hcpcs level ii: 2011 coding updates and...

12/14/2010

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HCPCS Level II:2011 Coding Updates and Rationales

Presented by: Alice Marie Reybitz, RN, BA, CPC, CPC-H, CPC-HI

Written by Alice Reybitz and G.J. Verhovhek, MA, CPC

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Disclaimer

This presentation was current when it was published. Every reasonable effort has been made to assure the accuracy of the information within these pages. The ultimate responsibility lies with readers to ensure they are using the codes, and following applicable guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains guidelines and principles in profitable, efficient health care organizations.

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Today's Objective

• Review substantial changes to the Healthcare Common Procedure Coding System (HCPCS) Level II code set since publication of the 2010 HCPCS Coding Manual– New Codes

– Revised Codes

– Deleted Codes

• We will proceed (more or less) in Alpha-numeric order

• Dental (D) codes and Physician Quality Reporting codes (G8000-G9139) will not be reviewed individually, but we will provide an overview

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HCPCS Level II Modifiers

• New Modifier "AY"– Item or service furnished to an ESRD patient that is not for the

treatment of ESRD

• Allows for separate payment of lab services, limited drugs and supplies, when provided for an ESRD patient, NOT for the treatment of ESRD

• MLN Matters #7064– cms.gov/MLNMattersArticles/downloads/MM7064.pdf

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• Revised Modifier "GA"– Waiver of liability … as required by payer policy, individual case

• New Modifier "GU"– Waiver of liability … as required by payer policy, routine notice

• New Modifier "GX"– Notice of liability issued, voluntary under payer policy

• For use with Advanced Beneficiary Notice (ABN)

• MLN Matters #6365 Revised– www3.cms.gov/MLNMattersArticles/downloads/MM6563.pdf

• More to come on GX…

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• New Modifier "NB" – Nebulizer system, any type, FDA-cleared for use with specific

drug

• No specific info. from CMS yet– Possibly for use with Altera™ Nebulizer System to administer

Cayston™ to cystic fibrosis patients

• www.accessdata.fda.gov/cdrh_docs/pdf10/K100380.pdf

• More to come!

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• New Modifier "PT"– Colorectal cancer screening test; converted to diagnostic test or other

procedure

• Use in the Ambulatory Surgical Center (ASC) setting

• append to the diagnostic procedure code that is reported instead of the screening colonoscopy or screening flexible sigmoidoscopy HCPCS code when the screening test becomes a diagnostic service

• deductible now is waived when a screening colonoscopy is converted to a surgical endoscopic procedure

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Minor revisions, effective July 1, 2010

• Modifiers "RA" and "RB" – Now describe replacement of DME, orthotic or prosthetic items

– CMS Transmittal 1967 (www3.cms.gov/transmittals/downloads/R1967CP.pdf)

• Modifiers V5, V6, V7 for hemodialysis vascular access– Descriptor refinements do not change use

– CMS Transmittal 1932 (cms.gov/Transmittals/downloads/R1932CP.pdf.)

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Supplies

• A7020 – Interface for cough stimulating device, includes all components,

replacement only

• replacement for CoughAssist™ Patient Circuit– face mask, mouthpiece, or tracheal adapter for patients with

endotracheal or tracheostomy tubes + tube and filter

– available in several sizes

– must be replaced approx. every two months

• for patients who are unable to perform an unassisted cough of sufficient force to remove secretions from the lungs

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Supplies

• A9273– Hot water bottle, ice cap or collar, heat and/or cold wrap, any type

• Replaces DELETED codes– E0220 Hot water bottle

– E0230 Ice cap or collar

– E0238 Non-electric heat pad, moist

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Supplies

Revisions

• B4035 – Enteral feeding supply kit; pump fed, per day, includes but not limited

to feeding/flushing syringe, administration set tubing, dressings, tape

• B4036 – Enteral feeding supply kit; gravity fed, per day, includes but not

limited to feeding/flushing syringe, administration set tubing, dressings, tape

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New Pass-through Device Code

• C1749– Endoscope, retrograde imaging/illumination colonoscope device

(implantable)

