CY12 Cosmetic Surgery Rates and CSE v8 UpdatePresented by TMA UBO Program Office Support

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26 June 2012 0800 – 0900 ET28 June 2012 1400 – 1500 ET

Background

Cosmetic Surgery Patient Information Brochure

CSE v8 New Procedures & Rate Methodology

CSE v8 Layout & Functional Changes

CSE Demonstration: Practice Scenarios

CSE v8 User’s Guide Update

CSE v8 Distribution & Effective Date

Questions & Answers

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Agenda

Elective cosmetic surgery is not a TRICARE covered benefit.

However, DoD Health Affairs Policy 05-020 authorizes elective cosmetic surgery in military treatment facilities (MTFs) to “support graduate medical education, board eligibility and certification, and skill maintenance for certified specialists.”

Services are provided on a “space available” basis and limited to:- TRICARE-eligible beneficiaries (including TRICARE for Life) who

will not lose eligibility for at least 6 months.- Active duty personnel who have written permission from their unit

commander.

All patients are fully responsible for surgical fees, applicable institutional and anesthesia charges, as well as the cost of all implants, cosmetic injectables, and other separately billable items associated with elective cosmetic procedures.

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Background

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The Basic Process

Patient Presents for Surgery

Consult

Provider Examines

Patient

Provider Determines

Procedure is Elective

Cosmetic Surgery

Provider Completes

CSE Superbill

Patient Takes CSE Superbill to MSA Clerk

MSA Clerk Enters

Information into CSE

MSA Clerk Prints CSE Report and Gives to Patient

1) Advance Payment RequiredEstimated charges must be paid, in full, prior to receiving treatment.

2) Prices Subject to ChangeRates are not guaranteed until estimated charges have been paid in full.

3) Additional Charges May ApplyThere may be additional charges for services such as laboratory, radiology, and pharmacy, or unforeseen, but necessary, procedures undertaken during the procedure.

4) Global PeriodsPostoperative visits that are unrelated to the original procedure, or that occur after the global period has expired, will incur additional charges. 

5) RefundsRefunds are processed for procedures not performed.

6) Follow-up CareFollow-up care is not guaranteed in an MTF and in accordance with TPM Chapter 4, Section 1.1, complications of cosmetic surgery procedures are excluded from coverage. 5

Acknowledgement of Terms

Target Audience:- Patients considering elective

cosmetic surgery- Patients receiving a cosmetic

surgery estimate

Topics Covered:- Eligibility- Payment- Standard Process:

Consultation Estimate & Payment Scheduling Post Procedure

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Elective Cosmetic Surgery Brochure

Substitute Skin Grafts

15271 Application of skin substitute graft to trunk, arms, first 25 sq cm

+15272 Application of skin substitute graft to trunk, arms, add’l 25 sq cm

15273 Application of skin substitute graft to trunk, arms, legs, > 100 sq cm

+15274 Application of skin substitute graft to trunk, arms, legs, add’l 100 sq cm

15275 Application of skin substitute graft to face, scalp, eyelids, mouth… first 25 sq cm

+15276 Application of skin substitute graft to face, scalp, eyelids, mouth… add’l 25 sq cm

15277 Application of skin substitute graft to face, scalp, eyelids, mouth… > 100 sq cm

+15278 Application of skin substitute graft to face, scalp, eyelids, mouth…add’l 100 sq cm

Biologic Implant

+15777* Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement

*CPT® code 15777 can be used with any of the above procedures as well as the following procedures currently listed in the CSE:

 

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New Cosmetic Procedures for 2012

19340 Immediate insertion of implant 19342 Delayed insertion of implant 19357 Breast reconstr; immed. / delayed19370 Open periprosthetic capsulotomy19371 Periprosthetic capsulectomy; breast19380 Revision of reconstructed breast

19300 Mastectomy for Gynecomastia 19316 Mastopexy (Breast Lift)19318 Mammaplasty; reduction19324 Mammaplasty; augmentation w/o implant19325 Mammaplasty; augmentation w/ implant19328 Removal of intact mammary implant19330 Removal of implant material

