Know more about Amyloid Imaging.
Evidence for Amyloid Scanning (IDEAS) Study is a Medicare-approved coverage with evidence development (CED) procedure. This nuclear medicine procedure uses positron emission tomography (PET) imaging to examine how amyloid plaques (a core feature of Alzheimer’s disease) in the brain help to guide doctors in patient treatment, and whether these changes in treatment lead to better medical outcomes. The IDEAS Study (activated Feb. 8, 2016) provides access to amyloid imaging for more than 18,000 patients for whom the cause of cognitive decline/dementia is ambiguous, and who may benefit from an early and accurate diagnosis.
A PET imaging facility may not perform an IDEAS Study PET scan unless they are enrolled in the IDEAS program, and until the referring physician has submitted a pre-PET clinical assessment form for the patient to the IDEAS Study database. After the PET scan is completed and the appropriate data uploaded to the IDEAS Study database, a system-generated notification is sent from the email address IDEAS-Study@acr.org to the PET imaging facility, indicating the case data are complete. Only after the email notification is received may the PET facility and the reading physicians begin to bill Medicare for the study and the radiopharmaceutical.
Reading physicians should coordinate with the PET imaging facility to obtain a copy of the system-generated notification prior to billing for PET studies reading. Both the PET imaging centers and the reading physician should maintain the email notification for each patient study as documentation, in case the Centers for Medicare & Medicaid Services (CMS) opts to audit the PET imaging facility.
The PET facility (and the interpreting physician, if technical and professional component billing are performed separately) may submit the claim for the service to the local Medicare administrative contractor (MAC) or Medicare Advantage (MA) plan, as appropriate.
It should be noted that Amyloid imaging services are currently not covered by any third-party payers.
Following are some tips to avoid common omissions/errors on IDEAS claim submissions:
- Providers should append modifier Q0 to the HCPCS Level II radiopharmaceutical codes. This is in addition to appending modifier Q0 to the CPT® procedure code for the PET study. MACs say this is the main issue that causes IDEAS claim denials.
- Providers should include the appropriate clinical trial number following CMS Transmittal 2955 (CR 8401, May 13, 2014). Examples are also provided by IDEAS in the Sample Medicare Claims on the IDEAS website.
- Independent diagnostic testing facilities (IDTF) should verify that the CPT® and HCPCS Level II codes to be used for IDEAS scans are on their CMS-855B form and accepted by the MAC for use prior to billing for IDEAS studies. This issue is the No. 1 issue for IDTF claim denials in IDEAS.
- If a payer instructs you to append modifier PI Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing or modifier PS Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treating physician determines that the PET study is needed to inform subsequent anti-tumor strategy to either the CPT® or HCPCS Level II codes on the claim, be aware that this is not a CMS billing requirement of IDEAS claims. Please notify Denise Merlino or the IDEAS team immediately with sample claims using the Claim Denial Form process noted.
- If an MA plan denies prior authorization for an IDEAS patient, it’s recommended you appeal all denials. Specifically, follow up with additional documentation to support your request, “This patient is enrolled in the CMS approved CED program IDEAS and provide the MA plan,” with the three references below:
A copy of the link to the CMS communication to MA plan.
A copy of the link to the IDEAS FAQ, specifically guiding them to the question:
Will managed Medicare plans (Medicare Advantage) reimburse for scans done as part of the IDEAS Study?
Yes, Medicare Advantage (MA) beneficiaries are eligible to be included in the IDEAS Study. The MA plans will make payments for MA enrollees. IDEAS Study claims should be billed to the MA plan. This policy is located in Publication 100-16, Chapter 4: Managed Care Manual 10.7.3 – Benefits and Beneficiary Protections – Payment for Clinical Studies Approved Under Coverage with Evidence.
There are many important elements to a CMS CED-approved study. If any element is not performed or not on the claim, the claim will likely deny for payment, or be considered by Medicare as not covered. Merlino Healthcare Consulting Corp. has been working with MACs regarding some claims processing issues to resolve them as quickly as possible. At the time this article was written, Noridian was updating the list of ICD-10 codes payable with only modifier Q0 for claims processing.
