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September 2010 EditionHot Topics:AMA Coding Guidance:Code Set Updates:General Coding News:Hot Topics:Status of ICD Code Set Updates During the ICD-10 Transition and the Reporting of 25 Diagnosis and Procedure Codes to MedicareBy Kim Charland, BA, RHIT, CCSMany of us in this industry anxiously wait each year for CMS to release its proposed and ultimately final rules on each of the prospective payment systems so that we can understand what changes will be required for the upcoming year. As we move toward the transition to ICD-10 (don’t forget the October 1st 2013 implementation date), the IPPS (Inpatient Prospective Payment System) federal register rules have become of great interest again as we all look to perform our own impact analysis, develop our implementation time line, and our “to do” list so we are ready for ICD-10. One component in this transition is of course how ICD-9 and ICD-10 code updates will occur over the next couple of years and what resources will we have to dedicate for training. In the FY 2011 IPPS Proposed Rule, CMS discusses several options on the ICD-9 and ICD-10 update process and then solicited comments from the public. In the IPPS Final Rule, all of the comments were listed. The comments ranged from supporting that no codes in either the ICD-9 or ICD-10 code sets be updated, to continuing to update both sets fully, or to perhaps only update both code sets for new diseases and new technologies. Several commentators reminded CMS that section 503(a) of the Medicare Modernization Act (MMA) (Public Law 108-173) includes a requirement for updating ICD-9 codes twice a year to capture new technologies and that CMS would have to make a provision to capture new technologies regardless of any requests to freeze code updates. One commenter who supports the limited freeze (only update both code sets for new diseases and new technologies), is concerned for their organization as it works through the conversion as they have identified that the impact not only affects their systems but also “physician documentation, problem lists, decision support, laboratory, emergency department, radiology, nursing, scheduling, registration management, and other internal systems.” “By continuing regular code updates without a freeze, they would have to rework activities and spend cycle time doing maintenance updates to software and content updates they had already performed to include additional annual code updates.” (See Proposed Rule, 75 FR 23852, May 4, 2010, on IntelliConnect at ¶220,759 and in the Coding Suite by viewing the CMS Federal Register Collection for May 2010. See MMA on IntelliConnect at ¶50,972 and in the Coding Suite by visiting the MMA Library.) CMS’s final comments stated that it will review all comments received as part of the next ICD-9 Coordination and Maintenance Committee Meeting on September 15-16, 2010, since they have jurisdiction over any action impacting the ICD-9 and ICD-10 code sets. CMS finished by stating, “We believe that this advance notice of a partial code freeze provides the health care industry ample time to request last major code updates to ICD-9-CM and ICD-10, which could be discussed at the September 15-16, 2010 and the March 2011 ICD-9-CM Coordination and Maintenance Committee meeting. Codes discussed at these two meetings would be considered for the final major code updates on October 1, 2011. Any code issues raised after that time would be addressed at the ICD-9-CM Coordination and Maintenance Meeting in September 2011 through March 2013 to determine if they represented new technologies or new diseases. Any new technologies and diseases would then be added during the regular annual updates. Other code requests would be held for implementation on October 1, 2014.” In the IPPS FY 2011 Final Rule, CMS also discussed the requests coming from commenter’s regarding Medicare being able to process more than nine ICD-9 diagnosis and six ICD-9 procedure codes. Although hospitals are currently able to submit and report 25 ICD-9 diagnosis and 25 ICD-9 procedure codes, Medicare cannot process them because of system limitations; yet they do realize the valuable information they are missing. CMS responded that with the conversion to the 5010 claim format starting on January 1, 2011, Medicare plans on being ready to accept and process 25 ICD-9 diagnosis and 25 ICD-9 procedure codes on hospital inpatient claims as part of the HIPPA ASC X12 Technical Reports Type 3, Version 005010 (Version 5010) standards system update. CMS does realize the value of the additional code information as they relate to “payment, quality, measures, outcome analysis, and other important uses.” (See Final Rule, 75 FR 50042, August 16, 2010, on IntelliConnect at ¶181,044 and in the Coding Suite by viewing the CMS Federal Register Collection for August 2010.) What is the Difference between a Requisition and an Order?By Robin Miller-Zweifel, BS, MT (ASCP)A number of significant changes are contained in the Medicare Physician Fee Schedule Proposed rule for 2011. This article will focus on only one of the proposed changes: Physician signature requirements for ordering of clinical diagnostic laboratory tests. Since 2000, with publication of the proposed rule for Negotiated Rulemaking: Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services”, hospitals and laboratories have struggled to define and differentiate an “order” and a “requisition” for laboratory tests. Are they the same – or – can a clear distinction be made between the two forms of documentation? (See Proposed Rule, 65 FR 13082, March 10, 2000, on IntelliConnect at ¶220,043 and in the Coding Suite by viewing the CMS Federal Register Collection for March 2000.) Requisition. A requisition is commonly defined as the document or form submitted to the laboratory indicating the test to be performed. The requisition is frequently designed by the laboratory to include fields for solicitation of information required under CLIA which includes name and contact information for ordering physician / practitioner, patient demographics and billing information as well as supporting diagnosis or indication of medical necessity for the requested test(s) and specimen related information