Look Inside

Ready...Set...Code! . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Hierarchical Condition Categoeries . . . . . . . . . . . . . .3

They’re Back.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

MUE Logic Update . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Adverse Effects of Radiation Therapy . . . . . . . . . . .10

Coding

2015 Radiation Oncology Procedure Code Preview

Here come the new codes! And for radiation oncology, there are an unprecedented number of coding changes

scheduled for calendar year 2015.

Evaluation and Management

For calendar year 2015, there is only one change to the Evaluation and Management (E/M) Guidelines: “Military history” has been added as one of the items included in social history. Many physicians currently document this history element already, so this may not be a big change for radiation oncologists.

The complex chronic care coordination codes have been renamed “complex chronic care management.” Previously there were two codes: 99487 for services without a face-to-face visit and 99488 for services with a face-to-face visit. For 2015 code 99487 has been revised, code 99488 has been deleted and add-on code 99489 has been revised. Finally, a new code (99490) has been created for services involving at least 20 minutes of clinical staff time.

Code Description

99487

Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; establishment or substantial revision of a comprehensive care plan; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care pro-fessional, per calendar month.;

99489

. . . each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

99490

Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; com-prehensive care plan established, implement-ed, revised, or monitored.

Based on the extent of code definition, these codes will probably not be charged by radiation oncologists.

Two new codes have been created for advance care planning, including completion of advance directive. This service is frequently performed by radiation oncologists, but must be completely documented in the medical record in order to report the following codes:

2015 Radiation Oncology Procedure Code Previewcontinued on next page

October 2014, Vol. 6, No. 10

October 2014

©2014 Coding Strategies® www.codingstrategies.com – 1-877-6-CODING Page 2

Copyright © Coding Strategies® Incorporated

All rights reserved. No part of this newsletter may be reproduced without written permission from the publisher. Published by Coding Strategies® Inc., Powder Springs, GA. This newsletter reflects coding information from the 2014 Physicians’ Current Procedural Terminology (CPT®) manual. CPT® is a registered trademark of the American Medical Association. The CPT® five digit codes, nomenclature and other data are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

Code Description

99497

Advance care planning including the expla-nation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the phy-sician or other qualified health care profes-sional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

99498 . . . each additional 30 minutes (List separate-ly in addition to code for primary procedure)

Teletherapy Isodose Plans

The three existing codes for simple, intermediate, and complex teletherapy isodose plans (77305, 77310, 77315) have been deleted and been replaced with two new codes for simple and complex teletherapy isodose plans; these new codes include basic dosimetry.

Code Description

77306

Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calcula-tion(s)

77307

. . . complex (multiple treatment areas, tan-gential ports, the use of wedges, blocking, rotational beam, or special beam consider-ations), includes basic dosimetry calcula-tion(s)

Brachytherapy Isodose Plans

The three existing codes for brachytherapy isodose plans (77326, 77327, 77328) have been deleted. They have been replaced by three new codes that define the levels for remote afterloading brachytherapy in terms of channels rather than sources; like the new teletherapy isodose plan codes, these plan codes include basic do-simetry.

Code Description

77316

Brachytherapy isodose plan; simple (calcula-tion[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)

77317

. . . intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s)

77318

. . . complex (calculation[s] made from over 10 sources, or remote afterloading brachythera-py, over 12 channels), includes basic dosime-try calculation(s)

IMRT Treatment Delivery

The existing IMRT treatment delivery codes (77418, 0073T) have been deleted and replaced by two new codes for simple and complex treatment delivery, both of which include image guidance and motion tracking (when per-formed). This means that IGRT and intra-fraction motion tracking will no longer be separately coded when IMRT treatment is performed.

