Transcript 2 new codes

2012 CPT UPDATES
AAHAM
January 20, 2012
Presented by
Lynn Pascoe, CHCA, CHCC, CPC, CPC-I, CEMC, PCS,
CCP
Innovative Medical Practices, LLC
Disclaimer
• Every reasonable effort has been taken to ensure that the educational
information provided in today’s presentation is accurate and useful. Pursuant
to the protection of proprietary documentation under established copyright
laws, the attendee may not distribute and/or sell all or any portion of this
material.
• This handout material is designed to provide information in regard to the
subject matter presented and is based on presenters experiences, opinion and
interpretation. Failure to abide fully with all the terms and conditions
contained in this material may result in possible civil and criminal penalties
including liquidating damages.
• Current Procedural Terminology (CPT®) is copyright 2012 American
Medical Association. All Rights Reserved. CPT is a registered trademark of
the American Medical Association.
• We appreciate your understanding and compliance with this notice and hope
you find the information presented of benefit.
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Agenda
1.CMS MFS, ABNs, ACA
updates and modifiers
2. 2012 CPT Code Changes
3.Question and Answer
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2012 CPT Changes Overview
Section
Modifiers
Eval & Mgmt
Surgery
Anesthesia
Radiology
Path & Lab
Medicine
Cat II and Cat III
New
Revised
0
0
55
0
10
104
15
59-II/
31-III
2
0
86
0
8
5
24
Cat II – 3
Cat III - 3
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Revised ABN
• Form CMS-R-131 (03/11)
Form Approved OMB No. 0938-0566
• Must be in place by 1/1/2012 – Older versions
invalid
• The mandatory use date has been changed from
September of 2011 to January of 2012 to
accommodate those providers and suppliers with
pre-printed stockpiles of ABNs - additional time
to exhaust their supplies of the outgoing ABN.
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Revised ABN
• CMS - no substantial changes to the form other than
the new release date
• New form shows that it was reviewed and approved by
the Executive Office of Management and Budget.
• Formatting changes intended to comply with
accessibility standards in Section 508 of the
Rehabilitation Act of 1973.
• There are also no changes other than formatting to the
instructions for use of the ABN.
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2012 Medicare Physician Fee
Schedule
• Significant in Fed Reg were comments re:
forecast of CMS’ plan to carry out government
mandates for a value-based payment modifier,
which will actually modify payments under the
Medicare Physician Fee Schedule based on
Medicare's record of the quality of care you
provide to patients compared with the cost of
that care.
• Sound familiar? PQRS or P4P
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2012 Medicare Physician Fee
Schedule
• What is clear from the rule is that the process is
underway to put the value-based modifier in
place by 2015 for some physicians (based on
claims and quality reporting in 2013) and
• By 2017 for all physicians (probably based on
claims and quality reporting in 2015).
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2012 Medicare Physician Fee
Schedule
CMS has this to say in the final rule:
"We strongly encourage physicians to participate in the Physician
Quality Reporting System program and the EHR Incentive
Program sooner rather than later and to choose to report quality
of care measures that best reflect their practice and patient
population.
Although we have not yet proposed the value modifier
methodology, our primary interest at this point is to increase the
quality of care for Medicare beneficiaries.
We note that we also plan to propose a value modifier in rule
making during 2012, prior to the initial performance period.
Thus, we believe it is reasonable to encourage physicians to
report appropriate quality measures well in advance and
irrespective of the exact value modifier methodology at this
time."
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Bundling and Misvalued Services
• CMS RUC committee continues to evaluate CPT
services that are performed together 75% or more
• Results in bundling codes and payment reductions –
continue each year
• CMS include review of codes with low RVUs but high
utilization, codes that have the largest growth in
utilization in the Medicare database, site of service
anomalies, etc.
• Practices should be prepared to negotiate adequate
payments from commercial payer contracts
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Preventive Medicine and Screening Services
Modifier Updates
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Affordable Care Act (ACA)
• Commercial plans – Eff 9/23/2010 – renewal of
all commercial plans
• No cost sharing
• Modifier -33 comes into play
• US Preventive Services Task Force – “we are
determining what is a ‘no cost’ service versus
costing sharing”
• Cost sharing may be allowed if service is not
completely preventive
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Affordable Care Act (ACA)
• Example #1
– Pt is seen for follow up of DM
– MD orders a screening blood glucose because
one had not been done recently
– MD reports 99213 – has cost sharing (off
copay)
• Lab test has no cost sharing USPSTF A/B
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Affordable Care Act (ACA)
• Example #2:
– MD sees a 45 y.o. patient for preventive
medical exam (99396) and orders a screening
PSA
– 99396 has NO cost sharing
• Lab test has cost sharing PSA is not a
USPSTF A/B test
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Affordable Care Act (ACA)
• Example #3
– At an annual well woman exam the MD performs
a Gail model risk assessment and asks about
personal and family hx of thromboembolic disease.
