2016 charge master update - hfma nj...january 1, 2016 – set up a tracking mechanism for high risk...

2016 Charge Master Update

Mike Kovar

Partner

WeiserMazars LLP

Taylor Pedone

Manager

WeiserMazars LLP

New Jersey HFMA

December 16, 2015

Introductions

Mike Kovar has led over 500 charge master, revenue capture, and

patient charge compliance reviews. He received his Masters’ in

Business Administration from Loyola University of Chicago, is an

advanced member of HFMA, and is a frequent speaker nationally on

charge master and other revenue capture-related issues.

Taylor Pedone has a background in assessment and implementation

of process improvement initiatives across the revenue cycle including

charge capture, patient financial services, denials, strategic and

transparent pricing, and compliance. She is a Certified Professional

Coder (CPC).

2 2

Learning Objectives

In our session, we will cover the following:

How to prepare your charge master and related processes and systems for 2016

Charge master and charge capture process changes related to the 2016 Outpatient Prospective Payment System changes

CPT Code additions, revisions, and deletions for 2016

3

Charge Master Impacts

Charge master must accurately align with the various sub-systems

that are linked to it. These sub-systems can include:

Order entry module of the billing system

Charge encounter forms, Preference Lists

Electronic medical record

Ancillary department systems such as the Radiology Information

System, Laboratory Information Systems and Pharmacy systems

Bill scrubbers

4

Charge Master-Other Payors There are other payors besides Medicare and their coding

requirements may vary

Understanding the CPT Code/Revenue Code requirements of your top payors besides Medicare is critical

– Top 3 to 5 manager care payors

– Medicaid

Managed Care Rate sheets and Medicaid provider manual are good resources

– Interaction will Contracting, Revenue Cycle are essential

Review contract terms/ provider manuals/ remittance advices, etc.

5

Charge Master Update Tools The following resources are usually required:

• 2016 OPPS Final Rule and, if available, January OPPS Medicare Transmittal

• 2016 AMA CPT Manual

• 2016 HCPCS Code listing

• Other major payor information as applicable

MANY CHARGE MASTER MAINTENANCE TOOLS HAVE SOME OF THESE CAPABILITIES

6

Charge Master Update-

Approach

– Proactive versus reactive approach

• Initiate and complete prior to January 1, 2016

– Active Clinical Department participation and ownership

– Establish deadlines and monitor compliance

– Implement CPT, HCPCS and UB-04 Revenue Code revisions and verify accuracy in the system

– Educate clinicians and finance professionals

7


Compliance Tracking Monitor high risk areas of the charge master post-implementation

January 1, 2016

– Set up a tracking mechanism for high risk areas of charge master changes

• Track for minimum of 3 months

– Perform a claims review for selected charge master update issues

• Ensure claims are post-bill scrubber

– Initiate corrective actions as necessary

8


Medicare Regulatory Process CMS publishes proposed annual rule changes to OPPS in

July/August each year in the Federal Register

– Comments due 30 days post publication in Federal Register

CMS publishes final annual changes to OPPS in October/November each year in the Federal Register

– Implementation is January 1 each year

9


Medicare Regulatory Process CMS through their sub-regulatory process details required OPPS

changes for the MACs using Medicare Program Transmittals

– January OPPS changes published in January transmittal in late December/early January each year

• Primary focus is OPPS annual changes

– Additional changes to OPPS issued for implementation in April, July, and October each year

• Pharmacy is usually most significant area

10

2016 Hospital Outpatient Prospective

Payment System (OPPS) and Ambulatory Surgery Payment System

(ASC) Final Rule

Published in the Federal Register on November 13, 2015

– Federal Register provides a list of OPPS contacts at CMS including phone numbers

(Page 39200). For example:

0.4% decrease in Medicare payments in 2016 to all hospitals including

cancer and children’s hospitals and CMHCs (2.3% increase in 2015)

– $133 million decrease from 2015

Overall Impact of 2016 OPPS Changes

This decrease is primarily attributed to a 2.0% decrease in the conversion

factor to redress inappropriate inflation of OPPS payment rates and remove

$1.0 billion in excess packaged payments related to the new 2014 Laboratory

packaging policy.

– CMS overestimated the adjustment for the 2014 laboratory packaging

policy and underestimated the spending for laboratory services paid

under the Clinical Laboratory Fee Schedule (CLFS) rather than under

OPPS by $1.0 billion

• Overpayment for packaging of Laboratory under OPPS

• Payment for same services under both OPPS & CLFS


Impacts on different “hospital categories” are as follows:

– urban hospitals -0.4%

– rural hospitals -0.6%

– sole community rural hospitals -0.6%

– urban hospitals 500 + beds -0.1%

– major teaching hospitals 0.1%

– non-teaching hospitals -0.7%

– governmental hospitals -0.3%

– proprietary hospitals -1.1%

– CMHCs 23.1%



(cont’d)

For CMHCs the 23.1% increase can be attributed to APC recalibration

– APC 172 $96.44 payment in 2015 decreased to $94.49 for renumbered

APC 5851

– APC 173 $114.27 payment in 2015 increased to $143.00 for

renumbered APC 5852

Total beneficiary liability for copayments would decrease as an overall

percentage of total payments

– 19.3% estimated in 2016 versus 20.5% in 2015


CMS has a publicly available file to estimate the impact of the 2016 OPPS

rule on it’s website for every OPPS hospital.

– 2016 OPPS NPRM Facility-Specific Impacts

Provider

Number

CBSA

Code

Total

Discounted

Units

Rural Sole

Community and

Essential Access

Hospitals

Post

Reclassification

Wage Index All Rural

Urban/Rural

Geographic

Location Region

Disproportionate

Share Patient

Percentage

Outpatient

Cost-to-

Charge Ratio

Estimated 2015

OPPS Payment

Estimated 2016

OPPS Payment

Estimated

2016 Outlier

Payment

010001 20020 230,531.0 0 0.6938 0 OURBAN ESC 28.0% 0.137 $38,597,993.14 $36,094,041.84 $72,193.28

010005 01 446,958.4 0 0.8270 1 RURAL ESC 27.5% 0.207 $24,459,130.82 $24,074,875.87 $1,703.86

010006 22520 54,740.3 0 0.6872 0 OURBAN ESC 23.0% 0.128 $17,619,724.69 $16,988,831.92 $16,599.24


Top 10 CPT Code Winners-2016 Versus 2015

HCPCS

Code Short Descriptor CI SI APC

2016 Payment

Rate

October 2015

Payment Rate

Payment

Variance

0100T Prosth retina receive&gen CH T 1599 $95,000.00 $ 3,122.56 $91,877.44

0312T Laps impltj nstim vagus CH J1 5464 $26,728.39 $ - $26,728.39

54411 Remov/replc penis pros comp CH J1 5377 $14,088.02 $ - $14,088.02

54417 Remv/replc penis pros compl CH J1 5377 $14,088.02 $ - $14,088.02

62360 Insert spine infusion device CH J1 5471 $15,350.22 $ 3,662.54 $11,687.68

0316T Replc vagus nerve pls gen CH J1 5464 $26,728.39 $17,106.04 $9,622.35

20696 Comp multiplane ext fixation CH J1 5125 $10,537.90 $ 2,602.13 $7,935.77

27356 Remove femur lesion/graft CH J1 5125 $10,537.90 $ 2,602.13 $7,935.77

24362 Reconstruct elbow joint CH J1 5125 $10,537.90 $ 3,364.30 $7,173.60

27441 Revision of knee joint CH J1 5125 $10,537.90 $ 3,364.30 $7,173.60


Top 10 CPT Code Losers-2016 Versus 2015

HCPCS

Code Short Descriptor CI SI APC

2016 Payment

Rate

October 2015

Payment Rate

Payment

Variance

0308T Insj ocular telescope prosth J1 5494 $17,550.83 $23,084.33 -$5,533.50

27412 Autochondrocyte implant knee CH J1 5123 $4,969.26 $10,224.00 -$5,254.74

47511 Insert bile duct drain CH D $ 4,095.89 -$4,095.89

23450 Repair shoulder capsule CH T 5122 $2,395.59 $ 6,322.79 -$3,927.20

23460 Repair shoulder capsule CH T 5122 $2,395.59 $ 6,322.79 -$3,927.20

24330 Revision of arm muscles CH T 5122 $2,395.59 $ 6,322.79 -$3,927.20

28264 Release of midfoot joint CH T 5121 $1,455.26 $ 5,219.15 -$3,763.89

26686 Treat hand dislocation CH T 5122 $2,395.59 $ 5,569.47 -$3,173.88

22612 Lumbar spine fusion CH J1 5124 $7,064.07 $10,224.00 -$3,159.93

24365 Reconstruct head of radius CH J1 5124 $7,064.07 $10,224.00 -$3,159.93

OPPS Background

Outpatient Prospective Payment System (OPPS) was first implemented

on August 1, 2000

Medicare pays for hospital outpatient services on a rate-per-service basis

that varies based on the ambulatory payment classification (APC)

assigned to the service

– Healthcare Common Procedure Coding System (HCPCS) is used to identify and group services in an APC

• HCPCS includes both CPT and HCPCS Level II Codes

• Payment is based on status indicators (See Addendum D1)

All services within an APC are comparable clinically and relative to

resource use.

