Non-Physician Practitioner Handbook Practical advice for ethically capitalizing on your non-physician practitioners time and talent

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2 Non-Physician Practitioner Handbook 2015 Practical advice for ethically capitalizing on your non-physician practitioners time and talent

3 Introduction Hiring non-physician practitioners (NPPs), such as nurse practitioners, physician assistants, or clinical nurse specialists, may be beneficial to your practice but you need to know about all of the implications before you start searching for qualified applicants. By leveraging the skills of your ancillary staff, you have an opportunity to see more patients in the practice and increase your revenue, while allowing your physicians to maximize their time and talents. But if you hire an NPP without learning the billing and coding rules that apply, you are setting your practice up for denials, lost revenue, or worse fraud charges. Brought to you by The Coding Institute, our handbook includes tips and tricks, expertanswered reader questions, and sample tools to ensure you learn the pros and cons of hiring NPPs, as well as the ins and outs of ethically maximizing reimbursement for NPP encounters. CONTACT INFORMATION Mail: 2222 Sedwick Drive, Durham, NC Phone: Fax: Terry Thurley, BS Editor Leesa A. Israel, CPC, CUC, CPPM, CMBS Managing Editor, Healthcare Handbooks Mary Compton, PhD, CPC Editorial Director and Publisher Jennifer Godreau, CPC, CPMA, CPEDC, Director of Development & Operations Non-Physician Practitioner Handbook 2015 ISBN: (Print), (E-Book) Content may include articles previously published in Eli Healthcare and The Coding Institute newsletters. Unauthorized reproduction prohibited by federal law. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold 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. Disclaimer: CPT codes, descriptions, and material only are copyright 2014 American Medical Association. All rights reserved. No fee schedules, basic units, relative value units, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use codinginstitute.com

4 Non-Physician Practitioner Handbook Contents Chapter 1: Billing Boost Your Productivity and Income By Adding an NPP, But Weigh the Pros and Cons First Follow 3 Easy Steps to Keep Your NPP Coding Incident Free Report Shared Visits Properly to Avoid Being A CERT Statistic Overcome Close Scrutiny of Incident-to Billing With These 4 Tips Define 'New Medical Condition' For Proper Incident-To Billing Know How to Handle Claims When a Consultation Is In Question Chapter 2: COMPLIANCE Focus on 5 Areas for Improvement in Your Provider Documentation Leave the HPI Details to the Provider Make Sure You re Implementing These E/M Coding Changes New Education Tool Explains F2F To Physicians Watch Out for Top Risk Areas When Adding NPPs Chapter 3: Documentation Avoid These F2F Pitfalls Keep These CMS and MAC Critical Care Documentation Guidelines Handy Ways to Make Your History Documentation Word Perfect Take These Steps to Ensure Your Time Documentation Makes the Grade Make Distinguishing Between New vs. Established Patient a Breeze Body System or Site? Be Sure You Clarify New MAC Tip Reminds Practices What Ancillary Staff Can and Cannot Document Note Who Provided the Service Before Billing Audiology Tests Chapter 4: MISCELLANEOUS Breeze Through Spring With Denial-Proof Allergy Coding Overcome Close Scrutiny of Incident-to Billing With These 3 Tips Are You Overlooking These 5 Opportunities to Collect Reimbursement? PA Assisting at Surgery? Check These Tips to Bill Properly Avoid Becoming a CERT Statistic and Paybacks Take 8 Steps to Avoid PECOS Rejections Collect What You Deserve With This 4 Step Approach Follow These Q&As to Keep Your Mid-Level Provider's Service Reporting Incident Free Get the Latest Scoop on Hydrocodone Combo Prescriptions Focus on Terminology to Navigate the NPP Maze Chapter 5: READER QUESTIONS Match POS Code and Provider Type Billing Same-Day Physician/Nurse Practitioner Services Multi-Provider Visit Could Be Shared Service codinginstitute.com I

5 Non-Physician Practitioner Handbook (Cont...) Focus on Incident-to Rules Avoid NP Billing Snafus With This Advice Here s Who Can Perform Spirometry, Oximetry Giving a Helping Hand Is a Shared Service Capturing PAs Work For Initial Nursing Facility Visits? Not so Fast Check Payer Policies When Billing Incident-to Services Can the Attending Bill For A NP s Procedure? Give Credit Where Credit is Due Chapter 6: Clip and Save Tools Quickly Determine If You Can Bill Your NPPs Service Incident to the Physician Avoid Substitute Physician Billing Challenges With These 13 Tips Incident-to Audit Checklist Chapter 7: 2015 Coding Updates Update Your 2015 Anesthesia Coding Get to Know the Changes to TAP Block and TEE Monitoring Codes Get Ready for Extra Scrutiny of Modifier AA Claims in Open Up Carotid Artery Stent Coding Options Replace Your Old Cat. III Codes for S-ICDs With New and Old Cat. I Options in See What s New for Chronic Care Management and Advance Care Planning in the New Year Look for Changes to Ultrasound Guided Arthrocentesis, Breast Ultrasound, and Care Management E/M Language Get Ready to Inject Your 2015 Vaccine Claims With New, Revised CPT Codes Non-Incisive Diverticulitis Drives New Esophagoscopy Changes Adds Carotid Stent Coding Option Refine Recent Esophagoscopy Overhaul With New/Revised Codes Prep for Upcoming Global Period Changes X May Soon Mark the Spot for Successful Same-Day Procedure Claims Tests That Your Ob-Gyn May Order Highlight The New CPT Changes For Brace For New and Revised TMJ Arthrocentesis Codes For 2015 Claims Prepare for Nearly 90 New, Revised, or Deleted Lab Codes Revamp Your IHC and ISH Reporting With 2015 Makeover : Check Out New GI Pathogen Detection Codes Get to Know Big Changes to Your MCHAT, ADHD Evaluation Coding Update Your CPT 2015 Arsenal With New Behavioral Assessment Code Prepare Your Coding Practice For New Codes As Technology Makes An Advance Watch For Codes With Ultrasound and Imaging Guidance Inclusions Get to Know the 2015 Cystourethroscopy Changes CPT Brings Update Your UroLift Coding or Face 2015 Denials II Contents 2015 codinginstitute.com

6 Billing Non-Physician Practitioner Handbook Billing Boost Your Productivity and Income By Adding an NPP, But Weigh the Pros and Cons First Be sure you consult your state laws and NPP scope of practice rules before hiring. Hiring a non-physician practitioner (NPP), such as a nurse practitioner (NP) or physician assistant (PA), can allow your practice to see more patients, in turn bringing in more money. Before starting the interviews, however, you ll want to weigh the pros and cons to determine if bringing an NPP on board will really benefit your practices. Start With the Positives Adding an NP or PA to your practice can have many benefits. First, you will likely be able to have more patients flow through the office each day. NPPs can be a valuable asset to a medical practice, says Nicole Orofino, CPC, owner of Innovative Coding Analysis in Allentown, Penn. NPPs such as ARNPs and PAs can provide care to more patients within a practice, agrees coding, billing, and practice management consultant Steven M. Verno, CMBS, CMSCS, CEMCS, CPM-MCS, in Orlando, Fla. In addition to allowing the practice to see more patients in general, NPPs also allow the physicians to focus on more complicated or serious cases. As an example, an emergency care practice can have NPPs assist with seeing more patients in the emergency room providing relief to an overburdened physician-patient system, Verno says. This leaves the emergency care physician with the ability to treat the more serious patients, leaving the minor injuries and minor illnesses to be seen by the NPP. Logically, when your practice can see more patients more efficiently, your practice income should increase as well. NPPs can help increase revenue to a practice when more patients are seen, Verno says. Bonus: There are even more benefits: Patient satisfaction increases due to extended visits and same-day appointments, and physicians are less harried when NPs help eliminate patient backlog, Orofino adds. They can increase the size of patient panels, producing larger capitation payments in managed care markets, and allow doctors to concentrate on better-paying cases with fee-for-service plans codinginstitute.com 1

7 Non-Physician Practitioner Handbook Billing Don t Forget the Negatives While your practice may decide that hiring an NPP will bring many benefits, you should also do your due diligence and make sure there are no hurdles to jump to reap those rewards. While I wouldn t consider the addition of NPPs a downside, there are many steps that must be taken to ensure a smooth successful onboarding, Orofino cautions. She says the following areas will require analysis and planning prior to hiring an NPP and prior to your NPP s first day: How you will utilize the NPP Whether your practice is financially ready to hire additional clinical staff If there are research programs your physicians participate in where the NPP can assist with clinical trial documentation and program regulations Determine how long it takes for a patient to get an appointment with one of your physicians Introduction of your new NPP to your patient population Collaborative agreements and the scope of practice parameters the NPP will follow for your organization Malpractice insurance Decision making on how the NPP s revenue will be distributed amongst the partners of the practice EMR set up for clinical documentation Billing set up in your practice management system including the set up of cost centers and the routing of revenue Insurance credentialing Hospital privilege requisitions if the NPP will be assisting with hospital rounds. Check Scope of Practice Limitations Different states, and even different payers, place limits on the types of services NPPs can perform. So before hiring an NP or PA, your practice will need to determine what those providers can actually do in the practice and decide which provider is best and what services they will provide. NPPs are limited to their scope of practice as to what they can provide based on their medical license limitations and state law limitations, Verno says. Some insurance companies do not recognize services rendered by NPPs and as such will deny claims sent to them when the claim reports that the provider is an NPP. This can be very costly to a practice when an NP or PA provides care to a patient with Medicare as primary and XXX insurance as secondary (XXX replaces the name of a real insurance company). Medicare recognizes services provided by NPPs and will pay the claim. The downside is that Medicare doesn t pay 100 percent of the physician fee schedule. Medicare will send the claim to XXX insurance. XXX insurance will deny the claim requiring the billing company or practice to spend administrative expenses to try and overturn the denial. To help avoid these issues, you should research your state laws as well as the rules of payers for your locale, especially those that the practice contracts with before you hire an NPP codinginstitute.com

