Coding Diagnosis in Fracture.
Fracture coding can be a challenge for both physicians and coders, however knowing how ICD-10 delineates initial and subsequent visits is key.
Although the terms initial and subsequent, relating to fracture care, were used in ICD-9-CM, they have new meaning in ICD-10-CM. Basically, neither term has little to do with whether a provider has previously seen or treated the patient for the condition.
Initial does not equate to a first visit — although, it may be the first time the provider has seen the patient for the fracture. Initial is interpreted as active treatment. When the visit is for the purpose of deciding what treatment is required to repair the fracture, it is an initial encounter. Likewise, when the visit results in a changed active plan of care, it is an encounter.
Subsequent equates to aftercare treatment and may be appropriate to code even when it’s the provider’s first time seeing the patient. For example, if the first time a provider sees the patient for the fracture is to continue post-treatment care, the initial visit is a subsequent fracture encounter.
G Codes for Medicare Mammography.
The 2017 CPT® codebook introduced three new codes to describe mammography services.
The new codes specifically include computer-assisted detection (CAD), when performed, unlike the codes they replaced (77051, 77052, 77055, 77056, and 77057):
- 77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral
- 77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral
- 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed
The new code descriptors match exactly those of HCPCS codes G0206, G0204, and G0202, respectively, which were required for Medicare payers. But, due to technical issues, the Centers for Medicare & Medicaid Services (CMS) was unable to ready its systems to process claims using CPT® codes 77065, 77066, and 77067. Although CMS intends to recognize the CPT® codes in 2018, claims to Medicare in 2017 must continue to use G0206, G0204, and G0202.
Mammography is described using the following codes:
- G0202 Screening mammography, bilateral ( 2-view study of each breast), including computer- aided detection (CAD) when performed.
- G0204 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral.
- G0206 unilateral.
Breast tomosynthesis is described using the following add-on codes:
- 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
- G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206).
When breast tomosynthesis is performed, practitioners should report one of G0202, G0204, or G0206 and one of G0279 or 77063. For purposes of billing digital breast tomosynthesis, the appropriate, accompanying 2D image(s) may either be acquired or synthesized.
Shoulder Arthroscopy in NCCI Manual.
The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services is updated once a year. Its been four months the 2017 updates have been released.
Chapter IV Surgery: Musculoskeletal system contains revisions to clarify limited and extensive debridement of the shoulder when performed with other shoulder procedures on the same shoulder.
In 2016, Section E (Arthroscopy), subsection 4, states, “With the exception of the knee joint, arthroscopic debridement should not be reported separately with a surgical arthroscopy when performed on the same joint at the same patient encounter. For knee joint arthroscopic debridement see the following paragraph.”
There is no specific information on the shoulder in this paragraph. It is a generic statement informing the reader that debridement is not separately reportable with another procedure on the same joint during the same encounter. Guidance is given for the knee joint.
In the 2017 NCCI Policy Manual for Medicare Services, Section E, (Arthroscopy) subsection 4, states,
“CMS considers the shoulder to be a single anatomic structure. With three exceptions an NCCI procedure to procedure edit code pair consisting of two codes describing two shoulder arthroscopy procedures should never be bypassed with an NCCI-associated modifier when the two procedures are performed on the ipsilateral shoulder. This type of edit may be bypassed with an NCCI-associated modifier only if the two procedures are performed on contralateral shoulders. The three exceptions are described in Chapter 4, Section E (Arthroscopy), subsection 7.”
Subsection 7 provides the three exceptions:
Shoulder arthroscopy procedures include limited debridement (e.g., CPT code 29822) even if the limited debridement is performed in a different area of the same shoulder than the other procedure. With three exceptions, shoulder arthroscopy procedures include extensive debridement (e.g., CPT code 29823) even if the extensive debridement is performed in a different area of the same shoulder than the other procedure. CPT codes 29824 (arthroscopic claviculectomy including distal articular surface), 29827 (arthroscopic rotator cuff repair), and 29828 (biceps tenodesis) may be reported separately with CPT code 29823 if the extensive debridement is performed in a different area of the same shoulder.
The revision specifically states limited debridement is bundled into other procedures performed on the same shoulder at the same encounter. It also states the same regarding extensive debridement with three exceptions.
Unlisted Procedure or Service Code.
When considering an unlisted procedure or service code, be sure to determine if the claim might be better represented using a specific procedure or service code with a modifier appended; or, by reporting a CPT® Category III code.
