Transcript
Page 1: January 18, 2005 Handout

AAPC – Omaha ChapterJanuary 18, 2005

7:00 am

Presented by:Cynthia A. Swanson, RN, CPCPaula L. Smith, RN, CPC, CCS-P Seim, Johnson, Sestak & Quist, LLP8807 Indian Hills Drive, Suite 300 Omaha, NE 68114402.330.2660

CPT 2005 Changes and Medicare Update

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AGENDA

2005 CPT Overview of CPT Code Changes Category II Codes Category III Codes

Medicare 2005 Changes Other Issues/Discussion

DisclaimerA presentation can neither promise nor provide a complete review of the myriad of facts, issues, concerns and considerations that impact upon a particular topic. This presentation is general in scope, seeks to provide relevant background, and hopes to assist in the identification of pertinent issues and concerns. The information set forth in this outline is not intended to be, nor shall it be construed or relied upon, as legal advice. Recipients of this information are encouraged to contact their legal counsel for advice and direction on specific matters of concern to them.

CPT is a trademark of the American Medical Association. CPT codes, descriptions and modifiers are copyright 2004 CPT American Medical Association.

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Overview of Changes for CPT 2005

Number of Annual CPT Coding Changes

1992 732

1993 1,467

1994 796

1995 410

1996 273

1997 162

1998 399

1999 686

2000 320

2001 408

2002 502

2003 428

2004 286

2005 277

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Overview of Changes for CPT 2005

Code changes

o New Codes – 170o Revised – 61o Deleted – 46 o Hundreds of “other changes” related to guidelines,

introductory notes, explanatory text, headings, and cross-references

o Total codes for CPT 2005 = about 8,492 compared to 8,368 in 2004

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Overview of Changes for CPT 2005 No longer a grace period for new codes – must be

used for services on or after January 1, 2005

National Standard Code Set/HIPAA

AMA Publication CPT™ Changes 2005–An Insider’s View

CPT Editing Marks The Symbols

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Overview of Changes for CPT 2005

CPT Symbols● -________________________ -________________________+ -________________________ -________________________-________________________

Fill in the descriptions for these symbols Color coding scheme

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Overview of Changes for CPT 2005

CPT Symbols A new symbol was added Conscious sedation “bulls-eye” symbol has

been added for 2005 Intended to indicate those procedures in

which the provision of conscious sedation services is considered to be inherent

Not separately reported by the same physician performing the primary service

Appendix G

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CPT 2005 Coding Manual

Appendix A – Modifiers Appendix B – Summary of Additions,

Deletions, and Revisions Appendix C – Clinical Examples Appendix D – Summary of CPT Add-on

Codes Appendix E – Summary of CPT Codes Exempt

from Modifier 51

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CPT 2005 Coding Manual FeaturesFour New Appendixes

Appendix F – Summary of CPT Codes Exempt from Modifier 63

Appendix G – Summary of CPT Codes which Include Conscious Sedation

Appendix H – Alphabetic Index of Performance Measures by Clinical Condition or Topic

Appendix I – Genetic Testing Code Modifiers

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Evaluation and Management (E/M) Services - continued

Excluding minor editorial modifications, revisions to the E/M section for CPT 2005 consist solely of clarification of the neonatal age

Consistency between diagnostic (ICD-9-CM) and procedural (CPT) code sets

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Evaluation and Management (E/M) Services - continued

Editorial revision made to the neonatal and pediatric critical care codes 99293, 99294, 99295, 99296 Most commonly utilized definition of the neonatal

period is beginning at birth and lasting through the 28th day following birth

Formerly, CPT utilized 30 days of age or less A critically ill patient of 29 days of age was reported using

a neonatal CPT code and a non-neonatal ICD-9-CM code

Resolution of discrepancy

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Evaluation and Management (E/M) Services - continued E/M Documentation Guidelines

Nothing new to report

The 1995 or 1997 E/M Documentation Guidelines are still in effect

Medicare – Can continue to use either set of guidelines

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Anesthesia

Minimal revisions

Addition of a single code

●00561 – Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, under one year of age

(Do not report 00561 in conjunction with 99100, 99116 and 99135)

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Anesthesia (continued)

Revision of the Anesthesia guidelines in tandem with the addition of Appendix G

Summary of CPT Codes Which Include Conscious Sedation

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Surgery

Notable changes in the surgery section this year include: Six new transplant series of codes and

guidelines Conversion of Category III codes to

Category I codes Addition of 10 Category I codes

Guideline additions New codes for skin debridement for

necrotizing infections New codes for gastric restrictive

procedures Revisions and additions to the

bronchoscopy codes

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Surgery/Integumentary System