8 Billing Non-Physician Practitioner Handbook Review Other Important Details Check the credentialing requirements and timing for each payer as well, Orofino says. Not all payers recognize NPPs. Credentialing for those who do takes time, she adds. Get all of your new NPP s credentialing documents as soon as possible after an employment arrangement has been executed so you may begin the credentialing process ASAP. You will also need to review the guidelines for billing NPP services. Brush up on your incident-to knowledge to ensure that your claims are not denied and to ensure you bring in the most revenue possible. Spend the time and cost if necessary to educate yourself and your staff on incident-to billing guidelines prior to billing for your NPP, Orofino says. Incident-to billling is a high area of audit and OIG scrutiny. v Follow 3 Easy Steps to Keep Your NPP Coding Incident Free Tip: Start by recognizing what constitutes incident-to circumstances. Billing Medicare for incident-to for services your non-physician practitioners (NPPs) provide can help you collect the entire assigned physician fee for your NPP if you handle things correctly. Let our answers to three top incident-to questions help you keep on the right track. Question 1: What Is Incident-To Billing? Incident-to is the term for services that the NPP provides under a supervising physician s authority and billed under the supervising physician s NPI (national provider identification) number). It s one way to bill services to Medicare. Before billing incident-to, you must meet several criteria set forth by CMS: The service is furnished by an NPP as an expense of the practice (the NPP can be an employee, leased employee, independent contractor of the practice, etc.). The treatment plan is initiated by the physician. The NPP can provide care once the plan is established and the physician remains active in the patient s care and management. The service is provided under the physician s direct personal supervision. The NPP performs the service within the scope of her practice and in accordance with state law. The service can be categorized as one that is commonly furnished in the physician s office or clinic (not in a facility setting). Note: The NPP cannot bill incident-to for evaluation of a new patient. Incident-to also does not apply when the NPP sees an established patient for a new problem or when an established patient has a change in his treatment or plan of care. Private payers: The above rules are set out by Medicare, but some private payers follow the same guidelines when creating their own incident-to criteria. Cigna s policy, for example, states, For services to be considered as incident to a physician s professional service, 1) they must be rendered under the physician s immediate personal supervision by his/her employee, 2015 codinginstitute.com 3

9 Non-Physician Practitioner Handbook Billing 2) they must be an integral, although incidental part of a covered physician s service, 3) they must be of kinds commonly furnished in physician s offices, and 4) the services of non-physicians must be included on the physician s bills. Important: Make sure you get from your private payers and your other non-medicare payers, such as Medicaid what their rules are for NPP billing and incident to services in writing to assure that you are providing following exactly what they expect from your practice. For example, Kansas Medicaid does not allow incident to billing for NPP services and they require the NPPs bill directly under their own NPI. Kansas Medicaid allows 75 percent of their fee schedule for NPP services. Remember: Physicians cannot bill incident-to another physician because you cannot bill services provided by one physician under another physician s name or number. Billing under the name of a physician who did not perform the service could lead to allegations of false claims submissions. Question 2: What Qualifies as Direct Supervision? In terms of incident-to, the physician whose name and NPI will be used for billing must be physically present in the office suite and immediately available to provide assistance and direction as necessary. The physician providing the direct supervision, the physician you bill under, however, might not always be the patient s regular physician or the physician who developed the problem s initial plan of care. Scenario: Dr. A saw Mrs. Jones and established a plan of care for ongoing treatment of her chronic back pain (338.29). She returns for her follow-up visit in two weeks. She sees the nurse practitioner, who continues the planned treatment. Dr. A is at the hospital performing pain management procedures that day and his partner, Dr. B, is the in-office physician. You would bill the visit as incident-to under Dr. B s name and NPI since he was physically present and able to provide direct supervision. If you billed under Dr. A., it would be considered fraud (billing for services not provided) because Dr. A did not provide direct supervision of the NPP when the services were provided to Mrs. Jones. So, even though Mrs. Jones received the service, she did not receive it from Dr. A, and as such, billing under Dr. A is considered fraudulent Medicare billing. Question 3: What Kind of Documentation Is Needed? The more detailed your documentation related to incident-to services can be the better. Keep these points in mind: Ensure that the documentation clearly notes who performed the service. Even if your claim has the doctor s number on it, the actual medical record should be signed by the NPP and note that the NPP was the practitioner. Verify that you have proof that a supervising physician was actually on site on the date and time of service. More than one incident to claim has been denied because auditors realized a physician was on vacation while he was purported to be overseeing several NPPs. Although many practices have proven the physician was present via the schedule codinginstitute.com

10 Billing Non-Physician Practitioner Handbook for that day, it is highly recommended that NPPs start out incident to notes with the following documentation: Dr. B was immediately available and provided direct supervision in the office during the patient visit today. With this documentation present, there will be no question as to who was present in the office providing direct supervision on the date of service. Pay out: Billing incident-to has numerous requirements, but can boost your bottom line when done correctly. When the claim meets incident-to criteria, Medicare will reimburse at 100 percent of the Medicare Physician Fee Schedule (MPFS) allowable for that service. If you don t meet all the incident-to criteria and the NPP bills Medicare directly with his or her own name and NPI on the claim form, the payment is reduced to 85 percent of the MPFS allowable by Medicare. All non-medicare payers will have their own reimbursement rules as demonstrated above with Kansas Medicaid. v Report Shared Visits Properly to Avoid Being A CERT Statistic Medicare allows NPP, physician to combine forces on some hospital services In the office setting, incident-to billing is a vital part of the practice s reimbursement machine: Under incident-to rules, qualified non-physician practitioners (NPPs) can treat certain patients and still bill the visit under the physician s National Provider Identifier (NPI). The hospital setting, however, is a different story, since incident-to billing is not allowed in the hospital. But shared/ split visit billing is an option. Shared-visit billing is not exactly incident-to, but it is a way to bill for services that are provided jointly by the physician and a qualified NPP. If the encounter meets shared-visit guidelines, you ll be able to report the entire visit under the physician s NPI thereby garnering you 15 percent more pay for the same service. Face Time Is a Must In a nutshell: The following example demonstrates how the typical shared visit works: - The NPP visits and examines a patient. The NPP documents her work establishing medical necessity. - At a different time, the doctor sees the patient. The physician documents her work. This can be immediately after or even before the NPP s visit, but it has to be on the same day. - Then, you can add the documentation together to establish a billing level. Benefit: In many shared visits, the NPP conducts the preliminary interview and exam, and then the physician sees the patient. To bill a shared visit under the physician s NPI, he must provide and document a face-to-face service codinginstitute.com 5

11 Non-Physician Practitioner Handbook Billing According to CMS Transmittal 1875, When a hospital in-patient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician s or the NPP s NPI number. However, if there was no face-to-face encounter between the patient and the physician, the service may only be billed under the NPP s NPI. When? There might be instances where the MD s note may not include the face-to-face encounter that is required. Maybe he only writes that he looked at the CT scan and made recommendations. Because the note doesn t fully illustrate the physician s contact with the patient, you should bill this visit under the NPP s NPI. Shared billing is an option only for select hospital E/M services you cannot bill shared visits for critical care. Make Sure Physician Is Available Under shared-visit rules, the NPP can treat patients in the hospital in accordance with his scope of practice and hospital privileges granted. During these visits, general supervision requirements apply. The physician must be accessible at all times by telephone or some other means of communication. When submitting your shared-service claims, be sure that you remember to: - clearly identify both providers in the medical record - link the physician s encounter notes to the NPP s - include legible signatures from the physician and the NPP. Tip: The documentation must prove the doctor provided at least one element of the encounter for you to bill under the physician s NPI. Examples: CMS offers the following two examples of a shared visit in Transmittal 1875: The NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service. In an office setting, the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the incident to requirements are met, the physician reports the service. If the incident to requirements are not met, the service must be reported using the NPP s NPI. v codinginstitute.com

12 Billing Non-Physician Practitioner Handbook Overcome Close Scrutiny of Incident-to Billing With These 4 Tips You could be costing your practice 15 percent of every NPP E/M service. You can avoid setting your practice up for payer take-backs. To ensure that your practice gets paid properly for incident-to services, you need to know how to bill for them appropriately. Read on to find out how to stay out of payers crosshairs. Does the NPP s service fall under incident-to? It s time to be sure, because Medicare MACs and private payers alike are scrutinizing incident-to services more than ever. Ensure your incident-to billing stands up to that scrutiny by learning the requirements you must meet and following them every time with these tips. Tip 1: Watch Out for New Patients and New Problems You can bill incident-to only when the NPP treats an established Medicare patient who has been seen initially by the physician who has established a particular plan of care (POC) for this individual patient. The POC must also be the reason for the encounter. If the NPP addresses a new problem during the visit or if the physician has not previously established a care plan for the patient, then you cannot bill the service as incident-to. Your physician should also document in the POC that the patient will be followed by an NPP to monitor the response to the planned therapy. You might encounter this follow-up visit by an NPP for many conditions such as infections, allergies, cancer diagnoses, or other medical conditions. Watch out: When there is a new problem, however, the physician must see the patient first and modify the plan of care before the NPP can provide follow-up care and bill the services as incident-to the physician. For Medicare you cannot bill new patient visits, consultations, or services provided in the hospital, nursing home, or outpatient facility as incident-to services. If the desire is to bill the service under the MD and the patient is new, only the review of systems (ROS) and past, family, and social history (PFSH) portion of the encounter can be recorded by the NPP, says Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC, manager of physician compliance auditing at Allegheny Health Network in Pittsburgh, Penn. The physician would need to reference this in his/her note. Important: You also need to know your state s laws governing the scope of practice for your different NPPs, warns Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Mich. Medicare guidelines specify that coverage is limited to the services a PA or NP is legally authorized to perform in accordance with state law, she adds codinginstitute.com 7