AMA’s Instructions for Use of the CPT® Codebook tell us, “do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.” The Instructions further note, “Each of these unlisted procedural code numbers (with the appropriate accompanying topical entry) relates to a specific section of the book and is presented in the guidelines of that section.” Many of these codes end with the final two digits, “99,” (e.g., 76999 Unlisted ultrasound procedure (eg, diagnostic, interventional).
Category III CPT® codes—which are found toward the rear of the CPT® codebook, behind the Category I codes—describe emerging technologies and allow for data tracking. CPT® guidelines require, “Use of unlisted codes does not offer the opportunity for the collection of specific data. If a Category III code is available, this code must be reported instead of the Category I unlisted code.”
The reporting provider’s documentation will need to be especially thorough when claiming an unlisted procedure or service. As much as possible, the provider should describe the service in simple, straightforward language:
- What was done, and why?
- Highlight areas of the documentation that are relative to the service. Where helpful, the provider might supply diagrams, photographs, copies of articles in medical journals, or other resources to help the payer understand what the service entailed, and why it was medically reasonable and necessary.
Compare the service provided to a similar service with a dedicated CPT® code. Explain how the unlisted procedure is similar to, and differs from, your reference code.
Investigate to find out exactly what the payer requires to process the claim, when payer denials are received for unlisted procedure or service codes. Follow your payer’s requirements to the letter, to make sure that your provider is appropriately reimbursed.
CMS proposes updates for Medicare hospital admissions.
The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update 2018 Medicare payment and policies when patients are admitted to hospitals. The proposed rule aims to relieve regulatory burdens for providers; supports the patient-doctor relationship in health care; and promotes transparency, flexibility, and innovation in the delivery of care.
“ This proposed rule would reduce burdens for hospitals so they can focus on providing high quality care for patients”. “Medicare is better able to support the work of dedicated hospitals and clinicians who provide the care that people need with these more flexible and simplified approaches.”
CMS is committed to transforming the health care delivery system – and the Medicare program – by putting a strong focus on patient-centered care, so providers can direct their time and resources to patients and improve outcomes. In addition to the payment and policy proposals, CMS is releasing a Request for Information to solicit ideas for regulatory, policy, practice and procedural changes to better achieve transparency, flexibility, program simplification and innovation. This will inform the discussion on future regulatory action related to inpatient and long-term hospitals.
In relieving providers of administrative burdens and encouraging patient choice, CMS is proposing a one year regulatory moratorium on the payment policy threshold for patient admissions in long-term care hospitals while CMS continues to evaluate long-term care hospital policies. CMS is also proposing to reduce clinical quality measure reporting requirements for hospitals that have implemented electronic health records.
Due to the combination of proposed payment rate increases and other proposed policies and payment adjustments, CMS projects that hospitals would see a total increase in inpatient operating prospective payments of 2.9 percent in fiscal year 2018. CMS also projects that, based on the changes included in the proposed rule, payments to long-term care hospitals would decrease by approximately 3.75 percent in
CMS also projects that, based on the changes included in the proposed rule, payments to long-term care hospitals would decrease by approximately 3.75 percent in fiscal year 2018.
Documentation of Critical Care Services
Critical Care services (99291-99292) are time-based, and improper documentation of time is a frequent reason that payers deny payment for these services. Educating providers to document time appropriately will help to maximize reimbursement and reduce additional documentation requests (ADRs).
The American Medical Association (AMA) defines critical care as the direct delivery by a physician(s) or other qualified healthcare professional of medical care for a critically ill or critically injured patient. A critically illness or injury is further defined as an impairment of one or more vital organ systems, with imminent or threatening deterioration in the patient’s condition.
Code 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes reports the first 30-74 minutes of critical care; while 99292 …each additional 30 minutes (List separately in addition to code for primary service) reports additional blocks of time in 30-minute increments beyond the first 74 minutes. These codes are reported once per calendar day.
To appropriately claim 99291 and 99292, the critical care note must specify the total duration of critical care time spent with the patient. The time must be explicit, and should include the verbiage “minutes.” The total time should include all time spent engaged in work directly related to the patient’s care, whether that time was at the immediate bedside, or elsewhere on the floor. The time spent does not have to be continuous, but the time cannot be the same for each critically ill/injured patient, nor can it be a span (Eg: “I spent two to three hours with the patient”).
CPT® guidelines explain that time spent on activities that do not directly contribute to the treatment of the patient, or time spent performing separate reportable procedures or services, should not be included in the time reported as critical care time. CPT® guidelines require that the reporting provider must devote his or her full attention to the patient during the time specified as critical care, and therefore cannot provide services to any other patient during the same time.