• for ASC Payment – with APC 143 Lower GI Endoscopy

• effective Oct. 1, 2010

• MLN Matters #7117 Revised– cms.gov/MLNMattersArticles/downloads/MM7117.pdf

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Outpatient PPS

• C8931 – Magnetic resonance angiography with contrast, spinal canal and

contents

• C8932 – … without contrast, spinal canal and contents

• C8933 – … without contrast followed by contrast, spinal canal and contents

• Replace CPT® 72159 for Medicare billing, when covered

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Outpatient PPS

• C8934– MRA with contrast, upper extremity

• C8935– … without contrast, upper extremity

• C8936 – … without contrast followed by with contrast, upper extremity

• Replace CPT® 73225 for Medicare billing

• MLN Matters #7040 – cms.gov/MLNMattersArticles/downloads/MM7040.pdf

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Outpatient PPS – Drug Supplies

• C9273 – Sipuleucel-T, minimum of 50 million autologous CD54+ cells

activated with pap-gm-csf, including leukapheresis and all other

preparatory procedures, per infusion

• Reports Provenge®

– patient-specific vaccine for prostate cancer

• Effective Oct. 1, 2010

• Learn more– www.provenge.com/video-resources.aspx

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• C9274 – Crotalidae polyvalent immune FAB (ovine), 1 vial

• Crofab®, an antivenin for snakebites

• C9275 – Injection, hexaminolevulinate hydrochloride, 100 mg, per study dose

• Cysview™ for detection of certain bladder cancers with Photodynamic Diagnostic D-Light C (PDD) System

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• C9276 – Injection, cabazitaxel, 1 mg

• Jevtana®, to treat metastatic hormone-refractory prostate cancer (mHRPC)

• C9277 – Injection, alglucosidase alfa (lumizyme), 1 mg

• Lumizyme®, enzyme replacement therapy (ERT) for Pompe disease

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• C9278– Injection, incobotulinumtoxin A, 1 unit

• Xeomin®, to treat cervical dystonia or blepharospasm

• C9279 – Injection, ibuprofen, 100 mg

• Caldolor®, to treat pain and fever

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Outpatient PPS

• C9367– Skin substitute, endoform dermal template, per square centimeter

• Endoform Dermal Template™ wound dressing– pressure ulcers

– venous ulcers

– diabetic ulcers

– chronic vascular ulcers

– tunneled/undermined wounds

– Surgical wounds

– trauma wounds

– draining wounds

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Outpatient PPS

• C9800– Dermal injection procedure(s) for facial lipodystrophy syndrome (LDS)

and provision of radiesse or sculptra dermal filler, including all items and supplies

• Facial lipodystrophy syndrome, for Medicare beneficiaries who manifest depression secondary to the physical stigma of HIV treatment

• Effective as of July 2010

• MLN Matters #6953 Revised – cms.gov/MLNMattersArticles/downloads/MM6953.pdf

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Dental (D) Codes

• The Dental, or "D," codes, are not part of HCPCS this year

• The ADA (American Dental Association) designates the Dental Procedure Codes (CDT)

• For more information, visit the ADA web site– www.ada.org/news/4599.aspx

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Durable Medical Equipment

• E0446– Topical oxygen delivery system, not otherwise specified, includes all

supplies and accessories

• TransCu O2

• Creates oxygen-rich environment to promote wound healing

• Treats "difficult to heal" wounds such as venous leg ulcers, pressure ulcers, etc.– http://eo2concepts.net/EO2_Concepts/EO2_Concepts.html

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DME – Orthopedic Devices

• E1831– Static progressive stretch toe device, extension and/or flexion, with or

without range of motion adjustment, includes all components and accessories

• MPJ extensionater® to "stretch" the big toe and treat decreased range of motion due to formation of scar tissue

• Check it out at:– www.getmotion.com/docs/MPJ_ExtenPlantar_Patient.pdf

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DME – Wheelchair Cushion

• E2622 (replaces K0734)

– Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth


– … width 22 inches or greater, any depth


– Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth


– …width 22 inches or greater, any depth

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Professional Services

• G0157 – Services performed by a qualified physical therapist assistant in the

home health or hospice setting, each 15 minutes

• G0158– Services performed by a qualified occupational therapist assistant in

the home health or hospice setting, each 15 minutes

• These codes (and G0159-G0164, to follow) likely fall under earlier CMS instruction as provided in Transmittal 1738