13 Non-Physician Practitioner Handbook Billing Tip 2: Ensure Proper Supervision Before Billing One of the first things you should check before you bill a service incident-to is whether a physician was directly supervising the NPP. In other words, the provider whose national provider identifier (NPI) you ll be billing under should be supervising the service. Define direct supervision: According to MLN Matters article SE0441 ( mlnmattersarticles/downloads/se0441.pdf), in order to bill incident-to the physician, the physician does not have to be physically present in the patient s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. Key: Do not use the term direct too loosely. Having the supervising physician available by phone or having the physician somewhere on the grounds in a large facility is not acceptable by Medicare standards. Also, you may want to check your state s practice requirements to see if your state has different supervision requirements. Under Medicare s ruling, incident-to can only be met if the MD is in the office, Berman confirms. If a mid-level provider (MLP) is in the office, the service could be billed incident-to him/her if the service is done by someone with a lesser license. For example, an MLP can supervise an RN (registered nurse) or MA (medical assistant). Example: The nurse practitioner (NP) provides a level-three E/M service to an established Medicare patient with a plan of care (POC) in place for his symptomatic diabetes. The visit is a check-up to see how the patient is responding to medication, diet, and other parts of the treatment plan, as well as how he might fare with other options. During this encounter, the physician is in the office suite seeing other patients. This encounter qualifies for incident-to billing under the physician s NPI. If, during the same encounter with the NP and the patient, the physician was five miles away at the hospital seeing patients, you would not be able to bill that E/M service incident-to the physician. Silver lining: The supervising physician does not need to be the physician who initiated the treatment plan, Berman says. You should bill in the name of the physician present in the office suite and providing the supervision at the time of the visit by the NPP, whether or not he initially saw the patient and developed the plan of care. The billing must reflect this difference, Young says. Physician supervising in the office goes in box 33. The physician who wrote the plan of care for the visit goes in 17. Tip 3: Switch to NPP s NPI When Necessary If you find the service does not meet incident-to billing requirements for example, if the NPP sees a new patient you don t have to forego payment altogether in many cases. If a Medicare credentialed NPP provides the service, you can bill under his own NPI. In that case, you ll usually receive between 65 and 85 percent of the normal global fee found in the Medicare Physician Fee Schedule, depending on the type of NPP, Young says codinginstitute.com

14 Billing Non-Physician Practitioner Handbook Exception: If a member of your auxiliary staff, such as a medical assistant (MA), provides a service when there is no direct supervision, you cannot bill for the service. Important: Different payers have different rules and some do not recognize Medicare s incident-to rules, so check with your private payers before billing NPP services. Tip 4: Beware of OIG Scrutiny The OIG states in its 2013 Work Plan the intention to review physician billing to determine whether payment for incident-to services had a higher error rate than that for non-incident-to services. The agency also intends to assess Medicare s ability to monitor incident-to services, which the OIG considers a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record. OIG is always scrutinizing incident-to billing. Because the claims are sent in by the physician, in the physician s name, the mid-level provider is not apparent. If the payers see more claims than normally expected for a specialty with a patient, they will investigate to make sure the patient is being seen and billed appropriately. Incident-to services have been listed in the OIG Work Plan in 2001, 2003, 2004, 2007 through 2009, and came back for 2012 and Many non-criminal and criminal cases originated by federal and state agencies overseeing CMS programs include allegations of improper billing for incident-to services. Resource: Visit the CMS website for more on coding incident-to services at Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. v Define 'New Medical Condition' For Proper Incident-To Billing Remember that not all payers follow the same rules. While incident-to billing can boost your practice s income, using non-physician practitioners (NPPs) can pose tricky billing situations if you aren t clear on the rules. One reader posed a question to our experts about the key phrase new medical condition in the CMS incident-to billing guidelines. Read on to see our experts advice to ensure your practice is on the right track. Review the Question Reader, Sherry McCain, billing representative with Denver West Pediatrics in Colorado, wrote in to ask: Our office is in desperate need of clarification on incident to. We need understanding for the following: The physician should establish the care plan for the new patient to the practice or any established patient with a new medical condition. NPPs may implement the established plan of care. What does new medical condition mean? 2015 codinginstitute.com 9

15 Non-Physician Practitioner Handbook Billing Start with the Basics The guideline above, from CMS, means that an NPP, such as a physician assistant or nurse practitioner, in your practice cannot see a patient with a new problem and bill incident to under the physician s national provider identifier (NPI) for 100 percent payment. Incident to only applies when the NPP is seeing a patient for a problem the physician has already established a plan of care for. Remember: If the NPP s scope of practice and state laws allow, the NPP can see a patient for a new problem and bill under her own NPI for 85 percent reimbursement. For example, if a patient has hypertension and the physician sees the patient about the hypertension when it is new (first diagnosed) and establishes a plan of care, the patient can then see the NPP in follow-up and the office can bill the encounter incident to the physician for 100 percent payment (assuming all other criteria for incident to billing are met). However, if the NPP sees the patient for hypertension when it is new and the physician has never seen the patient for it and established a plan of care, it doesn t meet incident-to requirements. Payer differences: One of the things we all need to keep in mind is that incident to is a Medicare payment coverage benefit says Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Fla. Not all payers honor the concept. Examine Condition vs. Problem To get to the bottom of the reader s question we must dig deeper. McCain continues, by asking: Is there a difference between a medical condition and a problem? For example, a patient comes in for strep throat or an ear infection. Is this considered a problem/condition and can this be billed as incident to if the requirements are met? In the CMS incident-to guidelines, there is no distinction between a medical condition and a problem, Acevedo explains. If you think about what incident to actually means, that the services are incidental to the physician s services, it may make more sense as to what the circumstances must be to bill an NPP s services under the name/npi of a physician. Define New Problem The final piece of the puzzle is what actually qualifies as a new problem. Is there a distinction between chronic conditions such as asthma and acute conditions like ear infections? What about when patients are seen repeatedly for ear infections or strep throat? When are those considered a new problem? Or are they? asks McCain. Chronic problems: For patients with chronic problems, you can bill incident to if the NPP is seeing the patient to follow through on the treatment plan and she is not making any changes to that plan. The physician must have already seen the patient for the chronic condition and set up the plan of care codinginstitute.com

16 Billing Non-Physician Practitioner Handbook Acute problems: For patients coming in with an acute problem, if the NPP sees the patient for that acute condition, the encounter doesn t qualify for incident-to billing. If the NPP sees the patient for the acute condition, by their very nature, treatment of these acute conditions are not incident to a physician s service, Acevedo explains. Recurrent conditions: If providers in your practice are seeing a patient repeatedly for acute recurrent conditions, such as otitis media, whether or not an NPP s visit for the patient who comes in again with the same acute recurrent problem qualifies as incident to will depend on the particular circumstances. It may meet the criteria if there is a formal standing order outlining the steps or changes in treatment the NPP is to follow based on defined criteria, Acevedo says. If, however, the NPP sees a patient, say, for the third ear infection and she switches the antibiotic to a different spectrum on her own, the services are not incident to. ` v Know How to Handle Claims When a Consultation Is In Question Don t automatically dismiss for every patient. Although CMS stopped accepting claims for office consultation services in January 2010, some private payers still reimburse for the service and some coders still have trouble with correct reporting. Decide what you think about the following scenario from an Otolaryngology Coding Alert subscriber and then see what our experts advise. Situation: We have a colleague we routinely refer to who generally sees our patients initially, charges a consult, and then has them back for follow-up a year later. She is charging a consult again for that follow-up visit. Is this appropriate? Understand What Constitutes a Consult According to CPT, a consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. Note: When requested by a physician or other appropriate source, a consultation may be provided by a physician or qualified non-physician practitioner (NPP). In order to be a qualified NPP, performing a consultation service must be within the scope of practice and licensure in the state in which the NPP practices and the NPP must bill out the consultation under their own NPI, since incident to rules require the plan of care be established by a physician, meaning that a new problem would not be cared for by a NPP as an incident to service. A consultation requested by a patient or family would not be reported as a consultative service. An appointment the patient schedules to seek a second opinion also does not fit the CPT definition of a consultation code. However, you can report these visits using another 2015 codinginstitute.com 11

17 Non-Physician Practitioner Handbook Billing applicable E/M service code such as an office visit code ( for a new patient or for an established patient). Verify Documentation of Criteria Before you can consider a service a consultation, your provider must meet and document the following criteria: A request for a physician s opinion from the requesting physician (or other appropriate source), along with the need for a consultation, must be documented by the consultant in the patient's medical record and included in the patient's medical record of the requesting practitioner. This should also include the reason for the request for the consultation. An opinion is rendered by the consulting practitioner. This opinion, along with any other service provided, is documented in the patient's health record. A written report of the consultant's findings and opinion or recommendation is communicated back to the requesting practitioner. If you can code the patient s visit as a consultation, choose the appropriate code from (Office consultation for a new or established patient ). Therapeutic and diagnostic procedures may be performed by the consultant at the time of the consultation. Once that initial visit is complete, and the physician has accepted to follow the patient for the care of the reason that they were sent for their opinion, subsequent visits are considered subsequent office visits ( ). Assess the Subscriber s Scenario When deciding how to handle the subscriber s situation, start by asking some background questions. First, did your physician (or any other provider) request the physician s opinion in the second year? asks Gloria Sikora with Trinity Mother Frances Hospitals and Clinics in Texas. Second, it could be assumed since she is following the patient that she accepted care of the patient (for that problem) and perhaps should not have charged a consult in the first place. The idea of a consult is to render an opinion (it is OK to follow through with diagnostic and/ or therapeutic procedures for the problem), but then return care of that patient to the PCP or other physician who may be the requesting provider of that opinion. Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J., agrees. Unless the other doctor s opinion is asked for, each time that the follow up for annual surveillance is done, it is a followup visit, not a consult. If the Plan of Care is to follow up with the patient in the year and check up on them, it is a follow up visit. Remember: For each consult, the opinion of the consultant needs to be requested from the referring physician in order for the consult to be valid (assuming the payer is a payer who accepts and processes on consults) codinginstitute.com

18 Billing Non-Physician Practitioner Handbook Otherwise, there are not any consults anytime, even when the consultant s opinion is being requested (such as with Medicare and any other payers who follow Medicare s rules for consults), Cobuzzi says. If the patient is non-medicare and the payer has not indicated that they follow Medicare s rules for consultations, you could code from for the consultant services in an outpatient setting. The level of consultation is based on the documentation in the medical record and the documented problem(s) establishes medical necessity for the consultation. If the patient is Medicare or is covered by a payer that doesn t recognize consultation codes, report the most appropriate E/M office code for the service. v 2015 codinginstitute.com 13

