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January 2010 EditionHot Topics:Code Set Updates:
AMA Coding Guidance:General Coding News
Hot Topics:Alternatives to Coding Inpatient ConsultationsBy Jana Gill, MA, CPCAs reported by CMS, effective January 1, 2010, all consultation services (99241-99255) were eliminated from the Medicare Physician Fee Schedule (MPFS). CMS outlined several reasons for the deletion of these codes, some of which included reducing inconsistencies with both coding and risk of regulatory non-compliance and, more frequently, eliminating disagreement amongst insurance companies, coders and providers as to the definition of what a true consult represents. CMS has attempted to revise the fee schedule for new and established evaluation and management codes for budget neutrality and provide some coding alternatives that may end up yielding a higher RVU in certain situations. As part of the 2010 CPT revisions, the admission series of codes have been redefined by CMS to include not only the admission of the patient, but also as the primary visit for other providers participating in the patient‘s care. CMS has also added modifier –“AI” to designate the admitting physician who is managing the overall patient care. The complication of cross-walking these two series of codes is the documentation criteria. In terms of the top three levels of inpatient consultation codes (99253-99255), the documentation criteria is mostly identical to the admission codes series (99221-99223). The last two levels of consultation codes (99251, 99252) do not meet the documentation criteria for an admission service. In this case, the only coding alternative is defaulting to the subsequent hospital codes (99231, 99232) as this criterion is relatively similar. The other major concern is comparing time criteria of the 2009 consultation codes against the admission and subsequent services. Most of the higher level consults defined “average time” as approximately 30 minutes over and above the equivalent (by documentation criteria) of an admission code. In various articles published by MLN Matters, the prolonged series of codes have been highlighted to offset this time variation. As illustrated in the table below, if physicians spend the “average time,” as published for the consultation codes and this time is clearly documented in the medical record, the visit may necessitate the use of both an admission code as well as a prolonged service code. Prolonged service codes have two categories for inpatient services: one requiring face-to-face time (99356-99357); and the other non-face-to-face time (99358-99359). The non-face-to-face codes were revised to be used as not a stand along code (add-on designation has been removed) that can also be used on days before or after seeing the patient to account for extensive record review or other services related to ongoing patient management. The Table below is not a direct coding crosswalk but a visual tool to provide coding alternatives for inpatient consultation services.
Key Research to Conduct to Understand New Consultation CodingBy Kathy Lindstrom, RHITAs Ms. Gill stated in the prior article, “Alternatives to Coding Inpatient Consultation” last fall, CMS announced that due to long standing problems with documentation of consults, they would no longer recognize consult codes for payment as of January 1, 2010. To help you better understand this change and rationale, it is recommended that you review three CMS publications: Transmittal No. 1875, Change Request (CR) 6740, dated 12/14/09; MedLearn Matters Article MM6740; and CMS’s Provider Inquiry Assistance Job Aid JA6740. This change is for fee-for-service Medicare Part B only. Advantage plans and other HMO-Medicare programs may or may not accept consult codes in 2010. For Medicaid plans that follow Medicare rules, consult codes will be denied. Providers will need to check with individual payers to see if policies regarding consultations are changing. The Provider Inquiry Assistance web page states that for observation services, the consulting physician would bill with the appropriate outpatient service codes, not the observation admission codes. CMS further reiterates that if another provider besides the ED provider sees a patient in the Emergency room, be it their regular physician or another physician called in to evaluate the patient, an ED code should be billed. The Medlearn article states “Medicare may pay for an inpatient hospital visit or an office or other outpatient visit if one physician or qualified NPP in a group practice requests an evaluation and management service from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.” It may be necessary to appeal a claim with the documentation and an explanation proving the consulting physician’s expertise. One of the prevailing