– Service are not considered comparable relative to resource use if the highest mean cost for an item or service in an APC is more than 2 times greater than the lowest mean cost of an item or service in the same APC.

OPPS Background

Hospitals excluded from OPPS:

– Maryland hospitals for services paid under the cost containment waiver

– Critical access hospitals

– Hospitals outside the 50 states, the District of Columbia, and Puerto Rico

– Indian Health Service hospitals

Updates Affecting OPPS Payments

Approximately 163 million (versus 161 million in 2015) final action claims

for services provided in a hospital outpatient setting from January 1, 2014

through December 31, 2014 were used to calculate the 2016 rates

Single/”pseudo” claims process used in previous years was again used

for 2016 rate setting purposes

– Medicare lists bypassed HCPCS Codes to determine single claims in Addendum N


Hospital-specific overall ancillary and department cost-to-charge ratios

(CCRs) used to convert charges to estimated costs through application of

a revenue code-to-cost center crosswalk

Most recent submitted, in most cases, cost reports beginning in CY 2013

used to calculate CCRs (cost-to-charge ratio) to be used to calculate

costs for the CY 2016 OPPS payment rates

– To calculate APC costs, Medicare calculated hospital specific overall

ancillary CCRs and hospital-specific departmental CCRs for each

hospital with 2014 claims data

Updates Affecting OPPS Payments CMS implemented 25 comprehensive APCs (C-APCs) for 2015

– Comprehensive APCs are HCPCS Codes designated as the primary

service (SI=J1) for which there is a single payment for all services

that are considered as integral, ancillary, supportive and adjunctive to

the primary service

• Only excludes services not covered by Medicare Part B or

services not payable under OPPS such as:

– Self-administerable drugs not considered supplies

– Pass-through drugs and devices

– Ambulance services

– Diagnostic and screening mammography

– Recurring therapy services

– Brachytherapy

– Preventive services


CMS is adding 10 more C-APCs in 2016 (Almost 800 HCPCS Codes

included in 35 C-APCs)

– Originally in proposed rule, 9 additional C-APCs

• Level 5 Musculoskeletal Procedures added in final rule


– Comprehensive Observation Services APC 8011

• Replaces Extended Assessment & Management Composite APC

8009

• New Status Indicator J2 assigned

• Must meet all the following requirements:

– No SI=T on the claims

» If there is a status T procedure on claim, the observation

will be packaged

– Must have at least 8 units of G0378

– Must have a G0379, 99281 through 99285, G0384, 99291 or

G0463

– No SI= J1 on claim

– Payment = $2,174.14


Stereotactic Radiosurgery (SRS) C-APC 5671 to be revised

– It includes the following CPT Codes:

• 77371 - Radiation treatment delivery, SRS, complete course of

treatment cranial lesion, one session; multi-sourced Cobalt 60-

based

– Treatment planning services frequently occur on same day

(Included in the C-APC)

• 77372 - Radiation treatment delivery, SRS, complete course of

treatment cranial lesion, one session; linear accelerator based

– Treatment planning services occur typically on different dates

of services (Not included in C-APC)


Stereotactic Radiosurgery (SRS) C-APC 5671 to be revised

– For 2016 that the following treatment planning services will be paid in

addition to the C-APC:

• CT localization (77011, 77014)

• MRI imaging (70551, 70552, 70553)

• Clinical treatment planning (77280, 77285, 77290, 77295)

• Physics consultation (77336)

• HCPCS Modifier “CP” required on each of the above services

• HCPCS Modifier “CP” also required on all adjunctive services

related to 77371 and 77372 reported on a different claim

Similar to SRS, CMS had proposed for 2016 to require the “CP” HCPCS

modifier on all services adjunctive to a C-APC primary service when the

adjunctive services are billed on a different claim

– Will not be implemented in 2016


C-APC 5881 Payment for claims reporting inpatient only services on

patient that dies prior to admission will be implemented in 2016

– Replaces composite APC 0375

– Comprehensive payment for all services on the claim when “CA”

modifier present with an inpatient only procedure

The composite APCs for LDR prostate brachytherapy, mental health

services and multiple imaging procedures continue “as is” for 2016

OPPS Packaging Policy Changes for 2016

Ancillary services/procedures consider clinically similar to currently

conditionally packaged categories of ancillary services considered integral,

ancillary, dependent, supportive, or adjunctive to the primary service will be

conditionally packaged

– 2015 $100 geometric mean cost criteria for packaging eliminated

– Also excluded are:

• Certain psychiatric and counseling services that are considered by

CMS to be visits and not ancillary such as psychotherapy, etc.

• Drug administration and add-on drug administration CPT Codes


The following ancillary services/procedures APCs will be conditionally

packaging in 2016:


The following ancillary services/procedures CPT Codes will be

conditionally packaged in 2016:

HCPCS Code Short Descriptor CI SI APC Payment Rate

0110T Nos quant sensory test CH Q1 5734 $91.18

0207T Clear eyelid gland w/heat CH Q1 5734 $91.18

0232T Njx platelet plasma CH Q1 5734 $91.18

0296T Ext ecg recording CH Q1 5734 $91.18

0297T Ext ecg scan w/report CH Q1 5734 $91.18

11720 Debride nail 1-5 CH Q1 5734 $91.18

11980 Implant hormone pellet(s) CH Q1 5734 $91.18

11981 Insert drug implant device CH Q1 5734 $91.18

11982 Remove drug implant device CH Q1 5734 $91.18

11983 Remove/insert drug implant CH Q1 5734 $91.18

15852 Dressing change not for burn CH Q1 5734 $91.18

15860 Test for blood flow in graft CH Q1 5734 $91.18

20665 Removal of fixation device CH Q1 5734 $91.18

29125 Apply forearm splint CH Q1 5734 $91.18

29126 Apply forearm splint CH Q1 5734 $91.18

30300 Remove nasal foreign body CH Q1 5734 $91.18

30901 Control of nosebleed CH Q1 5734 $91.18

36425 Vein access cutdown > 1 yr CH Q1 5734 $91.18

36591 Draw blood off venous device CH Q1 5734 $91.18

36592 Collect blood from picc CH Q1 5734 $91.18

36600 Withdrawal of arterial blood CH Q1 5734 $91.18

36680 Insert needle bone cavity CH Q1 5734 $91.18




40804 Removal foreign body mouth CH Q1 5734 $91.18

41250 Repair tongue laceration CH Q1 5734 $91.18

41800 Drainage of gum lesion CH Q1 5734 $91.18

42809 Remove pharynx foreign body CH Q1 5734 $91.18

46600 Diagnostic anoscopy spx CH Q1 5734 $91.18

51701 Insert bladder catheter CH Q1 5734 $91.18

51702 Insert temp bladder cath CH Q1 5734 $91.18

51736 Urine flow measurement CH Q1 5734 $91.18

51798 Us urine capacity measure CH Q1 5734 $91.18

53601 Dilate urethra stricture CH Q1 5734 $91.18

53661 Dilation of urethra CH Q1 5734 $91.18

57150 Treat vagina infection CH Q1 5734 $91.18




64402 N block inj facial CH Q1 5734 $91.18

65205 Remove foreign body from eye CH Q1 5734 $91.18




65430 Corneal smear CH Q1 5734 $91.18

67820 Revise eyelashes CH Q1 5734 $91.18

68200 Treat eyelid by injection CH Q1 5734 $91.18

68801 Dilate tear duct opening CH Q1 5734 $91.18

69200 Clear outer ear canal CH Q1 5734 $91.18

76510 Ophth us b & quant a CH Q1 5734 $91.18

85097 Bone marrow interpretation CH Q2 5674 $440.53

86870 Rbc antibody identification CH Q2 5673 $209.42

86890 Autologous blood process CH Q1 5673 $209.42

86891 Autologous blood op salvage CH Q1 5674 $440.53

86927 Plasma fresh frozen CH S 5673 $209.42

86931 Frozen blood thaw CH Q1 5673 $209.42




88120 Cytp urne 3-5 probes ea spec CH Q2 5673 $209.42

88184 Flowcytometry/ tc 1 marker CH Q2 5673 $209.42

88307 Tissue exam by pathologist CH Q2 5673 $209.42

88309 Tissue exam by pathologist CH Q2 5674 $440.53

88319 Enzyme histochemistry CH Q2 5674 $440.53

88333 Intraop cyto path consult 1 CH Q2 5674 $440.53

88342 Immunohisto antb 1st stain CH Q2 5673 $209.42

88344 Immunohisto antibody slide CH Q1 5673 $209.42

88346 Immunofluor antb 1st stain CH Q2 5673 $209.42

88348 Electron microscopy CH Q2 5674 $440.53

88358 Analysis tumor CH Q2 5673 $209.42

88360 Tumor immunohistochem/manual CH Q2 5673 $209.42

88361 Tumor immunohistochem/comput CH Q2 5673 $209.42

88362 Nerve teasing preparations CH Q2 5674 $440.53

88366 Insitu hybridization (fish) CH Q1 5673 $209.42

88367 Insitu hybridization auto CH Q2 5673 $209.42

88368 Insitu hybridization manual CH Q2 5673 $209.42

88374 M/phmtrc alys ishquant/semiq CH Q1 5673 $209.42

88377 M/phmtrc alys ishquant/semiq CH Q1 5673 $209.42

89251 Cultr oocyte/embryo <4 days CH Q2 5673 $209.42

89258 Cryopreservation embryo(s) CH Q2 5674 $440.53

89272 Extended culture of oocytes CH Q2 5674 $440.53

89280 Assist oocyte fertilization CH Q2 5674 $440.53

89346 Storage/year oocyte(s) CH Q2 5673 $209.42

91133 Electrogastrography w/test CH Q1 5734 $91.18

92020 Special eye evaluation CH Q1 5734 $91.18

92060 Special eye evaluation CH Q1 5734 $91.18

92065 Orthoptic/pleoptic training CH Q1 5734 $91.18

92081 Visual field examination(s) CH Q1 5734 $91.18

92083 Visual field examination(s) CH Q1 5734 $91.18




92136 Ophthalmic biometry CH Q1 5734 $91.18

92140 Glaucoma provocative tests CH Q1 5734 $91.18

92228 Remote retinal imaging mgmt CH Q1 5734 $91.18

92230 Eye exam with photos CH Q1 5734 $91.18

92250 Eye exam with photos CH Q1 5734 $91.18

92270 Electro-oculography CH Q1 5734 $91.18

92283 Color vision examination CH Q1 5734 $91.18

92284 Dark adaptation eye exam CH Q1 5734 $91.18

92285 Eye photography CH Q1 5734 $91.18

92286 Internal eye photography CH Q1 5734 $91.18

92287 Internal eye photography CH Q1 5734 $91.18

92311 Contact lens fitting CH Q1 5734 $91.18



92315 Rx cntact lens aphakia 1 eye CH Q1 5734 $91.18

92325 Modification of contact lens CH Q1 5734 $91.18

92520 Laryngeal function studies CH Q1 5734 $91.18

92541 Spontaneous nystagmus test CH Q1 5734 $91.18

92542 Positional nystagmus test CH Q1 5734 $91.18

92548 Posturography CH Q1 5734 $91.18

92552 Pure tone audiometry air CH Q1 5734 $91.18

92561 Bekesy audiometry diagnosis CH Q1 5734 $91.18

93024 Cardiac drug stress test CH Q1 5734 $91.18




93225 Ecg monit/reprt up to 48 hrs CH Q1 5734 $91.18

93226 Ecg monit/reprt up to 48 hrs CH Q1 5734 $91.18

93701 Bioimpedance cv analysis CH Q1 5734 $91.18

93786 Ambulatory bp recording CH Q1 5734 $91.18

93788 Ambulatory bp analysis CH Q1 5734 $91.18

93922 Upr/l xtremity art 2 levels CH Q1 5734 $91.18

94014 Patient recorded spirometry CH Q1 5734 $91.18

94200 Lung function test (mbc/mvv) CH Q1 5734 $91.18

94452 Hast w/report CH Q1 5734 $91.18

94453 Hast w/oxygen titrate CH Q1 5734 $91.18

94620 Pulmonary stress test/simple CH Q1 5734 $91.18

94644 Cbt 1st hour CH Q1 5734 $91.18

94667 Chest wall manipulation CH Q1 5734 $91.18

95004 Percut allergy skin tests CH Q1 5734 $91.18

95044 Allergy patch tests CH Q1 5734 $91.18

95060 Eye allergy tests CH Q1 5734 $91.18

95180 Rapid desensitization CH Q1 5734 $91.18




95801 Slp stdy unatnd w/anal CH Q1 5734 $91.18

95803 Actigraphy testing CH Q1 5734 $91.18

95860 Muscle test one limb CH Q1 5734 $91.18

95861 Muscle test 2 limbs CH Q1 5734 $91.18

95865 Muscle test larynx CH Q1 5734 $91.18

95870 Muscle test nonparaspinal CH Q1 5734 $91.18

95905 Motor &/ sens nrve cndj test CH Q1 5734 $91.18

95922 Autonomic nrv adrenrg inervj CH Q1 5734 $91.18

95923 Autonomic nrv syst funj test CH Q1 5734 $91.18

95970 Analyze neurostim no prog CH Q1 5734 $91.18

96103 Psycho testing admin by comp CH Q1 5734 $91.18

99195 Phlebotomy CH Q1 5734 $91.18

G0166 Extrnl counterpulse, per tx CH Q1 5734 $91.18

G0237 Therapeutic procd strg endur CH Q1 5734 $91.18

G0416 Prostate biopsy, any mthd CH Q2 5673 $209.42

G0455 Fecal microbiota prep instil CH Q1 5734 $91.18


Four drugs considered as integral to surgical procedures will be packaged

in 2016


For laboratory, the following new packaging policies will be implemented in

2016:

– All molecular pathology tests will be excluded from packaging including

new tests added in the future (Assigned SI=A)

– Preventive laboratory tests are excluded and also assigned SI=A

• Examples include PSA screening test, etc.

– Expand conditional packaging provision to include packaging of all

laboratory tests provided during the same encounter unless provided by

a different provider or for a different reason (L1 modifier to be used)

• Previously conditional packaging only applied to laboratory tests

provided on the same day of the primary services.

• Expands packaging to include all laboratory tests on a multiple day

single outpatient encounter


For laboratory, the following new packaging policies will be implemented in

2016:

– Revised use of L1 modifier

• L1 will only be used when laboratory tests are provided by a

different provider or for a different reason by the OPPS provider on

the same claim as other unrelated services.

• L1 will no longer be required when laboratory services are the only

items on the claim.

– SI changed to Q4 for all conditionally packaged laboratory tests

– CMS will implement edits which change SI from Q4 to A with a

13X bill type when only Q4 services appear on the claim


Outlier Payments For hospitals, outlier payments are made that equal 50 percent of the

amount by which the cost of furnishing the services exceeds 1.75 times

the APC payment when the following thresholds are met:

– Cost of furnishing the service by the hospital exceeds 1.75 times the

APC payment amount; and

– Exceeds a $3,250 fixed-dollar threshold ($2,775 in 2015)

– For example: Total Charges =$10,000; CCR=0.50; APC payment=

$1,000

Total Cost of Service=$10,000 X 0.50 = $5,000

Is $5,000 Cost of Service > 1.75 X $1,000 APC Payment= $1,750

YES

Is $5,000 Cost of Service > $3,250 Fixed dollar threshold YES

Outlier payment = ($5,000-$1,750) X 50% = $1,625

OPPS APC Group Policies

2016 OPPS APC Specific Policies

For new technology APCs, there are currently 37 cost bands. 11

additional cost bands (Levels 38-48):

2016 OPPS APC Group Policies Cardiac Rehabilitation CPT Codes: 93797, 93798, G0422, and G0423

will now be paid the same amount under a single APC: 5771

Diagnostic Tests and related services APCs consolidated from 19 APCs

to 4 APCs

– Impacts EKGs, EMGs, EEGs, pulmonary


For 2016, CMS will restructure and consolidate the imaging and nuclear

medicine APC structure from 54 APCs to 26 APCs (25 in proposed rule)


For 2016, CMS will restructure and consolidate the orthopedic related

APC structure from 24 APCs to 10 APCs (9 in proposed rule)


For 2016, CMS will restructure and consolidate the APCs in the following

areas:

– Skin procedures from 8 APCs to 5 APCs (APCs 5051-5055)

– Excision/Biopsy and Incision Drainage procedures from 7 APCs to 4

APCs (APCs 5071-5074)

– Gastrointestinal procedures from 23 APCs to 13 APCs (APCs 5301-

5303, 5311-5313, 5331,5341, 5351, 5352, 5391, 5392)

– Urology procedures from 16 APCs to 7 APCs ( APCs 5371-5377)

– Vascular procedures from 7 APCs to 3 APCs (APCs 5181-5183)

2016 Payment Changes for Devices

Pass-through Devices

– Devices with pass through status eligible for pass through payment

for at least 2 years but not more than 3 years

– Devices no longer eligible for pass through payment are packaged

into the cost of the procedure

– As of January 1, 2016, there are three devices eligible for pass-

through payment

• C2624 Implantable wireless pulmonary artery pressure sensor

with delivery catheter including all system components

• C2623 Catheter, transluminal angioplasty, drug coated, non-laser

• C2613 Lung biopsy plug with delivery system

– Increased transparency in pass through device application process


Pass-through Devices

– Reporting of device required for all device-intensive APCs in 2016

• Return to provider if no device present

Payment adjustment for discontinued device-intensive procedures

– Modifier 73 used when procedure requiring anesthesia discontinued

due to extenuating circumstances or due to circumstances

threatening the well-being of the patient after the patient has been

prepped and is brought to the room but prior to administration of the

anesthesia

• Payment is 50% of the OPPS payment rate

• Reduce by 100% the cost of the device for device-dependent

APCs


Payment adjustment for discontinued device-intensive procedures

– Modifier 74 used when procedure is discontinued after anesthesia

administration and procedure started due to extenuating

circumstances or due to circumstances threatening the well-being of

the patient.


