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May 2010 Edition


Hot Topics:

AMA Coding Guidance:

General Coding News:


Hot Topics:

New Laboratory Reimbursement Extensions

   By Betty Hatten, CPC-H, MHS, MT(ASCP)

Reasonable cost payment for rural hospitals and pathology technical component payment has been in limbo for a while now, but was recently addressed by CMS in two different MLN Matters articles as a result of the Patient Protection and Affordable Care Act enactment. (See MLN Matters articles SE0931 and MM6873.)

Surgical pathology technical component sees daylight after 12/31/09 sunset

The Patient Protection and Affordable Care Act, signed into law on March 23, 2010, by President Obama, not only extended the ability of independent laboratories to bill for pathology technical component services to inpatients and outpatients in hospitals; the provision is effective for services retroactive to January 1, 2010. What this means is that if you are an independent lab with denials for services provided in first quarter 2010, CMS recommends that you contact your Medicare contractor for re-submission instructions. Ultimately, this 10 year battle has been given breathing room for the 2010 calendar year.

Not familiar with the original issues surrounding the technical component billing debate? With the implementation of APCs, the technical component of most procedures and services is packaged into the APC. Many small hospitals with low volume surgical specimens have had long term arrangements with independent labs (or larger hospitals acting as reference labs) to process their pathology samples. Per industry requests, CMS has been “thinking” about this exception and every year or so, extends the “delay” of implementation of moving technical component billing into the APC system. Facilities have had to delay billing of service performed while bills meander through Congress. Once again we have a 12 month postponement that means we will yet again be talking technical components after December 31, 2010! In the meantime, you can find official instructions for this postponement in MLN Matters article, SE0931, dated April 1, 2010.

Giving rural hospitals a break regarding clinical lab reimbursement

Are you a rural hospital with fewer than 50 beds – but not a CAH? If so, the Patient Protection and Affordable Care Act, previously mentioned, gives you an opportunity to improve your laboratory reimbursement above the clinical laboratory fee schedule payments via your cost report.

Not aware of this revenue lifeline? A number of legislative changes since 2004 have provided small “qualified” rural hospitals a way to improve outpatient clinical lab payments. In addition to the Affordable Care Act, the Medicare Modernization Act of 2003 (signed February 13, 2004), the Tax Relief and Health Care Act of 2006 (signed February 2, 2007), and the SCHIP Extension Act of 2007 have all provided either the initial bill or extensions of the bill for laboratory claims to be reimbursed “better.”

Does your facility qualify? Lab services through June 30, 2012, may qualify for some rural hospitals dependent on whether the facility is located in an area with population densities in the lowest quartile of all rural county populations as found in the Medicare Zip Code File. If you think you may qualify, contact your FI or A/B MAC, and make sure to notify your finance officers, billers, and accountants who prepare your cost reports. For further details and references, see CMS Transmittal R1940, dated April 2, 2010.

PPACA Impact on January and April 2010 APC Data Files

   By Nicole Stone, J.D., MBA

On March 23, 2010, the Patient Protection and Affordable Care Act was signed into law. Section 3401(i) of this law imposes a 0.25 percentage point reduction to the OPPS market basket for Calendar Year (CY) 2010, effective for services furnished on or after January 1, 2010.

In response to these payment changes, CMS has released revised APC Addendum A and B files on their web site for both January and April 2010 quarters. Per CMS, providers will begin seeing payments under this provision in the late May/early June time frame and should be on the alert for more information about this provision and its impact on past and future claims. It is important to note that the current version of these files does differ from revised Addendum files that were released by CMS to reflect PPACA the week of May 10th.

Because there are so many changes to code set files being released as a result of PPACA, all versions of these tables with a description of when it was released and what the changes reflect have been stored in a downloadable Excel file in Coding Guidance for CCH Coding Comply. Further, a comparison of the tables has been made to help you easily see what differs from the original Addendum files to the new files. These documents are also linked as related documents to all APC codes in the Coding Comply tool for easy access.

The most recent changes for the APC files will be available in CCH Coding Comply on May 29th. To view the updated Code Sets on IntelliConnect or the IRN, go to the Search Code Sets tab in CCH Coding Comply, select the appropriate 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.

PPACA Impact on January Physician RVU Data Files

   By Nicole Stone, J.D., MBA

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act. One week later, on March 30, the President also signed into law the Health Care and Education Reconciliation Act of 2010. These two new laws have a significant impact on the Medicare program and many of the provisions have effective dates prior to this point in time. Over the past several weeks, CMS has begun implementing various provisions of the new laws, including those with past effective dates.

Once Medicare contractors have the new payment files in place, per the above, all claims going forward will be processed at the revised rates. However, CMS continues to work on the best way to address the many claims that are paid at the rates that were in place before the current corrections and updates are made. CMS advises that all should be on the alert for further information about how they will address past claims. Until then, providers should NOT resubmit previously-processed claims affected by the payment changes, as it is likely that these resubmissions may be denied as duplicate claims.