Coding Screening for Colorectal Polyp.
Colorectal cancer typically develops from a polyp. Polyps are abnormal growths of tissue (neoplasms) that can be found in any organ that has blood vessels — and the colorectal area has a rich supply of blood vessels. Most polyps are benign, but they can become cancerous. Colon polyps found in the early stages usually can be removed safely and completely.
Symptoms may include bleeding from the anus, constipation or diarrhea that lasts more than a week, and hematochezia (blood in the stool) that can make stool look black or show up as red streaks in the stool. Most colon polyps are asymptomatic and people are unaware of them until one or more is found during a screening or other testing.
When selecting an ICD-10 diagnosis code for colon polyps, the precise location of the polyp(s) is key. The type of polyp (e.g., benign, inflammatory, etc.), as confirmed by biopsy, is also required.
Codes for benign adenomatous polyp of the colon are found in the neoplasm chapter of ICD-10-CM, by location:
- 0Benign neoplasm of cecum
- 1Benign neoplasm of appendix
- 2Benign neoplasm of ascending colon
- 3Benign neoplasm of transverse colon
- 4Benign neoplasm of descending colon
- 5Benign neoplasm of sigmoid colon
- 6Benign neoplasm of colon, unspecified [Note: This code includes adenomatous polyp of colon and polyposis of colon]
- 7Benign neoplasm of rectosigmoid junction
- 8Benign neoplasm of the rectum
Codes for inflammatory colon polyps, found in category K51 Ulcerative colitis, also are considered possible complications:
- 40Inflammatory polyps of colon without complications
- 411Inflammatory polyps of colon with rectal bleeding
- 412Inflammatory polyps of colon with intestinal obstruction
- 413Inflammatory polyps of colon with fistula
- 414Inflammatory polyps of colon with abscess
- 418Inflammatory polyps of colon with other complication
ICD-10 instructs to use an additional code with category K51 to identify manifestations (e.g., pyoderma gangrenosum).
Polyps of the colon not documented as adenomatous, benign, or inflammatory are coded to K63.5 Polyp of colon. If a colon polyp is specified as hyperplastic, assign K63.5, even if greater specificity is provided regarding the location, according to the American Hospital Association’s (AHA) Coding Clinic for ICD-10-CM and ICD-10-PCS (Second Quarter 2015, pages 14-15).
Latest changes in Otorhinolaryngology.
Latest changes in Otorhinolaryngology: CPT® 2017 brings several code changes for Otorhinolaryngology, a specialty that has seen few, if any, code changes in the past several years. The changes are primarily new codes, with some code revisions, to keep the codes up to date with contemporary clinical practice.
The laryngoscopy codes revised for 2017, and what’s different from 2016, are shown in Table A. These procedures involve the use of a flexible laryngoscope and are typically performed in the office setting, but may occur in the operating room.
New guidelines state not to report 31575 with 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure), unless both are performed for separate conditions using separate endoscopes. Reporting both codes is not common, as both procedures are performed transnasal. The clinical rationale to support both codes should be documented clearly if both are reported. Both procedures should be separately documented, as well.
New flexible laryngoscopy codes allow us to report procedures more commonly performed by otolaryngologists in the past several years. These procedures are also typically performed in the office setting, using a flexible laryngoscope, but may occur in the operating room. Here are the 2017 codes, with examples for practical application:
- 31572Laryngoscopy, flexible; with ablation or destruction of lesion(s) with laser, unilateral. Code 31572 includes the removal of any number of lesions using the laser.
- 31573Laryngoscopy, flexible; with therapeutic injection(s) (eg, chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral. Code 31573 includes one or more injections at the same session.
- 31574Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateral. Code 31574 includes one or more injections at the same session. The procedure is commonly known as a percutaneous injection laryngoplasty.