Code Description

77385Intensity modulated radiation treatment deliv-ery (IMRT), includes guidance and tracking, when performed; simple

77386 . . . complex

Intra-fraction Localization

The existing Category III code for intra-fraction local-ization and tracking (0197T) has been deleted. Addi-tionally, code 77421 (Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy) has been deleted; the following new code has been created:

Code Description

77387Guidance for localization of target volume for delivery of radiation treatment delivery, in-cludes intrafraction tracking, when performed

Radiation Treatment Delivery

The radiation treatment delivery codes have been restructured for calendar year 2015. There is still a single code for superficial and orthovoltage treatment, but there are now only three codes for treatment delivery at any dose greater than 1 MeV (previously there were twelve codes

2015 Radiation Oncology Procedure Code Previewcontinued from previous page

2015 Radiation Oncology Procedure Code Previewcontinued on next page

October 2014

Page 3 www.codingstrategies.com – 1-877-6-CODING ©2014 Coding Strategies®

based on both the complexity and the MeV.) The following codes have been deleted:

• 77403, 77404, 77406 for simple treatment delivery• 77408, 77409, and 77411 for intermediate treat-

ment delivery• 77413, 77414, and 77416 for complex treatment

delivery

The remaining codes have been revised and the table below shows all of the existing treatment delivery codes with their 2015 definitions.

Code Description

77401Radiation treatment delivery, superficial and/or ortho voltage, per day

77402 Radiation treatment delivery, >1 MeV; simple77407 . . . intermediate77412 . . . complex

There has also been an update to add a HCPCS Level II code for lung cancer screening, effective October 1, 2014:

Code Description

S8032 Low dose computed tomography for lung cancer screening

Radiation oncology practices and hospital departments should ensure that fee tickets and chargemasters are updated and that all individuals responsible for code capture are trained on the new codes and their new definitions. Remember that Coding Strategies will present our 15th Annual CROWN® Conference in December 2014, which will include a full day of radiation oncology coding updates, documentation guidelines and regulatory information. The handout for this session is Coding Strategies’ Navigator® for Radiation Oncology, a helpful desk reference that can be used throughout the year.

2015 Radiation Oncology Procedure Code Previewcontinued from previous page

READY . . . SET . . . CODE!

Now, it’s your turn. Try your hand with the following real-world case. When you feel you have the answer,

turn to page 8.

Scenario: The patient was seen in radiation oncology for routine follow-up nine months after salvage radiation to the prostate bed post-prostatectomy for malignancy. According to physician documentation, he is symptomatically well and is currently history of prostate cancer with no evidence of detectable disease. However, his PSA remains stable and has not decreased subsequent to radiation treatment. The patient will return in six months for another PSA.

Payor

Hierarchical Condition Categories (HCC)

Submitting claims is easy – all you need to do is report the codes for the services performed and an unspecified

cancer diagnosis and the reimbursement is guaranteed. Per-haps, but do you have Medicare Advantage patients? If so, you need to know your HCCs as well as your ICDs.

Medicare Advantage (MA) was created in 1997 with the signing of the Balanced Budget Amendment and was previously referred to as Medicare Managed Care, Medicare Part C or the Medicare+Choice program; the Medicare Modernization Act of 2003 renamed the program Medicare Advantage. New types of plans were offered, including Provider Sponsored Organizations (PSOs), Preferred Provider Organizations (PPOs) and Private Fee-For-Service

Hierarchical Condition Categories (HCC)continued on next page

October 2014

©2014 Coding Strategies® www.codingstrategies.com – 1-877-6-CODING Page 4

plans (PFFS). Congress created Medicare Advantage to encourage private insurance companies to venture into the senior care market. The plans now insure 16 million elderly and disabled people, nearly a third of those eligible for Medicare.i They are popular among beneficiaries because they often provide extra benefits, such as vision and dental care, with lower out-of-pocket costs.

The traditional model for physician reimbursement has been fee-for-service; doctors get paid for each service they provide to a patient. Under fee-for-service, the CPT® procedure codes and their individual relative values drive reimbursement and the ICD-9-CM diagnostic codes support the medical necessity of those services. In 2007 the risk adjustment phase-in was completed for the participating Medicare Advantage plans. The Medicare Advantage HCC model turns this reimbursement system upside down. In the HCC system, the patient’s number and severity of medical problems is factored into the Capitated Payment using an actuarial prediction of costs. This means that the ICD-9-CM diagnosis codes do more than support the reason for the services; they now drive CMS payments to the Medicare Advantage plan for their members.

As a result, Medicare pays the Advantage health plans higher rates for sicker patients and less for healthy patients using a complex formula called a “risk score.” MA plans are paid a set monthly fee for each patient based on the risk scores and the government trusts these plans to accurately report the health status of the participants.