Fluoroscopy and Spinal Injections
Here are some points you should note when coding for Spinal Injections and Fluoroscopy.
In 2015, the CPT® codebook separated joint injections and aspirations into services “with” and “without” image guidance. This year, CPT® has taken a similar approach with spinal injection services.
As of Jan. 1, 62310-63219 are deleted, and replaced with:
- 62320Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
- 62321with imaging guidance (ie, fluoroscopy or CT)
- 62322Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
- 62323with imaging guidance (ie, fluoroscopy or CT)
- 62324Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
- 62325with imaging guidance (ie, fluoroscopy or CT)
- 62326Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
- 62327with imaging guidance (ie, fluoroscopy or CT)
All even numbered codes are without imaging guidance, and all odd numbered codes are with imaging guidance.
CPT® retains the instruction from previous years, “Fluoroscopic guidance and localization is reported with 77003, unless a formal contrast study (myelography, epidurography, or arthrography) is performed, in which case the use of fluoroscopy is included in the supervision and interpretation codes or the myelography via lumbar injection code.” But to aid you with the 2017 code changes, the codebook also now states, “Fluoroscopy or CT and any injection of contrast are inclusive components of 62321, 62323, 62325, 62327.” Parenthetical instructions following each of these codes explain, “Do not report [code] in conjunction with 77003, 77012, or 76942.”
You may report 62320-62327 only once, per session. Code choice is based on the region where the needle enters the body. CPT® instructions also explain that if a catheter is used only for a single day, report the services as if it were a single injection, using 62320-62323. If the catheter is left in place, report 62324-62327 for the initial placement of the indwelling catheter, or for the continuous infusion. Subsequent dates are reported with CPT® 01996 Daily hospital management of epidural or subarachnoid continuous drug administration.
When reporting these codes, you must ensure documentation supports the following five elements:
- An injection(s) of diagnostic or therapeutic substance(s)– All codes
- Interlaminar epidural or subarachnoid space– All codes
- Location of the spine(cervical, thoracic, lumbar, sacral, or caudal)
- Cervical or thoracic codes: 62320, 62321, 62324, 62325
- Lumbar or sacral (caudal) codes: 62322, 62323, 62326, 62327
- With or without imaging guidance
Without imaging guidance codes:
- Cervical or thoracic: 62320, 62324
- Lumbar or sacral (caudal): 62322, 62326
With imaging guidance codes:
- Cervical or thoracic: 62321, 62325
- Lumbar or sacral (caudal): 62323, 62327
- Single injection/single day infusion or continuous infusion/indwelling catheter
Single injection/single day infusion codes:
- Cervical or thoracic without imaging guidance: 62320
- Cervical or thoracic with imaging guidance: 62321
- Lumbar or sacral (caudal) without imaging guidance: 62322
- Lumbar or sacral (caudal) with imaging guidance: 62323
Continuous infusion/indwelling catheter codes:
- Cervical or thoracic without imaging guidance: 62324
- Cervical or thoracic with imaging guidance: 62325
- Lumbar or sacral (caudal) without imaging guidance: 62326
- Lumbar or sacral (caudal) with imaging guidance: 62327
When you have identified documentation for all five points, you can report the service properly.
The injection code changes required fluoroscopy codes changes. The CPT® codebook now classifies all fluoroscopy codes (77001-77003) as add-on services. Also updated are the lists of codes that may be reported with CPT® +77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure) and +77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure). If the procedure code is not listed under the appropriate fluoroscopy add-on code, the fluoroscopy service is not separately reported.
As noted, other blocks and injections (64461-64495) include image guidance, including the transverse abdominis plane blocks (64486-64489) added in January 2015. Given the changes in the 2017 CPT® codebook for fluoroscopy and spinal injections, it’s likely a matter of time before changes are made to nerve block codes 64400-64455, as many providers regularly report the service with CPT® 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.
Latest Updates on IPPS and LTCH by CMS.
IPPS and LTCH: The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule April 14 that would update 2018 Medicare payment and policies in the Inpatient Prospective Payment System (IPPS) and Long-term Care Hospitals Prospective Payment System (LTCH PPS).
The proposed changes apply to approximately 3,330 acute care hospitals and approximately 420 LTCHs and, if finalized, will affect discharges occurring on or after October 1.
The proposed increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users is approximately 1.6 percent.