– www.cms.gov/Transmittals/Downloads/R1738CP.pdf

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• G0159 – Services performed by a qualified physical therapist, in the home

health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes

• G0160 – Services performed by a qualified occupational therapist, …

• G0161– Services performed by a qualified speech-language pathologist, …

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• G0162 – Skilled services by a registered nurse (RN) in the delivery of

management & evaluation of the plan of care; each 15 minutes

– the patient's underlying condition or complication requires an RN to ensure that essential non-skilled care achieve its purpose in the home health or hospice setting

• Bonus info: 2011 Home Health PPS Final Rule– edocket.access.gpo.gov/2010/pdf/2010-27778.pdf

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• G0163 – Skilled services of a licensed nurse (LPN or RN) in the delivery of

observation & assessment of the patient's condition, each 15 minutes

– when the likelihood of change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting

• G0164 – Skilled services of a licensed nurse, in the training and/or education of

a patient or family member, in the home health or hospice setting, each 15 minutes

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Procedures

• G0428– Collagen meniscus implant procedure for filling meniscal defects (e.g.,

CMI, collagen scaffold, Menaflex)

• Reports Menaflex® (formerly CMI®), an implant that promotes growth of new cartilage in the knee

• Active since May 2010, but could be rescinded?

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Procedures

• G0430 DELETED

• G0431 REVISED– Drug screen, qualitative; multiple drug classes by high complexity test

method (e.g., immunoassay, enzyme assay), per patient encounter

• G0434 NEW– Drug screen, other than chromatographic; any number of drug classes,

by CLIA waived test or moderate complexity test, per patient encounter

• More CLIA info:– www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/IVDReg

ulatoryAssistance/ucm124105.htm

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• G0436 – Smoking and tobacco cessation counseling visit for the asymptomatic

patient; intermediate, greater than 3 minutes, up to 10 minutes

• G0437 – … greater than 10 minutes

• New Medicare benefit (no deduct. from 1/1/'11)

• Report by time

• CMS Transmittal 2058– www3.cms.gov/transmittals/downloads/R2058CP.pdf

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• G0438 – Annual wellness visit; includes a personalized prevention plan of

service (PPS), initial visit

• G0439 – … subsequent visit

• Requires six elements, as set forth in the 2011 MPFS Final Rule– edocket.access.gpo.gov/2010/pdf/2010-27969.pdf

– Page 231 begins the discussion

• No deductable

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• G0440 – Application of tissue cultured allogeneic skin substitute or dermal

substitute; for use on lower limb, includes the site preparation and debridement if performed; first 25 sq cm or less

• G0441 – … each additional 25 sq cm

• Apligraft® or Dermagraft® for application to the lower limbs

• Includes site preparation and debridement

• Report by area (sq. cm.)

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Physician Quality Reporting

• HCPCS contains many new/revised/deleted quality reporting codes for 2011 (250+ changes)

• PQRI is now a permanent Physician Quality Reporting System (PQRS)– 1 % incentive for 2011 reporting period

– 0.5 % incentive for 2012-2014

– 1.5 % penalty for not participating in 2015

– 2 % reduction for nonparticipation in 2016 and beyond

• CMS website for more info– www.cms.gov/PQRI/15_MeasuresCodes.asp

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Drug Codes

• J0128 DELETED (no replacement)

– Drug withdrawn from market

• J0170 DELETED

• J0171 NEW

– Injection, adrenalin, epinephrine, 0.1 mg

• To treat severe allergic reactions

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Drug Codes

• DELETED– J0559, J0530, J0540, and J0550

• J0558 NEW– Injection, penicillin g benzathine and penicillin g procaine, 100,000

units

• New, uniform reporting does of 100,000 units

• Bicillin® C-R, for treating a variety of streptococci infections

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Drug Codes

• DELETED– J0560, J0570, J0580

• J0561 NEW– Injection, penicillin g benzathine, 100,000 units

• New, uniform reporting does of 100,000 units

• Bicillin® L-A, for treating upper respiratory infections, Syphilis, prophylaxis for rheumatic fever and glomerulonephritis