– Based on this a f/u visit occurs to discuss
chemoprophylaxis of breast cancer. Mole is also
checked
– MD reports 99214 for 2nd visit
– Cost sharing does not apply to the 99214 (mod 33)
as the primary purpose was preventive USPSTF
A/B
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Affordable Care Act (ACA)
• The Patient Protection and Affordable Care
Act (PPACA) requires all health care
insurance plans to begin covering preventive
services and immunizations without any costsharing, i.e., they must provide first-dollarcoverage for specified preventive services.
• The timing is dependent on when health
insurance plans renew or change.
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Affordable Care Act (ACA)
• The regulations specify that plans cannot
impose cost-sharing requirements, such as copays, coinsurance or deductibles with respect to
specified preventive services, when preventive
services are billed separately.
• When these services are part of an office visit,
the visit may not require cost-sharing if the
primary reason for the visit is to receive
preventive services.
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Modifier 33 – Preventive Services
• Modifier -33: Been in effect since 1/1/2011
• Not found in the inside front cover of CPT
• Created to aid compliance with new health care
member cost sharing for defined preventive
services for non-grandfathered policies.
• The appropriate use will reduce claim
adjustments related to preventive services
• Reduce corresponding refunds to policy
members.
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Rationale Modifier 33
• All health care plans to begin covering immunizations
and preventive services without any cost sharing,
modifier 33 has been added to identify a service as a
preventive service.
• The new mandate may also affect payer coverage or
payment policies for services listed in the Counseling
Risk Factor Reduction and Behavior Change
Intervention section of CPT (99401–99429)
• AMA has publication with table on uses of Mod -33
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CMS Annual Wellness Visit
(AWV)
• Sect 4013 of ACA-allows coverage and payment for an
annual wellness visit after 1/1/2011 for an individual
who is more than 12 months out from the effective date
of his/her 1st MCR B coverage period, and hasn’t
received either an IPPE or an annual wellness visit
within the past 12 months
• G0438 – Annual wellness visit, personalized prevention
plan, first visit (2.43 work RVUs)
• G0439 – AWV, PPP, subsequent visit, 1.50 work RVUs
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Modifier 33 – Preventive Services
• Examples:
– Welcome to Medicare P/E – IPPE (MCR
initial preventive P/E-G0402)
– Annual Wellness Visit (G0438 and G0439)
• CMS Quick Reference Guide for Preventive
Services – Preventive Services Manual – Table
for Mod-33 scenarios
• http://www.healthcare.gov/law/resources/regulat
ions/ prevention/recommendations.html
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Differences between G codes and
99381-99397
• Requirements for G0438-G0439 (1/1/11) for
AWV (Annual wellness visit; includes a
personalized prevention plan of service (pps),
initial visit and subsequent visits) different from
PMS
• AWV does NOT include a complete P/E
• AWV focuses on:
– Identification of risk factors
– Personalized health advice and referral for..
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Modifier PT (HCPCS II)
• If MD converts screening test to a diagnostic test i.e.,
CPT 45385 – diagnostic colonoscopy, append modifier
–PT
• In this case the patient’s deductible should be waived
but coinsurance may apply.
