.

In those instances the hospital will report the appropriate APC code for Medicare or Medicaid patients or will use the CPT code with modifier -TC (Technical component) for the technical component only."