(+) Indicates an Add-on Code

0 Days17999-Y0019 Laser hair removal; chest

17999-Y0020 Laser hair removal; lip

17999-Y0021 Laser hair removal; lip and chin

17999-Y0022 Laser hair removal; back

17999-Y0023 Laser hair removal; arms

17999-Y0024 Laser hair removal; underarms

17999-Y0025 Laser hair removal; bikini

17999-Y0026 Laser hair removal; legs

17999-Y0027 Laser hair removal; beard

17999-Y0028 Laser hair removal; ears

17999-Y5000 Microlipoinjection/fat transfer; lips

17999-Y5001 Microlipoinjection/fat transfer; melolabial folds

17999-Y5002 Microlipoinjection/fat transfer; marrionette lines

17999-Y5003 Microlipoinjection/fat transfer; forehead

17999-Y5004 Microlipoinjection/fat transfer; glabella

17999-Y5005 Microlipoinjection/fat transfer; tear troughs

17999-Y5006 Microlipoinjection/fat transfer; crows feet

17999-Y5775 Micro/mini grafts 1- 500 hairs

17999-Y6001 Each Piercing, Each Body Location

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Global Periods for Y codes

10 Days17999-Y0050 Laser Vein Treatment of Leg

30 Days17999-Y0030 Laser tattoo removal; <= 30 sq. cm, initial session

17999-Y0031 Laser tattoo removal; <= 30 sq. cm, each addl session

17999-Y0032 Laser tattoo removal; >= 31 sq cm, initial session

17999-Y0033 Laser tattoo removal; >= 31 sq cm, each addl session* Based on the unique nature of the procedure requiring multiple sessions at specified intervals

90 Days17999-Y0001 Microdermabrasion; total face

17999-Y0002 Microdermabrasion; segment, facial

17999-Y0003 Laser Skin Resurfacing, Ablative; total face

17999-Y0004 Laser Skin Resurfacing, Ablative; segment, facial

17999-Y0005 Laser Skin Resurfacing, Non-ablative; total face

17999-Y0006 Laser Skin Resurfacing, Non-ablative; segment, facial

17999-Y0007 Laser Skin Resurfacing, Non-ablative; neck

17999-Y0008 Laser Skin Resurfacing, Non-ablative; chest

17999-Y0009 Laser Skin Resurfacing, Non-ablative; back and shoulder

17999-Y0010 Laser Skin Resurfacing, Non-ablative; arms

17999-Y0011 Laser Skin Resurfacing, Non-ablative; hands

17999-Y0012 Laser Skin Resurfacing, Non-ablative; legs

17999-Y5831 Abdominoplasty

17999-Y5835 Buttock Augmentation w/ implant

17999-Y5836 Buttock Augmentation w/o implant

17999-Y5837 Calf Augmentation

17999-Y5838 Umbilicoplasty

 

Global periods for Y codes are based on CMS global periods for comparable procedures with current valid CPT® codes.

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Updated Superbill

INSTRUCTIONS: Circle/highlight Procedure Description; check Bilateral (Bi) column; and enter the Quantity (Qty) of each procedure.

Professional Fees

+Facility Fees

+Anesthesia Fees

+Cost of Implants & Pharmaceuticals (e.g., Breast Implants, Chin Implants, Botox®, Restylane®)

=TOTAL COST

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Cost of Elective Cosmetic Procedures

Current Methodology: Anesthesia fees apply only to the primary procedure.

New Methodology: Anesthesia fees will be applied to both the primary procedure as well as additional procedures when General/Monitored Anesthesia Care is selected.

Rationale: This methodology accounts for the additional anesthesia drug and additional anesthesiology services provided to the patient when multiple procedures are performed.

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New Rate Methodology-Anesthesia

General/Monitored Anesthesia Care

(Anesthesia Base Units (Primary Procedure) +Average Time (Primary Procedure) + Average Time (Procedure 2) + …

x TRICARE Anesthesia Conversion Factor

Current Methodology: The facility fee for add-on codes performed in an outpatient operating room are reduced by 50%.

New Methodology: Eliminates multiple procedure discounts for add-on codes.

Rationale: Rates assigned to add-on codes are inherently “additional procedure rates” due to the nature of the procedure itself always being secondary to another procedure. Add-on codes are not subject to multiple procedure discounting.

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New Rate Methodology—Add On Codes

All Add-On Codes

Professional Fee, 100%Facility Fee, 100%

No additional Anesthesia Fee

Current Methodology: No facility fee is charged for additional inpatient procedures.

New Methodology: A reduced facility fee will be included for multiple inpatient procedures.