problems is that not all services that had been billed as consults crosswalk cleanly to another E/M code. For instance, a low level inpatient consult wouldn’t meet the documentation requirements to crosswalk to 99221, the lowest level admission code. Outpatient consultations are not differentiated by new or established patients, but outpatient codes 99201-99215 do differentiate. In Transmittal No. 1875, CMS reiterates the criteria for determining if a patient is new or established to a practice. If the consultant has provided services to the patient within the past 3 years, the consultant should be billing an established patient code. This is true even if the patient is being seen for a different diagnosis. Medicare as a secondary payer creates other issues, such as claims being submitted to the primary payer could be different than a claim going to Medicare particularly if the primary payer still accepts consult codes. Billing two admission codes to the primary payer might cause a rejection, but Medicare should pay the claim. Billing an admission and a consultation code to the primary would result in a denial if the claim is then submitted to Medicare directly from the primary payer. The Medlearn Matters article suggests these two scenarios:
On a helpful note, referring physicians no longer need to be submitted on claims; and split/shared visits for ‘consults’ are now okay, since split/shared visits for Medicare would be billed as visits where the split/shared visit is valid. Editor’s Note: Code Set UpdatesJanuary 2010 Clinical laboratory fee schedule updateThe 2010 annual update to the clinical laboratory fee schedule and laboratory services subject to reasonable charge payments was released. A number of new CPT codes were added in the fee schedule. The 2010 fee rates for new CPT codes 84145, 84431, 86305, 86780, 86826, 87150, 87493, 83876, and 88738 are priced at the same rate as codes 84146, 83520, 86316, 86781, 86356, 87798, 87798, 83880, and 88740, respectively. New HCPCS codes G0430 and G0431 are priced at the same rate as code 80100 and 80101, respectively. New code 83987 is priced at the sum of the rates of codes 82800 and 87015, new code 86352 is priced at the sum of the rates of codes 86353 and 82397, and new code 87153 is priced at the sum of the rates of codes 83891, 83898, 83904, 83912, and half of code 87900. In addition, new code 82043QW is priced at the same rate as code 82043 beginning October 1, 2009, new codes 82040QW and 87905QW are priced at the same rate as code 82040 and 87905 respectively, beginning January 1, 2009, and new codes 80069QW and 82550QW are priced at the same rate as code 80069 and 82550 respectively, beginning December 4, 2008. Also, codes 82307 and 86781 are deleted beginning January 1, 2010, 83520QW is deleted beginning October 1, 2009, and 82042QW is deleted beginning July 1, 2009. For 2010, there are no new test codes to be gap-filled. To view the updated Clinical Laboratory code set on IntelliConnect or the IRN, go to the Search Code Sets tab in CCH Coding Comply, select the Clinical Lab fee schedule code set, select added, modified, and/or deleted in the Filter Actions and in the Start Date field enter 01/01/2010. Via the search results, you will be able to export all or some codes in Excel format by checking the box next to individual codes or the “Select All” box; and then clicking on the “Export” icon in the upper right corner of the screen. To view the 2010 Clinical Lab fee schedule changes in the Coding Suite there is a link on the Coding tab under the Searchable Fee Schedules heading to the “Clinical Diagnostic Laboratory,” Users should click the link and then view the “Clinical Lab Fee Schedule Download Center” for the most recent changes. Emergency update to the 2010 Medicare physician fee schedule databaseAn emergency update to the payment files for the physician fee schedule was released with the changes are effective retroactive to January 1, 2010. Included are RVU data changes to codes 19340, 42145, 64490-64495, 77785-77787, 93740, 93770, and a status indicator change to "I" for codes S2118, S2270, S3628, S3711, S3860-S3862, and S9433. To view the updated Physician fee schedule code set on IntelliConnect or the IRN, go to the Search Code Sets tab in CCH Coding Comply, select the Physician fee schedule code set, select added, modified, and/or deleted in the Filter Actions and in the Start Date field enter 01/01/2010. Via the search results, you will be able to export all or some codes in Excel format by checking the box next to individual codes or the “Select All” box; and then clicking on the “Export” icon in the upper right corner of the screen. To view the 2010 Physician fee schedule changes in the Coding Suite there is a link on the Physician tab in the See also box for the “Physician Fee CodeBook,” Users