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Drug Codes

• J0597 – Injection, c-1 esterase inhibitor (human), Berinert, 10 units

• Replaces C9269

• Reports Berinert® to treat hereditary angioedema (HEA), an immune deficiency

• J0598 REVISED– Injection, c-1 esterase inhibitor (human), CINRYZE, 10 units

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Drug Codes

• J0638 – Injection, canakinumab, 1 mg

• Reports Ilaris® to treat cryopyrin-associated periodic syndrome (CAPS)

• J0702

– Injection, betamethasone acetate 3mg and betamethasone sodium phosphate 3mg

• Replaces J0704

• Celestone Soluspan

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Drug Codes

• J0775 – Injection, collagenase, clostridium histolyticum, 0.01 mg

• Xiaflex® for Dupuytren's contracture — "bent" finger(s)

• Deleted

– J0970, J1390

• For Delestrogen®, use instead J1380– Injection, estradiol valerate, up to 10 mg.

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Drug Codes

• J1290 – Injection, ecallantide, 1 mg

• Replaces C9263

• Kalbitor® to treat sudden attacks of HEA

• Deleted: J1470-J1550

• New: J1559 – Injection, immune globulin (hizentra), 100 mg

• Hizentra® for primary immunodeficiency

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Drug Codes

• J1599 – Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid),

not otherwise specified, 500 mg

• "Non-brand name" non-lyophilzed globulin injections

• When J1561, J1459 do not apply

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Drug Codes

• J1785 Deleted

• J1786 New– Injection, imiglucerase, 10 units

• Cerezyme® to treat Gaucher's disease

• J1825 Deleted

• J1826 New– Injection, interferon beta-1a, 30 mcg

• Avonex® to treat MS

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Drug Codes

• J2321, J2322 Deleted– Report J2320 Injection, nandrolone decanoate, up to 50 mg

• J2358 – Injection, olanzapine, long-acting, 1 mg

• Zyprexa® Relprevv antipsychotic

• J2426 – Injection, paliperidone palmitate extended release, 1 mg

• Invega® Sustenna antipsychotic

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Drug Codes

• J3095 – Injection, televancin, 10 mg

• Replaces C9258

• Vibativ™ for skin infections

• J3262

– Injection, tocilizumab, 1 mg

• Replaces C9264

• Actemra® for Rheumatoid Arthritis

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Drug Codes

• J3357 – Injection, ustekinumab, 1 mg

• Replaces C9261

• Stelara™ for psoriasis

• J3385 – Injection, velaglucerase alfa, 100 units

• Replaces C9271

• Vpriv™ for type 1 Gaucher's disease

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Drug Codes

• J7184 – Injection, Von Willebrand factor complex (human), Wilate, per 100 IU

VWF Rco

• Replaces C9267

• Wilate® for von Willebrand Disease (VWD)

• J7196 – Injection, antithrombin recombinant, 50 i.u.

• Atryn® to prevent thromboembolic events

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Drug Codes

• J7309 – Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1

gram

• Metvixia® for photodynamic therapy (PDT) to threat actinic keratosis (AK)

• J7312– Injection, Dexamethasone, intravitreal implant, 0.1 mg

• Replaces C9256

• Ozurdex™ for macular edema

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Drug Codes

• J7335 – Capsaicin 8% patch, per 10 square centimeters

• Replaces C9268

• Qutenza® to manage neuropathic pain

• J7686 – Treprostinil, inhalation solution, FDA-approved final product, non-

compounded, administered through DME, unit dose form, 1.74 mg

• Tyvaso™ for pulmonary arterial hypertension

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Drug Codes

• J8562

– Fludarabine phosphate, oral, 10 mg

• Replaces Q2025, C9262

• Oforta™ for B-cell chronic lymphocytic leukemia

• J9062 Deleted

• See J9060 for Cisplatin (Plantinol® AQ) injection, 10 mg

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Drug Codes

• Deleted– J9080-J9092 Cyclophosphamide

– J9094-J9097 Cyclophosphamide lyophilized

• No replacement/withdrawn from market

• For Oral Administration, see J8530 Cyclophosphamide; oral, 25 mg

• J9910 Deleted

• Use J9100 Injection, cytarabine, 100 mg

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Drug Codes

• Deleted J9140

• Use J9130 Dacarbazine, 100 mg to report dacarbazine

• Deleted J9290, J9291

• Use J9280 Mitomycin, 5 mg to report Mutamycin®

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Drug Codes

• J9302 – Injection, ofatumumab, 10 mg

• Replaces C9260

• Arzerra™f or chronic lymphocytic leukemia (CLL)