- Codes ●11004 – ●11006 were added to identify extensive debridement procedures

- High risk patients, soft tissue infections such as Fournier’s gangrene

- In addition to the risk and extensiveness involved in the performance of debridement procedure, transplantation or removal of organs, hernia and/or intestinal repair, or fistula repair may be necessary

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Surgery/Integumentary (continued)

Add-on code ●11008 has been established to identify concurrent removal of a mesh or prosthetic device

Includes parenthetical notes to identify procedures that should be separately reported and a list of exclusionary codes

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Surgery/Integumentary System (continued)

o Three codes added to the Breast Introduction Section

●19296

●19297

●19298

o Describe catheter placement and subsequent catheter removal for interstitial radioelement application in the breast following partial mastectomy

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Surgery/Integumentary System (continued)

Clarify reporting of spinal procedures related to:

- Exploration of spinal fusion - Revision of previously placed instrumentation

Introductory language has been revised and expanded

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Surgery – Musculoskeletal

Clarify reporting of spinal procedures related to:

Exploration of spinal fusion

Revision of previously placed instrumentation

Introductory language of the Spinal Arthrodesis and Spinal Instrumentation subsections has been revised and expanded

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Surgery – Musculoskeletal (continued)Exploration Subsection

- Instructs the appropriate method of reporting arthrodesis procedures which would be performed at the same session as the definitive spinal procedure

- Clarifies the use of 51 modifier

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Surgery – Musculoskeletal(continued)

Deletion of Category III codes 0012T, 0013T, 0014T

Five codes and nine cross-references were established to report techniques to provide hyaline or hyaline-like repair for articular knee defects

New codes●27412 – Autologous chondrocyte implantation,

knee●27415 – Osteochondral allograft, knee, open

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Surgery/Respiratory System

Codes ●31545 & ●31546 were added to describe direct operative laryngoscopy with removal of non-neoplastic lesion(s) of the vocal cord

Revisions to the bronchoscopy section to distinguish airway stents placed in the trachea versus the bronchus or bronchi

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Surgery – Transplantation Services

Transplantation Background

Transplantation Procedures

Donor Backbench Codes

Rationale for Changes

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Surgery/Respiratory System

Lung Transplantation

Three distinct components of physician work

1) Cadaver donor pneumonectomy(s)2) Backbench work3) Recipient lung allotransplantation

Two new codes (●32855 and ●32856) for backbench preparation of cadaver donor lung allograft prior to transplant

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Surgery/Cardiovascular System

Heart/Lung Transplantation

Codes ●33933 and ●33944 were added to describe backbench preparation of cadaver donor heart/lung allograft prior to transplantation

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Surgery/Cardiovascular System (continued)

o Four new codes added to report endovenous ablation therapy for incompetent veins

o ●36475, ●36476, ●36478 and ●36479

o Add-on code to each of the initial codes intended to report performance of ablation for each additional vein after the first vein

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Surgery/Digestive Systemo Several new gastric restrictive surgery codes were

added to reflect the rapidly expanding field of bariatric surgery

●43644 and ●43645 – laparoscopic techniques

●43845 – added to describe biliopancreatic diversion with duodenal switch

43846 – editorial revision to existing open Roux-en-Y gastric bypass for morbid obesity (150 cm or less)

For greater than 150 cm, use 43847

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Surgery/Digestive System

o New codes for backbench worko Intestine Transplant

New codes (●44715 – ●44721)

o Liver Transplant New codes (●47143 – ●47147)

o Pancreas Transplant New codes (●48551 – ●48552)

o Kidney Transplant New codes (●50323 – ●50329)

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Surgery/Nervous System

Two new codes have been added to describe laminoplasty procedures ●63050

●63051 Laminoplasty is an alternative approach

for posterior decompression of the cervical spinal cord

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Radiology

New Coding Tool

Clinical Examples in Radiology Newsletter

Authors: American Medical Association, American College of Radiology

Quarterly case-orientated format

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Radiology

o Guideline additions to the Radiology Section

o Provide greater clarity in coding

o Guidelines for reporting diagnostic angiographies in the Aorta and Arteries, Veins and Lymphatics, and Transcatheter Procedures subsections of Radiology

o Guidelines for ultrasound imaging services in the Abdomen and Peritoneum and Non-Obstetrical subsections of Radiology

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Radiology (continued)

o New codes for fetal ultrasound services ●76820

●76821

o Revisions in the Therapeutic Nuclear Medicine subsectiono Tumor Imaging

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Radiology (continued)

Six new (●78811 – ●78816) codes for reporting tumor imaging by positron emission tomography (PET) and computed tomography (CT) procedures have been added to the Nuclear Medicine Diagnostic subsection of CPT.