The risk adjusted reimbursement model is based on chronic and cumulative conditions called Hierarchical Condition Categories (HCCs).ii The HCCs are used to adjust capitation payments to these private health care plans for the health expenditure risk of their enrollees. This means that the Medicare Advantage plan must ensure that all appropriate diagnosis codes are included when the claim is processed: the primary diagnosis, other signs and symptoms, patient comorbidities, side effects of treatment, etc. Proper coding results in the revenue used to pay the medical bills of the membership and to prepare for those who have unpredictable medical problems.

The Centers for Medicare & Medicaid Services (CMS) Risk Adjustment Model measures the disease burden using approximately 70 HCC categories, which are correlated to about 3300 diagnosis codes. Diagnoses are classified into groups to include clinically related conditions with similar cost-of-care ramifications, called diagnostic groups (DXGs). About 80% of the diagnoses used in the Risk Adjustment Processing System (RAPS) originate from the claim forms submitted by physicians and hospitals. The RAPS creates a Risk Adjustment Factor (RAF) that identifies the individual patient’s status. All of this is highly influenced by the historic costs of caring for specific chronic diseases, and payments are based upon the most severe disease manifestation. Comorbidities

can have a significant impact on the RAF and HCC determination, and consequently the resulting reimbursement.

Physicians must then focus attention to accurate and complete diagnosis reporting according to the ICD-9-CM Official Guidelines for Coding and Reportingiii (such as, coding diagnoses accurately and to the highest level of specificity). The codes submitted are derived from physician documentation of face to face encounters; only medical record documentation can be used to support an HCC. This means that a Medicare Advantage plan can utilize an office visit, hospital inpatient or hospital outpatient medical record to support the diagnosis code(s) and resulting HCC, when more than one option is available.

The following ten principles guided the creation of this diagnostic classification system:iv

1. Diagnostic categories should be clinically meaningful; conditions must be sufficiently clinically specific to mini-mize opportunities for gaming or discretionary coding.

2. Diagnostic categories should predict medical ex-penditures; diagnoses in the same HCC should be reasonably homogenous with respect to their effect on both current and future costs.

3. Diagnostic categories that will affect payments should have adequate sample sizes to permit accurate and stable estimates of expenditures.

4. In creating an individual’s clinical profile, hierar-chies should be used to characterize the person’s illness level within each disease process, while the effects of unrelated disease processes accumulate. Because each new medical problem adds to an individ-ual’s total disease burden, unrelated disease processes should increase predicted costs of care.

5. The diagnostic classification should encourage specific coding. Vague diagnostic codes should be grouped with less severe and lower-paying diagnostic categories to provide incentives for more specific diag-nostic coding.

6. The diagnostic classification should not reward coding proliferation. The classification should not mea-sure greater disease burden simply because more ICD-9-CM codes are present.

7. Providers should not be penalized for recording ad-ditional diagnoses.

8. The classification system should be internally con-sistent. For example, if diagnostic category A is high-er-ranked that category B in a disease hierarchy, and category B is higher-ranked than category C, then cate-gory A should be higher-ranked than category C.

9. The diagnostic classification should assign all ICD-9-CM codes; since each diagnostic code potentially contains relevant clinical information, the classification should categorize all ICD-9-CM codes.

Hierarchical Category Condition (HCC)continued from previous page

Hierarchical Condition Categories (HCC)continued on next page

October 2014

Page 5 www.codingstrategies.com – 1-877-6-CODING ©2014 Coding Strategies®

10. Discretionary diagnostic categories should be ex-cluded from payment models. Diagnoses that are partic-ularly subject to intentional or unintentional discretionary coding variation or inappropriate coding by health plans/providers, or that are not clinically or empirically credible as cost predictors, should not increase cost predictions.

The HCC model is accumulative, meaning that an individual patient can have more than one HCC category assigned to them. Some categories override other categories and there is a hierarchy of categories. In addition, MA plans can look backward in the medical records to correct incomplete coding. This involves reviewing the patients’ medical records to look for documentation that supports any of those 3300+ previously unreported diagnoses (unreported because they may not have been documented to support medical necessity of a previously reported service.) Following are some of the HCCs that relate to oncology:v

HCC 8 Metastatic Cancer and Acute LeukemiaHCC 9 Lung and Other Severe CancersHCC 10 Lymphoma and Other CancersHCC 11 Colorectal, Bladder and Other CancersHCC 12 Breast, Prostate and Other Cancers and

