aama acca

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SPECT Myocardial Perfusion Imaging - 36 % cut

Transthoracic echo with spectral and color flow Doppler 10 % cut Coronar Stent 4 % c t

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Coronary Stent - 4 % cut EKG - 5 %cut Consults eliminated by CMS APC for Remote interrogation

of implantable cardiovascular monitor is reassigned reimbursement from $771 to $38

THE SKY IS FALLING …. THE SKY IS FALLING …

$38 Equipment Utilization impacts

practice expense formulas◦ Cardiac MR / Cardiac CT

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STOP◦ Playing the game by the wrong rules

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◦ Playing the game by the wrong rules◦ Providing FREE CARE◦ Adopting the wrong approach to denial management◦Under estimating the TEAM approach◦ Limiting technology to claim submission

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Document what was doneDocument why it was doneWhen appropriate – speak CPT

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The accuracy of CPT coding on the provider’s part unfortunately cannot guarantee payment

The RulesSlide 5

p y g p yby all payers and plans. Providers must review the coding and coverage policies of each individual carrier with whom they are contracted.

Copyright 2010, Coding Strategies, Inc.

Medicare Guidelines◦ Existing consultation codes will not be covered

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g(99241 – 99255) Primary or Secondary claims◦ Report outpatient ‘consults’ as Office Services New / Established ( 99201 – 99215 ) Has the patient been seen within 3 years? Documentation guidelines differ New – Est.


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◦ Report inpatient ‘consults’ as Hospital Inpatient Services

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Initial (99221-99223) for initial patient encounter Modifier AI admitting physician of record)

Subsequent evaluation during the same admission (99231 – 99233)

◦ Cross-walk … 5 levels of consults into 3 levels of Hospital Initial Inpatient Services Documentation documentation Documentation .. .documentation …


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CPT 76376◦ 3D rendering with interpretation and reporting of

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computed tomography, magnetic resonance imaging, ultrasound, or other tomographicmodality; not requiring image postprocessing on an independent workstation

◦ CPT 76377i i i i ; requiring image postprocessing on an

independent workstation


4 cardiac MRI codes that previously included flow/velocity quantification (75558, 75560, 75562, 75564) deleted

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CPT Description75557 Cardiac MRI for morphology and function wo contrast;75559 ..with stress imaging75561 Cardiac MRI for morphology and function wo contrast, followed

by contrast material and further sequences;75563 …with stress imaging

Velocity flow mapping (75565) may be used in conjunction with any cardiac MRI codes – once per encounter

+75565 Cardiac MRI for velocity flow mapping (list separately)


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Coronary Interventions Peripheral Interventions

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e p e a te e t o s Cervical Carotid Interventions

◦ Diagnostic angiography/venography separate?◦ Catheterizations separate?◦ Imaging separate?


Diagnostic angiography/venography separately reportable if:◦ No prior catheter-based angiography/venographic study is

available

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available ◦ a full diagnostic study is performed and the decision to

intervene is based on the diagnostic study A study is available, but …◦ The patient’s condition with respect to the clinical

indication has changed since the prior study, OR◦ There is inadequate visualization of the anatomy and/or

pathology ORpathology, OR◦ There is a clinical change during the procedure that

requires new evaluation outside the target area of intervention


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Via transseptal puncture, ablation catheter into the left atrium

Ring of lesions is created at the ostium of each

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Ring of lesions is created at the ostium of each affected pulmonary vein

TIME CONSUMING procedure (6+ hrs)

Report service with SVT ablation code (93651) Carriers may instruct to use unlisted code

(93799)( ) Modifier -22 may be utilized for physician

claims◦ Do more than just send in the report


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“One of the top billing

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One of the top billing errors determined by federal, state and private payors involves the incorrect use of modifiers.”


“Increased Procedural Services”

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Parenthetical notes define criteria for code as Increased: Intensity Time Technical difficulty Severity of PT condition Severity of PT condition


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Q: What would be the correct way to code the following scenario?

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A patient presents with atrial flutter or atrial fibrillation. Right atrial pacing cannot be performed because the arrhythmia cannot be paced. Right ventricle pacing/recording is not performed. Pacing and recording from the coronary sinus are done to assist in mapping the arrhythmia. Once the arrhythmogenic focus is mapped and ablated, programmed stimulation and pacing is performed in an attempt to induce the arrhythmia.