All of these laryngoscopy codes are unilateral, which means modifier 50 Bilateral procedure may be appended if performed on both paired structures of the larynx/pharynx. CPT® guidelines state paired structures include true vocal cords, arytenoids, false vocal cords, ventricles, pyriform sinuses, and aryepiglottic folds.
There are six new, three revised, and two deleted codes in the Larynx Repair section of CPT® 2017.
Direct laryngoscopy and bronchoscopy are included in all the open larynx repair codes for airway evaluation prior to the definitive procedure at the same operative session.
The following four codes reflect procedures for resection of laryngeal stenosis. These codes are differentiated by the age of the patient, and whether an indwelling stent was placed.
CPT® codes for patients younger than 12 years of age:
- 31551Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, younger than 12 years of age
- 31553 for laryngeal stenosis, with graft, with indwelling stent placement, younger than 12 years of age
CPT® code for patients aged 12 years or older:
- 31552Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, age 12 years or older
- 31554 for laryngeal stenosis, with graft, with indwelling stent placement, age 12 years or older
The graft harvest and placement is included in the above codes and should not be separately reported, even when performed through a separate incision.
The remaining two new airway CPT® codes are for specific procedures:
- 31591Laryngoplasty, medialization, unilateral. Code 31591 is typically performed for vocal fold paralysis.
- 31592Cricotracheal resection. Code 31592 is usually performed for subglottic stenosis.
There are three revised airway procedure codes in 2017. These are listed in Table B, with an explanation of the difference in code description from 2016.
Two airway procedure codes, 31582 and 31588, were removed to correspond with the new and revised codes, noted above.
Deletion of the “moderate sedation included” symbol () affected many otolaryngology endoscopy codes, such as 31615 Tracheobronchoscopy through established tracheostomy incision, the bronchoscopy codes (Eg: 31622 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)), and many esophagoscopy codes (Eg: 43200 Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)).
Reporting Mental Health in Drug Screening.
Major changes have occurred in mental health coding and drug screen services.The evolving public awareness of mental health, parity laws, revisions to CDC guidelines, and HCPCS Level II dual coding for drug screen services prompted more changes in 2017.
In 2013, CPT® created separate reporting guidelines for physicians and other mental health clinicians.
CPT® instructed physicians to report medication management through evaluation and management (E/M) codes (99201-99499), with psychotherapy reported as an add-on code,
because physicians focus on the medication management of the patient, with referrals to therapists and psychologists. For clinicians practicing only psychotherapy, CPT® created new psychotherapy codes. This prompted the creation of new guidelines, new definitions, and clarification on time reporting. Time-based psychotherapy codes began to adopt the Time Rule, which can be found in the introduction section of the CPT® codebook.
In 2015, CPT® changed drug screening services to define them as either presumptive or definitive. The Centers for Medicare & Medicaid Services (CMS) still required providers to use an appropriate HCPCS Level II code, which CMS subsequently updated in 2016.
HCPCS Level II codes adopted by CMS in 2016 for presumptive drug screen services became popular among coders and payers, forcing CPT® to adopt these code definitions in 2017. With the adoption of the new CPT® codes, CMS deleted the dual coding methodology for presumptive drug screen services in the HCPCS Level II codebook, creating a uniformed coding system for presumptive drug screen services.
The new CPT® codes are:
- 80305Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay); capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service [The old code was G0477.]
- 80306 read by instrument assisted direct optical observation only (eg, dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service [The old code was G0478.]
- 80307Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed per date of service [The old code was G0479.]
Presumptive drug screening services may be performed prior to definitive drug screen testing when a provider wants to:
- Rule out illicit drug uses;
- Confirm the presence of a particular drug class without identifying individual drugs; or
- Distinguish between structural isomers.
For example, a patient using prescription opioids for pain management may receive a randomized drug screen service to test for the presence of opioids and illicit drugs, or other prescription drugs that may cause risk to the patient when on opioids. One such risky combination, per a CDC warning, is the use of benzodiazepines with opioids.