19 Non-Physician Practitioner Handbook COMPLIANCE COMPLIANCE Focus on 5 Areas for Improvement in Your Provider Documentation While EMRs improve legibility, they may lead to other issues. When your practice faces an audit, the payer is not only going to look at your coding accuracy, but also your documentation compliance. If you fall short, you could be setting your practice up for paybacks, fines, or worse. Ensure your providers documentation will stand up to payer and government scrutiny by focusing on these five key areas for improvement. 1. Start with Authentication Requirements Every medical record must have authentication. Every service your medical staff provides or orders should be authenticated by the author, says Marsha S. Diamond, CPC, CPC-H, CCS, coding textbook author and past AAPC National Advisory Board member and past Greater Orlando (Fla.) AAPC Chapter President in the Audioeducator.com audioconference Compliance: It s Not Just About Coding. All notes should be dated, preferably timed, and signed by the author. Authentication must be either a handwritten or an electronic signature. Note that signature stamps are not acceptable for Medicare and many other payers. In the office setting, initials are acceptable as long as they clearly identify the author. Handwritten signature will be considered a mark or sign. If the signature is illegible, Medicare shall consider evidence in a signature log. Lack of such supporting documentation will result in claims denial. Remember: Every note must stand alone, meaning that the performed services must be documented at the onset. The medical record must stand on its own with the original entry corroborating that the service was rendered and medically necessary. Ensure legibility: Every entry in a patient s medical record must be legible to another reader to a degree that a meaningful review may be conducted. If the signature is not legible and does not identify the author, a printed version should also be recorded. 2. Check Timing Requirements When your providers actually complete their documentation matters. Documentation should be generated at the time of service or, as Medicare puts it, shortly thereafter, Diamond explains codinginstitute.com

20 COMPLIANCE Non-Physician Practitioner Handbook Delayed entries within a reasonable period of time are acceptable for the purposes of: Clarification Error correction Addition of information initially not available Unusual circumstances prevented generation of note at time of service (for example, if your EMR system is not working). Rule of thumb: Payers don t typically give a set timeframe on what qualifies as shortly thereafter. Diamond explains that the rule is usually that you are in good shape as long as the documentation is in the chart and documented in the time that the author has total recall of the patient encounter or service. 3. Be Careful Making Alterations The medical record cannot and should not be altered. Errors must be legibly corrected so that the reviewer can draw an inference to its origin. If your provider makes a correction, he should include the date and (preferably) the time of the amended. Then, the person making the change should also legibly sign or initial the entry. Example: Your provider accidently copies and pastes a sentence from one patient s record into another patient s record. Someone in your practice catches the error later on. Even if you realize that you put it on the wrong patient s record or that that comment is totally inappropriate for that particular patient, then it should not be taken out of the record, but corrected using an appropriate method such as lining through it and initialing above it and the date [added and a statement] to say that was an error. Be clear: Delayed written additions/explanations serve for clarification only and cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For example, if your practice did an audit and found that one of your providers was billing based on time but never included the total time spent with the patient in the chart notes, you cannot go back later on and add the time to support the billing. 4. Know the Rules for Using Scribes If a nurse or non-physician practitioner (NPP), such as a physician assistant (PA) or nurse practitioner (NP), acts as a scribe for the provider, the individual writing the note or entry in the record should note written by (name of NPP), acting as a scribe for Dr. (Physician Name). The physician should then co-sign and date the record, and also indicate that the note accurately reflects work and decisions he made during the encounter. It would be inappropriate for an employee of the physician to make rounds or see patients at one time and make entries in the record and then the provider make rounds later and note agree with above, unless the employee is a licensed, certified provider (NP/PA) billing for services under his/her own name/number, Diamond says codinginstitute.com 15

21 Non-Physician Practitioner Handbook COMPLIANCE 5. Watch Out for EMR Pitfalls With the introduction of electronic medical records (EMRs) the capability of carry over, repetitive fill ins, and cloning has become prevalent, Diamond says. Remind your providers and coding/billing staff that only medically necessary information is considered when you are deciding on the code to bill based on supporting documentation. Copy and paste, cloning, and the act of carrying information forward from another record or another portion of the record has the same effect on the integrity of the medical record. Eventually, there will be contradictions in a patient s record. Payers obviously frown on this type of documentation. Example: First Coast Service Options, the MAC in Florida, prohibited the practice of cloning in its 2006 Medicare Part B newsletter (medicare.fcso.com/publications_a/2006/ pdf), which states Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. First Coast further states that discovery of this type of documentation will result in denial of services for lack of medical necessity and recoupment of all overpayments made. Bottom line: Cloning of documentation is considered a misrepresentation of medical necessity requirement for coverage of services. Credibility of the record is compromised and an auditor will be unable to determine what is accurate and how much work was done on one visit versus another. v Leave the HPI Details to the Provider Identify which portions of the record ancillary staff can capture. Your podiatrist s time is valuable and, like most practices, you re likely trying to find ways to have ancillary staff take on duties to free up the physician s time for critical provider-only parts of patient care. But be careful: If you don t follow the E/M guidelines about what portions of an office visit your ancillary staff can actually perform, you are putting your practice at risk of compliance concerns. Watch the Chief Complaint All E/M documentation must include a chief complaint (CC), but who in your practice captures the chief complaint may not fit your insurer s requirements. The chief complaint is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the E/M encounter. It is typically stated in the patient s own words codinginstitute.com

22 COMPLIANCE Non-Physician Practitioner Handbook The challenge: Most payers and auditors want to see that the provider documented the chief complaint, and most experts agree. The chief complaint should be written by the billing provider, says Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC, manager of physician compliance auditing at Allegheny Health Network in Pittsburgh, Penn. For example: Palmetto GBA states: Ancillary staff may only document: Review of systems (ROS), Past, family and social history (PFSH), Vital signs. These three areas must be reviewed by the physician or non-physician practitioner (NPP) who must write a statement that it is reviewed and correct or add to it. Only the physician or NPP that is conducting the E/M service can perform the history of present illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances, an office or emergency room triage nurse may document pertinent information regarding the chief complaint (CC)/ HPI, but this information should be treated as preliminary information. (Source: Frequently asked questions page on) Other payers may allow ancillary staff such as MAs and nurses to capture the CC details. WPS Medicare, for instance, says ancillary staff can capture CC: The 1995 and 1997 Documentation Guidelines (DG) do not address who can record the chief complaint. WPS Medicare will allow the CC when recorded by ancillary staff. However, the physician must validate the CC in the documentation. (Source: provider_types/2009_0526_emqahistory.shtml) Don t miss: If your provider allows ancillary staff to capture the CC, be sure the provider still refers to it in his documentation. S/he could confirm the chief complaint and add information as long as it is evident this was done (initials, signature, electronic signature, mention by the MD in his/her note, etc.), Berman says. To add to the confusion, both the 1995 and 1997 E/M guidelines specifically address which personnel can document review of systems (ROS) and past medical, family, social history (PMFSH) as follows: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. Because the CC, HPI, physical examination, and medical decision making (MDM) are not addressed in this notation, many payers and experts by inference state that the provider is the only one who can document these elements. The reason there is confusion around this piece is because the guidelines clearly illustrate who can document the review of systems and past, family and social histories to include ancillary staff, Berman agrees. However, this distinction is not made anywhere else within the guidelines; they do not indicate ancillary personnel being able to document anything else; thus the confusion. Bottom line: Check your payer s rules to ensure you are compliant. HPI Differs From Other History Components Any employee who has been adequately trained can help document at least part of a patient s history codinginstitute.com 17

23 Non-Physician Practitioner Handbook COMPLIANCE Support: E/M service documentation guidelines state that ancillary staff can record the review of systems (ROS) and/or the past, family, and social history (PFSH) portions of the history. Only the physician or other qualified health care professional (such as a nurse practitioner or physician assistant), however, may complete the history of present illness (HPI). Tip: You can check with your payers for specific details on which providers can document which portions of the record. For example, Meredyth Hurt, CCS-P, physician coder at Sky Lakes Medical Center in Klamath Falls, Ore., points out that at a Noridian Medicare workshop, her MAC gave the following information: Question: If someone other than a physician collects the history of present illness (HPI), documents it, then the physician reiterates the HPI with the patient, can the physician then refer to the other person s documentation with the notation, I re-obtained the HPI, reviewed the documentation and agree? Answer: HPI must be done and individually documented by the physician. According to Hurt, Medicare B News (Issue 238; July ) states The Centers for Medicare and Medicaid Services (CMS) has clarified that only the physician or non-physician practitioner (NPP) who is conducting the evaluation and management (E/M) visit can perform the history of present illness (HPI) and chief complaint (CC). This is physician work and shall not be relegated to ancillary staff. Payers agree: WPS reiterates this guidance on its provider Website: The billing provider must perform the History of Present Illness (HPI). The ancillary staff cannot collect this information and enter it into the medical record with the provider only signing or acknowledging they read the notation. (Source: Remember: If another staff member takes part of the history, the provider must sign off on the patient s chart and indicate that he reviewed the history notes. He should include a note supplementing or confirming the information recorded. v Make Sure You re Implementing These E/M Coding Changes Know who can now render services and who can bill for services brought E/M descriptor changes to broaden the range of providers who can report services. Read on for advice on how these changes will affect E/M reporting in your practice. Eliminate Physician Focus from Your E/M Thinking Most E/M codes previously referred to physicians and providers in their descriptors, these have changed and the descriptors now say qualified health care professionals. Using as an example, the code changes are indicated with the strikethroughs (indicating deleted text) and underlining (indicating new text) as follows: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least codinginstitute.com

24 COMPLIANCE Non-Physician Practitioner Handbook 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and coordination of care with, other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. This really isn t a change per se, as much as it is a clarification, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, President of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. What this means: They are clarifying that all E/M codes can be reported by physicians or other qualified health care providers and changed the wording with regard to time in each of the codes which really has no bearing on how the codes are used, just that the typical time is spent by all qualified providers who bill these codes, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. In other words, if a payer allows someone other than a physician to provide and bill for a service, the CPT E/M codes are used by all providers who qualify. Key for neuro: This reinforces the role of nurse practitioners and physician assistants in providing follow-up E/M services, which may be under direct or indirect supervision of a physician, depending on the circumstances, says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. State regulations may influence which providers are considered appropriate for these services as well as the level of supervision required. I believe that there are a lot of physician extenders out there, says Christy Shanley, CPC, department administrator for the University of California, Irvine department of urology. This further clarifies what they can and or cannot perform on their own. This change clarifies things in two ways, Mac says: First, the change makes it clear that you can use E/M codes for nonphysician providers (NPPs). Second, it clarifies that you have to have that counseling with someone who is certified or technically licensed to provide that type of service; it can t be your office administrator, so to speak, she explains. It is just a clarification, and I think it was understood before but it could have been abused in some way. Apply the Change to Your NPP Billing The E/M service changes reinforce that NPPs, including PAs and NPs, can provide E/M services on their own, can bill on time alone, and can do counseling and coordination of care on their own, experts say. Impact: The description changes I feel are a benefit if RVUs do not go down, says Chandra L Hines, practice supervisor of Wake Specialty Physicians in Raleigh, NC. Allowing PAs to bill these E/M services on their own and bill for services based on time including the counseling and coordination of care services is a positive move. It is important to recognize that these changes will mean that you will need to train your PAs and NPs to document properly if they are not used to doing this. It is always a good idea to review E/M coding each year with your physicians/npps and staff codinginstitute.com 19