Similar to the APC data file changes, all versions of these tables with a description of when it was released and what the changes reflect have been stored in a downloadable Excel file in Coding Guidance for CCH Coding Comply. Further, a comparison of the tables has been made to help you easily see what differs from the original RVU files to the new files. These documents are also linked as related documents to all Physician Fee Schedule codes in the Coding Comply tool for easy access.

Editor’s Note: Because CMS has stated that further changes are pending for these RVU files, we are holding off on releasing them to the Coding Comply tool in an effort to ensure you have available to you the most up-to-date and accurate information with which you can use to file claims. All files, though, are available via Coding Guidance in the downloadable Excel file. We will keep you posted on the progress of these files and regarding when the final versions have been released by CMS.

AMA Coding Guidance:

April 2010 CPT Assistant

   By Jennifer Ridell, CPC

Integumentary vs Musculoskeletal Lesion Excisions

In an attempt to clear up frequent confusion over which code to report for the excision of soft tissue tumors, the American Medical Association updated guidelines in the 2010 CPT codebook for these types of procedures. Specifically, guidelines for choosing between the integumentary system and the musculoskeletal system were revised, because making the decision between the two systems is where there is the most confusion for coders.

Integumentary codes should be reported when the lesion is removed from somewhere within the full thickness of the dermis, and Musculoskeletal codes should be reported when the lesion is removed from the subcutaneous, superficial, or deep soft tissues under the dermis. When reporting an integumentary code, simple closures are included but intermediate and complex closures should be reported separately using CPT codes 12031-12057 or 13100-13153. The removal of Musculoskeletal lesions includes simple and intermediate closures but complex closures are not included and should be reported separately.

Coding Communication: Bronchoscopy

Two new bronchoscopy codes were added to the 2010 CPT code book. This first code, 31626 (bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of fiducial markers, single or multiple), is a stand-alone code that covers bronchoscopy with the placement of fiducial markers to help mark the position of a tumor. The 2010 codebook includes a note to help users understand that the supply of fiducial markers needs to be reported separately. The second code, 31627 (with computer-assisted, image-guided navigation (list separately in addition to code for primary procedure)), is used for bronchoscopy with computer-assisted, image-guided navigation. This code was created as an add-on code for codes 31615, 31622-31631, 31635, 31636, and 31638-31643. This new procedure is especially helpful in guiding physicians to distal regions of the lung and can be helpful in numerous brochoscopic procedures. CPT code 31627 should not be reported with codes 76376 and 76377. Both new codes, 31626 and 31627, include moderate sedation.

Ventricular Assist Devices --Insertion, Removal, Replacement

Ventricular Assist Devices (VAD) are used to help patients suffering from some form of cardiomyopathy. Usually a VAD is a temporary solution until a heart transplant is possible or until the heart recovers on it's own, but it can also function as a permanent solution for cardiomyopathy. There are new replacement VAD CPT codes (33981-33983) that should be used in place of removal and insertion codes to describe replacement services. Since VADs can be used for an extended period of time, there may be the need for replacement of the pump; to report this replacement, CPT codes 22981-22983 should be used. Also, when a VAD is used as a long term solution there is a period of programming and interrogation that will occur during the first couple months. During this time the physician might make adjusts to how the VAD is working to accommodate changes in the patient. To report this period of programming and interrogation CPT code 93750, interrogation of ventricular assist device (VAD), in person, with physician analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow and volume status, septum status, recovery), with programming, if performed, and report, should be used. This code does not include the evaluation of the patient, that needs to be reported separately with the proper E/M code.

CT Colonography Procedures (Codes 74261-74263)

Category III codes 0066T and 0067T were converted to Category I codes for 2010. The new Category I CPT codes are 74261, Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material, 74262, with contrast material(s) including non-contrast images, if performed, and 74263, tomographic (CT) colonography, screening, including image postprocessing. Codes 74261 and 74262 are used for diagnostic CT colonography studies and are differentiated by the presence or absence of intravenous contrast material. CPT code 74263 is used for a screening CT colonography that is used to identify disease at an early treatable stage. To only report the professional component of 74261 and 74262 modifier 26 needs to be appended.

Coding Consultation: Questions and Answers

An article by the CPT Editorial Panel answers questions posed to the panel regarding the subjects of surgery/musculoskeletal, integumentary, nervous and respiratory systems, medicine/neurology and neuromuscular procedures, radiology/diagnostic radiology (diagnostic imaging), and pathology and laboratory/chemistry. The responses answer multiple questions including: would it be appropriate to report code 82248 for the same encounter when code 80053 is reported and when performing a palmar fasciotomy for -Dupuytren's disease to release the contracture, in which the disease may involve each hand, may code 26040 be reported for each digit released per hand? Would Modifier 50, Bilateral procedure, be appended, if performed on each hand?

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 “April 2010.”

General Coding News

Update to HCPCS Codes for Payment of Surgical Dressings in Indian Health Service Providers

CMS periodically updates the list of surgical dressing HCPCS codes billable by Indian Health Service (IHS) providers to the specialty contractor Trailblazer Health Enterprises, LLC. This transmittal updates these codes for the calendar years 2009 and 2010 and updates the surgical dressing HCPCS codes payable under revenue code 0623, surgical dressings, on type of bill (TOB) 12X (hospital inpatient part B), 13X (hospital outpatient) or 85X (Critical Access Hospital) for the calendar year 2009.