TumorsHCC 46 Severe Hematological DisordersHCC 47 Disorders of Immunity

Clinical Vignette

In addition to various documents that incorporate coding instructions, CMS provides the following example:vi

To illustrate the CMS-HCC model, we have created a hypothetical clinical vignette of a female, age 76, who lives in the community and has several chronic conditions. She received eight ICD-9-CM diagnosis codes from visits to hospitals and physicians, which are grouped into seven DXGs: acute myocardial infarction (AMI); angina pectoris; emphysema/chronic bronchitis; chronic renal failure; renal failure, unspecified; chest pain; and sprains. These seven DXGs in turn group into six CCs [condition categories], with the chronic renal failure and unspecified renal failure DXGs mapping to a single CC of renal failure. Finally, the six CCs result in three payment HCCs—AMI, Chronic obstructive pulmonary disease (COPD), and Renal failure—that are used in risk adjusting Medicare capitation payments. Although this female receives CCs for both AMI and angina, she receives no payment HCC for angina because AMI is a more severe manifestation of coronary artery disease, and thus excludes angina in the coronary artery disease hierarchy. The HCCs for major symptoms

and other injuries are also excluded from the payment calculation. Chest pain is a symptom associated with a variety of medical conditions ranging from minor to serious, and sprains are typically transitory, with minimal implications for next year’s cost.Along with the demographic factors of age 76 and female ($3,409), each of the three payment HCCs identified in the clinical vignette contributes additively to this person’s risk profile (AMI $2,681; COPD $2,975; Renal failure $2,745). Her total predicted expenditures are the sum of the individual increments, or $11,810. Her total risk score is the sum of the individual relative factors, or 1.583. [Calendar Year 2011]

HHS Study

The Medicare & Medicaid Research Review, Volume 4, Number 2 (2014) discusses “Measuring Coding Intensity in the Medicare Advantage Program.”vii According to this report, the average MA risk score has increased faster than the average FFS (fee-for-service) score every year. This means that the number of patients diagnosed with diseases that result in higher payment increased faster at MA plans than among beneficiaries enrolled in Original Medicare. If MA health plans intentionally exaggerated the severity of a patient’s medical condition, this would be considered “upcoding.” For example, “drug and alcohol dependence” is as much as eight times more common in the highest coding MA plan than among patients in standard Medicare. The report states, in part:

If MA enrollees are, in fact, getting sicker more quickly than FFS [Fee For Service] beneficiaries, we would expect to see MA mortality rates increase relative to FFS mortality.

While upcoding is always a possibility, MA plans have a vested interest in complete diagnosis coding and they may be working harder to obtain comprehensive diagnosis information to ensure each patient is accurately classified. This report adds:

Concerns about coding intensity in MA plans would be minor if coding in FFS were relatively complete, because in that case there would be little opportunity for MA plans to legitimately increase risk scores through efforts at increasing diagnostic reporting. However, FFS coding is known to be both incomplete and variable. Incomplete coding is evidenced by lack of persistence in coding of chronic conditions.Incomplete and variable coding provide ample opportunities for MA plans to increase risk scores of beneficiaries through coding intensity efforts, and a number of vendors actively market services that help plans to do so, often advertising high returns on investment (ROIs) for their services.

Hierarchical Condition Categories (HCC)continued on next page

Hierarchical Category Condition (HCC)continued from previous page

October 2014

©2014 Coding Strategies® www.codingstrategies.com – 1-877-6-CODING Page 6

Bottom Line

It all boils down to the data collection process, which of course always points back to the physician’s office and/or hospital and the documentation of the patient encounter. Good documentation begins at the time of the patient’s face-to-face encounter with the radiation oncologist when the physician documents the clinical findings in the medical record, and the medical record is used to determine ICD-9-CM codes. The CMS report states:

Coding more carefully may have real health benefits. Better identification of problems and better documentation of problems that have been identified could improve the quality of treatment provided and may even lower costs – or they may lead to unnecessary treatment and higher costs.