CMS is proposing to make five changes to existing HAC Reduction Program policies:
- Specify the dates of the time period used to calculate hospital performance for the 2020 HAC Reduction Program;
- Request comments on additional measures for potential future adoption;
- Request comments on accounting for social risk factors;
- Request comments on accounting for disability and medical complexity in the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC NHSN) measures in Domain 2; and
- Update the Extraordinary Circumstance Exception(ECE) policy.
In accordance with the 21st Century Cures Act, CMS is proposing:
- A methodology for calculating the proportion of dual-eligible patients;
- A methodology for assigning hospitals to peer groups; and
- A payment adjustment formula calculation methodology.
CMS is proposing for 2017:
- Reporting period: For eligible hospitals and CAHs demonstrating meaningful use for the first time in 2017 or that have demonstrated meaningful use in any year prior to 2017, the reporting period would be two self-selected quarters of CQM data in 2017;
- CQMs: If an eligible hospital or CAH is only participating in the EHR Incentive Program or is participating in both the EHR Incentive Program and the Hospital IQR Program, the eligible hospital or CAH would report on at least six (self-selected) of the available CQMs;
CMS is proposing for 2018:
- Reporting period: For eligible hospitals and CAHs reporting CQMs electronically that demonstrate meaningful use for the first time in 2018 or that have demonstrated meaningful use in any year prior to 2018, the reporting period would be the first three quarters of 2018. For the Medicare EHR Incentive Program only, the submission period for reporting CQMs electronically would be the two months following the close of the calendar year, ending February 28, 2019.
- CQMs: For eligible hospitals and CAHs participating only in the EHR Incentive Program, or participating in both the EHR Incentive Program and the Hospital IQR Program, the eligible hospital or CAH would report on at least six (self-selected) of the available CQMs.
For EPs in the EHR Incentive Program, CMS is proposing the following changes:
- Reporting Periods: For 2017, CMS is proposing to modify the CQM reporting period for EPs electronically reporting CQMs under the Medicaid EHR Incentive Program to a minimum of a continuous 90-day period during the calendar year.
- CQMs: Align the specific CQMs available to EPs participating in the Medicaid EHR Incentive Program with those available to professionals participating in the Merit-based Incentive Payment System.
CMS is proposing to modify the EHR reporting periods for new and returning participants attesting to CMS or their state Medicaid agency from the full year to a minimum of any continuous 90-day period during the calendar year.
As mandated by the 21st Century Cures Act, CMS is proposing to add a new exception from the Medicare payment adjustments for EPs, eligible hospitals, and CAHs that demonstrate through an application process that compliance with the requirement for being a meaningful EHR user is not possible because their certified EHR technology has been decertified under the Office of the National Coordinator for Health Information Technology (ONC) Certification Program.
Also mandated by the 21st Century Cures Act, CMS is proposing to exempt ambulatory surgical center (ASC)-based EPs from the 2017 and 2018 Medicare payment adjustments if they furnish substantially all of their covered professional services in an ASC. To determine the final definition of “substantially,” CMS is requesting public comment on two proposed alternative definitions:
- An EP who furnishes 75 percent or more of their covered professional services in sites of service identified by the codes used in the HIPAA standard transaction as an ASC setting in the calendar year that is two years before the payment adjustment year
- An EP who furnishes 90 percent or more of their covered professional services in sites of service identified by the codes used in the HIPAA standard transaction as an ASC setting in the calendar year that is two years before the payment adjustment year.
CMS also proposes to use Place of Service (POS) code 24 to identify services furnished in an ASC and is requesting public comment on whether other POS codes or mechanisms should be used to identify sites of service in addition to or in lieu of POS code 24.
CMS is proposing to:
- Re-word the current pain management questions in the hospital Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to focus on the hospital’s communications with patients about the patients’ pain during the hospital stay beginning with surveys in January 2018; and
- Change the risk adjustment methodology used in the Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate following Acute Ischemic Stroke Hospitalization measure to include stroke severity codes (based on the NIH Stroke Scale), beginning with the 2023 payment determination.
CMS is also proposing voluntary reporting of one new measure, the Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record Data, for the 2018 reporting period.
