presented by: shelly cronin, cpc, cpma, cgsc,...

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8/16/2010 1 1 Policies Presented by: Shelly Cronin, CPC, CPMA, CGSC, CANPC, CGIC 2 Agenda Understand the roles of Policies and your practice Overview of NCD, LCDs and Carrier Policies Impact on coding and payment How to stay current on policy changes

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8/16/2010

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1

Policies

Presented by: Shelly Cronin, CPC, CPMA, CGSC, CANPC, CGIC

2

Agenda

• Understand the roles of Policies and your

practice

• Overview of NCD, LCDs and Carrier

Policies

• Impact on coding and payment

• How to stay current on policy changes

8/16/2010

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Policy Roles

Insurance Companies

Policies

Policy

Holders

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What is a Policy?

• An insurance policy is a contract between the

insurer and the insured, known as a

policyholder, which determines the claims

which the insurer is legally required to pay.

• Medical Policies serve as one of the sets of

guidelines for coverage decisions. Benefit

plans vary in coverage and some plans may

not provide coverage for certain services

discussed in the medical policies.

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Coverage Decisions

• Coverage decisions are subject to all

terms and conditions of the applicable

benefit plan, including specific exclusions

and limitations, and to applicable state

and/or federal law. Medical policy does not

constitute plan authorization, nor is it an

explanation of benefits.

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Policy Development

• Policy development

– External professional organizations

– Medical societies

• State

• Specialty

– Independent physician advisory board

• Important issues to physicians

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How to Read a Policy

• May include subsections

– Description

• Explanation of the policy topic

– Diabetes Tests, Programs and Supplies

– Coverage Determination

• Outlines what is covered under the plan based on

the policy description

– Different tests, procedures, and equipment relevant to

disease

• Guide for specific information

– Benefit coverage and limitations

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How to Read a Policy cont.

• Background

– Contains information

• Clinical Medical information regarding conditions

treated by a specific

– Device

– Medication

– Procedures

– Medical Alternatives

• Possible alternatives to the device or procedure

– Provider Claim Codes

• Contains

– CPT®, HCPCS, & ICD-9-CM codes

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How to Read a Policy cont.

• Medical Terms

– Definitions of terminology

• Dysphagia is a swallowing disorder that may be

due to various neurological, structural, and

cognitive deficits

• References

– Details

• Titles

• Authors

• Publication dates

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How does this help you?

• Better understanding

– What to look for

– What is covered

– What constitutes medically necessary

reasons for treatment

• Determined by each individual payer

– When the treatment or service will not be

covered and why

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Policy Example• Clinical Policy Bulletin: HIV Testing

– Number: 0542

Policy - Aetna considers human immunodeficiency virus (HIV) testing medically

necessary for screening persons for HIV infection, according to the

recommendations of the U.S. Preventive Services Task Force and the Centers

for Disease Control and Prevention.

• Aetna considers the Orasure oral HIV test kit (OraSure Technologies,

Bethlehem, PA) medically necessary for the same indications as standard

HIV testing.

• Aetna considers the OraQuick Rapid HIV-1 Antibody point-of-care test kit

(OraSure Technologies, Bethlehem, PA) an adequate alternative to

laboratory HIV blood tests for medically necessary indications for HIV

testing. Note: Aetna does not cover home HIV test kits that do not require a

physician's prescription under any plans. These include:

– Home Access At Home HIV Test

– Confide Home HIV Test (Johnson & Johnson).* Withdrawn due to lack of interest

CPT® Codes / HCPCS Codes / ICD-9 Codes

CPT® codes covered if selection criteria are met:

86689 Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot)

86701 Antibody; HIV-1

86702 Antibody; HIV-2

86703 Antibody; HIV-1 and HIV-2, single assay

87390 Infectious agent antigen detection by enzyme immunoassay technique, qualitative

or semiquantitative, multiple-step method; HIV-1

87391 Infectious agent antigen detection by enzyme immunoassay technique, qualitative

or semiquantitative, multiple-step method; HIV-2

HCPCS codes covered if selection criteria are met:

S3645 HIV-1 antibody testing of oral mucosal transudate

ICD-9 codes covered if selection criteria are met:

042 Human immunodeficiency virus [HIV] disease

V01.79 Contact with or exposure to other viral diseases

V08 Asymptomatic human immunodeficiency virus [HIV] infection status

V73.89 Special screening examination for other specified viral diseases

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National Correct Coding

Initiative• Developed by CMS to reduce Medicare

program expenditures

• NCCI – used to prevent improper payment

when incorrect code combinations are

reported (unbundling)

• Contains

– Over 140,000 code pairs or edit pairs that

cannot be reported on the same claim on the

same date of service

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National Correct Coding

Initiative• Coding policies are based on:

– Analysis of standard medical and surgical

practices

– Coding conventions included in CPT®

– Coding guidelines developed by medical

specialty societies

– Local and national coverage determinations

– Review of current coding practices

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National Correct Coding

Initiative• NCCI contains two tables of edits

– Column One/Column Two Correct Coding

Edits table

– Mutually Exclusive Edits table

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NCCI Terms and Definitions

• CCI edits – applied to services billed by

the same provider for the same beneficiary

on the same date of service

– Pairs of CPT® and/or HCPCS codes not

separately reportable except under certain

circumstances

• Example - If a laparoscopic procedure becomes

open, you should only report the open CPT® code

and not both open and laparoscopic

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NCCI Terms and Definitions

• Column 1 code – represents the major

procedure or service than to the other

code

– Higher payments are associated due to the

codes greater work, effort, and time

• Example – A patient has a deep and superficial

biopsy of the same site report only the deep

biopsy, reporting both with result in a denial

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NCCI Terms and Definitions

• Column 2 code – represents the lesser

procedure when reported with another

code

– Can be considered a component code, lower

payments are associated with these services

• Example - A patient has a deep and superficial

biopsy of the same site, but the surgeon

determines that it is medically necessary and has

supporting documentation, a modifier should be

added to either of the code pairs.

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ExampleColumn 1 Column 2 Modifier 0= not

allowed, 1=allowed,

9=N/A

40490 51703 1

40490 62310 0

40490 64550 9

0 = not allowed - means that there is no modifier that you can apply

to this code to make it billable and override the edit

1 = Allowed - means that you can use a 59, 24 or 25 modifier to

override this edit

9 = N/A - means that the edit is not applicable, or that there is no

conflict requiring a modifier to override

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Misuse of Column 2

• CMS manuals and instructions often

describe groups of HCPCS/CPT® codes

that should not be reported together for

the Medicare program

– Edits based on these instructions are often

included as misuse of column two code with

column one code

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Example• CMS limits separate payment for use of the operating

microscope for microsurgical techniques (CPT® code

69990) to a group of procedures listed in the online

Claims Processing Manual (Chapter 12, Section 20.4.5

(Allowable Adjustments)).

– The NCCI has edits with column one codes of surgical

procedures not listed in this section of the manual and column

two CPT® code of 69990. Some of these edits allow use of

NCCI-associated modifiers because the two services listed in the

edit may be performed at the same patient encounter as a third

procedure for which CPT® code 69990 is separately reportable.

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Example• There may be limited circumstances when the column

two code is separately reportable with the column one

code.

– For example, the NCCI has an edit with column one CPT® code

of 80061 (lipid profile) and column two CPT® code of 83721

(LDL cholesterol by direct measurement). If the triglyceride level

is less than 400 mg/dl, the LDL is a calculated value utilizing the

results from the lipid profile for the calculation, and CPT® code

83721 is not separately reportable. However, if the triglyceride

level is greater than 400 mg/dl, the LDL may be measured

directly and may be separately reportable with CPT® code

83721 utilizing an NCCI-associated modifier to bypass the edit.