• J9307– Injection, pralatrexate, 1 mg

• Replaces C9259

• Folotyn™ for refractory peripheral T-cell lymphoma (PTCL)

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Drug Codes

• J9315 – Injection, romidepsin, 1 mg

• Replaces C9265

• Istodax® for cutaneous T-cell lymphoma

• Deleted J9350

• New J9351 – Injection, topotecan, 0.1 mg

• Hycamtin® for chemotherapy

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Drug Codes

• Deleted J9375, J9380

• Report J9370 Vincristine sulfate, 1 mg for Oncovin® and Vincaser PFS®, with a reporting dose of 5 mg

• Chemotherapy drug to treat leukemia, neuroblastoma, and non-Hodgkin's lymphoma

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Ortho.

• Deleted L3672, L3673

• New L3674 – Shoulder orthosis, abduction positioning (airplane design), thoracic

component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment

• Reports thoracic component and support bar of an airplane design shoulder orthosis, either with or without nontorsion joint or turnbuckle

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Ortho.• L4631

– Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated

• To correct an inward/outward turning of the ankle

• L8693– Auditory osseointegrated device abutment, any length, replacement

only

• Baha® with Softband replacement part

• www.dsmig.org.uk/library/articles/BAHA%20DSA%20article.pdf

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Q (Temporary) Codes• Q0478

– Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type

• Q0479

– Power module for use with electric or electric/pneumatic ventricular assist device, replacement only

• Q0499 (Revised)

– Belt/vest/bag for use to carry external peripheral components of any type ventricular assist device, replacement only

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Q (Temporary) Codes

• Q2026– Injection, Radiesse, 0.1 ml

• Radiesse® facial filler

• DELETED S0196

• NEW Q2027 – Injection, Sculptra, 0.1 ml

• Sculptra® facial filler

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Q Codes – Influenza Vaccines

• Q2035 = Afluria®

• Q2036 = Flulaval®

• Q2037 = Fluvirin®

• Q2038 = Fluzone ®

• Q2039 = "catch all" code for split virus influenza vaccines administered to individuals three years of age or older, not otherwise described

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Q (Temporary) Codes• Q4101-Q4108 Revised

• Q4110-Q4116 Revised– Distinguish these as grafts, rather than as bioengineered skin

substitutes

• Q4109 Deleted

• See J7348 Dermal (substitute) tissue of nonhuman origin, with or without other bioengineered or processed elements, without metabolically active elements (tissuemend), per square centimeter

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Q (Temporary) Codes

• Q4117 – Hyalomatrix, per square centimeter

• Q4118 – Matristem micromatrix, 1 mg

• Q4119 – Matristem wound matrix, per square centimeter

• Q4120 – Matristem burn matrix, per square centimeter

• Q4121 – Theraskin, per square centimeter

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Temporary Codes

• Q5010 – Hospice home care provided in a hospice facility

• Effective Oct. 1, 2010

• Deleted S0146

• New S0148– Injection, pegylated interferon alfa-2b, 10 mcg

• Pegintron® for chronic hepatitis C

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S (Non-Medicare) & T (State Medicaid)

• DELETED S0161

• NEW S0169– Calcitrol, 0.25 microgram

• Calcitriol as calcium supplement

• T1505 – Electronic medication compliance management device, includes all

components and accessories, not otherwise classified

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Resources

• HCPCS Committee Public Meeting Minutes– www.cms.gov/medhcpcsgeninfo/08_hcpcspublicmeetings.asp

• OPPS Final Rule– http://edocket.access.gpo.gov/2010/pdf/2010-27969.pdf

• MLN Matters Homepage– https://www.cms.gov/MLNMattersArticles/

• Advanced Beneficiary Notice – www.cms.gov/BNI/02_ABN.asp

• Full HCPCS File and Table of Drugs– www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp

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Conclusion, HCPCS for 2011

[email protected]

800-626-2633, ext. 168

mailto:[email protected]

hcpcs level ii: 2011 coding updates and...

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