25 Non-Physician Practitioner Handbook COMPLIANCE Time assignment: In addition, CPT includes typical times to the same-day observation or inpatient admission and discharge codes (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ), assigning 40 minutes to 99234, 50 minutes to 99235, and 55 minutes to Previously, these codes did not have typical times associated with them, so this change could be helpful to physicians who are at the patient s bedside or on the unit counseling or coordinating care for more than half of the visit, which would allow them to select a code based on time. Don t miss: There are often circumstances where the level of documentation for history, examination and medical decision making would result in choosing a lower level E/M service compared with the time required to provide the service. In circumstances where more than half of the service involves counseling or coordination of care, the provider may choose to base the level of service on the actual time spent with the patient rather than based on the complexity of the three key components of history, examination and medical decision making, says Przybylski. v New Education Tool Explains F2F To Physicians CMS is offering you a helping hand to get docs on board with face-to-face encounter documentation requirements. The agency has issued a new MLN Matters article on the topic aimed at physicians. The Affordable Care Act mandates that prior to certifying a beneficiary s eligibility for the HH benefit, the certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the beneficiary, the Centers for Medicare & Medicaid Services stresses in the article. Further, the homebound status of the patient and his/her need for skilled services must be written in a brief narrative, signed by the physician, titled Home Health Face to Face Encounter, and dated, CMS continues in the article. A list of diagnoses or procedures won t cut it when it comes to documenting skilled need, CMS warns. And jotting down brief phrases like gait abnormality or taxing effort won t prove homebound status either, the agency maintains. The face-to-face encounter documentation must explain why the findings from the encounter support the medical necessity of the services ordered and the beneficiary s homebound status, CMS insists. The article, which includes examples of correct and incorrect F2F documentation as attachments, is at MLNMattersArticles/Downloads/SE1405.pdf. v codinginstitute.com

26 COMPLIANCE Non-Physician Practitioner Handbook Watch Out for Top Risk Areas When Adding NPPs Incorrect incident-to billing isn t the only pitfall of which to beware. Employing a non-physician practitioner (NPP) can have big benefits for your practice by increasing the number of patients you can serve each day, freeing up physician time to focus on complex cases, and bringing in additional income. But if you aren t careful about which services you let NPPs perform, you could actually cost your practice time and money spent on audits and fraud investigations. Take a look at these four criteria that you have to meet to make sure you don t fall victim to heightened payer and OIG scrutiny. Capture an Extra 15 Percent Under incident-to rules, qualified NPPs can treat certain patients and still bill the visit under the physician s provider number (NPI), bringing in 100 percent of the assigned fee (i.e., what the payer would have allowed if the physician had personally performed the service), says Elin Baklid-Kunz, MBA, CHC, CPC, CCS, director of physician services for a large health system in Florida, during her recent audioconference Risk Areas for NPPs and Incident-To." To qualify for incident-to, you must first ensure the visit meets a few criteria, as established by the Center for Medicare and Medicaid Services (CMS): 1. The NPP performs the service in a physician s office. 2. The NPP performs the service within the scope of her practice and in accordance with state law. 3. The physician should establish the care plan for the new patient to the practice or any established patient with a new medical condition. NPPs may implement the established plan of care. 4. The physician must be on site (direct supervision) when the NPP is rendering the service. Private payers: The above rules are based on Medicare requirements, but most private payers follow that lead when creating incident-to rules. Cigna s policy, for instance, states, For services to be considered as incident to a physician s professional service, 1) they must be rendered under the physician s immediate personal supervision by his/her employee, 2) they must be an integral, although incidental part of a covered physician s service, 3) they must be of kinds commonly furnished in physician s offices, and 4) the services of non-physicians must be included on the physician s bills. Let s take a closer look at each of the four criteria codinginstitute.com 21

27 Non-Physician Practitioner Handbook COMPLIANCE Determine Encounter Place of Service As noted in the first criterion, you should not report services rendered in a hospital either outpatient, inpatient, or in the emergency department or skilled nursing facility setting as incident-to, Baklid-Kunz says. Medicare doesn t allow it. In addition, any NPP providing incident-to services must represent a direct financial expense to the physician, according to Medicare guidelines that most private insurers adopt. This means that the NPP must be an employee or independent contractor of the physician s practice. Check Your State s Scope of Practice Rules In its release of the 2014 Medicare Physician Fee Schedule, CMS amended its incident-to regulations to directly require that personnel performing incident-to services meet any applicable state law requirements to provide the services, including licensure. What it means to you: So what this does if you look at the language, is it provides a clear basis to deny claims and to help ensure there is a recourse to recover Medicare dollars when the services are not furnished in compliance with the state laws, Baklid-Kunz warns. We may see additional audits for incident-to where the focus maybe more on the registered nurse or even LPN to see if the work that they re doing incident-to a physician is within the scope of what they are allowed to furnish to Medicare patients. Save New Problems for the Physician The third criterion to check for is that the physician must have seen the Medicare patient during a prior visit and established a clear plan of care. If the NPP is treating a new problem for the patient, or if the physician has not established a care plan for the patient, then you cannot report the visit incident to. Remember: If you find the service does not meet incident-to billing requirements, you don t have to forego payment altogether in many cases. If a Medicare credentialed NPP provides the service, you can bill under his own NPI. In that case, you ll usually receive 85 percent of the normal global fee found in the Medicare Physician Fee Schedule, says Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Mich. For example, a physician assistant (PA) can see a patient with a new problem such as strep throat, but you just can t bill the service incident-to the physician at the 100 percent fee. Differentiate Supervision Types Finally, if a physician does not directly supervise the NPP for the encounter, the incident-to rules do not apply. Direct supervision means a supervising physician must be immediately available in the office suite during the service. The supervising physician, however, does not need to be the physician who initiated the treatment plan codinginstitute.com

28 COMPLIANCE Non-Physician Practitioner Handbook You should bill in the name of the physician present in the office suite and providing the supervision at the time of the NPP visit, whether or not he initially saw the patient and developed the plan of care. The billing must reflect this difference, Young says. The physician supervising in the office goes in box 33. The physician who wrote the plan of care for the visit goes in 17 of CMS Form Caution: If a member of your auxiliary staff, such as a medical assistant (MA), provides a service when there is no direct supervision, you cannot bill for the service. v 2015 codinginstitute.com 23

29 Non-Physician Practitioner Handbook Documentation DOCUMENTATION Avoid These F2F Pitfalls Does your docs F2F documentation include an explanation of clinical findings? Medical reviewers are poring over your home health claims even for second and later episodes with a focus on face-to-face encounter documentation from the physician. Here s what will bring you denials. Home Health & Hospice Medicare Administrative Contractor Palmetto GBA has begun a more comprehensive review regarding F2F issues, MAC CGS has announced a new widespread probe with F2F as the topic, and NHIC will be checking for F2F documentation for all home health claims it reviews. In a message to providers, CGS notes the F2F documentation must: Be a separate and distinct section of or an addendum to the Start of Care Certification Include a clear title to show it is a F2F encounter (the HHA may provide the title) Contain the patient s name; include the date of the encounter; have a description of the clinical findings during the encounter Explain how the clinical findings support the patient s homebound status Explain how the clinical findings support the need for skilled home care Include the certifying physician s dated signature (the HHA may enter date received if it s not dated by the physician). Sidestep These F2F Landmines Many commonly used phrases in F2F documentation will not pass medical review, CGS warns. For homebound: Using the phrases functional decline, dementia, confusion, difficult to travel to doctor s office, unable to leave home, weak and unable to drive will not support the patient s homebound status or your claim, CGS says. Listing just a diagnosis like osteoarthritis, procedure like total knee replacement, injury such as hip fracture, or conditions like gait abnormality or weakness won t support the homebound determination, Palmetto adds. The doc must list specific clinical findings explaining why those things cause the homebound condition. For medical necessity: Including the language Family is asking for help, continues to have problems, patient unable to do wound care, or diabetes, and including a list of tasks for the nurse to do will not support the need for skilled services, CGS adds. v codinginstitute.com

30 Documentation Non-Physician Practitioner Handbook Keep These CMS and MAC Critical Care Documentation Guidelines Handy Ensure you re following the rules by reviewing these 11 citations and quotes from CMS and MACs on critical care time documentation, provided by Todd Thomas, CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK. 1. CMS Claims Manual Critical Care Visits and Neonatal Intensive Care (Codes ) E. Critical Care Services and Physician Time Critical care is a time-based service, and for each date and encounter entry, the physician s progress note(s) shall document the total time that critical care services were provided. Resource: 2. CMS Medicare Claims Processing Manual, Publication , Chapter 12, Section : Critical care is a time-based service, and for each date and encounter entry, the physician s progress note(s) shall document the total time that critical care services were provided. The duration of critical care services to be reported is the time the physician spent evaluat ing, providing care and managing the critically ill or injured patient s care. That time must be spent at the immediate bedside or elsewhere on the floor or unit so long as the physi cian is immediately available to the patient. For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time. The CPT critical care codes and are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT code is a prerequisite to reporting CPT code Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician. 3. E/M Services Billing Guide March 2011 NHIC, Corp. Critical care is a time-based service, and for each date and encounter entry, the physician s progress note(s) shall document the total time that critical care services were provided. Resource: MLN/MLNProducts/downloads/eval_mgmt_serv_guide-icn pdf 2015 codinginstitute.com 25