According to CPT® guidelines, sample validation in each of the codes “may include, but are not limited to, pH, specific gravity, and nitrite.” These sample validation tests are included in the drug screen services, so urinalysis, immunoassay tests, and other lab tests bundle into these codes, by definition. It is not appropriate to use modifiers 59 Distinct procedural service, XE Separate encounter, XP Separate practitioner, XS Separate structure, or XU Unusual non-overlapping service to override the bundling combination. Chapter 10 of the National Correct Coding Initiative (NCCI) Policy Manual confirms providers should not separately report the validity testing (p. X-7).
CPT® also limits each of these codes to one unit per billing. Because CPT® is adopting the CMS model, CMS advises providers to report these codes for presumptive drug screening services, and is including these codes in the Clinical Laboratory Fee Schedule.
Because substance abuse requires mental health intervention, it’s important to address mental health changes, as well.
When the original psychotherapy codes were created in 2015, the term “with patient and/or family” was included in psychotherapy codes 90832-90838. This caused confusion, and may have caused coders and providers to use these codes erroneously for family psychotherapy (which should be reported with 90846-90847).
To correct this, CPT® has removed this terminology from the codes and clarified the guidelines. The guidelines now state:
Codes 90832, 90833, 90834, 90836, 90837, 90838 describe psychotherapy for the individual patient, although times are for face-to-face services with patient and may include informant(s). See codes 90846, 90847 when utilizing family psychotherapy techniques, such as focusing on family dynamics.
This clarification instructs us not to use the individual psychotherapy codes for family psychotherapy, and directs us to the correct code. Doing so ensures 90832-90838 remain as individual psychotherapy codes that may involve an informant(s) to help the clinician better treat the individual patient and their individual needs.
In making these changes and to provide consistency, CPT® made psychotherapy codes 90846 and 90847 time-based, 50-minute codes. Coders are further advised not to report family psychotherapy services less than 26 minutes in length.
Auditors and payers will also be looking at coding based on time:
- Did the documentation support the time spent performing the services?
- Did the physician use time for both the E/M and the psychotherapy for the same encounter, against coding guidelines?
- Did the clinician actually perform psychotherapy, or was only medication management performed?
- Did the service meet the time criteria for the psychotherapy services?
Regarding drug screen services: Auditors and investigators look for orders, lab results, medical necessity, frequency, and custom panels. All lab studies require orders, results, and medical necessity. Frequency is important, particularly with drug screen services for an individual who is compliant with medication regimen and no risk of illicit drug use, for example. Custom panels do not provide convincing evidence of medical necessity because the ordering provider determines what tests are required. The lab should not bill for services not ordered and not deemed medically necessary.
The correct way of using Modifier L1.
Modifier L1 Separately payable lab test was implemented in 2014 by the Centers for Medicare & Medicaid Services (CMS) as part of the July Outpatient Prospective Payment System (OPPS) package updates (CMS 2014). Under the 2014 OPPS packaging edits, if a laboratory service with status indicator A Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS is on the same claim as a service with status indicator Q1, Q2, or Q3, the laboratory service is denied and bundled into the payment for the other service. Modifier L1 bypasses this bundling edit, indicating the laboratory service is unrelated to the other ancillary services provided on the same day. “Unrelated” is defined as:
- Ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services; and
- For a different diagnosis than the other hospital outpatient services (CMS Pub. 100-04).
- Implementation of status indicator Q4Conditionally packaged laboratory tests has revised the instances where modifier L1 may be used.
The functions of the Q1-Q4 edit set are based on CPT®/HCPCS Level II status indicators. Most laboratory services are assigned status indicator A. The edit looks to see if there are any other ancillary services on the same date of service with a status indicator Q1, Q2, or Q3. If one of these services is included on the claim with the same date of service, the laboratory service is flipped to status N Items and services packaged into APC rates and bundled into the line item with the status indicator Q Packaged services subject to separate payment under OPPS payment criteria.
Status indicator Q1 codes are STVX-packaged codes. These codes are packaged when billed on the same date of service with any other code with a status indicator of S, T, V, or X:
- Indicator S codes are significant procedures, not subject to the multi-procedure discount.