– Modifier 52 used when procedure is partially reduced, completed or

cancelled and no anesthesia is required.


• Proposal to reduce by 100% the cost of the device for device-

dependent APCs will not be implemented

2016 Payment Changes for Drugs,

Biologicals, and Radiopharmaceuticals

For drugs and biologicals, pass-through payment is the amount by which

the drug or biological exceeds the portion of the otherwise applicable

Medicare OPD fee schedule that is associated with the drug or biological

(SI=G)

Due to the postponement of the Part B Drug Competitive Acquisition

Program, CMS pays the rate paid in the physician's office setting for all

drugs and biologicals with pass-through status

– ASP + 6%



12 drugs and biologicals with pass-through status ending December 31, 2015



32 drugs/biologicals have pass-through status (SI=G) in 2016


Biologicals, and Radiopharmaceuticals $100 per day cost threshold for separate payment (SI=K) of non-pass through

drugs with payment at ASP+6% ($95 in 2015)

Biosimilar products will be treated in a manner comparable to other drugs

– Pass through status determination and the $100 packaging threshold apply

Packaging determinations will be made on a drug-specific basis rather than a HCPCS Code-specific basis for those HCPCS codes that describe the same drug or biological but different doses

Non-pass-through therapeutic radiopharmaceuticals (per day cost of $100) payment is ASP + 6%

Currently three diagnostic radiopharmaceuticals with pass-through payment

• A9586 Florbetapir f18, diagnostic, per study dose, up to 10 millicuries

• C9458 Florbetaben, f18, diagnostic, per study dose, up to 8.1 millicuries

• C9459 Flutemetamol, f18, diagnostic, per study dose, up to 5 millicuries



Blood clotting factors under OPPS to be paid at ASP+6%

Methodology for calculating high cost versus low cost skin substitutes is changing for 2016

– Skin substitutes with a weighted average mean unit cost (MUC) above $26 per square cm or per day cost (PDC) greater than $773 will be classified as “high cost”



5 Biologicals that were in the skin substitute category because these products are typically used for internal surgery procedures to reinforce or repair soft tissues and not typically used to promote healing of skin.

– They will be packaged since they are integral to the surgical procedure

Other 2016 OPPS Payment and Coding

Changes

Hospital coding and payment for visits

– Current single HCPCS Code G0463 for clinic visits will continue to be used in 2016

– No changes to current ED level structure


Changes

Chronic Care Management visits

– CPT Code 99490- Chronic care management, at least 20 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month, with following required elements:

• 2 or more chronic conditions expected to last at least 12 months or until patient’s death;

• Chronic conditions place patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and

• Comprehensive care plan established, implemented, revised, or monitored


Changes

Chronic Care Management visits

– The following additional requirement apply for hospitals to bill these visits:

• Documentation of the beneficiary’s agreement to have the services provided in the hospital medical record or in the beneficiary’s medical record that can be accessed by the hospital;

• Medical record documentation of all elements of the services were explained and offered to the beneficiary and they were provided the option to accept or decline the services;

• Only one hospital can bill for the services in a single calendar month service period


Changes Chronic Care Management visits

– The following additional requirements apply for hospitals to bill this CPT Code:

• Creation of a structured clinical record in the EHR

• Access to care 24 hours/7 days per week

• Continuity of care with a designated practitioner

• Care management for chronic conditions

• Documentation of patient-centered plan of care

• Plan of care provided to beneficiary using EHR

• Management of care transition between various practitioners

• Coordination of care with home and community based providers

• Enhanced communication through secure messaging, internet, or other asynchronous non-face-to face consultations

• Use of EHR technology that has been certified under OC Health Information Technology Certification Program


Changes

• Partial Hospitalization

– Payment based on type of provider and number of services


Changes

• Inpatient only list is detailed in Addendum E

• 9 CPT Codes removed from the inpatient only list

2016 Nonrecurring Policy Changes

• Advanced Care Planning Services

– Two CPT Codes created in 2015:

• 99497 Advanced care planning including explanation and

discussion of advanced directives such as standard forms by

qualified health professional, first 30 minutes, face-to-face with

patient, family member and/or surrogates

– Packaged in 2015

– Changed to Status Indicator Q1 for 2016

• 99498 Advanced care planning including explanation and

discussion of advanced directives such as standard forms by

qualified health professional, each additional 30 minutes, face-to-

face with patient, family member and/or surrogates

– Packaged in 2015 and 2016


• Payment for CT Services

– CT exams provided using equipment that does not meet the attributes

of the North American Electrical Management (NEMA) standards will

result in:

• 5% payment reduction for the technical component in 2016

• 15% payment reduction for the technical component in 2017

• Limited to the following “CT” CPT Codes: 70450-70498, 71250-

71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706,

74150-74178, 74261-74263, 75571-75574

– Modifier ”CT” must be put on claims for above CT studies performed on

equipment not meeting the NEMA standards


• Lung Cancer Screening with low dose CT

– Two new HCPCS Codes implemented:

• G0296 Counseling visit to discuss need for low dose CT

• G0297 Low dose CT for lung cancer screening

• Corneal Tissue Payment in HOPD and ASC

– Corneal tissue acquisition costs related to use for non-corneal

transplants such as tissue patches for glaucoma shunt surgery would no

longer be paid separately

• Packaged in HOPD and ASC

• V2785 HCPCS Code for corneal acquisition costs would be

reported and paid separately with the following CPT Codes: 65710,

65730, 65750, 65755, 65756, 65765, 65767

2016 OPPS Payment Status and Comment

Indicators

• Addendum B of the Federal Register is your "guide"

– Pay attention to items with the following status indicators changes:

• “J2"-This status indicator has been added for payment of the C-APC

for observation APC 8011

• “Q4”- This status indicator is used for conditionally packaged

laboratory tests.

– Complete list of 2016 status indicators are listed in Addendum D1

2016 OPPS Payment Status and Comment

Indicators

• Addendum B of the Federal Register is your "guide"

– Pay attention to items with the following comment indicators:

• "CH"-Active HCPCS code with change in status indicator or APC

assignment or active HCPCS code that is being discontinued.

• "NI"-Existing code with substantial change in 2016 with code

descriptor or APC assignment

• “NP”-New code for 2016 or existing 2015 code with substantial

change in 2016 with code descriptor or APC assignment

CPT Code Deletions-Required Actions

Determine if there is a replacement for CPT Code deletion

– Determine replacement CPT Code

– Is there an impact on pricing?

Revise charge master and related subsystems

Provide education to clinical department on how to use the replacement CPT Code

Verify in the charge master and subsystems that the CPT codes are deleted

Monitor and test replacement CPT Codes

80

CPT Code Additions-Required Actions

Determine if new CPT Code is new service or replaces a deleted CPT Code

Determine if new CPT Code is reimburseable

– Category 3 CPT Codes implemented by CMS in July

Determine if new CPT Code requires a pricing revision


Provide education to clinical department on the new line item

Verify the CPT codes are added correctly

Monitor and test CPT Codes for accuracy of use

81

CPT Code Revisions-Required Actions

Determine the impact of the CPT Code revision


Provide education to clinical department

Verify the CPT code descriptions are revised accurately

Determine if pricing change is required

Monitor and test CPT Codes for appropriate use

82

Laboratory

There were 9 chromatography CPT Codes specific to the type of chromatography deleted in 2016

– Replaced by single chromatography code to be used irrespective of method unless constituent specific CPT Code is available

• 82542 Column chromatography includes mass spectrometry, if performed (e.g. HPLC, LC, LC/MS-MS, GC, GC/MS-MS, GC/MS, HPLC/MS) non-drug analytes not elsewhere specified, qualitative or quantitative, each specimen

There were 2 mass spectrometry CPT Codes based on qualitative(83788) and quantitative analysis (83789) in 2015

– Replaced in 2016 by a revised CPT Code 83789 that includes both qualitative and quantitative mass spectrometry