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Modifiers and NCCI

• Modifiers may be appended to

HCPCS/CPT® codes only if the clinical

circumstances justify the use of the

modifier

• A modifier should not be appended to a

HCPCS/CPT® code solely to bypass an

NCCI edit if the clinical circumstances do

not justify its use

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Modifiers and NCCI

• Modifiers that may be used under

appropriate clinical circumstances to

bypass an NCCI edit include

– Anatomic modifiers: E1-E4, FA, F1-F9, TA,

T1-T9, LT, RT, LC, LD, RC

– Global surgery modifiers: 25, 58, 78, 79

– Other modifiers: 27, 59, 91

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Modifier 59 and NCCI

• Modifier 59 is an important NCCI-

associated modifier that is often used

incorrectly

• For NCCI its primary purpose is to indicate

that two or more procedures are

performed at different anatomic sites or

different patient encounters

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Modifier 59 and NCCI

• Only used if no other modifier more

appropriately describes the relationships

of the two or more procedure codes

• Modifier 59 and other NCCI-associated

modifiers should NOT be used to bypass

an NCCI edit unless the proper criteria for

use of the modifier is met

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Modifier 59• Most common misuse of modifier 59

– Letting the definition of modifier 59 confuse you

in appropriate assignment

• code descriptors of the two codes of a code pair edit usually

represent different procedures or surgeries

– Attaching a 59 modifier to report two codes being

different procedures/surgeries

• If two procedures/surgeries are performed at separate

anatomic sites or at separate patient encounters on the same

date of service, modifier 59 may be appended to indicate that

they are different procedures/surgeries on that date of

service

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59 Modifier Example• Example: Column 1 Code/Column 2 Code 93529/76000

– CPT Code 93529 – Combined right heart catheterization and left

heart catheterization through existing septal opening (with or

without retrograde left heart catheterization)

– CPT Code 76000 – Fluoroscopy (separate procedure), up to one

hour physician time, other than 71023 or 71034 (eg, cardiac

fluoroscopy)

• Policy: Standards of medical/surgical practice

• Modifier -59 is: 1) Only appropriate if the fluoroscopy

service 76000 is performed for a procedure done

unrelated to the cardiac catheterization procedure.

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Medically Unlikely Edits (MUEs)

• Developed by CMS – January 1, 2007

• Used to reduce claim payment errors for

Part B claims

• MUEs

– Maximum units allowable by the same

provider for the same beneficiary for the same

date of service• http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage

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Medically Unlikely Edits Example

• Eve Smith underwent a cataract extraction

in her right eye.

– Claim was submitted with a 4 units in block 24

• Result: Claim Denied

– Rational: The claim was denied due to medically unlikely

edit because the units indicate that the patient had a

cataract removed from 4 right eyes. The patient had only

one right eye.

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Medicare Coverage Database

• Medicare Coverage Database (MCD) – used to

determine whether a procedure or service is

reasonable or necessary for the diagnosis or

treatment of an illness or injury.

• Contains:

– National Coverage Determinations (NCDs)

– Local Coverage Determinations (LCDs)

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National Coverage

Determinations (NCDs)

• Updated “real-time” by CMS to create edits for

rules, called local coverage determinations

(LCDs)

• Link ICD-9-CM diagnosis codes with procedures

or services considered medically necessary

• Use this to determine if an ABN is needed

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National Coverage

Determinations (NCDs)• Additional uses for NCDs

– Prevents payment of surgical errors

• Wrong surgical or other invasive procedures

performed on a patient

• Wrong body part

• Wrong patient

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• Example – NCD for Bariatric Surgery– B. Nationally Covered Indications

• Effective for services performed on and after February 21, 2006, Open

and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and

laparoscopic Biliopancreatic Diversion with Duodenal Switch

(BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are

covered for Medicare beneficiaries who have a body-mass index > 35,

have at least one co-morbidity related to obesity, and have been

previously unsuccessful with medical treatment for obesity. These

procedures are only covered when performed at facilities that are: (1)

certified by the American College of Surgeons as a Level 1 Bariatric Surgery

Center (program standards and requirements in effect on February 15,

2006); or (2) certified by the American Society for Bariatric Surgery as a

Bariatric Surgery Center of Excellence (program standards and

requirements in effect on February 15, 2006).

• Effective for services performed on or after February 12, 2009, the Centers

for Medicare & Medicaid Services (CMS) determines that Type 2 diabetes

mellitus is a co-morbidity for purposes of this NCD.

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Local Coverage Determination

(LCDs)• LCDs - a decision by a fiscal intermediary (FI) or

carrier whether to cover a particular service on

an intermediary-wide or carrier-wide basis in

accordance with Section 1862(a)(1)(A) of the

Social Security Act (e.g., a determination as to

whether the service or item is reasonable and

necessary).