- Indicator T codes are significant procedures subject to the multiple procedure discount.
- Indicator V codes include clinic or emergency department visits.
- Indicator X codes are ancillary services.
When not packaged, these codes are paid separately under an Ambulatory Payment Classification (APC). APCs are a method of paying facilities for outpatient services provided to Medicare patients. Each APC is composed of services that are similar in clinical intensity, resource utilization, and cost.
Codes with a status indicator of Q2 T-packaged codes are packaged only if they are billed on the same date of service with any other status indicator T codes. Otherwise, they are separately payable under a separate APC. If you report more than one STVX or T-packaged code without a separately payable service into which it would otherwise be packaged, CMS makes separate payment only for the highest paying service, and packages all others into that code. Status indicator Q3 May be paid through a composite APC-based on composite-specific criteria or separately through single code APCs when the criteria are not met codes are subject to payment as part of a composite rate when all criteria for that composite are met. Otherwise, Q3 services become separately payable if assigned to a separate APC, or packaged into other services.
For 2016, CMS implemented status indicator Q4. This status indicator designates packaged APC payment for codes billed on the same claim as a HCPCS Level II code assigned status indicator J1, J2, S, T, V, Q1, Q2, or Q3. Status indicator Q4 identifies outpatient bills (TOB 13x) where there are only laboratory HCPCS Level II codes on the Clinical Laboratory Fee Schedule (CLFS), automatically changes their status indicator to A, and pays them separately at the CLFS payment rates. When status indicator Q4 applies, modifier L1 may only be used to identify laboratory tests ordered for a different diagnosis and by a different provider unrelated to the other OPPS services on the claim.
Ways to minimize NCCI denial risk.
NCCI denial risk: Becoming knowledgeable about National Correct Coding Initiative (NCCI) policies and edits may be the difference between having a profitable revenue cycle or placing your facility at risk for denials. In recent years, NCCI policies and edits have become key factors in outpatient facility and professional claims denials. You must have a strong understanding of these guidelines to ensure coding compliance and to mitigate risk.
Follow NCCI Policy Manual Annual Updates:
The NCCI Policy Manual is updated annually. The new guidance becomes effective Jan. 1 of each year.
Special attention should be paid to claims denied during the first quarter of the year to ensure you are consistent with the most recent published guidelines.
NCCI Edits Are Updated Quarterly:
NCCI edits are updated quarterly and are effective Jan. 1, April 1, July 1, and Oct. 1 each year. Because the NCCI Policy Manual is updated only annually, the quarterly updates may not correlate with the information published in the NCCI Policy Manual.
The July 2016 NCCI updates eliminated the procedure-to-procedure code edits precluding the assignment of code 29823 Arthroscopy, shoulder, surgical; debridement, extensive with several other ipsilateral shoulder surgeries; however, the 2016 NCCI Policy Manual maintained the following language, “With the exception of the knee joint, arthroscopic debridement should not be reported separately with a surgical arthroscopy procedure when performed on the same joint at the same patient encounter.”
In this case, the encoder would no longer flag the debridement as not separately reportable by the procedure-to-procedure edits, but the language in the NCCI Policy Manual would still preclude the assignment of a debridement code with another ipsilateral arthroscopic shoulder surgery.
The quarterly updates must be reviewed when they are published and compare them to the guidance published in the NCCI Policy Manual.
Not Every NCCI Policy Guideline Has an Edit
You may think that, if there isn’t an edit to preclude a particular code assignment, you can combine codes as you please.
One should remember that not every NCCI policy has an associated NCCI edit. Per the NCCI Policy Manual, “Providers are obligated to code correctly even if edits do not exist to prevent the use of an inappropriate code combination.”
Become familiar with guidelines published in the NCCI Policy Manual. Do not rely on your encoder, alone, to flag NCCI edit violations for code pairs.
CPT® Assistant Versus NCCI Policy Guidance
One may encounter cases where the guidance published in the NCCI Policy Manual differs from that published in CPT® Assistant. When this occurs, establish which set of guidelines has precedence.