Rationale: The new calculation maintains consistency with the current CSE outpatient rate methodology. 13

Rate Methodology—Inpatient Procedures

CSE v7 (July 2011)

Primary Inpatient Procedure:Professional Fee, 100%

Facility Fee, 100%Anesthesia, 100%

Additional Inpatient Procedure:Professional Fee, 50%

No Additional Facility FeeNo Additional Anesthesia Fee

CSE v8 (July 2012)

Primary Inpatient Procedure:Professional Fee, 100%

Facility Fee, 100%No Additional Anesthesia Fee

Additional Inpatient Procedure:Professional Fee, 50%

Facility Fee, 50%No Additional Anesthesia Fee

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CSE v7-Primary Procedure Screen

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CSE v8-Primary Procedure Screen

Section 2: Costs are automatically calculated

Section 3: •Edit Estimate Entries•View, Print, Save a Cost Report

Section 1: Enter a Primary Procedure

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CSEv7-Additional Procedure Screen

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CSEv8-Additional Procedure Screen

Section 1: Additional Procedure Entry Form

Section 2: List of Additional Procedures Added to the Estimate

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CSE-Cost Report

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Saving A Cost Estimate

Issue: Estimates can only be generated for initial and additional sessions together. Often times, additional sessions are scheduled after the initial session has been performed.

Solution: Procedure codes representing “additional sessions” are available in the CSE as either a primary or additional procedure.

Example:

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Pricing an Additional Session Only

Procedure Code Description17999-Y0031 Laser tattoo removal; <= 30 sq cm, each add’l session17999-Y0033 Laser tattoo removal; >= 31 sq cm, each add’l session

Issue: Estimates cannot be generated for:- Pharmaceuticals for patients who have chemodenervation

touch-ups within the global period- Cosmetic implants priced after the initial estimate has been

generated- Elective implants for medically necessary procedures

Solution: New codes have been created that will allow estimates for pharmaceuticals, implants, and supplies without an associated procedure.

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Pricing Only a Pharmaceutical

Procedure Code Description

J9999 Pharmaceutical Only

C9999 Implant or Supply Only

CSE v8 Demonstration:

Practice Scenarios

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A patient returns 6 days after having the following procedure:

- CPT® code -64612 Chemodenervation of muscle(s) innervated by facial nerve

- This procedure has a 10 day global period

Practice Scenario #1: Pharmaceutical Only

PHARMACEUTICAL ONLY Price Qty

Name: J9999

IMPLANT/SUPPLY ONLY Price Qty

Name: C9999

Xeomin® $8.99 5

CSE Demonstration #1: Pharmaceutical Only

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A patient is scheduled to have a melanoma lesion removed and requests that a skin graft to remove an unsightly birthmark be performed at the same time. The birthmark is approximately 50 sq cm in size and the graft will require a biologic implant to close the wound.

The procedure will be performed:1) In an OR/outpatient setting2) With general anesthesia.

Practice Scenario #2: Multiple Add-on Codes

Description Code Bilateral? Quantity

SKIN SUBSTITUTE GRAFT

Trunk, arms, legs

Wound area ≤ 100 sq cm; first 25 sq cm 15271

Wound area ≤ 100 sq cm; ea add'l 25 sq cm 15272 +

Wound area ≥ 100 sq cm; first 100 sq cm 15273 Wound area ≥ 100 sq cm; ea add'l 100 sq cm 15274 + BIOLOGIC IMPLANT (May be used w/ any of the above skin graft procedures)

Implantation of biologic implant 15777 +

1

1

CSE Demonstration #2: Multiple Add-on Codes

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CHEMODENERVATION (Procedure performed by resident? Yes No )

Description Code Bilateral? Quantity

Chemodenervation; facial 64612  

Qty Price

Botox® J0585 $5.36

Chemodenervation; eccrine glands, both axillae 64650

Qty Price

Botox® J0585 $5.36

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A patient requests Botox® injections for unsightly crows feet and embarrassingly sweaty palms.

The procedure will be performed:1) In a provider’s office by a dermatology resident2) With topical anesthesia.

Practice Scenario #3: Chemodenervation

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CSE Demonstration #3: Chemodenervation

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Redesigned to work as a ‘Help’ function in the Estimator.

Press F1 to open a new window displaying the CSE User’s Guide.

Hyperlinks allow users to easily navigate to different sections of the document.

Provides line by line instructions and information.

Incorporates all of the tables from the previous version.

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User’s Guide Update

CSE Demonstration:

Electronic User’s Guide

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The CSE v8 application and all associated materials will be available for download from the new Cosmetic Surgery Estimator Web site at: https://www.ubocse.org.

Files will be password protected for controlled access.

User ID and password will be distributed to UBO Service Managers who will disseminate information to MTF staff.

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CSE v8 Distribution

Cosmetic Surgery Rates are included in the CY 2012 Outpatient Itemized Billing (OIB) Rate Package which is scheduled to be effective 1 July 2012.

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Effective Date

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Questions & Answers

Please contact the UBO Helpdesk if you have any questions or concerns at (703) 575-5385 or UBO.helpdesk@altarum.org.

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Contact Us

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Instructions for CEU Credit, cont.

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Other Organizations Accepting AAPC CEUs