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August 2010 EditionHot Topics:AMA Coding Guidance:Code Set Updates:General Coding News:Hot Topics:2011 ICD-9-CM and IPPS UpdatesBy Kathy Lindstrom, RHITICD-9-CM. With all the focus on ICD-10, do not forget that ICD-9-CM is still being updated. The new ICD-9-CM codes, effective October 1, 2010, have been finalized and published. CMS publishes the changes on its web site within a zipped file containing six documents. There are three documents for diagnosis codes and three for procedure codes, one for each that lists new codes, one that lists invalid codes and one that list revised titles. In the list of new codes, some have a single asterisk and some have two asterisks. Those with a single asterisk were discussed at the March 9-10 ICD-9-CM Coordination and Maintenance Committee meeting and were not finalized in time to include in the proposed rule, but they will still be implemented on October 1, 2010. Codes with a double asterisk have had a code title changed from the proposed rule. These files include the expansion of avian influenza codes, uterine anomaly codes, ABO and Rh incompatibility reaction codes, and body mass index over 40 codes. There is also a new procedure code for a central venous catheter placed with guidance, and expanded carotid sinus stimulation codes for revision and removal. Included in the 2011 ICD-9-CM update are revised official coding guidelines. These are the guidelines approved by the Cooperating Parties and the Editorial Advisory board for Coding Clinic. The guidelines are posted on the Centers for Disease Control and Prevention web site and become effective on October 1, 2010. In an effort to make changes stand out, narrative changes in the document appear in bold text. An example of this is on page 9, where the term “with” (item 8) is explained to mean ““associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.” Another example of this is on page 65, with new text in item 3 explaining status codes. Additional bolded items with explanation on status can be found on page 67. Items that are underlined have been moved within the guidelines since the October 1, 2009, publication. IPPS. The fiscal year 2011 IPPS final rule tables can be found on the CMS’s web site, which is an information packed webpage. Almost all the files offered contain information that is 508 complaint. For example, Table 5 is a list of the MR-DRGs, with relative weighing factors and Length of Stay. Tables 6A-6F contain the ICD-9-CM new/revised/deleted codes lists and are in a 508 compliant format. These are the same documents that are on the ICD-9 CMS page. Tables 6G-6K contain additions and deletions to the CC list and the MCC list. Of note, code 584.9, acute kidney failure, unspecified has been deleted from the MCC list and added to the CC list. There are two additions to the MCC list, new codes 488.01 Influenza due to identified avian influenza virus with pneumonia and 488.11 influenza due to identified novel N1N1 influenza virus with pneumonia. Two other new influenza codes 488.02 influenza due to identified avian influenza virus with other respiratory manifestations and 488.09 influenza due to identified avian influenza virus with other manifestations were added to the CC list. The other new Tables 7A and 7B contain the number of discharges, and selected percentile lengths of stay for both MS-DRGs version 27 and MS=DRGs version 28 as published in the Federal Register. Revised Signature Guidelines Issued by CMSBy Marianne Russo, CPC, CMCIn a continuing effort to identify fraud and abuse in the Medicare program, the Centers for Medicare and Medicaid Services (CMS) implemented new signature guidelines for their auditors to apply when reviewing medical record documentation. In April 2010, CMS clarified what is defined as a “legible identifier” in the medical record for each service that is either performed or ordered. The auditor has the authority to reject the documentation if the services are not authenticated by the provider. The new guidelines may be costly to practices that do not carefully follow the instructions. One major update is that physician signature stamps are NOT acceptable. CMS has instructed the contractors who review Medicare claims to accept handwritten or electronic signatures. Signature logs are also allowable. These guidelines are far reaching, as they not only pertain to the provider’s local Medicare Administrative Contractor (MAC), but also to the Comprehensive Error Rate Testing Contractors (CERTs) and the Recovery Audit Contractors (RACs) during their pre/post payment review process as well. There are three exceptions to the ruling:
CMS defines the handwritten signature as “a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation.” The signature must be dated timely, allowing for a minimal delay for the note to be transcribed. CMS instructs providers not to add a late signature into the medical record. Instead, CMS offers a provider the option of utilizing an attestation statement for illegible or unsigned notes. Remember that when using a signature attestation statement, a medical record entry must also be submitted otherwise a reviewer may reject the claim. A member of the same group practice cannot sign an attestation statement for the author of the medical record entry. If required, a provider can submit the following voluntary authentication statement:
When documenting these services, the entire event should be included, remembering that it is an established E/M service. Therefore, two of the three key components of an E/M service (e.g., history, exam, medical decision making) should be recorded. At the current time, this signature attestation statement is only a suggested format. This generic statement can be tailored to the situation, i.e. missing versus illegible signatures. The Office of Management and Budget is considering the above statement for approval. After the affidavit is approved, it will become mandatory. Although Medicare approves of a signature attestation statement, it is not clear how Medicaid views this process. The MAC and CERT auditors are also required to review the orders for prescriptions written by providers. When the order is submitted through a qualified e-Prescribing system, the auditor will not require a signature. This is only for non-controlled substances. Currently, controlled substances remain subject to the written signature guidelines. A more detailed definition of the new requirements is published in the Medicare Program Integrity Manual at Change Request (CR) #: 6698, Transmittal No. 327, dated March 16, 2010. Collaboration between CMS and FDABy Beth Browne, RN, MSN, NP, CCSOn Wednesday, August 11, 2010, the Federal Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS) announced a memorandum of understanding (MOU) in the Federal Register (Vol. 75, No. 154). The MOU was signed on June 25, 2010. The purpose of the MOU is to promote the sharing of information and expertise between the FDA and CMS. The goals of the collaboration are to explore ways to further enhance information sharing efforts through more efficient and robust inter-agency activities, promote efficient utilization of tools and expertise for product analysis, validation, and risk identification, and build infrastructure and processes that meet the common needs for evaluating the safety, efficacy, utilization, coverage, payment, and clinical benefit of drugs, biologics, and medical devices. The MOU allows the sharing of FDA data submissions with CMS, and reciprocal sharing of Medicare data with the FDA. The MOU also includes protections from unauthorized public disclosure of trade secrets and other confidential commercial information that would be protected from public disclosure by Federal statutes. Prior to the MOU, the FDA and CMS had completely separate processes for market clearance vs. determination of Medicare coverage. Typically, Medicare coverage is not available at the time of FDA approval, and usually requires additional data collection and market experience prior to issuance of Medicare local or national coverage. While the agencies will maintain separate processes for market clearance and coverage analysis, the MOU has the potential to impact reimbursement for new medical technologies as they enter the market. Data sharing between FDA and CMS may allow for parallel review for FDA clearance and Medicare coverage. This could result in Medicare coverage at the time of FDA marketing approval. Historically, it has been rare for this to occur, due to differing data requirements for FDA clearance and CMS coverage. While the potential for expedited Medicare coverage may be attractive to the medical technology industry, there may be concerns regarding how data sharing between the FDA and CMS will impact each agency's decision-making since CMS and the FDA have different goals and perspectives. Medicare’s scope is limited to Medicare beneficiaries, and coverage determinations are based on whether a technology is deemed “reasonable and necessary”. In contrast, the FDA is concerned with the general population, and the bar for approval is set to what is “safe and effective” (not necessarily “medically necessary”). Historically, the FDA data has not been sufficient for Medicare coverage, and this will not change as a result of the MOU. The exchange of data will not eliminate the need for specific clinical trials endpoints to meet each agency’s specific requirements. The MOU may potentially result in earlier reimbursement planning by industry via incorporation of reimbursement endpoints into clinical trials designed for regulatory clearance. While this may increase the expense and timeline to market clearance, it may eliminate the need for some post-market data that is currently required for Medicare coverage. Without the exchange of data, it is not uncommon for years to elapse after FDA clearance before a new technology is covered by Medicare—if at all. It is important to note that the MOU will not impact the jurisdictions of either CMS or FDA. As such, it should be expected that the sharing of information should not influence the processes of FDA clearance or Medicare coverage, but rather enhance the ability of each agency to carry out its’ respective responsibilities. AMA Coding Guidance:July 2010 CPT AssistantBy Jennifer Ridell, CPC Category II CPT® Codes and Physician Performance MeasuresData elements for physician performance measures are usually identified at the point of clinical service. The major elements comprising performance measures are the denominator (population eligible for inclusion in the measurement ), numerator (the segment of the population in compliance with the measure), and exclusions or exceptions (subsets of the denominator population for which legitimate reasons exist for not complying with the measure). CPT Category II codes are used to report numerators (and sometimes denominators) of physician performance measures in claims-based reporting systems. Most measure denominators are defined by a combination of ICD-9-CM diagnosis codes and