For Medicare claims, the NCCI policies prevail. According to page I-28 of the NCCI Policy Manual:
The American Medical Association publishes CPT® Assistant which contains coding guidelines. CMS does not review nor approve the information in this publication.
In the development of NCCI PTP edits, CMS occasionally disagrees with the information in this publication. If
a physician utilizes information from CPT® Assistant to
report services rendered to Medicare patients, it is possible that Medicare Carriers (A/B MACS processing practitioner service claims) and Fiscal Intermediaries may utilize different criteria to process claims.
For commercial claims, know whether the payer follows NCCI edits prior to code assignment to ensure compliance.
Apply Policies to Your Healthcare Organization
These are just a few of the potential risks your practice or facility may prevent by having a thorough understanding of the NCCI policies.
Coding managers should review the NCCI Policy Manual, and ensure their coding staff receives training on the sections applicable to their place of service.
The National Correct Coding Initiative (NCCI) was developed by the Centers for Medicare & Medicaid Services (CMS) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Medicare Part B claims. Although the NCCI policies were initially established for the Medicare program, several commercial insurers have adopted it.
Easy ways to correct surgical coding.
Surgical coding: Many coders struggle with coding operative reports because there are so many guidelines and policies that affect code selection. The process is easier when you break it into seven steps:
- Review the header of the report.
- Review the CPT®codebook (start in the Index).
- Review the report/documentation.
- Make a preliminary code selection.
- Review the guidelines (for the preliminary codes).
- Review policies and eliminate the extras.
- Add any needed modifiers.
These seven steps will ensure all the factors that may affect code selection are accounted.
Step 1 Review the Header of the Report
PREOPERATIVE DIAGNOSIS: Left medial compartment osteoarthritis of the knee.
POSTOPERATIVE DIAGNOSIS: Left medial compartment osteoarthritis of the knee.
PROCEDURE PERFORMED: Left unicompartmental knee replacement.
Based on the documentation above, a unicompartmental knee replacement on the left knee was performed. A unicompartmental knee replacement indicates only one of the three compartments of the knee (medial, lateral, or patellofemoral) was altered during the procedure. The postoperative diagnosis field indicates the altered compartment was the medial compartment of the left knee. Verification of the statement will take place as part of Step 3.
Step 2 Review the CPT® Codebook (Start in the Index)
Based on the header information from the report, review the CPT® codebook to identify the code options. Also identify the differences between the codes and the documentation required to support one service over another.
Continuing with the example given, the Index is reviewed first to identify all possible code options for knee replacement procedures.
- Intraoperative Use, Kinetic Balance
- Sensor … +0396T
- Partial … 27446
- Total … 27447
Three options are given:
- +0396TIntra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (List separately in addition to code for primary procedure),
- 27446Arthroplasty, knee, condyle and plateau; medial OR lateral compartment, and
- 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty).
Upon reviewing the three options, 0396T is found to be an add-on code, so it may not be reported alone, nor may it be the first-listed CPT® code reported. But it does indicate a specific technology was used during the procedure. If that technology is included in the full report (which will be reviewed in Step 3), +0396T will be included in Step 4 (Preliminary Code Selection).
CPT® codes 27446 and 27447 differ based on one key word: “OR” vs. “AND.” Code 27446 indicates a partial knee replacement (including either the medial OR the lateral compartment) was performed; whereas, 27447 indicates a total knee replacement (including both the medial AND lateral compartments) was performed. When the documentation is reviewed fully (Step 3), the primary focus will be to determine which compartments were altered during the procedure.
Step 3 Review the Report/Documentation Details
Based on the documentation, a unicompartmental knee replacement using a Biomet, Inc., prosthesis was performed. The components were cemented into the tibia and distal femur after the necessary cuts and trial fit/placement were performed. According to the Cleveland Clinic, “Medial knee joint degeneration is the most common deformity of arthritis.”