Numerous additions and revisions in the Molecular Pathology area again in 2016

83

Laboratory CPT Deletions

84

2015 CPT

Code Description Department 2016 Replacement CPT Codes

82486 CHROMATOGRAPHY QUAL COLUMN ANALYTE NES Laboratory 82542

82487 CHROMATOGRAPHY QUAL PAPR 1-DIMENSNL ANALYTE NES Laboratory 84999

82488 CHROMATOGRAPHY QUAL PAPR 2-DIMENSIONAL ANAL NES Laboratory 84999

82489 CHROMATOGRAPHY QUAL THIN LAYER ANALYTE NES Laboratory 84999

82491 CHROMATOGRAPHY QUAN COLUMN 1 ANALYTE NES Laboratory 82542

82492 CHROMATOGRAPHY QUAN COLUMN MULTIPLE ANALYTES Laboratory 82542

82541 COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE NES Laboratory 82542

82543 COL-CHR/MS STABLE ISOTOPE DIL 1 ANALYTE NES Laboratory 82542

82544 COL-CHR/MS STABLE ISOTOPE DIL MLT ANALYTES NES Laboratory 82542

83788 MASS SPECT&TANDEM MASS SPECT ANAL QUAL EA SPEC Laboratory 83789

88347 IMMUNOFLUORESCENT STUDY EA ANTIBODY INDIR METHOD Laboratory 88346, 88350

0103T HOLOTRANSCOBALAMIN QUANTITATIVE Laboratory 84999

Laboratory HCPCS Deletions

85

2015 HCPCS Code Short Descriptor Replacement 2016 Codes

G0431 Drug screen multiple class Applicable Drug Testing CPT Codes

G0434 Drug screen multi drug class Applicable Drug Testing CPT Codes

G0475 Hiv combination assay Applicable Drug Testing CPT Codes

G0476 Hpv combo assay ca screen Applicable Drug Testing CPT Codes

G6030 Assay of amitriptyline Applicable Drug Testing CPT Codes

G6031 Assay of benzodiazepines Applicable Drug Testing CPT Codes

G6032 Assay of desipramine Applicable Drug Testing CPT Codes

G6034 Assay of doxepin Applicable Drug Testing CPT Codes

G6035 Assay of gold Applicable Drug Testing CPT Codes

G6036 Assay of imipramine Applicable Drug Testing CPT Codes

G6037 Assay of nortiptyline Applicable Drug Testing CPT Codes

G6038 Assay of salicylate Applicable Drug Testing CPT Codes

G6039 Assay of acetaminophen Applicable Drug Testing CPT Codes

G6040 Assay of ethanol Applicable Drug Testing CPT Codes

G6041 Assay of urine alkaloids Applicable Drug Testing CPT Codes

G6042 Assay of amphetamines Applicable Drug Testing CPT Codes

G6043 Assay of barbiturates Applicable Drug Testing CPT Codes

G6044 Assay of cocaine Applicable Drug Testing CPT Codes

G6045 Assay of dihydrocodeinone Applicable Drug Testing CPT Codes

G6046 Assay of dihydromorphinone Applicable Drug Testing CPT Codes

G6047 Assay of dihydrotestosterone Applicable Drug Testing CPT Codes

G6048 Assay of dimethadione Applicable Drug Testing CPT Codes

G6049 Asssay of epiandrosterone Applicable Drug Testing CPT Codes

G6050 Assay of ethchlorvynol Applicable Drug Testing CPT Codes

G6051 Assay of flurazepam Applicable Drug Testing CPT Codes

G6052 Assay of meprobamate Applicable Drug Testing CPT Codes

G6053 Assay of methadone Applicable Drug Testing CPT Codes

G6054 Assay of methsuximide Applicable Drug Testing CPT Codes

G6055 Assay of nicotine Applicable Drug Testing CPT Codes

G6056 Assay of opiates Applicable Drug Testing CPT Codes

G6057 Assay of phenothiazine Applicable Drug Testing CPT Codes

G6058 Drug confirmation Applicable Drug Testing CPT Codes

Laboratory CPT Additions

86

2016

CPT

Code 2016 Code Description Department

80081 OBSTETRIC PANEL Laboratory

81162 BRCA1&BRCA2 FULL SEQ ANALYS/FULL DUP/DEL ANALYS Molecular Pathology

81170 ABL1 GENE ANALYSIS KINASE DOMAIN VARIANTS Molecular Pathology

81218 CEBPA GENE ANALYSIS FULL GENE SEQUENCE Molecular Pathology

81219 CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9 Molecular Pathology

81272 KIT GENE ANALYSIS TARGETED SEQUENCE ANALYSIS Molecular Pathology

81273 KIT GENE ANALYSIS D816 VARIANT(S) Molecular Pathology

81276 KRAS GENE ANALYSIS ADDITIONAL VARIANT(S) Molecular Pathology

81311 NRAS GENE ANALYSIS VARIANTS IN EXON 2&3 Molecular Pathology

81314 PDGFRA GENE ANALYS TARGETED SEQUENCE ANALYS Molecular Pathology

81412 ASHKENAZI JEWISH ASSOC DSRDRS GEN SEQ ANAL 9 GEN Molecular Pathology

81432 HEREDITARY BRST CA-RELATED GEN SEQ ANALYS 14 GEN Molecular Pathology

81433 HEREDITARY BRST CA-RELATED DUP/DEL ANALYSIS Molecular Pathology

81434 HEREDITARY RETINAL DSRDRS GEN SEQ ANALYS 15 GEN Molecular Pathology

81437 HEREDTRY NURONDCRN TUM DSRDRS GEN SEQ ANAL 6 GEN Molecular Pathology

81438 HEREDTRY NURONDCRN TUM DSRDRS DUP/DEL ANALYSIS Molecular Pathology

81442 NOONAN SPECTRUM DISORDERS GEN SEQ ANALYS 12 GEN Molecular Pathology

81490 AUTOIMMUNE RHEUMATOID ARTHRTS ANALYS 12 BIOMRKRS Molecular Pathology

81493 COR ART DISEASE MRNA GENE EXPRESSION 23 GENES Molecular Pathology

81525 ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES Molecular Pathology

81528 ONCOLOGY COLORECTAL SCREENING QUAN 10 DNA MARKRS Molecular Pathology

81535 ONCOLOGY GYNE LIVE TUM CELL CLTR&CHEMO RESP 1ST Molecular Pathology

81536 ONCOLOGY GYNE LIVE TUM CELL CLTR&CHEMO RESP ADD Molecular Pathology

81538 ONCOLOGY LUNG MS 8-PROTEIN SIGNATURE Molecular Pathology

81540 ONCOLOGY TUM UNKNOWN ORIGIN MRNA 92 GENES Molecular Pathology

81545 ONCOLOGY THYROID GENE EXPRESSION 142 GENES Molecular Pathology

81595 CARDIOLOGY HRT TRNSPL MRNA GENE EXPRESS 20 GENES Molecular Pathology

Laboratory HCPCS Additions

2016 HCPCS Code Short Descriptor

G0475 Hiv combination assay

G0476 Hpv combo assay ca screen

P9070 Pathogen reduced plasma pool

P9071 Pathogen reduced plasma sing

P9072 Pathogen reduced platelets

87

Laboratory CPT Revisions

88

2016

CPT

Code 2016 Code Description Department Specific Revision82542 COL-CHR/MS NONDRUG ANALYTE NES QUAL/QUAN EA SPEC Laboratory Add "qualitative/quantitative each specimen"

83789 MASS SPECT&TANDEM MASS SPECT NONDRG ANAL NES EA Laboratory Add "qualitative/quantitative each specimen"

86708 HEPATITIS A ANTIBODY HAAB Laboratory Remove "total" from description

87301 IAAD IA ADENOVIRUS ENTERIC TYP 40/41 Laboratory Add "immunoassay technique" to description

87305 IAAD IA QUAL/SEMIQUAN MULTIPLE STEP ASPERGILLUS Laboratory Add "immunoassay technique" to description

87320 IAAD IA CHLAMYDIA TRACHOMATIS Laboratory Add "immunoassay technique" to description

87324 IAAD IA CLOSTRIDIUM DIFFICILE TOXIN Laboratory Add "immunoassay technique" to description

87327 IAAD IA CRYPTOCOCCUS NEOFORMANS Laboratory Add "immunoassay technique" to description

87328 IAAD IA CRYPTOSPORIDIUM Laboratory Add "immunoassay technique" to description

87329 IAAD IA GIARDIA Laboratory Add "immunoassay technique" to description

87332 IAAD IA CYTOMEGALOVIRUS Laboratory Add "immunoassay technique" to description

87335 IAAD IA ESCHERICHIA COLI 0157 Laboratory Add "immunoassay technique" to description

87336 IAAD IA ENTAMOEBA HISTOLYTICA DISPAR GRP Laboratory Add "immunoassay technique" to description

87337 IAAD IA ENTAMOEBA HISTOLYTICA GRP Laboratory Add "immunoassay technique" to description

87338 IAAD IA HPYLORI STOOL Laboratory Add "immunoassay technique" to description

87339 IAAD IA HPYLORI Laboratory Add "immunoassay technique" to description

87340 IAAD IA HEPATITIS B SURFACE ANTIGEN Laboratory Add "immunoassay technique" to description

87341 IAAD IA HEPATITIS B SURFACE AG NEUTRALIZATION Laboratory Add "immunoassay technique" to description

87350 IAAD IA HEPATITIS BE ANTIGEN Laboratory Add "immunoassay technique" to description

87380 IAAD IA HEPATITIS DELTA ANTIGEN Laboratory Add "immunoassay technique" to description

87385 IAAD IA HISTOPLASM CAPSULATUM Laboratory Add "immunoassay technique" to description

87389 IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE Laboratory Add "immunoassay technique" to description

87390 IAAD IA HIV-1 Laboratory Add "immunoassay technique" to description

87391 IAAD IA HIV-2 Laboratory Add "immunoassay technique" to description

87400 IAAD IA INFLUENZA A/B EACH Laboratory Add "immunoassay technique" to description

87420 IAAD IA RESPIRATORY SYNCTIAL VIRUS Laboratory Add "immunoassay technique" to description

87425 IAAD IA ROTAVIRUS Laboratory Add "immunoassay technique" to description

87427 IAAD IA SHIGA-LIKE TOXIN Laboratory Add "immunoassay technique" to description

87430 IAAD IA STREPTOCOCCUS GROUP A Laboratory Add "immunoassay technique" to description

87449 IAAD IA MULT STEP METHOD NOS EACH ORGANISM Laboratory Add "immunoassay technique" to description

87450 IAAD IA SINGLE STEP METHOD NOS EA ORGANISM Laboratory Add "immunoassay technique" to description

87451 IAAD IA POLYV MLT ORGANISMS EA POLYV ANTISERUM Laboratory Add "immunoassay technique" to description

88346 IMMUNOFLUORESCENCE PER SPEC 1ST SINGL ANTB STAIN Pathology Change entire description

Radiology For hip radiography, the CPT Codes restructured based on unilateral 1

view, 2-3 views and minimum of 4 views. There is a comparable structure for bilateral hips.