CMS is proposing a number of changes in relation to the reporting of electronic clinical quality measures (eCQMs):
- Modify the previously finalized eCQM reporting requirements for the 2017 reporting period/2019 payment determination, such that hospitals would be required to select and submit six of the available eCQMs included in the Hospital IQR Program measure set and provide two, self-selected, calendar year quarters of data, in alignment with the electronic reporting requirements for CQMs in the Medicare EHR Incentive Program for hospitals;
- Modify the previously finalized eCQM reporting requirements for the 2018 reporting period/2020 payment determination, such that hospitals would be required to select and submit six of the available eCQMs, and provide data for the first three calendar quarters (Q1-Q3) of 2018, in alignment with the electronic reporting requirements for CQMs in the Medicare EHR Incentive Program for hospitals;
- Make changes to several related technical eCQM submission requirements beginning with the 2019 payment determination, including which edition of certified EHR technology hospitals should use for eCQM reporting, in alignment with the Medicare EHR Incentive Program for hospitals;
- Modify the previously finalized validation process for eCQM data to reduce the number of cases required to be submitted and to include additional exclusion criteria beginning with the 2020 payment determination and subsequent years; and
- Continue the medical record submission requirements for validation of eCQM data that were finalized in the 2017 IPPS/LTCH PPS final rule for the 2021 payment determination and subsequent years.
In this program, CMS is proposing to:
- Remove the current 8-indicator Patient Safety for Selected Indicators (PSI 90) measure from the Safety domain beginning with the 2019 program year;
- Adopt the 10-indicator modified Patient Safety and Adverse Events Composite PSI 90 measure beginning in the 2023 program year;
- Adopt the Hospital-Level, Risk-Standardized Payment Associated with a 30-day Episode of Care for Pneumonia measure for the Efficiency and Cost Reduction domain beginning with the 2022 program year; and
- Revise the Efficiency and Cost Reduction domain weighting beginning with the 2021 program year to reflect the implementation of condition-specific payment measures in the Hospital VBP Program.
CMS is proposing to add four measures that assess end-of-life care:
- Proportion of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (NQF #0210);
- Proportion of Patients Who Died from Cancer Admitted to the ICU in the Last 30 Days of Life (NQF #0213);
- Proportion of Patients Who Died from Cancer Not Admitted to Hospice (NQF #0215); and
- Proportion of Patients Who Died from Cancer Admitted to Hospice for Less than Three Days (NQF #0216).
CMS is also proposing to remove three cancer-specific, chart-abstracted process measures:
- Adjuvant Chemotherapy is Considered or Administered Within four Months (120 Days) of Diagnosis to Patients Under the Age of 80 with AJCC III (Lymph Node Positive) Colon Cancer (NQF #0223);
- Combination Chemotherapy is Considered or Administered Within four Months (120 Days) of Diagnosis for Women Under 70 with AJCC T1c, or Stage II or III Hormone Receptor Negative Breast Cancer (NQF #0559); and
- Adjuvant Hormonal Therapy (NQF #0220).
Beginning with 2020 payment determination and continuing for subsequent years, CMS is proposing to:
- add the Medication Continuation following Inpatient Psychiatric Discharge measure, which is calculated from claims data;
- update the IPFQR Program’s extraordinary circumstances exception (ECE) policy to align with other programs’ ECE provisions;
- change how the annual data submission period is specified to align the end of this period with the deadline for submitting a Notice of Participation (NOP) or withdrawing from the program; and
- consider factors by which it would evaluate measures to be removed from or retained in the IPFQR Program.
CMS is proposing to update the LTCH PPS standard federal payment rate by 1 percent, consistent with the provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
In addition, CMS is proposing a regulatory moratorium on the implementation of the 25-percent threshold policy for 2018 while it conducts an evaluation to determine if it is still needed.
CMS is also proposing to:
- revise its short-stay outlier payment adjustment; and
- implement various provisions of the 21st Century Cures Act that affect LTCHs.
Under the LTCH QRP, the applicable annual update to the LTCH PPS standard federal payment rate for discharges is reduced by two percentage points if the LTCH does not submit data on specified quality measures. Beginning with the 2020 program year, LTCHs must also report standardized patient assessment data related to five specified patient assessment categories.
CMS is proposing to replace the current pressure ulcer measure with an updated version of that measure, as well as adopt two new companion measures (one process and one outcome), beginning with the 2020 LTCH QRP. The proposed measures are:
- Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury;
- Compliance with Spontaneous Breathing Trial (SBT) by Day 2 of the LTCH Stay; and
- Ventilator Liberation Rate.
Further, CMS is proposing to remove two currently adopted measures: Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) and All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from LTCHs.