Medicare contractors should pay claim lines submitted on TOB 12X, 13X or 85X by IHS providers with dates of service January 1, 2009, through December 31, 2010, and revenue code 0623 for the following surgical dressings HCPCS codes: A6010-A6011, A6021-A6024, A6154, A6196-A6197, A6199, A6203-A6204, A6207, A6209-A6212, A6214, A6219- A6220, A6222-A6224, A6229, A6231-A6238, A6240-A6248, A6251-A6255, A6257-A6259, A6266, A6402-A6403, A6407, A6410, and A6441-A6457. In addition, HCPCS code A6412 is added to the 2009 list for calendar year 2010. Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1957, April 28, 2010.

This transmittal can be viewed on the IRN or IntelliConnect at ¶158,923 in the May 10, 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 “R1957CP Update to the HCPCS Codes for Payment of Surgical Dressings in Indian Health Service (IHS) Providers.”

Change in Claims Filing Jurisdiction for Tracheo-Esophageal Voice Prosthesis HCPCS Code

HCPCS code L8509 describes a tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type. This type of prosthesis is inserted in a physician's office or other outpatient setting. Therefore, claims for code L8509 should not be submitted to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC), but instead should be submitted to the A/B MAC or Part B carrier. Effective October 1, 2010, licensed, professional health care providers should bill claims for HCPCS code L8509 to their A/B MAC (or Part B carrier, as applicable). Medicare does not cover the item if it is shipped or dispensed to the beneficiary, who then takes the item to their physician's office for insertion. The A/B MACs or Part B carriers should deny claims in these instances. Trachea-esophageal voice prostheses identified by HCPCS code L8507 are changed by the patient/caregiver in the home setting. The filing jurisdiction for claims for HCPCS code L8507 remains with the DME MACs. HCPCS code L8509 is covered as a prosthetic device, and the Medicare allowed payment amount is based on the lower of the actual charge or the fee schedule amount for the item. Effective for claims with dates of service on or after October 1, 2010, the DME MACs must deny claims containing HCPCS code L8509 as not payable under the contractor's claims jurisdiction area. One-Time Notification Manual, Pub. 100-20, Transmittal No. 686, April 29, 2010.

This transmittal can be viewed on the IRN or IntelliConnect at ¶158,919 in the May 10, 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 “R686OTN Change in Claims Filing Jurisdiction for Tracheo-Esophageal Voice Prosthesis Healthcare Common Procedure Coding System (HCPCS) Code.”

NOTE: To follow the MediRegs links above, you will need to be a subscriber to the Coding Suite of products and if prompted, enter your username and password. If you cannot remember your user name or password go to: http://wk.mediregs.com/login_fs.html and the system will let you request a reminder. For the Internet Research Network or IntelliConnect links, you will need to be a subscriber to the CCH Coding Comply.

Requests for information about article submission and comments from readers are welcome and should be directed to at Nicole Stone at Nicole.Stone@wolterskluwer.com, Fax 847-267-2514. Customer service inquiries should be directed to 800-449-9525. CCH Coding Compliance Advisor is published monthly by CCH, a Wolters Kluwer business.

©2010 CCH. All rights reserved. No claim is made to original government works; however, the gathering, compilation, and arrangement of such materials, the historical, statutory and other notes and references, as well as commentary and materials in this Publication are subject to CCH copyright. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the publisher is not engaged in rendering legal, accounting or other professional service. If legal advice or other expert assistance is required, the services of a competent professional should be sought. For more information about the The Coding Suite or CCH Health Care Portfolio, please visit our online store at http://mediregs.com or http://health.cch.com.

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Managing Editor’s Note:

This edition of the Coding Compliance Advisor primarily focuses on laboratory, outpatient and physician coding changes that have been released retroactive to earlier 2010 dates to reflect the Patient Protection and Affordable Care Act impact. As this is being written, the January and April 2010 APC and RVU files have been re-released twice with over 5,000 code changes in each file. Take a look at the “Hot Topics” section of this newsletter to learn more about these file changes and how they will impact your claims.

Nicole Stone, J.D., MBA, Managing Editor

About the Authors

Betty Hatten, CPC-H, MHS, MT(ASCP), is a manager in health care services at HORNE LLP. Her primary responsibilities include oversight of the chargemaster assessment and maintenance team, as well as providing charge capture audits, performance improvement assessments, and focused compliance reviews. Betty is a board member of the 2010 CCH & MediRegs Coding Compliance Advisory Board.

Jennifer Ridell, CPC, is the Data Application Coordinator for CCH Coding comply, CCH Reimbursement Toolkit, and creates all value-add content in the CCH and MediRegs Coding Suite product line. She is the lead editor for the weekly Coding Comply newsletter and also writes for the CCH Medicare and Medicaid Guide weekly report letter where she serves as a coding and billing expert contributor.

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