The only way to be certain is for every physician, freestanding cancer center and hospital to make an effort to accurately document and report diagnosis codes that classify the individual patient, including the reason for each patient encounter, all medical conditions treated and all conditions that impact the treatment provided. With complete and accurate diagnosis coding, the data will reflect the complexity of patient care and the intensity of treatment.

i. http://www.kaiserhealthnews.org/Stories/2014/August/07/Medicare-ad-vantage-plans-exaggerate-diseases-to-make-money-says-study.aspx ii. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c07.pdf iii. http://www.cdc.gov/nchs/icd/icd9cm.htm iv. http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/04Summerpg119.pdf v. https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateS-tats/downloads/Evaluation_Risk_Adj_Model_2011.pdf vi. https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRat-eStats/downloads/Evaluation_Risk_Adj_Model_2011.pdf viii. http://www.cms.gov/mmrr/Downloads/MMRR2014_004_02_a06.pdf

Hierarchical Category Condition (HCC)continued from previous page Breaking News!

They’re Back…

Faithful readers will remember that on February 18, the Centers for Medicare & Medicaid Services (CMS) an-

nounced that the Recovery Auditor program [RA, formerly Recovery Audit Contractors (RACs)] would be put on hold until new vendor contracts are awarded. In May 2014 CMS published additional information indicating that the current RAs would continue to update the “Claims Status” portion of their provider portals, continue to support the appeals process and continue to maintain their customer service areas, until further notice.

On June 2, 2014 CMS announced the “establishment of a Provider Relations Coordinator to help increase pro-gram transparency and offer more efficient resolutions to providers affected by the medical review process.” For example, if a provider believes that a Recovery Auditor is failing to comply with the documentation request limits, CMS would encourage the provider to contact the Provid-er Relations Coordinator.

Due to the continued delay in awarding new Recovery Auditor contracts, CMS announced on August 4, 2014 that they would initiate contract modifications to all the current RAs to restart some reviews. While most of these audits will be performed on an automated basis, a limited number will constitute complex reviews of selected topics (as determined by CMS).

To keep up with changes to the Recovery Audit Pro-gram or obtain contact information for the Provider Rela-tions Coordinator, visit this CMS webpage: http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Pro-grams/Recovery-Audit-Program/Recent_Updates.html

October 2014

Page 7 www.codingstrategies.com – 1-877-6-CODING ©2014 Coding Strategies®

READY . . . SET . . . CODE!

Scenario: The patient was seen in radiation on-cology for routine follow-up nine months after

salvage radiation to the prostate bed post-prostatec-tomy for malignancy. According to physician docu-mentation, he is symptomatically well and is currently history of prostate cancer with no evidence of detect-able disease. However, his PSA remains stable and has not decreased subsequent to radiation treatment. The patient will return in six months for another PSA.

Answer: There will be individual cases where there are only codes from the Supplementary Classification that can be reported to describe the patient’s current status. The correct ICD-9-CM codes for this patient include:

V67.1 Follow-up examination, following radiotherapy

V10.46 Personal history of prostate cancerV45.77 Acquired absence of genital organs

(prostate)V15.3 Personal history of irradiation

According to the ICD-9-CM Official Guidelines for Coding and Reporting, the follow-up diagnosis codes are used to explain continuing surveillance following completed treatment of a disease. These codes imply that the condition has been fully treated and no longer exists and they may be reported in conjunction with history codes to provide a complete picture of the healed condition.

To locate these codes, select main term “Follow-up” in the Alphabetic Index, subterm “radiotherapy.” Then review main term “History,” subterms “malignant neoplasm” and “prostate.” Next, review main term “Absence” and “prostate, acquired.” For the final code, again access main term “History,” subterm “irradiation.” Verify all diagnosis codes in the Tabular List to ensure that they are accurate to report the patient’s condition.

The procedures to locate ICD-10-CM codes for this patient are similar and these codes include:

Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm

Z85.46 Personal history of malignant neoplasm of prostate

Z90.79 Acquired absence of other genital organs (prostate)

Z92.3 Personal history of irradiation

Compliance

MUE Logic Update

CMS has decided to make public some important infor-mation about its Medically Unlikely Edits (MUEs). In

this article we’ll explain what this new information is and how you can use it to help prevent denials.

Background

The MUEs are claims edits that are designed to keep Medicare from paying for excessive units of service. The MUEs are one of three types of CCI edits, the other two being the Procedure-to-Procedure (bundling) Edits and the Add-On Code Edits. Each MUE consists of a procedure code together with an associated number of units. This number, according to CMS, represents “the maximum units of service that a provider would report under most circum-stances for a single beneficiary on a single date of service.” It’s important to note that not all procedure codes have an MUE. Furthermore, CMS keeps some of the MUEs secret in order to prevent unethical providers from “gaming the system.”