CMS is also proposing that, beginning with the 2020 program year, LTCHs begin reporting standardized patient assessment data and additional standardized patient assessment data with respect to five specified patient assessment categories required by law, including:
- functional status;
- cognitive function;
- special services, treatments and interventions;
- medical conditions and co-morbidities; and
CMS is providing notice that it will direct Quality Improvement Organizations (QIOs), Medicare administrative contractors, the Supplemental Medical Review Contractor (SMRC), and recovery audit contractors (RACs) to make the CAH 96-hour certification requirement a low priority for medical record reviews conducted on or after October 1. Absent concerns of probable fraud, waste or abuse of the coverage requirement, these contractors will not conduct medical record reviews.
Changes in Bunionectomy Coding for 2017.
Let’s look at how bunionectomy coding has changed for 2017.
- 28291 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant
CPT® code 28291 was added to report hallux rigidus (bunion) correction with implant; and revised code 28289 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant, which describes the correction of arthritis and deformity of the joint where the head of the metatarsal bone attaches to the first bone of the greater toe, now specifies the procedure was done without an implant. Prior to 2017, code 28293 reported placement of an implant for correction of hallux valgus. Because a prosthetic implant is placed for arthritis of a joint, the descriptor for 28289 is more consistent with the condition being treated (in this instance, “implant” does not mean a screw, or plate and screw, but a prosthetic implant).
- 28295 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method
CPT® code 28295 describes bunion correction when a proximal metatarsal osteotomy is necessary and includes sesamoidectomy, when performed. An osteotomy may be performed when there is moderate metatarsus primus varus (deviation of the first metatarsal away from the other metatarsals) and the intermetatarsal angle is greater than 40 degrees. The osteotomy is performed at the base of metatarsal or, for a long continuous osteotomy, it may start in the metatarsal neck and extend through the shaft to the base of the metatarsal.
CPT® codes 28292-28299 were revised and 28290, 28293, and 28294 were deleted to remove legacy-named procedures such as Keller, McBride, Mayo, Mitchell, Chevron, and concentric- and Lapidus-type procedures. All of the new and revised bunionectomy codes now read “sesamoidectomy, when performed,” instead of “with or without.” Instead of using the legacy names, the procedures are defined as “any method,” making it more clear that the coding is based on the location on the bone, as well as whether the correction was done using an osteotomy or fusion.
- 28292 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method
CPT® code 28292 describes the correction of a hallux valgus deformity, and includes sesamoid bone removal or a proximal phalanx base resection, when necessary. The sesamoid bone removal, or removal of part of the articulating end of the bone (closest to where it attaches), realigns the toe with the metatarsal at the metatarsophalangeal joint. This is generally done for mild deformities where there is very little deviation of the metatarsal. CPT® instructs us to also use the code for simple exostectomy, previously reported with 28290.
- 28296 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method
CPT® code 28296 was revised to add the word “distal,” which describes the location of the metatarsal osteotomy. Report 28296 to correct a hallux valgus deformity with a distal metatarsal osteotomy. The procedure may also include sesamoid bone removal, when necessary, to help with bone realignment. This type of correction is done for patients with mild hallux valgus of less than 40 degrees and a minimal increase in the deviation of the metatarsal.
- 28297 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method
CPT® code 28297 reports a bunion correction with a joint fusion between the foot bone located behind the big toe (first metatarsal) and the bone of the middle foot located behind the first metatarsal. The fusion may be done with sesamoid bone removal, when necessary. This type of correction is done for a severe intermetatarsal angle or instability of the first tarsometatarsal joint.
- 28298 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal phalanx osteotomy, any method
CPT® code 28298 reports a bunion correction that includes a proximal phalanx osteotomy where bone is removed at the base of the big toe to help straighten it. This procedure may be performed with sesamoid bone removal, when necessary, to help with bone realignment.
- 28299 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double osteotomy, any method
CPT® code 28299 reports a bunion correction where two osteotomy procedures are done to straighten the toe and the metatarsal. These procedures may be done along with sesamoid bone removal, when necessary, to help with realignment. The double osteotomy can be a combination of an osteotomy of the phalanx and the metatarsal (proximal or distal) or a proximal and distal metatarsal osteotomy.
Carefully review all the codes in this range before choosing your final code for bunion correction. According to the American Medical Association’s (AMA) CPT® Assistant, all hallux valgus (bunionectomy) procedures include:
- Removal of the bony prominence (bunion)
- Removal of additional osteophytes
- Tendon releases
- Placement of internal fixation
- Removal of bursal tissue
The majority of bunionectomy procedures are performed to correct the deviation of the metatarsal. When correcting that deformity, the valgus deformity of the toe often corrects without the need for additional surgery, such as an osteotomy of the phalanx.
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.