such as time and date of collection. The request, however, may also be submitted on a physician defined form or script which provides limited information other than patient name and test to be performed. Currently Medicare does not require a physician's signature on a requisition for clinical diagnostic laboratory tests. See below- “Medicare does not require the signature of the ordering physician on a laboratory service requisition. While the signature of a physician on a requisition is one way of documenting that the treating physician ordered the service, it is not the only permissible way of documenting that the service has been ordered. For example, the physician may document the ordering of specific services in the patient's medical record.” (See CMS Transmittal AB-02-030, dated March 5, 2002, on IntelliConnect at ¶152,545 and in the Coding Suite at “Transmittal AB-02-030, Administrative Policies Related to Processing Claims for Clinical Diagnostic Laboratory Services.”) Order. An order is typically defined as the physician / practitioner’s notation within a patient’s medical record that indicates the tests to be performed – and – hopefully links the test procedure to a medically necessary indication by providing a sign, symptom or diagnosis that prompted the order. The notation within the patient record is to be signed (hand-written or electronic signature) thereby authenticating the order. The two terms, however, are often confused by the order definition provided in the CMS internet-only manual (IOM) that states,
In the CY 2010 MPFS final rule, CMS stated, “an order may be delivered via any of the following forms of communication:
Based on the above citations, it would seem that the requisition and order are one-in-the-same. CMS, however, has stated that “a written order, which may be part of the medical record and the requisition, are two different documents, although a requisition that is signed may serve as an order.” Validation. The key question at hand is how does the hospital or testing laboratory validate that an authenticated order exists unless a copy of the signed order from the medical record accompanies the requisition – or - the requisition is also signed? In CMS-1503-P the Proposed rule for CY 2011 Payment Policies under the Physician Fee Schedule, we find language regarding the proposed policy that would implement signature requirements for laboratory requisitions. Enforcement of this policy would thereby standardize the guidelines for signature on the order and the requisition for laboratory testing and reduce compliance related issues for the testing laboratory. (See Proposed Rule, 75 FR 40040, June 26, 2010, on IntelliConnect at ¶220,761 and in the Coding Suite by viewing the CMS Federal Register Collection for June 2010.) Next on the list of signature related issues is how will the laboratory respond when the requisition does not include a hand-written or electronic signature? Remember, a stamped signature is not acceptable! AMA Coding Guidance:August 2010 CPT Assistant 2010By Jennifer Ridell, CPC Coding Clarification: Neck Dissection ReportingWhen reporting neck dissection it is important to understand all of the possibilities for coding the procedure. Neck dissection is a surgical procedure used in the control of neck lymph node metastasis. The goal of the procedure is to remove the neck lymph nodes where cancer may be present and to stage the cancer. There are times when resection procedures are performed on nonlymphatic structures in conjunction with neck dissection, there are specific CPT codes that should be used to report these combined procedures and they are limited to certain types of ipsilateral neck dissections. There are numerous CPT codes used to report procedures relating to Neck Dissections and some of them are: 38700, 38720, 38724, and 42426. If multiple codes are being reported it may be necessary to use modifiers 50, 51, or 59. To help code neck dissection procedures appropriately it is important that there is an understanding of the different neck dissection classification and the tumor-node-metastases classification system which helps identify the extent of cervical lymphadenopathy. Pain Medicine ClarificationThe “February 2010 CPT Assistant” included an article on pain medicine codes and detailed information on reporting instructions for pain medicine codes. The “August 2010 CPT Assistant” includes an article clarifying coding information from the February article, specifically, the use of new CPT codes 63661, 63662, 63663, and 63664 for pain medicine and how they relate to existing pain medicine codes 63650 and 63655. Coding Brief: After Hours Office Services (Codes 99050-99051)CPT 2009 included a new after hours office services code, 99051, Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service. This code was added to allow for the reporting of extended services in settings that normally have evening, weekend, and holiday hours. The original after hours services code, 99050, Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service, was revised to easily identify that it applies to extended services in settings that do not normally have evening, weekend, or holiday hours. There are currently no values assigned to these codes in the Medicare Physician Fee schedule but values can be assigned by third-party payers making it very important to record the medical necessity and services rendered on the patient's medical record. Tongue Base Tissue Volume ReductionCPT code 41530, Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session, was added in 2009 and it replaced the Category III code 0088T. Radiofrequency tongue base tissue volume reduction is a minimally invasive procedure used to improve the hypopharyngeal airway. It is usually performed in an outpatient setting under local and topical anesthesia and includes a postoperative period that includes pain and swelling only lasting for several days. Several treatment sessions may be required to remove the necessary amount of obstructive tissue but CPT code 41530 should only be reported once per session even if multiple sites at the base of the tongue were treated. Tongue Base SuspensionCPT 2009 included a new code to describe tongue base suspension using a permanent suture technique, 41512, Tongue base suspension, permanent suture technique. This code is similar to 41500 but 41500 uses a non-suture tongue base suspension and is not typically used to treat obstructive sleep apnea which is the goal of the procedure described by 41512. Coding Consultation: Questions and AnswersAn article by the CPT Editorial Panel answers questions posed to the panel regarding the subjects of surgery: nervous system and medicine: cardiovascular and neurology and neuromuscular procedures. The responses answer multiple questions including: lumbar medial branch blocks were performed on the right at L3, L4, and L5. Would codes 64490, 64491, and 64492 be reported because three different levels were injected, and please describe CPT code 36522, Photopheresis, extracorporeal. 