• Can use with appropriate CPT code for colonoscopy,
flexible sigmoidoscopy or barium enema when the
service is initiated as a colorectal cancer screening
service but becomes a diagnostic service
• Part B deductible does not apply
• This modifier is valid for CPT codes 10000 through
69999
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Examples HCPCS Modifier PT
• 68 y.o. presents for pre-scheduled screening
colonoscopy (HCPCS II code G0121)
• Polyp discovered and service turns into CPT 45385
polypectomy
• add-on PT to 45385
• Copay and deductible waived for this service
• Diagnosis does not affect benefit
• Anesthesia – moderate sedation included in CRC
screen, but if anesthesia services used, cost sharing
applied
• Lab/Path – cost sharing applies
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Modifier -92 Revised
• Modifier -92: Alternative laboratory platform testing
when:
– A lab test is performed using a kit or transportable
instrument that wholly or in part consists of a
single use, disposable chamber
– That test doesn't require permanent dedicated
space
– The test is designed to be carried or transported to
the vicinity of the patient for immediate testing at
the site
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Modifier -92 Revised
• CMS – modifier 92 indicates POS HIV testing
• CMS Transmittal 2277 states modifier -92
effective 10/1/11 for this purpose
• www.cms.gov/transmittals/downloads/R2277CP.pdf
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Evaluation and Management Services
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Evaluation & Management
Services
• CPT Added back Decision Tree – New versus
Established Patients page 5 of CPT Professional
2012
• Revised guidelines New and Established Patients
• Observation care (typical times added)
• Prolonged Services (editorial changes)
• Inpatient Neonatal Intensive Care Services –
guideline revisions
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New vs Established Patient
 Solely for the purposes of distinguishing
between new and established patients,
professional services are those face-to-face
services rendered by a physician and reported by
a specific CPT code(s). A new patient is one
who h as not received any professional services
from the physician or another physician of the
exact same specialty and subspecialty who
belongs to the same group practice, within the
past three years
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New vs Established Patient
 An established patient is one who has received
professional services from the physician or
another physician of the exact same specialty
and subspecialty who belongs to the same group
practice, within the past three years
See Decision Tree
Bottom line: did the MD have personal
knowledge/relationship with the patient(s)
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Question 1: New or Established
• Drs. Smith and Jones are in the same
nephrology group practice. Dr. Smith is a
general nephrologist. Dr. Jones does
interventional nephrology exclusively. Dr.
Jones has separate boards in I/N and payers
classify him in that specialty.
• Dr. Smith refers a patient to Dr. Jones for
consideration of a clotted fistula. Is this a new
patient to Dr. Jones?
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Question 1: New or Established
• Answer:
– The patient is “new” to Dr. Jones
– Specialty is not exactly the same
– Payer recognizes specialty and physician has
designation through separate boards
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Question 2: New or Established?
• Dr. Brown, a cardiologist, is treating a patient
with CAD. He is not responding well to
treatment and he elects to send the patient to Dr.
White who is a cardiologist CAD specialist in his
practice for further recommendations.
• Is this a new patient to Dr. White or established?
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Question 2: New or Established?
• Answer:
– The patient is “established” to Dr. White
– Specialists/subspecialists are the same in the
same group practice
– Many subspecialty areas do not have board
certifications
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Initial Observation Codes (9921899220)
• RUC established median times and
recommended RVUs
• CPT may adopt these times as typical for a
service
• Times are most relevant in relation to Prolonged
Services
• Times are consistent with Initial Hospital Care
at the same level (99221-99223)
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Prolonged Services
• Codes 99354-99355 (Office or outpatient) and
99356-99357 (inpt or OBS) gain instructions
that state: these codes may be used by “other
qualified healthcare professionals”
• Face to Face reference removed and “Direct
patient contact” defined
• Rationale relates to face-to-face and units of
time as both being direct
• Inpatient side – floor/unit time is considered
face-to-face
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Prolonged Services – CMS
Manual
• Claims Manual 100-4 CH 12:
*30.6.15.1 Prolonged Services with Direct Face-to-Face
Patient Contact Service (codes 99354-99357)
Definition: Prolonged MD services 99356 in the inpt
setting, with direct face-to-face patient contact which
require one hr beyond the usual services are payable
when they are billed on the same day by the same MD
or qualified NPP as the companion E/M codes. Each
add’l 30 min of direct f to f contact following the first
hour or prolonged services may be reported by 99357.
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Prolonged Services – CMS
Manual
• Requirement for Physician Presence
– In the case of prolonged hospital services,
time spent reviewing charts or discussion of a
patient with house medical staff and not with
direct face-to-face contact with the patient, or
waiting for test results, for changes in the
patient’s condition, for end of a therapy, or
for use of facilities, cannot be billed as
prolonged services.