CPT service or procedure codes. Exclusions are specified in Category II CPT codes with two-character modifiers appended to a numerator code with a hyphen (e.g., 3555F-2P). The exclusion modifier explains why the numerator criteria were not met. Performance measures developed for physicians are also used by other qualified health care professionals, while some performance measures are developed expressly for nonphysician providers. Coding for Varicose Veins TreatmentCPT code 37760, Ligation of perforator vein(s), subfascial, radical (Linton type), including skin graft, when performed, open, 1 leg, describes subfascial ligation of incompetent perforator veins. Although this procedure is done in a radical fashion and is usually accompanied by a split thickness skin graft, code 37760 was revised in 2010 to clarify that placement of a skin graft is included, when performed. This is a unilateral procedure, as indicated by the new language “1 leg.” If performed bilaterally, modifier 50, Bilateral procedure, may be appended. For endoscopic ligation of subfascial perforator veins, report code 37500, Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS). Do not report codes 37760 and 37761 in conjunction with codes 76937, 76942, 76998, or 93971. Code 37761, Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg, was established in 2010 to describe a less radical open approach to perforating veins. This is a vascular surgical operation requiring a direct incision over the perforator vein and direct ligation of a visualized vessel below the fascia. Code 37761 includes ultrasound guidance as indicated in the code descriptor. Cardiac Diagnostic ImagingFive new codes were added to the Cardiac Diagnostic Imaging subsection of the Radiology section in the CPT 2010 codebook to describe cardiac magnetic resonance imaging (MRI) for velocity flow mapping and computed tomography (CT) of the heart. Add-on code 75565 was established to report cardiac MRI for velocity flow mapping. Code 75565 is reported in conjunction with cardiac MRI codes 75557, 75559, 75561, and 75563. Do not report the three-dimensional rendering codes 76376 and 76377 separately with code 75565. Prior to the establishment of code 75565, cardiac MRI codes 75558, 75560, 75562, and 75564 included velocity flow mapping; however, these codes were deleted in CPT 2010. Code 75565 is reported only once per session. Codes 75571, 75572, 75573, and 75574 were established in CPT 2010 to describe cardiac computed tomography (CT) and coronary computed tomographic angiography (CTA), and include any quantitative assessment that may be performed as part of the same encounter. The Category III codes previously used to describe these services - 0144T, 0145T, 0146T, 0147T, 0148T, 0149T, 0150T, and 0151T - were deleted concurrent to the establishment of these new Category I codes. Codes 76376 and 76377 are considered an integral part of codes 75571-75574 and so are not reported separately. Coding Consultation: Questions and AnswersAn article by the CPT Editorial Panel answers questions posed to the panel regarding the subjects of surgery/integumentary and nervous systems and medicine/special services, procedures, and reports and physician medicine and rehabilitation. The responses answer multiple questions including: what is the appropriate code to report for excision of epidermal or pilar cysts; is there a CPT code to report serial transverse enteroplasty (STEP); is it appropriate to report insertion of indwelling tunneled pleural catheter with cuff in addition to thoracentesis; and when performing ablation of multiple veins, do add-on codes 36476 and 36479 represent any number of vessels treated beyond the first vessel? 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 “July 2010.” Code Set Updates2011 ICD-9-CM annual updateThe fiscal year (FY) 2011 MS-DRGs have been released and are currently reflected in Coding Comply. These code updates become effective October 1, 2010. This update includes changes to relative weight values for most MS-DRGs. To view the updated Code Set 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 10/01/2010. 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 updated Code Sets in the Coding Suite there is a link on the Coding tab for each code set and users should choose the appropriate code set and then view the download page for the most recent changes. General Coding NewsPayment for implantable tissue markers and implantable radiation dosimetersEffective November 6, 2010, HCPCS code A4648, Tissue marker, implantable, any type, each, and HCPCS code A4650, Implantable radiation dosimeter each, are separately billable and payable when used in conjunction with CPT® codes 19499, 32553, 49411 and 55876 on a claim for physician services. When billed on a physician claim, Medicare contractors should deny HCPCS code A4648 or HCPCS code A4650 if either CPT® code 19499, 32553, 49411or 55876 is not paid on the same claim, or in history, with the same date of service. One-Time Notification Manual, Pub. 100-20, Transmittal No. 745, August 6, 2010. This transmittal can be viewed at ¶159,205 in the August 16, 2010, CCH Coding Comply What’s New newsletter; or on Rex via The Coding Suite in the CMS Manuals section under the title “R745OTN Payment for Implantable Tissue Markers (HCPCS Code A4648) and Implantable Radiation Dosimeters (HCPCS Code A4650).” 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. You are subscribed to CCH® NetNews, sponsored by CCH INCORPORATED. 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