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 “August 2010.” Code Set UpdatesCPT 2011 Annual UpdateThe American Medical Association has released the 2011 update to the CPT code set, effective, January 1, 2011. The update included over 150 new codes and over 100 each of modified and deleted codes. The new codes for 2011 included three new E/M codes for subsequent observation care (99224-99226), six injection procedure codes used during cardiac catheterization (93563-93568), and six repair codes for paraesophageal hiatal hernias (43332-43337). There were modifications made to E/M codes for physician supervision in the home health, hospice, and nursing facility settings (99374, 99375, 99377-99380), transluminal balloon angioplasty (75962 and 75964), and transcatheter placement of intravascular stent/s (37205-37208). The deleted codes for 2011 include but are not limited to: 20000, 35480-35485, 75992-75996, and 90465-90468. You can view a summary of the 2011 CPT changes via Excel in the Coding Guidance CPT section of Coding Comply on IntelliConnect at ¶801,077 or on the Coding Suite by visiting the "CodeBook updates and Changes Report" inside the 2011 HCPCS and CPT Codebook. October 2010 Physician Fee Schedule Code Set UpdateThe Physician Fee Schedule has been directly affected by legislation this year. The biggest impact has been to extend a zero percent update that was put in place for January 1, 2010 through February 28, 2010, by the Department of Defense Appropriations Act, 2010 (PubLNo 111-118). The Temporary Extension Act of 2010 (PubLNo 111-144) extended the zero percent update to March 31, 2010 and the Continuing Extension Act of 2010 (PubLNo 111-157) made the final extension to May 31, 2010. On June 25, 2010, the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (PubLNo 111-192) created a 2.2 percent update to the Physician Fee Schedule effective for June 1, 2010 through November 30, 2010. Recently CMS has released October 2010 update files and files applicable to the zero percent update with changes retroactive back to January 1, 2010. CMS has confirmed that there is currently no information available regarding the Physician Fee Schedule and what will happen come December 1, 2010 when the 2.2 percent update expires. Stay tuned to the Coding Suite for further information on updates to the Physician Fee Schedule for 2010. CMS has also released October quarterly updates to the Physician Fee Schedule via Medicare Claims Processing Manual, Transmittal No. 2051, September 17, 2010. There are three new codes, HCPCS codes Q5010, S0148, and S0169, effective October 1, 2010. There are also Status Code changes from N to R, effective June 1, 2010, for CPT codes 72159, 72159-TC, 72159-26, 73225, 73225-TC, and 73225-26, and Status Code changes from M to I, effective January 1, 2010, for HCPCS codes G8443, G8445, and G8446. (See Transmittal No. 2051 on IntelliConnect at ¶159,252 and in the Coding Suite at “October Update to the 2010 Medicare Physician Fee Schedule Database (MPFSDB).”) 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 1/1/2010, 6/1/2010, or 10/1/2010. 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. HCPCS annual update reminderCMS has issued a reminder that the annual update of the HCPCS data file will be available via the CMS mainframe telecommunication system after 8 PM Eastern time, on October 27, 2010. HCPCS codes are used by Medicare providers to report services provided on claims submitted to Medicare contractors. HCPCS consists of Level-I CPT codes from the American Medical Association and the Level-II alpha numeric codes maintained by CMS. Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 2037, Aug. 27, 2010. This transmittal can be viewed at ¶159,227 in the September 7, 2010, CCH Coding Comply What’s New newsletter; or on Rex via The Coding Suite in the CMS Manuals section under the title “R2037CP 2011 Healthcare Common Procedure Coding System (HCPCS) Annual Update Reminder.” General Coding NewsDiscarded drugs and biological policy at contractor discretionCMS has received several inquiries from various providers related to CR 6711, Transmittal 1962, regarding how the modifier JW, Drug amount discarded/not administered to any patient, is to be used for their Medicare Part B drug claims. This transmittal instructs all contractors to notify their providers of their locally determined requirements associated with the use of the JW modifier for discarded drugs and biologicals. Contractors should post the CMS provider education Medlearn Matters article related to this change request, or a direct link to the article, on their Web site and include information about it in a listserv message within one week of its availability. In addition, this provider education article should be included in the contractor's next regularly scheduled bulletin. Contractors should supplement Medlearn Matters articles with localized information that would benefit their provider community in billing and administering the Medicare program correctly. One-Time Notification Manual, Pub. 100-20, Transmittal No. 758, August 20, 2010. This transmittal can be viewed at ¶159,222 in the August 30, 2010, CCH Coding Comply What’s New newsletter; or on Rex via The Coding Suite in the CMS Manuals section under the title “R758OTN Discarded Drugs and Biological Policy at Contractor Discretion.” 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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