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Inpatient Neonatal IC Services and
Pediatric CC Services
• Added guidelines:
– Define more precisely the services included
and how the codes are applied
• New codes: Car Seat Evaluation (94780-94781)
for nursing observation, vital signs, and bundled
with the global neonatal and pediatric initial and
subsequent critical care initial and continuing
intensive care codes
• Set up to determine airway integrity before
releasing infant to car seat
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Integumentary System
• Complete overhaul of skin replacement/skin
substitute codes
• CPT cleaned up wound debridement guidance
and code descriptions – (11042-11047)
• Revised guidelines directs coders to use modifier
-59 with either codes 11042 or 11044 as
appropriate
• Many codes in 15300-15431 range deleted
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Integumentary System
• Replaced by fewer and much more simplified
codes ex: 15271
– Application of skin substitute graft to trunk,
arms, legs, total wound surface areas up to
100 sq cm; first 25 sq cm or less wound
surface area
– 15272….each add’l 25 sq cm wound surface
area or part thereof
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Musculoskeletal
Not many changes to this system
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Musculoskeletal
• Mostly descriptor revisions
– Clarify the intent of the service
– Describe bundled services
Ex: Percutaneous vertebroplasty (2252022522) specifically identify bone bx as an
bundled service if performed
• Several injection procedures such as 27096 –
injection for Sacroiliac joint, now clearly
includes imaging guidance
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Musculoskeletal
• 2 new codes for treatment of Dupuytren’s
contracture (pronounced "DOO puh trenz)Patient’s can’t straighten their fingers
Caveat -paired
with hundreds of
codes from the
surgical section;
especially those
related to trigger
point injections,
fracture and
dislocation
services.
 20527 –
injection
enzyme
palmar fascial
cord
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Musculoskeletal
• Application of Casts/Strapping – Lower
Extremity
29582 thigh and leg, including ankle and foot,
when performed
• Like 20527 – bundled with many surgery
specialty codes – be sure to check new CCI edits
• Also – remember the rules governing casts and
strapping – who can use and when is
appropriate
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Musculoskeletal
• 2 new codes: 22633 and
22634 describe arthrodesis
via combined posterior and
posterolateral techniques with
posterior interbody technique
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Changes in Respiratory
Surgical System
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Respiratory
• Significant changes with a full page of new
instructions and added parenthetical notes that reflect
current practice.
• Every “removal of lung” code (32440-32491) has
been revised
• 6 new codes
– thoracotomy (32096-32098) with bx
– 32505-+32507 with wedge resection
– Entirely new category (32601-32674) for VATS
thoracic surgery with a dozen new codes
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Cardiovascular
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Cardiovascular
• Cardiology: Again – CPT recognized several
codes often reported together
– Revised guidelines including new definitions
• Radiological S&I is now included in these
codes
– Numerous revised codes
– Numerous new codes (9)
– New Table (pg 171 for Pacemakers) to assist
with coding
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Cardiovascular
• Combination codes were added to report renal
catheterization and angiography (36251-36254)
• New codes include the S&I portion again
• Additional instructions given to clarify
replacement of ventricular assist device pumps
(33981-33983) including removal of the new
pump in addition to connection, de-airing, and
initiation of new pump
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Digestive
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Digestive
• Few changes in this surgical section
• Several parenthetical notes added
• Ex: Stomach: Laparoscopy codes (4364443659) instructs, “for laparoscopic implantation,
revision or removal of gastric neurostimulator
electrodes, lesser curvature (morbid obesity) use
43659”.
• 3 new codes (49082-49084 describe abdominal
paracentesis replace deleted codes 49080 and
49081
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Digestive
Incision
• ▲ 47000 Biopsy of liver, needle;
percutaneous
– Rationale:
• Code 47000 revised, adding the
conscious sedation symbol to note
that moderate sedation is inherently
included as part of this procedure
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Male/Female Genital Systems
• No changes in Male GU system portion
• Female GU system:
– Several parenthetical notes added throughout
the section
– Example: Instruction to report 11981 for
insertion of a non-biodegradable
contraception implant, and 11976-11981 for
removal with subsequent insertion
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Nervous and Pain Medicine
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Nervous and Pain Medicine
• New guidelines – such as use of fluoroscopy
– Placement and use of a catheter
– Threading a catheter
– Intermittent bolus
– Reporting of codes 62310-62319
– Percutaneous spinal procedures (clarification)
– Endoscopic assistance during an open procedure
• Revised codes
• New codes
• Deleted codes
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Nervous and Pain Medicine
• Majority of guidelines changes for refinement
and clarification
• Codes 64622-64627 deleted; replaced by 6463364636 for destruction of paravertebral facet
joints by neurolytic agent
• New codes specify location (cervical, lumbar,
etc.) and the number of joint injected
– Single and then each additional
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Eye/Ocular Adnexa and Auditory
• Minor revisions with new parenthetical
instructions
– E.g., “For fitting contact lens for treatment of
disease, see 92071, 92072
– Must have evidence of disease
• Deletion 69802 – Labyrinthotomy with perfusion
with mastoidectomy
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Radiology
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Radiology
• MANY changes for developing codes for new services
and deleting codes for obsolete services
• Spine Radiology
– Part of the on-going “clean-up” of radiology codes
• Elimination of potential ambiguity
• Clarification of “complete” study
• Focus on number of views, rather than specific types of
views
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Radiology
• Improvement in technical notes
• Last yr concurrent CT of abdomen/pelvis are reported
with single bundled code
• Same principle now applies to CT Angiography bundled
– CTA: Technical note
• Always includes IV contrast
• Do not report CT separately for same session
• Bottom line – don’t unbundle
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Radiology
• New codes for intra-operative radiation
treatment delivery (77424, 77425)
– Intraoperative radiation treatment
management (77469)
• New instructions specify radiation tx
management is reported in units of five fractions
or treatment sessions, regardless of the actual
time period in which services performed
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Radiology
• Atherectomy code deleted and replaced with
other codes
• Summary:
– Bundle, bundle, bundle
– Most changes are modification and
clarifications and deletions
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Path and Lab
• Summary of changes:
– 2 new codes: 86386, 87389
– 5 revised codes: 86703, 88312-14, 88319
– 2 deleted codes: 88107, 88318
– 2 Category III codes: 0279T, 0280T
– Revision of Modifier -92
– AND………………..