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Pathology and Laboratory

Codes and cross-references added to report Helicobacter pylori testing/interpretation

Additions and revisions made to the morphometric analysis codes in the Surgical Pathology subsection

Guidelines added to the Molecular Diagnostics and Cytogenetics subsections

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Medicine

Revisions to: Vaccine administration procedure codes Gastric testing codes Acupuncture codes Neurostimulator codes Echocardiography guidelines

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Medicine (continued)

Immunization Administration for Vaccines/Toxoids

Series of new codes (●90465 – ●90468) for immunization administration which incorporates the work of physician immunization counseling for young children (under 8 yrs. of age)

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Medicine (continued)

Gastroenterology

Five new codes (●91034 – ●91040) to report esophagus reflux testing, esophageal function testing and esophageal balloon distension provocation study

New testing methods in recent years

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Medicine (continued)

Active Wound Care Management

Updated section includes revised introductory guidelines

Revised codes to report selective debridement based on total surface area of wound(s) size

New procedures to describe negative pressure wound therapy techniques based on total surface area wound(s) size

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Medicine (continued)

Acupuncture Codes 97780 and 97781 were deleted Codes ●97810 – ●97814 were established

to more clearly describe acupuncture and electroacupuncture services

Codes based on 15 minute increments of personal contact with the patient

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Category II Codes

A new section of Category II (Performance Measurement) CPT codes and introductory notes was added to CPT 2004

All of the 2004 Category II codes have been deleted and renumbered

Four new codes have been added to represent Maternity Care Management

Eight new categories added for future expansion

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Category III Codes

Emerging Technology, Services and Procedures

CPT Codes – Alphanumeric identifier with a letter (T) in last field

27 new codes added

Many Category III codes have been converted to Category I codes for 2005

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Category III Codes

Series of codes added for reporting

Percutaneous transcatheter placement of extracranial vertebral or intrathoracic carotid artery stents

Ultrasound ablation of uterine leiomyomata

Acoustic heart sound recording and computer analysis

Computed tomographic colonoscopy

Percutaneous intradiscal annuloplasty

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MMA 2003

Medicare Prescription Drug, Improvement, and Modernization Act of 2003

Largest change to the Medicare program since its inception

Huge social debate

Medicare 1964 – Disease Specific benefit

Movement to preventive medicine benefit with a co-pay

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MMA 2003 (continued)

Other Changes

- Regulation

- Managed Care

- Fee Schedule Changes

- Demonstration Projects

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2005 Medicare Changes

MMA provision replaced a 4.5% reduction with a 1.5% increase for 2004 and a 3.3% reduction with a 1.5% increase for 2005

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2005 Medicare Changes (continued) Medicare Physician Fee Schedule

Conversion Factor

2004 - Conversion Factor $37.3374 2005 - Conversion Factor $37.8975

Anesthesia Conversion Factor

2004 - Conversion Factor $17.4969 2005 - Conversion Factor $17.7594

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Medicare Changes 2005 (continued) Venipuncture HCPCS Code G0001 is deleted

for 2005 Report venipuncture service with CPT code

36415 In the final rule, the status indicator for CPT

code 36415 reflects “I” – Invalid for Medicare. This is an error and it should be a “C” – Carrier priced.

Medicare reimbursement remains at $3.00 for 2005

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Medicare Changes 2005 (continued)New Medicare Preventive Services

1) Initial preventive physical examination (HCPCS “G” codes)

2) Cardiovascular screening blood tests

3) Diabetes screening tests

Specific coverage provisions apply for each of these new benefits

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Medicare Changes 2005 (continued) Preventive Physical Examination

Eligible beneficiary An initial preventive physical examination

Medical history Physician Qualified NPP Social History Review of individual’s functional ability and level

of safety Performance and interpretation of ECG

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Medicare Changes 2005 (continued) Initial Preventive Physical Examination (IPPE)

G Codes G0344 IPPE; face to face visit services limited to

new beneficiary during the first six months of Medicare enrollment

G0366 EKG, routine EKG with at least 12 leads with interpretation and report, performed as a component of the IPPE

Report IPPE and the applicable EKG (G code)

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Medicare Changes 2005 (continued)

G0367 tracing only, without interpretation and report, performed as a

component of the IPPE

G0368 interpretation and report only, performed as a component

of the IPPE

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Medicare Changes 2005 (continued) Diabetes Screening

The term “diabetes screening tests” is defined in Section 613 of the MMA as testing furnished to an individual at risk for diabetes and includes a fasting blood glucose test and other tests

Not a benefit if previously diagnosed diabetic

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Medicare Changes 2005 (continued) Diabetes Screening