In the past the MUEs were applied only to individual line items, not to the claim as a whole. The February 2014 issue of Coding & Compliance Expert included the following information from the CMS National Correct Coding Policy Manual:

Providers/suppliers should be cautious about report-ing services on multiple lines of a claim utilizing mod-ifiers to bypass MUEs. If a provider/ supplier does this frequently for any HCPCS/CPT code, the provid-er/supplier may be coding units of service incorrectly.

The Government Accountability Office and Office of Inspector General found that some providers were billing multiple claim lines with modifiers to bypass these quan-tity limits and obtain overpayments from Medicare, and they urged CMS to make appropriate changes. Therefore, starting in second quarter of 2013, CMS began applying the MUEs for certain procedures to the date of service (DOS) rather than to the line item. This meant that the limit applied regardless of whether the additional procedures were re-ported on separate line items, or even on a separate claim.

Although CMS publicized the fact that some MUEs were being converted to DOS instead of line item, the agency did not identify the specific procedures that were affected. Correct Coding Solutions LLC (the contractor responsible for the Correct Coding Initiative edits) stated in a February 2013 letter to the AMA that CMS would withhold this infor-mation since the change was required “due to documented program abuses.”

MUE Logic Updatecontinued on next page

October 2014

©2014 Coding Strategies® www.codingstrategies.com – 1-877-6-CODING Page 8

Edit Status Revealed

CMS has now had a change of heart about keeping the edit status secret. In a special edition MLN Matters article (SE1422) issued on June 30, 2014, CMS announced that starting July 1, it would indicate in the MUE file whether a spe-cific procedure’s MUE will be applied to the DOS or to the line item. You can access this article on the CMS website at:http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1422.pdf

The table below shows some examples of radiation oncology services taken from the third quarter physician/practi-tioner MUE file. This is not a complete list of all radiation oncology codes and their respective MUEs. Also, there is a separate file for hospital MUEs.

HCPCS/ CPT Code

Practitioner Services MUE Values MUE Adjudication Indicator MUE Rationale

77014 2 1 Line Edit Clinical: Data77263 1 3 Date of Service Edit: Clinical Nature of Service/Procedure77280 2 1 Line Edit Nature of Service/Procedure77290 1 1 Line Edit Nature of Service/Procedure77293 1 3 Date of Service Edit: Clinical Nature of Service/Procedure77295 1 1 Line Edit Nature of Service/Procedure77301 1 1 Line Edit Nature of Service/Procedure77315 2 1 Line Edit Nature of Service/Procedure77321 1 2 Date of Service Edit: Policy Code Descriptor/CPT Instruction77328 1 1 Line Edit Nature of Service/Procedure77333 4 1 Line Edit Clinical: Data77336 1 2 Date of Service Edit: Policy Code Descriptor/CPT Instruction77370 1 3 Date of Service Edit: Clinical Nature of Service/Procedure77427 1 2 Date of Service Edit: Policy Code Descriptor/CPT Instruction77470 1 2 Date of Service Edit: Policy Code Descriptor/CPT Instruction77778 1 1 Line Edit Nature of Service/Procedure

The “Practitioner Services MUE Values” field shows you the number of units of the procedure that the MUEs allow. The “MUE Adjudication Indicator” field shows you whether that procedure is subject to a line item limit (indicator 1) or a date of service limit (indicators 2 and 3). The “MUE Rationale” field shows you whether the edit is based on anatomy, CMS policy, CPT® guidelines, or other factors.

For the date of service (DOS) MUE edits, Medicare Contractors will sum all of the units of the procedure code on the current claim and any past paid claims for the same date of service. If the sum total is greater than the MUE limit, the contractor will deny all claim lines for that code on the current claim. The claim already paid will not be reopened as part of this process. And, this rule will apply regardless of whether the claim line has a modifier or not!

Now let’s take a detailed look at each of the different Adjudication Indicators and what they imply for your reimburse-ment.