31 Non-Physician Practitioner Handbook Documentation 4. Time-Based Services J1 Medicare Part B Palmetto GBA Critical Care Services Provider s Time: Total time must be documented for each date and encounter entry. Resource: Based_CPT_Codes_ pdf 5. Novitas: Evaluation & Management: Service-Specific Coding Instructions Medical Review Guidelines Regarding Full Attention and Physician Time in Criti cal Care Services Since critical care is a time-based code, the physician s progress note must contain documentation of the total time involved providing critical care services. 6. Jurisdiction 12 Medicare Part B Presents: Critical Care Critical Care Documentation Requirements Time-based codes require documentation of total time spent providing critical care services Medical necessity must be evident. Resource: pdf/tc-handout j12.pdf 7. WPS Medicare Documentation Q&As Q5. Can I use a check box indicating minutes instead of saying I spent 51 minutes in critical care? In addition, the doctor was in and out of critical care for the patient all day. Is it okay at the end of the day to document 45 minutes today? A5. Document the total time spent each time you visit the patient. CMS IOM, Section E states, Critical care is a time-based service, and for each date and encounter entry, the physician s progress note(s) shall document the total time that critical care services were provided. Resource: 8. WPS Documenting Time in Medical Records Critical Care Services Critical care is a time-based service, and for each date and encounter entry, the physi cian s progress note(s) shall document the total time that critical care services provided. The duration of critical care services to be reported is the time the physician spent evaluating, providing care and managing the critically ill or injured patient s care. That time must be spent at the immediate bedside or elsewhere on the floor or unit so long as the physician is immediately available to the patient. Resource: codinginstitute.com

32 Documentation Non-Physician Practitioner Handbook 9. Noridian Administrative Services Critical Care Billing and Coding Workshop Q&A Q9. Is it necessary to document start and stop times or just the total amount of time spent providing critical care? A9. The physician must document the total time spent providing critical care for the patient. Resource: coding.html 10. Critical Care Billing and Coding NAS Part B Critical Care Documentation Accurate reflection of the critical nature Complexity of medical decision making Aggregation of time spent by the billing provider if applicable Patient assessment Family discussions- substance of discussion Total time Key Component Resource: Noridian Administrative Services Evaluation and Management Billing, Coding, and CERT Workshop Q&As Q8. In addition to time and the documenting of time, what other documentation is required when coding critical care? Does the provider need to document briefly or extensively as to what type of care he/she provided? A8. The physician needs to extensively document what they construed as critical care for the patient. The critical care section of the CPT outlines the context of what is needed in order to qualify for critical care. v 2015 codinginstitute.com 27

33 Non-Physician Practitioner Handbook Documentation 5 Ways to Make Your History Documentation Word Perfect Tip: Avoid repeating yourself. Losing money on your E/M visits? The history documentation portion could be to blame. Use these five tips to help your physician actually document the questions the patient was asked about what she was experiencing and past medical, family and social history. 1. Remember the difference between the history and the exam. Especially when it comes to the review of systems (ROS) portion of the history, doctors may try to write down things that should actually be counted toward the exam and not the history. Teach your physicians that ROS typically comes from discussing the issue with the patient, whereas the physical exam comes from the doctor s firsthand observations. 2. Make sure the physician gets the information down on paper. Often, physicians will ask all the right questions, but they won t write down the answers. For instance, they may ask the patient, On a scale of one to ten, how much does your hip hurt when you first get out of bed in the morning? but then they might forget to write down the pain index number, which can be counted toward severity in the history of present illness (HPI). 3. Avoid double-dipping. You shouldn t list the same items under more than one area of the history. For example, allergies can fall under either ROS or past, medical, family and social history (PMFSH). You can count it once in either place, but you can t double-dip. 4. Give the patients a form. Your patients can fill out their history as long as the doctor writes down that he reviewed it and is aware of it. Create your own tailored form, and then ask the doctor to go through the form with the patient and ask the patient to elaborate on her answers. The doctor might want to either write the exam results on the back and fill in medical deci sion-making to create a complete report, or can check off items in the electronic health record while going over the patient s history to ensure everyone knows he reviewed it. 5. Know the loophole for patients unable to give history. Many coders have dropped their physicians coding down to lower new patient codes because the physician can t obtain an accurate history, often due to conditions such as a concussion, heavy bleeding, or a coma. However, CMS does have an exception to the rule that a new patient code requires you to take a history. If the physician is unable to obtain a history from the patient or other source, the record should describe the patient s condition or other circumstance which precludes obtaining a history, CMS says in its Evaluation and Management Services Guide, available at gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/ eval_mgmt_serv_guide-icn pdf. v codinginstitute.com

34 Documentation Non-Physician Practitioner Handbook Take These Steps to Ensure Your Time Documentation Makes the Grade Auditors will not be impressed if you rely on the provider s memory; only sound documentation will hold up in court. You know that you deserve to be paid for 99215, but you can expect it to get downcoded unless you have the documentation to prove that your provider really spent an hour with the patient. Apart from being cautious about recording the necessary elements, be certain to record time spent in counselling the patient and/or family. Background: When medical auditors review E/M claims, they typically code the reports based on history, exam, and medical decision-making, unless the physician meets the criteria to code a claim based on time spent with the patient. However, full-time auditors say that they hear from physicians at least once a day who argue that, although their documentation may not support 99214s and 99215s, the codes are justified based on the fact that the patient had questions and counseling took up an hour of their time. Myth: The provider s argument that he spent a significant amount of time counseling the patient justifies high-level codes. Reality: The provider s memory may be pristine, but it can t be relied upon if the payer asks for a refund due to insufficient documentation. Instead, the doctor must note the time spent in the record. Case in point: See if you can spot the problem with this chart entry: A 72-year-old patient seen for COPD (chief complaint) FU visit. She has been on inhalant medication (HPI-modifying factor) for one month (HPI-duration) but is not doing well (HPIqual ity). She is still having problems breathing, especially while walking in the city, where she lives (social history living arrangements) and with having difficulty when she leans back or lies down and then feels short of breath instantly (HPI-severity). Her sons have also noted problems with appetite (ROS-constitutional) and sleep issues (ROS-neurological or respiratory not both). Physical examination consists of a brief respiratory examination (can t give credit here as there are no details). Extensive counseling is done, discussing additional ways she can use a pillow to prop herself up when she rests to decrease her symptoms, and also to talk about ways to combat breathing problems when walking in the city (suggested a mask and told her the pros and cons of oxygen and when it s likely that she may need to use it) (counseling description). Her inhalant dosage is increased (prescription drug management table of risk moderate) (MDM risk: 2 pts) and FU planned in one month. Total face-toface time is 25 minutes. Did you spot it? The problem with this record is that you can t use the 25 minutes of time spent without knowing how much of that time was spent counseling codinginstitute.com 29

35 Non-Physician Practitioner Handbook Documentation Step 1: Include 3 Items in Documentation Before using time as the controlling factor, check off the following requirements that must be documented: 1. the total time spent with the patient 2. that more than 50 percent of the face-to-face time the physician spent with the patient/and or family is counseling/coordination of care. For instance, Saw the patient for 25 minutes face-to-face; 20 minutes of that visit was spent in counseling. 3. a description or summary of the counseling/coordination of care provided. For the example above, you could consider, Done to address coping strategies for the patient s diagnosis of COPD and treatment options. CPT lets you select an office visit code based on time only when the physician spends more than 50 percent of the face-to-face time with the patient and/or family member on counseling and/or coordination of care. Step 2: Use Elements When Time is Unknown In this case, because the time spent in counseling/coordinating care is unknown, you instead have to code the visit based on the documented history, exam, and medical decision-making, as follows: History: Detailed HPI quality, severity, duration, modifying factors Extended ROS: One element: Constitutional, Neuro (or respiratory not both) PFSH Social: 1 element Exam: None that can be used in counting the elements. Medical Decision-Making: Low Est. Problem worsening 2 points Data None Risk Problem worsening CODE: (History-Detailed and MDM-Low complexity). Without knowing how much of the 25 minutes the physician spent counseling, the key documented elements support 99213, not Solution: Adding the actual time that the doctor spent on counseling would indicate that the encounter meets time-based coding is greater than 50 percent on counseling/and or coordination of care criteria and would therefore justify a for this case. v codinginstitute.com

36 Documentation Non-Physician Practitioner Handbook Make Distinguishing Between New vs. Established Patient a Breeze Tip: Keep track of timelines. Evaluation and management of a patient differs depending on whether your provider is seeing a new or an established patient. And the 3-year rule only complicates matters by requiring you to determine whether a patient has been previously seen by another provider belonging to the same practice and specialty in the last three years. See what the experts have to say about when a specific provider, you will need to code (Office or other outpatient visit for the evaluation and management of an established patient ) rather than (Office or other outpatient visit for the evaluation and management of a new patient ) even if your provider is seeing a patient for the first time. Turn to CPT for Guidance The chief factor in determining whether a patient is new or established is time, and you must decide whether your provider has seen the patient in the past, and if he has, how long ago. Rule: CPT clearly defines what qualifies as an established patient: An established patient is one who received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. Ask yourself, Has the patient seen the provider in the past three years? Here s how to code based on your answer: Yes: If your provider has billed for a professional service in the past three years for a patient, you ll report any subsequent visits using established patient E/M codes (such as ), says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia. No: If your provider has not seen the patient within the past three years, you can report a new patient E/M code (such as ), instructs Christy Shanley, CPC, CUC, administrator for the University of California, Irvine department of urology. Don t Assume a New Provider New Patient Means If the patient has been seen before within the same practice, even though he switched doctors, he is an established patient. If you are in a group provider setting, under the same tax ID, you have to determine if the patient has seen any of the doctors (of the same specialty) and when before you can decide on a new or established patient code. Example: An internist in your practice provides an initial inpatient consultation to a patient he s never seen before. The patient then comes to your office for follow-up care one week later, but sees a different internist because the first provider is unavailable. You should report 2015 codinginstitute.com 31

37 Non-Physician Practitioner Handbook Documentation an estab lished patient office visit for the provider s in-office follow-up. Even though the patient has never been to your office, and the second provider has never seen the patient, you should report an established patient code. The patient is an established patient because a provider in the same specialty and group provided professional services within the past three years. Exception: The rules differ for subspecialties. If your practice has sub-specialists, you may have a situation when you should use new patient E/M codes for an otherwise established patient. Check with your individual payers to see how they define new and established patient visits with regard to different specialties and sub-specialties in the same group. CPT 2012 clarified the definition stating, A new patient is one who has 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. The portions of the description that were new for 2012 are underlined. What this means to you: If your practice employs various subspecialists, CPT now makes it clear that you can bill claims for patients who see different doctors with different subspecialties using a new patient code [such as ], according to Peter A. Hollmann, MD, chair of the CPT Editorial Panel, during the CPT 2012 Annual Symposium in Chicago. Avoid Coding Based on Location You should not use place of service (POS) as an indication of new versus established patient. Based on CPT s established patient definition, new versus established refers to the patient s relationship to the provider, not his relationship to the practice or its location. POS is irrelevant, Shanley says. Even if your provider saw a patient in the emergency room rather than in your office, the next time your provider or one of his associates sees that patient he is an established patient. Guideline: If a provider provides professional services to a patient in the hospital, all of his partners (physicians), with or without the same tax identification number, who provide subsequent office or outpatient care must consider the patient an established patient and bill the appropriate established patient office visit code ( ). Pay Attention When Providers Change Practices All of these new versus established patient rules also apply to a new provider in your practice. If the new provider has provided professional services to a patient elsewhere, such as in a hospital or other practice, within the last 36 months, the patient is an established patient even if this is his first visit to your practice. If a patient s doctor leaves the practice but the patient starts seeing another doctor within that practice, the patient is still established because the providers (assuming they re in the same specialty) use the same tax ID, Boone says. And if that patient follows the doctor to a new location, s/he is still an established patient. To determine new or established patient payments, insurers will look at the provider s National Provider Identifier (NPI), not where the service was provided. v codinginstitute.com