Individual at risk Hypertension Dyslipidemia Obesity, BMI < or = to 30 kg/m2 Previous elevated fasting glucose Two out of four risk factors

Overweight, as defined Family history of diabetes History of gestational diabetes mellitus or

delivery of a baby weighing greater than 9 lbs 65 years of age or older

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Medicare Changes 2005 (continued) Diabetes Screening

Pre diabetic twice per 12 month period V77.1 diagnosis code CPT codes 82947, 82950, 82951

Watch for additional Medicare instructions regarding applicable coding and billing of these services

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Medicare Changes 2005 (continued) Cardiovascular Screening

Ordered as panel or individually 80061 82465 Cholesterol – total 83718 HDL – cholesterol 84478 Triglycerides

Once every five years Labs must offer lipid panel without doing LDL

above certain parameters V81.0, V81.1 and V81.2

Watch for additional Medicare instructions regarding applicable coding and billing of these services

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2005 Medicare Changes (continued) Chemotherapy Drug Demonstration Project

Goals and Objectives

Review and analyze pain control management

Minimization of nausea and vomiting Assess lack of energy Assess quality of life Assess patient symptoms and complaints

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2005 Medicare Changes (continued) Chemotherapy Drug Demonstration Project

Calendar Year 2005 Chemotherapy encounter 12 new G codes for assessment

Not at all A little Quite a bit Very much

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2005 Medicare Changes (continued)

Chemotherapy Assessment

G0921 – G0924 Assessment of nausea and vomiting

G0925 – G0928 Assessment of pain G0929 – G0932 Assessment of lack

of energy (fatigue)

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2005 Medicare Changes (continued) Chemotherapy Assessment

Participating physicians must bill the applicable G-codes for each patient status factor assessed in each of the three categories during a chemotherapy encounter

A G-code for each patient status factor must appear on the claim for payment to be made

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2005 Medicare Changes (continued)

A patient chemotherapy encounter is defined as chemotherapy administered through intravenous infusion or push, limited to once per day

An additional payment of $130 per encounter will be paid to participating providers for submitting the patient assessment data as described, during the demonstration project

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Medicare Changes 2005 (continued) MMA – Drugs Paid by Average Selling

Price Beginning January 1, 2005, the payment limit

for Part B drugs and biologicals, not paid on a cost or prospective payment basis, will be paid based on the Average Sales Price (ASP) plus 6 percent.

Drugs will be paid based on the date of service and the lower of:

The submitted charge; or The ASP plus 6 percent

Quarterly pricing updates

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Medicare Changes 2005 (continued) Medicare Incentive Payment

5% incentive payment to physicians furnishing services in physician scarcity areas (PSA)

Primary care and specialty physicians MMA defines a primary care physician as a

general practitioner, family practice practitioner, general internist, obstetrician, or gynecologist

Applies to the professional services including E/M, surgery, consultation, and home, office and institutional visits (technical services are not eligible)

Dentists, Optometrists, Podiatrists and Chiropractors are not eligible

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Medicare Changes 2005 (continued) Clinical Psychologists

Supervision of Diagnostic Tests

CP may supervise the performance of diagnostic psychological and neuropsychological testing services in addition to performing them

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Medicare Changes 2005 (continued) Other Provisions

ESRD Care Plan Oversite (CPO) Hospice Consultation CMS Replacement Drug Demonstration

“G” Codes Vaccinations

Increase in allowances Others that may be applicable to your practice

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Other 2005 Changes

CPT 2005 Erratawww.ama-assn.org

2005 Medicare Physician Fee Schedule

HCPCS 2005 Additions, Revisions, and Deletions

2005 ICD-9-CM Diagnosis Codes Effective Oct. 1 your practice should already be using

Office of Inspector General (OIG) Work Plan Fiscal Year 2005www.oig.hhs.gov

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OIG Work Plan Fiscal Year 2005

Medicare Physicians and Other Health Professionals Billing Service Companies Medicare Payments to VA Physicians Care Plan Oversight Ordering Physicians Excluded from Medicare Physician Services at Skilled Nursing Facilities

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OIG Work Plan Fiscal Year 2005 (continued)

Physician Pathology Services performed in the physician office

Cardiography and Echocardiography Services

Physical and Occupational Therapy Services

Part B Mental Health Services

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OIG Work Plan Fiscal Year 2005 (continued)

Wound Care Services

Coding of E/M Services

Use of Modifier 25

“Long Distance” Physician Claims

Provider-Based Entities

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Considerations

Practitioner/staff education on changes

Available tools/resources

Update of office and out of office encounter forms

Fee analysis/updates

Computer updates/changes

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Other Issues/Concern

Questions

Discussion


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