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… Because the right atrium could not be paced, and the right ventricle may not have b d d d d Alth h th

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been paced and recorded. Although the procedures described in the add-on codes 93621/93623 were done, a full comprehensive study was absent.

A: To use the add-on codes, a base code must first be reported and if all the elements of afirst be reported, and if all the elements of a comprehensive are not done, then modifier 52, Reduced services, is appropriate. (93620-52).


However, it is usually proper to perform a complete study once a sinus rhythm is obtained after

d bl f l fl d

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cardioversion or ablation for atrial flutter and fibrillation. This is to ensure that there is not a hidden accessory pathway or another problem. If atrial and ventricular pacing is done before or after the ablation, the code for a complete EP study can be reported. Whether the induction of arrhythmia is successful is irrelevant because the code describessuccessful is irrelevant, because the code describes the attempt at induction, not the success of the procedure, and supports the use of code 93620.

CPT Assistant October, 2008 Q&A


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Procedure was set up, patient came down and was prepped for an EP study. 12-lead

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p pp yshowed no arrhythmia and the decision was made to give IV Isoprel.

Option 1 – report the infusion (approx $125) Option 2 – 93620-(discontinued 53/73) (50% of

the APC rate or approx. $1700)


Designed to reduce errors due to clerical entries and incorrect coding.“ h li f l i i dj di t d t l i t

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“..each line of a claim is adjudicated separately against the MUE of the code on that line, the appropriate use of CPT modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of a MUE CPT modifiers such as -service in excess of a MUE. CPT modifiers such as 76, -77, -91, and -59 will accomplish this purpose. Modifier -59 should be utilized only if no other modifier describes the service.


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Fluoroscopic guidance can be reported by both the

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be reported by both the physician and the facility –when documented

CPT®

CodeDefinition

71090 Insertion pacemaker, fluoroscopy andradiography radiological supervisionradiography, radiological supervisionand interpretation


Importance of clinical history◦ Medical necessity◦ Signs and symptoms or

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Signs and symptoms, or◦ Confirmed diagnosis

Documentation of procedure:◦ Complete description of technique◦ Identify ancillary services such as mapping and ICE◦ When a diagnostic procedure is performed followed

by a therapeutic procedure describe the sequence ofby a therapeutic procedure, describe the sequence of events including the decision to perform the therapeutic service


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Right heart catheterization and atrial and ventricular angiography (93501, 93529-

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g g p y ( ,93533, 93539, 93543, 93555) are integral components of percutaneous transcatheter closure of septal defect and should not be reported separately.

Echocardiography (including transthoracic, transesophageal, and intracardiac) may be reported separately.


Do not rely on the coding team ◦ Can’t abstract what wasn’t documented

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◦ Can’t confirm what was done was documented

Clinical staff – providers and non-physician staff need to understand CPT guidelines for the top procedures


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Understand Medical Necessity – the carrier’s versionCommunicate Medical NecessityExpect patient participation and share of cost(s)


Health plans deny service◦ 47% … not medically necessary

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◦ 23% lack information to approve coverage◦ 17% are non-covered services

Do not assume all plans under the same payer are equal◦ Employers exclude services and/or conditions to◦ Employers exclude services and/or conditions to

reduce medical expenses


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Be familiar with evidence-based clinical guidelines

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g◦ Confirm which guidelines are used by the health

plan(s)◦ Submit documentation clearly stating the reason(s)

for the requested service Because it was ordered … Because the patient needs it …. Why is this path of treatment better than the next What is unique with this patient’s care that needs to be an

exception to the rule


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Most often used for:◦ Exam ordered for a

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Exam ordered for a condition that is not covered under the Medicare LCD

◦ Screening Studies

E bj t t◦ Exam subject to frequency limitations.


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More than resubmitting a claimThink Dandelions


All services are coded correctly All modifiers are assigned correctly

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All services are preauthorized correctly Medical necessity is clearly explained simply

with ICD-9 codes All carrier requirements are met consistently All systems are programmed correctlyy p g y Insurance carriers pay for all services

performed Pigs fly


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1) Recipient not eligible on DOS2) Recipient has other insurance coverage

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3) Past filing time w/o acceptable documentation4) NDC missing or invalid5) Duplicate claim6) Procedure code / age conflict7) Service is bundled into another service8) Service is not covered8) Service is not covered9) Procedure requires preauthorization10) Lack of medical necessity


Working denials to be paid? Working denials to get it off my desk?