Indicator 1

Adjudication Indicator 1 indicates that the edit has not been converted to DOS and still applies only to the individual line item. For example, the treatment planning CT (77014) falls into this category. This procedure has an MUE value of 2, meaning that no more than 2 units will be paid per line. However, if medically necessary services in excess of the MUE value are provided, you can receive payment for them by reporting them on a separate line with an appropriate modifier on second line. Refer to your local Contractor website for information on modifier use.

MUE Logic Updatecontinued from previous page

MUE Logic Updatecontinued on next page

October 2014

Page 9 www.codingstrategies.com – 1-877-6-CODING ©2014 Coding Strategies®

Indicator 2

Adjudication Indicator 2 (Date of Service Edit: Poli-cy) indicates an absolute DOS edit. According to CMS article SE 1422, an indicator of 2 is “based on regulation or subregulatory instruction,” which includes the code description and the anatomy. The article gives two ex-amples. One involves a procedure that is reported once per cervical vertebra and has an MUE limit of 7. This procedure would have an indicator of 2 since patient anatomy allows the procedure to be performed no more than 7 times. The other example involves a code that is defined as “first 15 minutes,” which can be reported only once since any additional time would be subsequent rather than “first.”

Our table shows several examples of radiation on-cology codes with indicator 2. For example, code 77470 represents a special treatment procedure, which can be performed only once during a course of therapy based on authoritative coding guidance.

CMS believes that there are no instances when it is ap-propriate to report services in excess of the MUE value for a procedure with Adjudication Indicator 2. The article states that CMS expects any claims with services in excess of the MUE value for indicator 2 procedures “will represent either clerical errors or errors in the interpretation of instructions.” CMS has instructed the Medicare contractors to deny claims for services in excess of the MUE value, including redeterminations.

Indicator 3

Adjudication Indicator 3 (Date of Service Edit: Clinical) is also a DOS edit. However, it is based on clinical infor-mation such as “billing patterns; prescribing instructions; or other information.” Most DOS edits are indicator 3 rather than indicator 2.

For procedures with indicator 3, CMS states that ex-ceptions (that is, units in excess of the MUE value) “could occur,” but “would be sufficiently rare that the abnormally high units of service value should be considered to be a billing error.” In the “rare instance” when the provider is positive that the units of service in excess of the MUE value are correctly coded and medically necessary, the provider should submit an appeal.

Special physics consultation code 77370 is an example of a radiation oncology code with indicator 3. CMS has assigned an MUE value of 1 to this code based on Clin-ical Policy, and since this is a DOS edit, that means one unit per day rather than one unit per line item. In the rare instance that a patient receives two medically necessary special physics services on the same day by the same

physician during two separate and distinct encounters, and the procedures could not have been performed during the same encounter, it would be appropriate to appeal the denial of the second service.

Reopenings

CMS states in the article that providers may request a reopening, rather than filing an appeal, if they need to correct a clerical error that resulted in an MUE denial, as long as the corrected claim is equal to or less than the MUE value. However, CMS cautions providers that this will delay the full payment and is not a substitute for correct billing. For example, if a code has an MUE value of 1 and the provider submits a bilateral claim as 2 units instead of with modifier 50, the provider may request a reopening. But going forward, the provider should comply with CMS instructions and submit bilateral procedures with modifier 50 instead of 2 units.

NO ABNs!

Providers are reminded that a denial of services due to an MUE is a coding denial, not a medical necessity denial. As a result, providers cannot have the patient sign an Ad-vanced Beneficiary Notice (ABN) and shift payment liability to the beneficiary.

Conclusion

You may want to download the MUE Excel file to help you better evaluate any MUE denials you receive. You can find the file on the MUE page of the CMS website:http://www.cms.gov/Medicare/Coding/NationalCorrectCodI-nitEd/MUE.html Be sure to select the correct version of the file—“Prac-titioner Services MUE Table” for physicians or “Facility Outpatient Services MUE Table” for hospitals.

Also, there is one last caveat: CMS is still keeping the MUEs for certain procedures secret, fearing that providers might use them to “game the system.” Therefore if you do not see a particular procedure listed in the MUE file, don’t assume that there is no MUE value for that code, as it may have an unpublished value. This is generally the case with procedure code 77300 (basic dosimetry calcula-tions); while this service is subject to an MUE allowance, CMS does not publish any data regarding the maximum allowable units.