CPT Codes for operative hip radiography and infant hip radiography eliminated in 2016

For femur radiography, now 2 CPT codes

73551- 1 view

73552-minimum 2 views

For Interventional Radiology, there is continuing efforts to compress separate imaging and surgical component CPT Codes into a single CPT Code that includes both the imaging and surgical components

Ensure pricing is evaluated to minimize gross revenue contraction

89

Radiology CPT Deletions

The following CPT Codes were deleted in Radiology

90

2015 CPT


70373 LARYNGOGRAPHY CONTRAST RS&I Radiology 76499

72010 RADEX SPINE ENTIRE SURVEY STD ANTEROPOST & LAT Radiology 72082

72069 RADEX SPINE THORACOLMBR STANDING SCOLIOSIS Radiology 72081, 72082, 72083, 72084

72090 RADEX SPINE SCOLIOS STUDY W/SUPINE & ERECT STUDY Radiology 72081, 72082, 72083, 72084

73500 RADEX HIP UNILATERAL 1 VIEW Radiology 73501

73510 RADEX HIP UNILATERAL COMPLETE MINIMUM 2 VIEWS Radiology 73502, 73503

73520 RADEX HIPS BILATERAL 2 VIEWS ANTEROPOST PELVIS Radiology 73521, 73522, 73523

73530 RADEX HIP OPERATIVE PROCEDURE Radiology 73501, 73502, 73503

73540 RADEX PELVIS&HIPS INFT/CHLD MINIMUM 2 VIEWS Radiology 73501, 73502, 73503

73550 RADIOLOGIC EXAMINATION FEMUR 2 VIEWS Radiology 73551, 73552

Radiology CPT Additions

The following CPT Codes were added in Diagnostic Radiology

91

2016

CPT


72081 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 1 VW Radiology

72082 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW Radiology

72083 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 4/5 VW Radiology

72084 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 6/> VW Radiology

73501 RADEX HIP UNILATERAL WITH PELVIS 1 VIEW Radiology

73502 RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS Radiology

73503 RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS Radiology

73521 RADEX HIPS BILATERAL WITH PELVIS 2 VIEWS Radiology

73522 RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS Radiology

73523 RADEX HIPS BILATERAL WITH PELVIS MINIMUM 5 VIEWS Radiology

73551 RADIOLOGIC EXAMINATION FEMUR 1 VIEW Radiology

73552 RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS Radiology

74712 FETAL MRI W/PLACNTL MATRNL PLVC IMG SING/1ST GES Radiology

74713 FETAL MRI W/PLACNTL MATRNL PLVC IMG EA ADDL GES Radiology

Radiology CPT Deletions

The following CPT Codes were deleted in Interventional Radiology

92

2015 CPT


37202 TCAT THER INFUSION OTH/THN THROMBOLYSIS ANY TYPE Interventional Radiology None

37250 IV US NON-C VSL DX EVAL&/THER IVNTJ 1ST VSL Interventional Radiology 37252, 37253

37251 IV US NON-C VSL DX EVAL&/THER IVNTJ EA VSL Interventional Radiology 37252, 37253

47500 INJECTION PX PRQ TRANSHEPATIC CHOLANGIOGRAPHY Interventional Radiology 47532

47505 INJ PX CHOLANGIOGRAPHY VIA CATHETER/T-TUBE Interventional Radiology 47531

47510 INTRO PRQ TRANSHEPATC CATH BILIARY DRG Interventional Radiology 47533

47511 INTRODUCJ PERCUT TRANSHEPATC STENT BILIARY DRG Interventional Radiology 47534

47525 CHANGE PERCUTANEOUS BILIARY DRAINAGE CATHETER Interventional Radiology 47535-47541

47530 REVISION &/REINSERTION TRANSHEPATC TUBE Interventional Radiology 47535-47541

47630 BILIARY DUCT STONE XTRJ PRQ VIA BASKET/SNARE Interventional Radiology 47544

50392 INTRO INTRACATH/CATH IN RNL PELVIS DRG&/NJX PRQ Interventional Radiology 50432

50393 INTRO URETER CATH/STNT RENAL PELVIS DRG&/NJX Interventional Radiology 50693, 50694, 50695

50394 INJECTION PROCEDURE PYELOGRAPHY VIA TUBE/CATH Interventional Radiology 50430, 50431

50398 CHANGE NEPHROSTOMY/PYELOSTOMY TUBE Interventional Radiology 50435

74305 CHOLANGIO&/PANCREATOGRAPHY THRU CATH RS&I Interventional Radiology 47531

74320 CHOLANGIO&/PANCREATOGRAPHY TRANSHEPATC RS&I Interventional Radiology 47532

74327 POSTOP BILIARY STONE RMVL PRQ T-TUBE RS&I Interventional Radiology 47544

74475 INTRO CATH IN RENAL PELVIS DRG&/NJX PRQ RS&I Interventional Radiology 50432, 50433, 50434, 50435, 50606, 50693,50694 50695

74480 INTRO URETERAL CATH/STENT PRQ RS&I Interventional Radiology 50432, 50433, 50434, 50435, 50606, 50693,50694 50695

75896 TRANSCATHETER INFUSION OTHER THAN THROMBOLYSIS Interventional Radiology 37211, 37212, 37213, 37214, 61650, 61651

75945 IV ULTRASOUND RS&I INITIAL VESSEL Interventional Radiology 37252

75946 IV ULTRASOUND RS&I EACH NON-CORONARY VESSEL Interventional Radiology 37253

75980 PRQ TRANSHEPATC BILIARY DRG W/CONTRAST MNTR RS&I Interventional Radiology 47533, 47534, 47535, 47536, 47537

75982 PRQ PLMT INT/EXT BILIARY DRNG CATH/STENT RS&I Interventional Radiology 47533, 47534, 47535, 47536, 47537, 47538,47539, 47540