should click the link and then view the “Changes and Updates to the PFS CodeBook” for the most recent changes. AMA Coding Guidance:December 2009 CPT AssistantBy Jennifer Ridell, CPC Coding Brief: Special EEG Tests.Two specific EEG tests can be used to provide information on cerebral seizures. CPT code 95953, monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours, is commonly provided in a physician's office to patients with a known history of epilepsy. This test is a take home test that does not require the presence of an EEG technician at all times. The patient will be hooked up to a portable EEG with 16 or more channels in the physician's office, sent home to capture activity overnight, return to the physician to return the equipment, and the data from the portable EEG will interpreted by the physician. A second possible test for cerebral seizures is reported with CPT code 95956, monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours. This code describes a diagnostic test that can be provided to patients in an inpatient or outpatient setting as part of an epilepsy evaluation. This test can also be performed in intensive care units on patient with multiple medical problems who are comatose. This test must be monitored throughout the entire 24 hour testing period by a technician, so it will most likely be performed in a free-standing facility or sleep center. Coding Clarification: Ureterotomy (Code 50605).CPT code 50605, ureterotomy for insertion of indwelling stent, all types, is being reported with increased frequency. There is only one situation where this code should be reported so there is a good chance that there is confusion over this CPT code. The only time this code should be reported is if a physician can not insert a stent into the ureter through the bladder or kidney; then the only other way is via an open ureterotomy which is reported with 50605. If a urologist is called into an operating room by a surgeon to insert a stent for purposes of marking the ureter to avoid accidentally cutting it during the operative procedure, this code should be reported in addition to modifier 52, reduced services, because the urologist did not open or close the patient. Continuous Glucose Monitoring.Continuous Glucose Monitoring (CGM) provides ongoing monitoring and recording of blood glucose levels by continuous measurement of interstitial fluid glucose levels. There are two CPT codes valid for reporting CGM services. Code 95250, ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording, and 95251, ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; interpretation and report, are valid for CGM services. These codes can only be reported once per month regardless of the total duration of CGM during that month. Coding Consultation: Questions and Answers.An article by the CPT Editorial Panel answers questions posed to the panel regarding the subjects of evaluation and management services, surgery/integumentary system, musculoskeletal system, respiratory system, cardiovascular system, digestive system, nervous system, urinary system, eye and ocular adnexa, radiology, medicine/hydration, therapeutic infusion services and physical medicine and rehabilitation. The responses answer multiple questions including: when performing an open repair of a parastomal hernia, colostomy is freed and mobilized, but not revised or moved to a different site; is it necessary to append Modifier 52 in order to report code 44346; and can code 65435, Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage), be reported for rust ring removal of cornea when no foreign body is found or removed? To view these articles via CCH Coding Comply, search from the Search Code Sets tab in Coding Comply for any of the codes listed above, view the Related Documents by clicking on the paper icon next to the code, then select the article. To view these articles in The Coding Suite go to the CPT Assistant Archives folder and in the Search field within this folder and enter “December 2009.” General Coding NewsPharmacogenomic testing for Warfarin response.On August 3, 2009, CMS issued a final decision stating that the available evidence does not demonstrate that pharmacogenomic testing to predict Warfarin (Coumadin) responsiveness improves health outcomes in Medicare beneficiaries, but the available evidence does support pharmacogenomic testing for Warfarin responsiveness under coverage with evidence development (CED). Effective August 3, 2009, pharmacogenomic testing to predict Warfarin responsiveness is covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin; have not been previously tested for CYP2C9 or VKORC1 alleles; and have received fewer than five days of Warfarin in the anticoagulation regimen for which the testing is ordered; and only then in the context of a prospective, randomized, controlled clinical study when that study meets certain criteria as outlined in Pub 100-03, section 90.1, of the National Coverage Determinations Manual. A new temporary HCPCS Level II code effective August 3, 2009, G9143, warfarin responsiveness testing by genetic technique using any method, any number of specimen(s), was developed to enable implementation of CED for this purpose. This is a once-in-a-lifetime test absent any reason to believe that the patient's personal genetic characteristics would change over time. Institutional clinical trial claims for pharmacogenomic testing for warfarin response must include HCPCS modifier Q0 and ICD-9 diagnosis code V70.7 as a secondary diagnosis. Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1880, Dec. 18, 2009 and Medicare National Coverage Determinations Manual, Pub. 100-03, Transmittal No. 111, Dec. 18, 2009. These transmittals can be viewed on the IRN or IntelliConnect at ¶158,596 and ¶158,591 in the January 4, 2010, CCH Coding Comply What’s New newsletter; or on Rex via The Coding Suite in the CMS Transmittals and MLN Matters Articles folder under the titles “R111NCD Pharmacogenomic Testing for Warfarin Response.” Coverage of kidney disease patient education services.Contractors must pay claims for kidney disease education services containing HCPCS codes G0420 or G0421 with ICD-9 diagnosis code 585.4 (chronic kidney disease, Stage IV (severe)). Contractors should deny claims for kidney disease education services billed without diagnosis code 585.4. Effective for claims with dates of service on or after January 1, 2010, Common Working File will create a line item edit to ensure that claims with HCPCS G0420 or G0421 with ICD-9 585.4 billed for kidney disease education services are not allowed on both a professional and institutional claim on the same service date. Effective for claims with dates of service on or after January 1, 2010, Common Working File will create an edit to allow no more than 6 sessions of kidney disease education services, HCPCS G0420 or G0421 with ICD-9 585.4, in a beneficiary's lifetime. Contractors should deny claims containing HCPCS G0420 or G0421 with ICD-9 585.4, for kidney disease education services when submitted for more than 6 sessions. Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1876, Dec. 18, 2009, and Medicare Benefit Policy Manual, Pub. 100-02, Transmittal No. 117, Dec. 18, 2009. These transmittals can be viewed on the IRN or IntelliConnect at ¶158,592 and ¶158,589 in the January 4, 2010, CCH Coding Comply What’s New newsletter; or on Rex via The Coding Suite in the CMS Transmittals and MLN Matters Articles folder under the titles “R117BP Coverage of Kidney Disease Patient Education Services.” Expansion of Medicare telehealth services for calendar year 2010.The 2010 physician fee schedule final rule expands Medicare telehealth services, effective January 1, 2010. CMS added three codes to the list of Medicare distant site health services for individual health and behavior assessment and intervention (HBAI) services and three codes for initial inpatient telehealth consultations. Additionally, the definition of follow-up inpatient telehealth consultations was expanded to include consultative visits provided via telehealth to beneficiaries in hospitals or Skilled Nursing Facilities (SNFs). Individual HBAI can now be reported with new CPT codes 96150-96152 and initial inpatient telehealth consultations can be reported with new codes G0425-G0427. Modifiers GT, via interactive audio and video telecommunications system, and GQ, via asynchronous telecommunications system, are valid when billed with these new telehealth codes. Follow-up inpatient telehelath consultations, HCPCS codes G0406-G0408, are now valid when billed for beneficiaries in hospitals or SNFs. Finally, CMS has eliminated the use of all consultation CPT codes. As a result of this change, office/outpatient consultation codes (99241-99245) and initial inpatient consultation CPT codes (99251-99255) will no longer be recognized by CMS. Instead, physicians and practitioners should begin billing new or established patient visit codes (99201-99215) for all office/outpatient visits performed via telehealth. Initial inpatient consultation services should now be billed with HCPCS codes G0425-G0427. Medicare Benefit Policy Manual, Pub. 100-02, Transmittal No. 118, Dec. 18, 2009 and Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1881, Dec. 18, 2009. These transmittals can be viewed on the IRN or IntelliConnect at
¶158,610
and
¶158,611
in the January 11, 2010, CCH Coding Comply What’s New newsletter; or on Rex via The Coding Suite in the CMS Transmittals and MLN Matters Articles folder under the title
“R118BP
Expansion of Medicare Telehealth Services for
CY 2010.”
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