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Working denials to improve the process?◦ Consider the feedback /communication ◦ Consider tracking mechanisms – education

Think Dandelions!


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Appeals Alert!

Highmark Medicare Services Appeals department isHighmark Medicare Services Appeals department is seeing numerous requests for Monitored Anesthesia Care (MAC) where the diagnosis does not meet the medical necessity requirements outlined in the Local Coverage Determination (LCD). Please double check your medical documentation against the requirements outlined in LCD L27489 prior to requesting a redetermination Remember to report diagnosis codesredetermination. Remember to report diagnosis codes that are supported by the medical documentation.

Effective January 1, 2010 … sort of◦ CMS will delete the edit retroactively but not until

April 1st

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April 1


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Working denials means understanding◦ Coding conventions

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g◦ Medical framework of the procedures◦ Communication skills needed to speak to multiple

audiences

◦ IR cases◦ EP studies – not the typical mix of services must be yp

appealed – with more than the report


An add-on code is used for ICE:

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Appropriate for specific base CPT codes; otherwise, ICE may be reported using an

CPT® Code Definition

+93662(-26) Intracardiac echocardiography during therapeutic/diagnosticintervention, including imaging supervision and interpretation (Listseparately in addition to code for primary procedure)

, y p gunlisted procedure code (93799)


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The mapping codes can be reported in conjunction with:

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◦ Comprehensive EP study (93620)◦ Ablation of arrhythmogenic focus (93651-93652)

Only one mapping code can be reported for each encounter◦ If both were done, report 3D mapping

Do not apply modifier 26 to 3-D mapping for professional component billing


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Understand the patient’s coverage Understand the carrier’s meaning of medical necessity

h l d

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Gear the letter to your audience Explain beneficiary’s condition◦ Make the patient a real person facing a difficult

situation◦ Impact of the condition of patient’s life without the

treatment◦ Describe the alternative treatments that have been◦ Describe the alternative treatments that have been

considered Explain how the treatment will reduce risk for further

treatment


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Maintain an appeals resource file◦ Template letters for frequently challenged

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gprocedures

Persistence pays off“ Keep appealing. It may take more than one

appeal to reverse a health plan’s incorrect denial. When a procedure or service has been appropriately performed, documented and pp p y p ,reported, be persistent to ensure your practice obtains the proper compensation based on the negotiated health plan contracted rate. “ AMA Practice Management Center


◦ “Appeal of a Medical Necessity or Experimental / Investigational Adverse Determination”

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Investigational Adverse Determination 90 days from date of notice (denial) Anthem acknowledges within 5 days of receipt Request for information must be received within 10

days Reviewed by specialist in same or similar specialty not

involved in initial review Resolution letter within 30 days◦ Request for external review is also an option


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Specific forms for appeals / reconsiderations State specific forms


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Training – education –Feedback –I’m just a “ x “


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Communication between provider and coding staff is a critical component

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p◦ Routine opportunities to discuss issues Protocols in conflict with coverage guidelines Discuss procedures – medical necessity

Communication within the coding staff is a critical component◦ Eliminate the need for staff to hoard information◦ Eliminate the need for staff to hoard information


Illustrate for each employee how they impact the real bottom line.

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PATIENT CARE

Accept the diversity in work style, motivation, and adapt wherever possible

Cl l id tif Th C t d d Clearly identify The Customer and respond accordingly


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Analysis (RAC) data miningInternal Edits / AuditsNatural language processingWeb based learning


Learn the rules ◦ Educate the key stakeholders

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Perform internal review of coding /documentation / denials◦ Identify opportunities to improve dictation –

revenue◦ Don’t pick the weeds – eliminate ‘em

Evaluate the team◦ Best fit for each task◦ Best fit for each task◦ Accept the hard task if necessary

Maximize the technology available


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Your Presenter:Karna W. Morrow

Coding Strategies, [email protected]

aama acca

Economy & Finance

function wo contrast

velocity flow mapping

medical documentation

coding strategies

arrhythmogenic focus

working denials

cpt modifiers

reported separately