The following CPT Codes were added in Interventional Radiology

93

2016

CPT


10035 PERQ SFT TISS LOC DEVICE PLMT 1ST LES W/GDNCE Interventional Radiology

10036 PERQ SFT TISS LOC DEVICE PLMT ADD LES W/GDNCE Interventional Radiology

37252 INTRAVASCULAR US NONCORONARY RS&I INTIAL VESSEL Interventional Radiology

37253 INTRAVASCULAR US NONCORONARY RS&I ADDL VESSEL Interventional Radiology

47531 NJX CHOLANGIO PRQ W/IMG GID RS&I EXISTING ACCESS Interventional Radiology

47532 NJX CHOLANGIO PRQ W/IMG GID RS&I NEW ACCESS Interventional Radiology

47533 PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I EXTERNL Interventional Radiology

47534 PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I INT-EXT Interventional Radiology

47535 CONV EXT BIL DRG CATH TO INT-EXT BIL DRG CATH Interventional Radiology

47536 EXCHANGE BILIARY DRG CATHETER PRQ W/IMG GID RS&I Interventional Radiology

47537 REMOVAL BILIARY DRG CATHETER REQ FLUOR GID RS&I Interventional Radiology

47538 PLMT BILE DUCT STENT PRQ EXISTING ACCESS Interventional Radiology

47539 PLMT BILE DUCT STENT PRQ NEW ACCESS W/O SEP CATH Interventional Radiology

47540 PLMT BILE DUCT STENT PRQ NEW ACCESS W/SEP CATH Interventional Radiology

47541 PLMT ACCESS THRU BILIARY TREE INTO SMALL BWL NEW Interventional Radiology

47542 BALLOON DILAT BILIARY DUCT/AMPULLA PRQ EACH DUCT Interventional Radiology

47543 ENDOLUMINAL BX BILIARY TREE PRQ ANY METH SNG/MLT Interventional Radiology

47544 REMOVAL BILIARY DUCT &/GLBLDR CALCULI PERQ RS&I Interventional Radiology


The following CPT Codes were added in Interventional Radiology

94

2016

CPT


49185 SCLEROTHERAPY FLUID COLLECTION PRQ W/IMG GID Interventional Radiology

50430 NJX PX ANTEGRDE NFROSGRM &/URTRGRM NEW ACCESS Interventional Radiology

50431 NJX PX ANTEGRDE NFROSGRM &/URTRGRM EXSTNG ACESS Interventional Radiology

50432 PLMT NEPHROSTOMY CATH PRQ NEW ACCESS RS&I Interventional Radiology

50433 PLMT NEPHROURETERAL CATH PRQ NEW ACCESS RS&I Interventional Radiology

50434 CONVERT NEPHROSTOMY CATH TO NEPHROURTRL CATH PRQ Interventional Radiology

50435 EXCHANGE NEPHROSTOMY CATHETER PRQ W/IMG GID RS&I Interventional Radiology

50606 ENDOLUMINAL BX URTR &/RNL PELVIS NONENDOSCOPIC Interventional Radiology

50693 PLMT URTRL STENT PRQ PRE-EXISTING NFROS TRACT Interventional Radiology

50694 PLMT URTRL STNT PRQ NEW ACESS W/O SEP NFROS CATH Interventional Radiology

50695 PLMT URTRL STENT PRQ NEW ACCESS W/SEP NFROS CATH Interventional Radiology

50705 URETERAL EMBOLIZATION/OCCLUSION W/IMG GID RS&I Interventional Radiology

50706 BALLOON DILAT URETERAL STRICTURE W/IMG GID RS&I Interventional Radiology

61645 PERQ ART TRLUML M-THROMBEC &/NFS INTRACRANIAL Interventional Radiology

61650 EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART 1ST Interventional Radiology

61651 EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART ADDL Interventional Radiology

0397T ERCP WITH OPTICAL ENDOMICROSCOPY ADD ON Interventional Radiology

0398T MRGFUS STEREOTACTIC ABLATION LESION INTRACRANIAL Interventional Radiology

0399T MYOCARDIAL STRAIN IMAGING QUAN ASSMT Interventional Radiology

0404T TRANSCERVICAL UTERINE FIBROID ABLTJ W/US GDN RF Interventional Radiology


The following CPT Codes were added in Nuclear Medicine

95

2016

CPT


78265 GASTRIC EMPTYNG IMAG STD W/SM BWL TRANSIT Nuclear Medicine

78266 GSTRC EMPTNG IMAG STD W/SM BWL COL TRNST MLT DAY Nuclear Medicine

Radiology HCPCS Additions

The following HCPCS Codes were added in Nuclear Medicine

96


C9458 Florbetaben, f18, diagnostic, per study dose, up to 8.1 millicuries

C9459 Flutemetamol f18, diagnostic, per study dose, up to 5 millicuries

Radiology CPT Revisions

The following CPT Codes were revised in Interventional Radiology

97

2016

CPT

Code 2016 Code Description Department Specific Revision

37184 PRIM PRQ TRLUML MCHNL THRMBC N-COR N-ICRA 1ST Interventional Radiology Add "non-intracranial" to description

37185 PRIM PRQ TRLUML MCHNL THRMBC N-COR N-ICRA SBSQ Interventional Radiology Add "non-intracranial" to description

37186 SEC PRQ TRLUML THRMBC N-CORONARY N-INTRACRANIAL Interventional Radiology Add "non-intracranial" to description

37211 THROMBOLYSIS ARTERIAL INFUSION ICRA RS&I INIT TX Interventional Radiology Add "intracranial" to description

50387 RMVL & RPLCMT XTRNL ACCESSIBLE NEPHROURTRL CATH Interventional Radiology Add "nephroureteral catheter" to description


The following CPT Codes were revised in Diagnostic Radiology

98

2016

CPT


72080 RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS Radiology Change to "minimum of 2 views"


The following CPT Codes were revised in Nuclear Medicine

99

2016

CPT


78264 GASTRIC EMPTYING IMAGING STUDY Nuclear Medicine " (eg, solid, liquid, or both)" to description

Radiation Therapy Remote afterloading high dose rate radionuclide split in 2016 based on body

location(includes basic dosimetry):

– Skin source brachytherapy

• 77767 lesion diameter up 2.0 cm or 1 channel

• 77768 lesion diameter over 2.0 cm and 2 or more channels

– Interstitial or intracavitary brachytherapy

• 77770 1 channel

• 77771 2-12 channels

• 77772 over 12 channels

CPT 77778 Interstitial radiation source application, complex now includes supervision, handling, loading of radiation source when performed

– 77776 simple application eliminated

– 77777 intermediate application eliminated

100

Radiation Therapy CPT Deletions

101

2015 CPT


77776 INTERSTITIAL RADIATION SOURCE APPLIC SIMPLE Radiation Therapy 77799

77777 INTERSTITIAL RADIATION SOURCE APPLIC INTERMED Radiation Therapy 77799

77785 REMOTE AFTLD RADIONUCLIDE BRACHYTX 1 CHANNEL Radiation Therapy 77770

77786 REMOTE AFTLD RADIONUCLIDE BRACHYTX 2-12 CHANNEL Radiation Therapy 77771

77787 REMOTE AFTLD RADIONUCLIDE BRACHYTX > 12 CHANNEL Radiation Therapy 77772

0182T HDR ELECTRONIC BRACHYTHERAPY PER FRACTION Radiation Therapy 0394T, 0395T

Radiation Therapy CPT Additions

102

2016

CPT


77767 HDR RDNCL SKN SURF BRACHYTX LES </2CM/1 CHAN Radiation Therapy

77768 HDR RDNCL SK SRF BRCHYTX LES >2CM&2CHAN/MLT LES Radiation Therapy

77770 HDR RDNCL NTRSTL/INTRCAV BRACHYTX 1 CHANNEL Radiation Therapy

77771 HDR RDNCL NTRSTL/INTRCAV BRACHYTX 2-12 CHANNEL Radiation Therapy

77772 HDR RDNCL NTRSTL/INTRCAV BRACHYTX >12 CHANNELS Radiation Therapy

0394T HDR ELECTRONIC BRACHYTHERAPY SKIN SURFACE Radiation Therapy

0395T HDR ELECTRONIC BRACHYTHERAPY NTRSTL/INTRCAV Radiation Therapy

Radiation Therapy CPT Revisions

103

2016

CPT


77778 INTERSTITIAL RADIATION SOURCE APPLIC COMPLEX Radiation Therapy Add "complex, includes supervision, handling, loading of radiation source when performed"