38 Documentation Non-Physician Practitioner Handbook Body System or Site? Be Sure You Clarify Escape scrutiny and ensure proper payment with specific body part descriptions. If you want to avoid coming under the microscope during audits and OIG reviews, then you must clean up your E/M documentation act. To get credit for the exam the provider performed, the E/M notes need to clearly specify organ systems rather than generalized body parts. The problem: Many doctors will write abdomen instead of gastrointestinal tract or even just GI. The patient s abdomen isn t an organ system for purposes of the physical exam portion of the E/M visit, but the GI tract is, say experts. So your doctor may lose credit for examining the patient s GI tract. At the very least, it doesn t sound as if your doctor performed a thorough examination of the GI tract. Also, many doctors will write head when they examined the patient s eyes as well as the patient s ear, nose and throat. Eyes count as one organ system, and so do ENT. But if the doctor merely writes head, he or she will receive credit for one body part instead of two organ systems or no credit at all. If they re supposed to be documenting organ systems and they re documenting body sites, then auditors could knock those claims down. Auditors will be looking for documentation that doesn t support the level of service you claimed. Tip: You should use a template to make sure your doctor documents the correct organ systems instead of body parts. This can be a paper checklist or an electronic record. v New MAC Tip Reminds Practices What Ancillary Staff Can and Cannot Document Documenting HPI is the job of the doctor or NPP. Your ancillary staff might be quite adept at recording your documentation but if they document too much, your notes might not be applicable to your coding choices. That s the word from a new E/M Tip that Part B MAC Palmetto GBA issued, reminding doctors what ancillary staff members can document in your Medicare records. Ancillary staff may only document the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs, the latest tip, indicates. As for the history of present illness, leave that to the physician or NPP, Palmetto says. Only the physician or NPP that is conducting the E/M service can perform the history of present illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam 2015 codinginstitute.com 33

39 Non-Physician Practitioner Handbook Documentation and medical decision making are also considered physician work and not relegated to ancillary staff. Exception: In certain instances, an office or emergency room triage nurse may document pertinent information regarding the chief complaint (CC)/HPI, but this information should be treated as preliminary information, Palmetto continues. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail. Reality: This clarification makes it obvious that your doctor can t get credit for HPI unless he elaborates on what the triage nurse wrote. Other payers have expanded on Palmetto s announcement, letting physicians know that they cannot simply initial the nurse s documentation. For example, Noridian Medicare published a policy that states, Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be I have reviewed the HPI and agree with above. What About Scribes? In many practices, the physician dictates his findings to a mid-level provider who acts as a scribe, documenting the information as the physician says it. Medicare payers also maintain specific rules for this type of arrangement. In E/M services, surgical, and other such encounters, the scribe does not act independently, but simply documents the physician s dictation and/or other activities during the visit, says Part B MAC WPS Medicare in its Guidelines for the Use of Scribes in Medical Record Documentation. The physician who receives the payment for the services is expected to be the person delivering the services and creating the record, which is simply scribed by another person. Key difference: The main difference between a scribe and an ancillary staff member recording the documentation is the source of where the person is getting the information. If the doctor or NPP is speaking and someone is writing it down word-for-word, that s a scribe. If, however, the patient is speaking and someone is writing that down, that s progress note documentation, not a scribe situation. In addition, if an NPP performs the whole visit for an inpatient and the doctor later makes rounds and signs the note, that s not a scribe situation either, and cannot be billed under the physician s NPI (since incident to is not applicable in the facility setting). A situation like this would have to be billed using the NPP s name and NPI, WPS Medicare says. This should not be confused with shared visits where the physician sees the patient on the same calendar date, performs a portion of the E/M service face-to-face with the patient and documents this information and signs the medical record, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla.. This can be billed as a shared service under the physician s NPI. But simply signing off on the medical record would not constitute a shared visit and should be billed under the NPP name and NPI. v codinginstitute.com

40 Documentation Non-Physician Practitioner Handbook Note Who Provided the Service Before Billing Audiology Tests Ensure physician s order to prevent having to write off claim. Bear in mind that audiological diagnostic tests are a separate benefit and not an incident-to service. Heed the following advice if your practice includes an audiologist. Only Schedule Audiology with a Physician Order Although an audiologist can submit claims under her own name, a physician must order the test. Medicare patients have to have a doctor s referral, says Catherine Tinkey of ENT Medical Services in Iowa City. Some commercial insurers don t require it, but most do. Our rule of thumb is, if we are submitting a medical claim, there has to be a physician involved, adds Gloria Sikora with Trinity Mother Frances Hospitals and Clinics in Tyler, Tx. And I would get that order in writing and keep it in the patient s medical file. From CMS: All audiological diagnostic tests must be ordered. Most orders should be from a physician, but a non-physician provider (NP or PA) may order and perform audiological testing when the order and testing are within their state scope of practice, per CMS Transmittal 84. Look at Professional and Technical Components According to CMS Transmittal 84, audiological diagnostic tests are not covered as an incidentto service because they are a separate benefit. Because of this, the Centers for Medicare & Medicaid Services (CMS) only allows audio technicians to perform procedures that include both professional and technical components. The audio technician s service is considered the technical component. A physician, audiologist, or non-physician practitioner provides the test supervision and clinical judgment of the professional component. The physician, audiologist or qualified non-physician practitioner bills the directly supervised service as a diagnostic test. Possible change: If an audiological diagnostic test is not broken into two parts (professional and technical components), CMS says that only the audiologist, physician or non-physician practitioner can provide the service and bill with his or her individual NPI. For example, (Pure tone audiometry [threshold]; air and bone) does not have both a technical and professional component. Therefore, an audio technician cannot bill for any part of this test. Only the audiologist, physician, or non-physician practitioner can complete the test (assuming that audiologic testing is within the NPP s state scope of license). If an audio technician performs the technical component of a service that does not require the skills of an audiologist such as (Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus 2015 codinginstitute.com 35

41 Non-Physician Practitioner Handbook Documentation test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording), the physician, audiologist, or NPP shall provide and document his or her work related to the professional component of the service. This would include clinical decision making and other active participation in the delivery of the service. Caution: Do not bill this participation as evaluation and management or as part of other billed services. The sum of the work performed by the audio technician and the audiologist, physician, or NPP will equal the service defined by the code with no modifier. In this case, would cover the work of a technician and an audiologist under the audiologist s NPI number. Get Familiar With the Codes The CMS Physician Fee Schedule allows a professional and technical component for many CPT codes in Audiology section. Refer to CPT for a complete listing, but a few common examples (in addition to listed above) include the following: Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording, Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording, Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive, Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report. Exceptions: When coding these procedures, you ll find one exception to the technical/ professional component requirement, for (Tympanometry [impedance testing]). CMS states in Transmittal 84 that since tympanometry is mostly automatic, the procedure may be performed by an audio technician and still be billed under the supervising audiologist s, physician s, or NPP s NPI. v codinginstitute.com

42 MISCELLANEOUS Non-Physician Practitioner Handbook MISCELLANEOUS Breeze Through Spring With Denial-Proof Allergy Coding Counting units, not scratches, is key with Springtime pollen is upon us, which means your otolaryngologist could be seeing more patients to test for specific allergies. Refresh your knowledge of reporting one of the most common tests the scratch test to file your claims correctly. Learn the Code s Purpose If you see documentation of procedures such as scratch test, prick test, or puncture test, your provider is referring to (Percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests). You might also see reference to the procedure as a multi-test for allergies. What happens: In a scratch test, the provider applies test solutions of possible allergens to scratches or shallow punctures of the skin. Code applies to allergens such as dust, cat dander, mold, pollen, and dust mites. Note: In previous years, you reported (Percutaneous tests [scratch, puncture, prick] sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, including test interpretation and report by a physician, specify number of tests) for some of the other allergens, but that code was deleted in January Instead, you report codes for combination puncture/prick testing such as (Allergy testing, any combination of percutaneous [scratch, puncture, prick] and intracutaneous [intradermal], sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests) or (Allergy testing, any combination of percutaneous [scratch, puncture, prick] and intracutaneous [intradermal], sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests). Count Your Units Correctly You should report one unit of for each allergen tested not based on each scratch. Even if the physician performs multiple scratches for one allergen, that allergen counts as one unit of service. The total number for allergens tested goes in the units field of your claim form. Example: A physician tests a patient for reactions to ragweed, oak, maple, and dust mites. You report x 4 units codinginstitute.com 37