Step 4 Make a Preliminary Code Selection
The emphasis here is to make a preliminary code selection based on the documentation. It’s preliminary because reviewing the guidelines, policies, etc., may lead to eliminating certain codes, or the need for additional codes and/or modifiers.
Based on the documentation above, a unicompartmental knee replacement is supported. A unicompartmental knee replacement is also referred to as a “partial” knee replacement, so based on the code options, CPT® code 27446 is supported, preliminarily. Guidelines, policies, and the like still need to be reviewed (Steps 5-7).
Note: If coding for a facility (as this procedure is fairly common in the outpatient facility or ambulatory surgery center setting), the implant also needs to be reported.
Step 5 Review the Guidelines
Review all relevant CPT® guidelines, including parenthetical references, to ensure all rules are followed, additional, supported services are captured, etc. Steps 5, 6, and 7 are all related, and are frequently performed concurrently.
The “Femur (Thigh Region) and Knee Joint/ Repair, Revision, or Reconstruction” CPT® codes do not include specific subsection guidelines. But there are two parenthetical references below code 27447 to review, and the general surgery guidelines (at the beginning of the Surgery section of CPT®) still apply.
The parenthetical references under 27447 read:
- (For revision of total knee arthroplasty, use 27487)
- (For removal of total knee prosthesis, use 27488)
Both parenthetical references are specific to total knee arthroplasties — particularly revision or removal of previously placed prosthesis — and are not relevant.
Based on the documentation for this scenario, a partial knee arthroplasty was performed in a knee without a previous prosthesis or implant. No additional CPT® guidelines appear to be relevant for this scenario.
Step 6 Review Policies and Eliminate the Extras
Because there is only one service supported based on the documentation and steps above, it does not appear there are any extras. Review all of the relevant edits and policies (National Correct Coding Initiative (NCCI) edits, local and national coverage determinations (LCDs, NCDs), payer contracts, medical policies, etc.) to ensure bundled services are appropriately eliminated (and tracked internally, if applicable).
This step is essential in scenarios where more than one service is performed and more than one code may be warranted. Reviewing the NCCI edits and payer policies will help you identify bundled services, instances where modifiers may be needed, or situations where a contract limitation restricts reporting a service that would otherwise be reportable (e.g., a colonoscopy in which multiple procedures were performed such as snare polypectomy, biopsy polypectomy, and submucosal injection).
Step 7 Add Necessary Modifiers
Based on the description for 27446, there is no indication as to which knee was repaired. The story is incomplete. A modifier is needed to indicate which knee was affected.
Modifier options are:
- LTeft side
- RTight side
- 50ilateral procedure
Based on the documentation, the left knee was replaced because the patient had a right-side replacement previously. For this scenario, modifier LT is added to the procedure to indicate the procedure was performed on the left knee. Without this modifier, a denial or request for additional information may be received from the payer because the patient had the previous knee replacement.
Final code selection for this scenario is: 27446-LT.
Although the scenario used in this example is fairly straight-forward, these seven steps will work for any level of sophistication in an operative report. Use them for consistent review of all relevant factors, and correct coding is certain.
Final updates to Prescription Drug Program.
Prescription Drug Program: The Center Medicare & Medicaid Services (CMS) released final updates to the Medicare Advantage and Part D Prescription Drug Program for 2018, as an ongoing effort to strengthen the Medicare Advantage and the Prescription Drug Program by supporting flexibility, efficiency, and innovation.
The final policies are similar to the proposal released in February’s 2018 Advance Notice and Draft Call Letter. There are several changes, however, in response to feedback received during the public comment period.
Some of the policies in the rate announcement will according to CMS’ April 3 press release will provide:
- Flexibility and incentives to encourage organizations to develop new plan offerings
- Incentives for plans to submit complete encounter data
- Modify the phase-in of the use of encounter data
- Use encounter data for 15 percent of the risk adjustment payment to Medicare Advantage plans
- Help combat overuse of opioids by encouraging safeguards before an opioid prescription is dispensed at the pharmacy
- Employ best practices and the most appropriate care management interventions for enrollees using high dosage opioids
The “Year-to-Year Percentage Change in Payment” is:
|Effective Growth Rate||2.8%||2.7%|
|Change in Star Ratings||-0.4%||-0.4%|
|MA coding intensity adjustment||-0.25%||-0.25%|
|Expected Average Change in Revenue||0.25%||0.45%|
|Expected Average Change in Revenue
with Coding trend
Proper Reporting of Modifier 99.