77789 SURFACE APPLIC LOW DOSE RATE RADIONUCLIDE SOURCE Radiation Therapy Add "low dose rate radionuclide"

Cardiology CPT Deletions

104

2015 CPT


0223T ACOUSTIC CARDIOGRAPHY W/INTERPRETATION & REPORT Cardiology 93799

0224T ACOUSTIC CARDIOGRAPHY MULT ANALYSIS W/I&R Cardiology 93799

0225T ACOUSTIC CARDIOGRAPHY MULT ALYS W/I&R & REPROG Cardiology 93799

0262T IMPLANT CATH DELIVRD PROSTH PULM VALVE ENDOVASC Invasive Cardiology 33477

0311T N-INVAS CAL & ALYS CNTRL ARTL PRESSURE WAVEFORM Invasive Cardiology 93050

Cardiology CPT Additions

105

2016

CPT


33477 TCAT PULMONARY VALVE IMPLANTATION PRQ APPROACH Invasive Cardiology

93050 ART PRESS WAVEFORM ANALYS CENTRAL ART PRESSURE Cardiology

0387T TRANSCATH INSERT OR REPLACE LEADLESS PM VENTR Invasive Cardiology

0388T TRANSCATH REMOVAL LEADLESS PM VENTRICULAR Invasive Cardiology

0389T PROG DEVICE EVAL IN PERSON LEADLESS PM SYSTEM Cardiology

0390T PERI-PROC DEVICE EVAL IN PERS LEADLESS PM SYSTEM Cardiology

0391T INTERROG DEVICE EVAL IN PERSON LEADLESS PM SYST Cardiology

Endoscopy CPT Deletions

106

2015 CPT


31620 ENDOBRNCL US BRONCHOSCOPIC DX/THER IVNTJ Endoscopy None

39400 MEDIASTINOSCOPY INCL BIOPSIES WHEN PERFORMED Endoscopy 39401, 39402

0240T ESOPH MOTILITY 3D PRESSURE TOPOGRAPHY W/I&R Endoscopy 91010, 91013

0241T ESOPH/GASTROESOPH MOTILITY W/STIM/PERFU W/I&R Endoscopy 91010, 91013

Endoscopy CPT Additions

107

2016

CPT


31652 BRNCHSC EBUS GUIDED SAMPL 1/2 NODE STATION/STRUX Endoscopy

31653 BRNCHSC EBUS GUIDED SAMPL 3/> NODE STATION/STRUX Endoscopy

31654 BRNSCHSC TNDSC EBUS DX/TX INTERVENTION PERPH LES Endoscopy

39401 MEDIASTINOSCOPY INCLUDES MEDIASTINAL MASS BIOPSY Endoscopy

39402 MEDIASTINOSCOPY WITH LYMPH NODE BIOPSY/IES Endoscopy

43210 EGD PARTIAL/COMPL ESOPHAGOGASTRIC FUNDOPLASTY Endoscopy

0392T LAPS ESOPHGL SPHINCTER AUGMENT PROC PLACE DEVICE Endoscopy

0393T ESOPHGL SPHINCTER AUGMENT DEVICE REMOVAL Endoscopy

0406T NSL NDSC SURG ETHMD SIN PLMT DRUG ELUTNG IMPLNT Endoscopy

0407T NSL NDSC SURG ETHMD PLMT DRUG ELUTNG IMPLNT W/BX Endoscopy

Surgery CPT Deletions

108

2015 CPT


47560 LAPS SURG W/GID TRANSHEPATC CHOLANGRPH W/O BX Surgery 47579

47561 LAPS SURG W/GID TRANSHEPATC CHOLANGRPH W/BX Surgery 47579

Surgery CPT Additions

109

2016

CPT

Code 2016 Code Description Action Department

54437 REPAIR OF TRAUMATIC CORPOREAL TEAR(S) N Surgery

54438 REPLANTATION PENIS COMP AMPUTATION W/URETH REP N Surgery

0396T INTRAOP KINETIC BALANCE SENSR KNEE RPLCMT ARTHRP N Surgery

Pharmacy CPT Deletions

110

Pharmacy HCPCS Deletions

111

2015 HCPCS

Code Short Descriptor 2016 Replacement Code

C9025 Injection, ramucirumab J9308

C9026 Injection, vedolizumab J3380

C9027 Injection, pembrolizumab J9271

C9442 Injection, belinostat J9032

C9443 Injection, dalbavancin J0875

C9444 Injection, oritavancin J2407

C9445 C-1 esterase, ruconest J0596

C9446 Inj, tedizolid phosphate J3090

C9449 Inj, blinatumomab J9039

C9450 Fluocinolone acetonide implt J7313

C9451 Injection, peramivir J2547

C9452 Inj, ceftolozane/tazobactam J0695

C9453 Injection, nivolumab J9299

C9454 Inj, pasireotide long acting J2502

C9455 Injection, siltuximab J2860

C9456 Inj, isavuconazonium sulfate J1833

C9457 Lumason contrast agent None

J0886 Epoetin alfa 1000 units esrd Q4081

J9010 Alemtuzumab injection J0202

Q9975 Factor viii fc fusion recomb J7205

Q9976 Inj ferric pyrophosphate cit J1443

Q9977 Compounded drug noc J7999

Q9978 Netupitant palonosetron oral J8655

Q9979 Injection, alemtuzumab J0202

Pharmacy CPT Additions

112

2016

CPT


90620 MENB RECOMBINANT PROT W/OUT MEMBR VESIC VACC IM Pharmacy

90621 MENB RECOMBINANT LIPOPROTEIN VACCINE IM Pharmacy

90625 CHOLERA VACCINE ADULT 1 DOSE LIVE FOR ORAL USE Pharmacy

90697 DTAP-IPV-HIB-HEPB VACCINE INTRAMUSCULAR Pharmacy

Pharmacy HCPCS Additions

113


C9460 Injection, cangrelor

J0202 Injection, alemtuzumab

J0596 Injection, ruconest

J0695 Inj ceftolozane tazobactam

J0714 Ceftazidime and avibactam

J0875 Injection, dalbavancin

J1447 Inj tbo filgrastim 1 microg

J1833 Injection, isavuconazonium

J2407 Injection, oritavancin

J2502 Inj, pasireotide long acting

J2547 Injection, peramivir

J2860 Injection, siltuximab

J3090 Inj tedizolid phosphate

J3380 Injection, vedolizumab

J7121 5% dextrose in lac ringers

J7188 Factor viii recomb obizur

J7205 Factor viii fc fusion recomb

J7313 Fluocinol acet intravit imp

J7340 Carbidopa levodopa enteral

J7512 Prednisone ir or dr oral 1mg

J7999 Compounded drug, noc

J8655 Netupitant palonosetron oral

J9032 Injection, belinostat, 10mg

J9039 Injection, blinatumomab

J9271 Inj pembrolizumab

J9299 Injection, nivolumab

J9308 Injection, ramucirumab

Q4161 Bio-connekt per square cm

Q4162 Amnio bio and woundex flow

Q4163 Amnio bio and woundex sq cm

Q4164 Helicoll, per square cm

Q4165 Keramatrix, per square cm

Q9950 Inj sulf hexa lipid microsph

Pain Management CPT Additions

114

2016

CPT


64461 PVB THORACIC SINGLE INJECTION SITE W/IMG GID Pain Management

64462 PVB THORACIC SECOND & ADDL INJ SITE W/IMG GID Pain Management

64463 PVB THORACIC CONT CATHETER INFUSION W/IMG GID Pain Management

Ophthalmology CPT Deletions

115

2015 CPT


0099T IMPLTJ INTRASTROMAL CORNEAL RING SEGMENTS Ophthalmology 65785

0123T FISTULIZATION SCLERA GLAUCOMA CILIARY BODY Ophthalmology 66999

Ophthalmology CPT Additions

116

2016

CPT


65785 IMPLANTATION INTRASTROMAL CORNEAL RING SEGMENTS Ophthalmology

99177 INSTRUMENT BASED OCULAR SCR BI W/ONSITE ANALYSIS Ophthalmology

0402T COLLAGEN CROSS-LINKING OF CORNEA Ophthalmology

Ophthalmology CPT Revisions

117

2016

CPT


65855 TRABECULOPLASTY BY LASER SURGERY Ophthalmology Remove "One or more sessions"

67227 DESTRUCTION RETINOPATHY CRYOTHERAPY DIATHERMY Ophthalmology Remove "One or more sessions"

67228 TREATMENT EXTENSIVE RETINOPATHY PHOTOCOAGULATION Ophthalmology Remove "One or more sessions"

Dermatology CPT Deletions

118

2015 CPT


0233T SKIN ADVANCED GLYCATION ENDPRODUCTS SPECTROSCOPY Dermatology 88749

Dermatology Additions

119

2016

CPT


96931 RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ I&R 1ST Dermatology

96932 RCM CELULR & SUBCELULR SKN IMGNG IMG ACQUISITION Dermatology

96933 RCM CELULR & SUBCELULR SKN IMGNG I&R 1ST LES Dermatology

96934 RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ I&R ADD Dermatology

96935 RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ EA ADDL Dermatology

96936 RCM CELULR & SUBCELULR SKN IMGNG I&R EA ADDL Dermatology

0400T MULTI-SPECTRAL DIGITAL SKIN LES ANALYSIS 1-5 LES Dermatology

0401T MULTI-SPECTRAL DIGITAL SKIN LES ANALYSIS 6+ LES Dermatology

Other CPT Deletions

120

2015 CPT


21805 OPEN TX RIB FRACTURE W/O FIXATION EACH Emergency Room None

47136 LVR ALTRNSPLJ HTRTPC PRTL/WHL DON ANY AGE Other 47399

92543 CALORIC VESTIBULAR TEST EA IRRIGATION W/RECORD ENT 92537, 92538

95973 ELEC ALYS NSTIM PLS GEN CPLX SC/PERPH EA 30 MIN Neurology None

0243T INTERMIT MEAS WHEEZE RATE BRONCHODIL DX W/I&R Pulmonary 94799

0244T CONT MEAS WHEEZE RATE BRONCHODIL SLEEP 3-24 HRS Pulmonary 94799

Other CPT Additions

121

2016

CPT


69209 REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT Clinic

92537 CALORIC VESTIBULAR TEST W/REC BI BITHERMAL ENT

92538 CALORIC VESTIBULAR TEST W/REC BI MONOTHERMAL ENT

0381T XTRNL HRT RATE EPI SEIZ UP TO 14 DAYS COMPLETE Neurology

0382T XTRNL HRT RATE EPI SEIZ UP TO 14 DAYS R&I ONLY Neurology

0383T XTRNL HRT RATE EPI SEIZ 15 TO 30 DAYS COMPLETE Neurology

0384T XTRNL HRT RATE EPI SEIZ 15 TO 30 DAYS R&I ONLY Neurology

0385T XTRNL HRT RATE EPI SEIZ OVER 30 DAYS COMPLETE Neurology

0386T XTRNL HRT RATE EPI SEIZ OVER 30 DAYS R&I ONLY Neurology

0403T DIABETES PREVENTION PROG STANDARDIZED CURRICULUM Other

0405T OVERSIGHT CARE OF XTRCORP LIVER ASSIST SYS PAT Other

Wrap up and Question/ Answers

122

Presenter Information

Mike Kovar

410-916-0824

[email protected]

Taylor Pedone

440-666-0930

[email protected]

124

mailto:[email protected]

mailto:[email protected]

2016 charge master update - hfma nj...january 1, 2016 – set up a tracking mechanism for high risk...

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