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Local Coverage Determination

(LCDs)• Important:

– Only employed for a specified geographical

area based on contractor

– Provides guidance not guidelines

– NCDs take precedence over LCDs

– Carefully read the LCDs to ensure that you

are looking at active policies

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LCD example• Several National Coverage Determinations (NCDs) relevant to the

Local Coverage Determination (LCD) are available at the "coverage"

website at CMS. Based on National Coverage Decisions, Medicare

does not cover: • Gastric balloon surgery,

• Intestinal Bypass;

• Open adjustable gastric banding;

• Open and laparoscopic sleeve gastroectomy;

• Open and laparoscopic vertical banded gastroplasty or

• Bariatric surgery to treat obesity alone.

• Medicare does cover bariatric surgery with these limitations:

(1) Body Mass Index (BMI) must be equal to or greater than 35, (2)

and at least one co-morbidity related to obesity such as diabetes or

hypertension must be present, and (3) there was previously

unsuccessful medical treatment of obesity.

• Several forms of surgery are allowed, while others are disallowed.

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Tricare

• Policies do not include appropriate

diagnosis coding; they include

– Included

– Excluded

– Provides cost coverage depending on the

procedure or service

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Tricare

• Pricing exampleOffice Visits /

Consultations

TRICARE

Prime

TRICARE

Extra

TRICARE

Standard

ADFM None 15% 20%*

Retirees and

Others

$12 20% 25%*

Standard and Extra cost shares are applied after the deductible is

met.

*TRICARE Standard beneficiaries may be required to pay up to 15%

above the TRICARE allowed amount when using a provider that does

not participate in TRICARE.

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Never-Event Policies

• Never-events - serious events or medical errors

that are clearly identifiable and preventable.

• New policies have been implemented to

supplement Medicare’s policies on wrong

procedure, wrong patient, and wrong body site.

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Never-Event Policies

• New policies include the following list of

hospital acquired conditions:– Pressure ulcers stages III & IV

– Catheter-associated urinary tract infections

– Vascular catheter-associated infection

– Surgical site infection, mediastinitis, following

coronary artery bypass graft (CABG)

– Air embolism

– Blood incompatibility

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Never-Event Policies– Foreign object retained after surgery

– Falls and trauma (fracture, dislocation, intracranial

injury, crushing injury, burn, electric shock)

– Surgical-site infections following certain orthopedic

procedures

– Surgical-site infections following bariatric surgery for

obesity

– Manifestations of poor glycemic control

– Deep vein thrombosis and pulmonary embolism

following certain orthopedic procedures

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Impact of ICD-10

• ICD-10 implementation will have a huge

impact on healthcare policies

– All existing policies will be updated reflecting

the higher specificity

– Expect new policies to be created

– Think strategically about how to update your

policies in a quick and efficient way

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• What do I do if no policy exists?

– Does the page require a login?

• Apply or signup for a user name and password

– If no written policy or web page

• Create a cheat sheet list with phone numbers of

your contracted payers to call for verification and

clarification on established policies

– Beyond the policy page

• To go beyond the policy page you might have to

review your contracts to ensure that the services

outlined are geared to what your practice offers.

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Best Practices• Carefully read the policies, LCDs, NCDs or

whatever your carriers have available for you

• If unavailable contact the carrier to verify the

information needed

• See if your carriers have a list serve or other

email listings that would keep you up-to-date

about any policy changes

• Do not keep old policies or store policies without

updating the information

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Resources• Tricare -

https://www.hnfs.net/common/benefits/benefits_limitations_exclusio

ns.htm

• Centers for Medicare and Medicaid Services (CMS) -

http://www.cms.gov/mcd/index_local_alpha.asp?from=alphalmrp&let

ter=A;

http://www.cms.gov/NationalCorrectCodInitEd/01_overview.asp#To

pOfPage

• Aetna - http://www.aetna.com/healthcare-professionals/policies-

guidelines/medical_clinical_policy_bulletins.html

• Understanding Health Insurance-A Guide to Billing and

Reimbursement – by Michelle A. Green & JoAnn C. Rowell

• Blue Cross Blue Shield -http://www.bcbs.com/coverage/the-blues-

and-medicare/index.html

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THANK YOU