Modifier 99 Multiple modifiers do not get a lot of attention as it is rarely needed , but knowing when to apply it can make the difference in getting a claim paid.
Appendix A — Modifiers tells us:
Under certain circumstances, 2 or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
In practice, call on modifier 99 only if a single line item requires five or more modifiers. The reason is the standard 1500 Health Insurance Claim Form (or electronic equivalent) field 24D accommodates the entry of up to four modifiers:
If a single line item requires more than four modifiers, enter modifier 99 (and only modifier 99) in the first space available for modifiers in field 24D. All other applicable modifiers should be entered in field 19 “Additional Claim Information,” or the equivalent electronic data field. You may use modifier 99, when applicable, with any CPT® code.
Medicare Carriers Manual Part 4 – Professional Relations, Transmittal 25, Change Request (CR) 1910 (Nov. 1, 2001) further specifies, “If modifier -99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a -99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and ‘mod’ represents all modifiers applicable to the referenced line item.”
When listing multiple modifiers for the same line item, take care to sequence the modifiers affecting payment first. Level I payment modifiers include:
- 26Professional component
- 50Bilateral procedure
- 53Discontinued procedure
- 54Surgical care only
- 55Postoperative management only
- 56Preoperative management only
- 62Two surgeons66 Surgical team
- 78Unplanned return to operating/procedure room by the same physician or other qualified healthcare professional following an initial procedure for a related procedure during postoperative period
- 80Assistant surgeon
- 81Minimum assistant surgeon
- 82Assistant surgeon (when qualified resident surgeon not available)
- 91Repeat clinical diagnostic laboratory test
Informational or statistical modifiers (any modifier not classified as a payment modifier) are sequenced after payment modifiers. If multiple informational/statistical modifiers apply, you may sequence them in any order (as long as they are sequenced after any payment modifiers).
Effective Date of Home Health Agency CoPs delayed.
The Centers for Medicare & Medicaid Services (CMS) issued on March 31 a proposed rule (CMS-3819-P2) to delay the effective date for the Medicare and Medicaid Programs: Conditions of Participation for Home Health Agencies (HHA CoPs) final rule. The current effective date for the final rule is July 13. The proposed rule would delay the effective date an additional six months, until Jan. 13, 2018.
CMS also proposes to revise a phase-in date for the requirements at §484.65(d) — “Standard: Performance improvement projects” from Jan. 13, 2018, to July 13, 2018, and to extend the July 13, 2017, effective date at §484.115(a)(1) and (2) to Jan. 13, 2018.
Following publication of the January 2017 HHA CoPs final rule, CMS says it received inquiries that represented a large number of HHAs requesting that the agency delay the effective date for the new HHA CoPs. The inquiries asserted that HHAs were not able to effectively implement the new CoPs until CMS issued its revised Interpretive Guidelines (State Operations Manual, CMS Pub. 100-07, Appendix B). In addition, one of the inquiries stated that HHAs were unable to effectively implement the new CoPs until CMS issued further sub-regulatory guidance related to converting subunits to branches or independent HHAs, which would affect 216 HHAs nationwide. One of the inquiries cited the estimated $300 million cost to implement the new requirements as a reason for delaying the effective date.
The January 2017 HHA CoPs final rule revised the conditions of participation home health agencies must meet o participate in the Medicare and Medicaid programs. “The requirements focus on the care delivered to patients by HHAs, reflect an interdisciplinary view of patient care, allow HHAs greater flexibility in meeting quality care standards, and eliminate unnecessary procedural requirements,” CMS states in the proposed rule.