MUE Logic Updatecontinued from previous page

October 2014

©2014 Coding Strategies® www.codingstrategies.com – 1-877-6-CODING Page 10

Coding

Adverse Effects of Radiation Therapy

Cancer cells tend to be fast-growing and radiation ther-apy uses high-energy radiation to kill cancer cells

by damaging their DNA. However, radiation treatments can damage normal cells as well as cancer cells, so the course of therapy must be carefully planned to minimize side effects. This damage to healthy cells, such as those in the skin, spinal cord or mucous membranes, can cause various side effects. This doesn’t mean that the treatment was incorrect! An adverse effect of treatment occurs when the procedure is correctly prescribed and correctly admin-istered, but the patient experiences a reaction to the treat-ment.

While this article focuses on coding adverse effects of treatment using ICD-10-CM codes, the principles are the same in the ICD-9-CM classification.

Physician Documentation

Side effects, also referred to as complications of care, experienced by cancer patients include, but may not be limited to: diarrhea, fatigue, hair loss, mucositis, nausea and/or vomiting, sexual dysfunction, urinary variations and skin changes.

The ICD-10-CM guidelines (Section I.B.16) include the following instructions regarding complications of care:

Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless

of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.

This means that the medical coder should not assume that a condition is caused by the patient’s treatment unless the physician clearly documents the relationship. As a result, the first step is to make certain that physician documentation clearly reports whether the patient has diarrhea resulting from radiation therapy or diarrhea resulting from a food consumed the night before treatment.

In order to correctly code an adverse effect, the physician must document:

1. The condition(s) the patient is experiencing, such as fatigue, pain, vomiting, etc.

2. The circumstance, such as radiation treatment cor-rectly prescribed and administered.

3. Use as many codes as necessary to describe com-pletely all effects and treatments.

The focus of this article is adverse effects of radiation therapy; there are different codes for adverse effects of chemotherapy, poisoning (e.g., prescription drug and alcohol) and underdosing.

Adverse Effects of Radiation Therapycontinued on next page

October 2014

Page 11 www.codingstrategies.com – 1-877-6-CODING ©2014 Coding Strategies®

Coding Adverse Effects

Reporting adverse effects requires a minimum of two codes: one (or more) for the nature of the effect and one (or more) for the substance, treatment or procedure that caused the effect. Following is the process for reporting an adverse effect:

1. Look up the nature of the effect (for example, di-arrhea) in the Alphabetic Index and verify the code se-lected in the Tabular List.

2. If there is more than one adverse effect, report the code for each condition the patient experiences (for ex-ample, pain and fatigue).

3. The ICD-10-CM Official Guidelines for Coding and Reporting state to include code Y84.2 (Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure) as the final code.

http://www.cdc.gov/nchs/data/icd/icd10cm_guide-lines_2014.pdf

Now that you know the guidelines for coding adverse effects, apply those skills on the following example:

A patient is evaluated by the radiation oncologist and medical record documentation supports diarrhea, nocturia and erectile dysfunction due to IMRT for prostate cancer. The codes for this patient include:

Code DescriptorR19.7 Diarrhea, unspecifiedR35.1 NocturiaN52.8 Other male erectile dysfunctionC61 Malignant neoplasm of prostate

Y84.2

Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient or of later complication, without mention of misadventure at the time of the procedure

Adverse Effects of Radiation Therapycontinued from previous page

There is increased specificity in the ICD-10-CM codes; for example, if the patient’s erectile dysfunction was due to the disease process (e.g., due to the prostate malignancy or an enlarged prostate), the correct ICD-10-CM diagnosis code would be N52.1 (Erectile dysfunction due to diseases classified elsewhere). Code N52.1 would be reported as a secondary code; the primary code would be assigned to designate the underlying disease responsible for the dysfunction.

Also, remember that the effect of radiation treatment is not always a default symptom code; for example (not a comprehensive list):

K52.0 Gastroenteritis and colitis due to radiation

J70.0 Acute pulmonary manifestations due to radiation

L58.0 Acute radiodermatitis

L58.1 Chronic radiodermatitis

L59.0 Erythema ab igne

It is important to note that the physician documented the cause of the diarrhea, nocturia and erectile dysfunction (due to radiation therapy). By accurately reporting all relevant diagnosis codes, including treatment of adverse effects, you can illustrate quality care and support the complexity of patient treatment.