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Path and Lab
• New Molecular Pathology Section in CPT!
– Guidelines and Introductory Notes (2 full pages)
– Definitions
• Tier 1 – 92 new codes
• Human Leukocyte Antigen (HLA) typing
– Tier 2 –
• 9 new codes/levels
• Current CPT coding was more non-uniform than uniform for
a given analysis
• Concern that we don’t stifle innovation and technology and
want to provide beneficial results for our patients
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Medicine
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Immunization Administration for
Vaccines/Toxoids
Revised guidelines:
– ”A component refers to all antigens in a vaccine
that prevents disease(s) caused by one organism
(90460-61). Multi-valent antigens or multiple
serotypes of antigens against a single organism are
considered a single component vaccine
– Combination vaccines are those that contain
multiple vaccine components.
– Conjugates or adjuvants contained in vaccines are
not considered to be component parts of the
vaccine as defined above”. 
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Immunization Administration for
Vaccines/Toxoids
• What does this mean?
– Descriptor revisions clarify immunization
coding (90460, +90461) by vaccine
component, rather than per injection
– Clarifies original intent
– Pneumococcal vaccine has up to 23 antigens,
but is a single disease vaccine (not a combo in
any way)
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Immunization Administration for
Vaccines/Toxoids
• What does this mean (con’t)?
– Influenza has multiple sub-types, but is
fundamentally a single disease vaccine
– Confusion in code 90644: tetanus toxoid as a
conjugate vs tetanus vaccine
–90644 descriptor revised
• 90470 H1N1 immunization administration IM,
Intranasal is deleted
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Immunization Administration for
Vaccines/Toxoids
Influenza coding
• One major change - inclusion of 90654
(Influenza virus vaccine, split virus,
preservative-free, for intradermal use),
• Adds another choice to flu vaccine coding
• Addition expands on the code family 9065590668 that already addressed influenza vaccines
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Immunization Administration for
Vaccines/Toxoids
•
•
Code 90654 is not age specific unlike codes
90655-90658 which specify the patient’s age
(either 6 to 35 months of age, or age 3 years
and older).
Code 90654 represents an intradermal
injection (administered to the dermal layer of
skin), whereas other codes (e.g. 90655-90658
and 90662) describe intramuscular injections
(administered to muscle tissue) and intranasal
administration (e.g. 90660).
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Immunization Administration for
Vaccines/Toxoids
• Code 90654 represents the vaccine product only.
• You must include the appropriate administration
code (90460-90474) on your claim.
• If your physician provides a significant,
separately identifiable E/M service during the
encounter for the vaccine, you must also report
the appropriate E/M code (99201-99205 for a
new patient or 99211-99215 for an established
patient).
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Medicine
• Esophageal motility study – use revised codes 91010
(for motility study) and +91013 for stimulation or
perfusion
• 92070 deleted; replaced with 2 new codes (92071and
92072) for contact lens fitting to treat specific ocular
surface disease
• Full page instructions added for sleep medicine testing
• New codes for EMGs per extremity
• Hydration codes 96360 and +93631 significant
additional instructions – clarifies meaning of initial
infusion and concurrent infusion
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Questions
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Thank You!!!!!!!
Lynn L. Pascoe, CHCA, CHCC, CPC, CPC-I,
CEMC, PCS, CCP
Innovative Medical Practices, LLC
 (410) 859-5757
(410) 850-0360
Mobile: (443) 822-0519
Email: [email protected]
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