43 Non-Physician Practitioner Handbook MISCELLANEOUS Although the supervision guidelines are similar to incident to rules, the rules actually fall under different rules, the Supervision for Diagnostic Testing when it comes to allergy testing. Medicare requires direct physician supervision of allergy testing services, including those that qualify for Report any allergy diagnostic skin testing services using the name and NPI for the on-site supervising physician. Other important points related to supervision of diagnostic testing include: Non-physician practitioners (NPPs) (mid-level providers, nurse practitioners, or physician assistants) cannot bill as the supervisor when non credentialed auxiliary personnel are performing allergy testing. The NPP can bill using his or her own NPI for any testing personally performed. You should be allowed 100 percent of the fee schedule if auxiliary personnel (such as a nurse or medical assistant) perform the test and bill by the on-site supervising physician. If an NPP performs and bills the test, you ll receive 85 percent of the allowable payment from Medicare. Check Specifics Before Reporting E/M As with any other procedure the otolaryngologist performs, always verify documentation to ensure it meets requirements before you submit an E/M code with Take note: The descriptor for specifies that the code includes the physician s test interpretation and report. Because of this, don t submit an E/M code if the patient only comes to the office to receive test results. Tip: Ask your physicians to document the testing interpretation with documentation of the actual test. When you report the test code, you need documentation for both the test and the interpretation. Keeping the notes together makes it easy to see both components during an audit. You can report an E/M service during the same encounter as allergy testing or sharing test results, if the situation supports modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). For example, if the patient mentions that they have been feeling ear pain radiating down their right jaw during the visit for allergy testing, the physician sees the patient, documents a comprehensive interval history, an expanded problem focused exam and the MDM is documented as low with this new problem. The doctor would code a along with the allergy testing on that day. The diagnosis associated with the E/M will be for unspecified ear pain and for Dysfunction of Eustachian tube. The diagnoses for the allergy testing would include the signs and symptoms as well as the definitive diagnoses that lead the otolaryngologist to order the testing. These can include for Other disease of nasal cavity and sinuses (for the patient s nasal obstruction) and perhaps for Hypertrophy of nasal turbinates. v codinginstitute.com

44 MISCELLANEOUS Non-Physician Practitioner Handbook Overcome Close Scrutiny of Incident-to Billing With These 3 Tips You could be costing your practice 15 percent of every NPP E/M service. You can avoid setting your practice up for payer take-backs. To ensure that your practice gets paid properly for incident-to services, you need to know how to bill for them appropriately. Read on to find out how to stay out of payers crosshairs. Does the NPP s service fall under incident-to? It s time to be sure, because Medicare MACs and private payers alike are scrutinizing incident-to services more than ever. Ensure your incident-to billing stands up to that scrutiny by learning the requirements you must meet and following them every time with these tips. Tip 1: Watch Out for New Patients and New Problems You can bill incident-to only when the NPP treats an established Medicare patient who has been seen initially by the physician who has established a particular plan of care (POC) for this individual patient. The POC must also be the reason for the encounter. If the NPP addresses a new problem during the visit or if the physician has not previously established a care plan for the patient, then you cannot bill the service as incident-to. Your physician should also document in the POC that the patient will be followed by an NPP to monitor the response to the planned therapy. You might encounter this follow-up visit by an NPP for many conditions such as infections, allergies, cancer diagnoses, or other medical conditions. Watch out: When there is a new problem, however, the physician must see the patient first and modify the plan of care before the NPP can provide follow-up care and bill the services as incident-to the physician. For Medicare you cannot bill new patient visits, consultations, or services provided in the hospital, nursing home, or outpatient facility as incident-to services. If the desire is to bill the service under the MD and the patient is new, only the review of systems (ROS) and past, family, and social history (PFSH) portion of the encounter can be recorded by the NPP, says Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC, manager of physician compliance auditing at Allegheny Health Network in Pittsburgh, Penn. The physician would need to reference this in his/her note. Important: You also need to know your state s laws governing the scope of practice for your different NPPs, warns Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Mich. Medicare guidelines specify that coverage is limited to the services a PA or NP is legally authorized to perform in accordance with state law, she adds codinginstitute.com 39

45 Non-Physician Practitioner Handbook MISCELLANEOUS Tip 2: Ensure Proper Supervision Before Billing One of the first things you should check before you bill a service incident-to is whether a physician was directly supervising the NPP. In other words, the provider whose national provider identifier (NPI) you ll be billing under should be supervising the service. Define direct supervision: According to MLN Matters article SE0441 ( mlnmattersarticles/downloads/se0441.pdf), in order to bill incident-to the physician, the physician does not have to be physically present in the patient s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. Key: Do not use the term direct too loosely. Having the supervising physician available by phone or having the physician somewhere on the grounds in a large facility is not acceptable by Medicare standards. Also, you may want to check your state s practice requirements to see if your state has different supervision requirements. Under Medicare s ruling, incident-to can only be met if the MD is in the office, Berman confirms. If a mid-level provider (MLP) is in the office, the service could be billed incident-to him/her if the service is done by someone with a lesser license. For example, an MLP can supervise an RN (registered nurse) or MA (medical assistant). Example: The nurse practitioner (NP) provides a level-three E/M service to an established Medicare patient with a plan of care (POC) in place for his symptomatic diabetes. The visit is a check-up to see how the patient is responding to medication, diet, and other parts of the treatment plan, as well as how he might fare with other options. During this encounter, the physician is in the office suite seeing other patients. This encounter qualifies for incident-to billing under the physician s NPI. If, during the same encounter with the NP and the patient, the physician was five miles away at the hospital seeing patients, you would not be able to bill that E/M service incident-to the physician. Silver lining: The supervising physician does not need to be the physician who initiated the treatment plan, Berman says. You should bill in the name of the physician present in the office suite and providing the supervision at the time of the visit by the NPP, whether or not he initially saw the patient and developed the plan of care. The billing must reflect this difference, Young says. Physician supervising in the office goes in box 33. The physician who wrote the plan of care for the visit goes in 17. Tip 3: Switch to NPP s NPI When Necessary If you find the service does not meet incident-to billing requirements for example, if the NPP sees a new patient you don t have to forego payment altogether in many cases. If a Medicare credentialed NPP provides the service, you can bill under his own NPI. In that case, you ll usually receive between 65 and 85 percent of the normal global fee found in the Medicare Physician Fee Schedule, depending on the type of NPP, Young says. Exception: If a member of your auxiliary staff, such as a medical assistant (MA), provides a service when there is no direct supervision, you cannot bill for the service. Important: Different payers have different rules and some do not recognize Medicare s incident-to rules, so check with your private payers before billing NPP services. v codinginstitute.com

46 MISCELLANEOUS Non-Physician Practitioner Handbook Are You Overlooking These 5 Opportunities to Collect Reimbursement? Tip: Don t delay follow up if you want to keep reimbursement flowing. Leaving no stone unturned is a good maxim to apply when you re looking to recoup payment and in these cash-strapped times, practices need to do that more than ever. Taking direct action on these five problem areas could really make a difference to your bottom line in the coming year. 1. Not Collecting Coinsurance and Copays With some copays running up to $60 you certainly can t afford to write these off but many practices are guilty of doing just that. Keep in mind that you can collect coinsurance amounts up-front for defined contribution copayments, which many Medi care Advantage programs offer, since they don t depend on which services you render. Some electronic subscription services allow you to verify the patient s coinsurance amount and whether their deductible has been met before the patient arrives for his visit. Therefore, when you make the patient reminder call, tell them approximately how much they ll owe you in coinsurance or deductible amounts. In other cases, when you must first read the chart to determine what services the patient underwent before billing a copay, make sure you collect it before the patient leaves the practice. 2. Waiting Too Long to Collect Collecting patient balances becomes increasingly difficult after the patient leaves your office. So if you didn t follow the advice in #1 above, you should bill the patient as soon as you realize they have a balance due. Experts say that after 90 days, you only have about a 70 percent chance of collecting the debt owed. Therefore, you should review outstanding patient balances every 30 days, with the following as a guideline in creating your timing: Send the first statement within five days of your system recognizing a patient-due balance exists. Send the second statement 30 days later. At this point, the patient has had three opportunities to pay one at the time of service, and two statements. Practices handle the next steps differently based on their internal policies. For instance, some practices choose to write off balances of $50 or below, while others aggressively fight for every balance. You might make a courtesy call next, followed by a collection letter. If you end up having to write off any balances, keep track of them to tally up how much money you lost. This should prompt you to have a staff meeting where you ll discuss how to avoid such losses in the future codinginstitute.com 41

47 Non-Physician Practitioner Handbook MISCELLANEOUS 3. Consistently Undercoding You may think that chronic undercoding will allow you to avoid raising a red flag to Medicare auditors, but if you re knowingly reporting the wrong code (even if it s lower than what s justified), you are still coding incorrectly. According to CMS s Comprehensive Error Rate Testing (CERT) results, CMS noted that it still owes $1.1 billion to providers who underbilled in Even if your practitioner only undercodes one claim per week by just one level, you re still losing significant revenue. For instance, a physician whose documentation justifies but who only reports and does this once a week for a year will lose over $1,700 annually. 4. Failing to Append Modifiers When used properly, modifiers can be the only thing between having your claims paid versus being rejected. For instance, suppose your physician performs a maxillary nerve injection (64400) and trig ger point injection on two muscles (20552). He addresses the maxillary nerve, also known as V1 of the trigeminal nerve, for trigeminal neuralgia (350.1) and injects trigger points in the left multifidus muscle at L5 (vertebral level) and left latissimus dorsi muscle at L1, both for myofascial pain (729.1). The CCI bundles (column 2 code) into the (column 1 code). Since your doctor performed the injections in different anatomic locations, you are clear to bypass the bundling edit by appending modifier 59 to Without modifier 59, you could forfeit the entire payment for 20552, which averages about $ You should also make sure that the ICD-9 diagnosis codes are correctly linked to the corresponding CPT codes. Important: You should never use modifier 59 for E/M services. If you re reporting a separately identifiable E/M service with another procedure on the same day, you ll turn to modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). 5. Failing to Bill A Sick Visit With an AWV When Indicated When your physician encounters a problem during the performance of an annual wellness visit (AWV), you don t have to write off the charge for that evaluation. Although the CCI bundles office visit codes into both G0438 and G0439, you can use a modifier (such as 25) to the E/M code if you have a medically necessary reason to separate these bundles. In black and white: CMS requires you to append modifier 25 when reporting an E/M code with an AWV. CMS Transmittal 2159 noted, When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes may be reported depending on the clinical appropriateness of the circumstances. CPT modifier 25 shall be appended to the medically necessary E/M service. Make sure your documentation clearly shows a difference between the services you performed for your E/M visit and those performed for the AWV, so you can demonstrate the separately identifiable nature of both services. v codinginstitute.com

48 MISCELLANEOUS Non-Physician Practitioner Handbook PA Assisting at Surgery? Check These Tips to Bill Properly Differentiate modifiers AS and 80 for billing success. When PAs serve as first assistants during difficult surgeries, coding the assist shouldn t be as tough as coding the procedure itself. The following four expert-tested steps can help your practice nail down your PA s reimbursement every time he assists your surgeon. Step 1: Check the Fee Schedule Each year, as part of the Physician Fee Schedule, Medicare publishes those procedures for which it approves technical surgical assisting (TSA) by a physician, physician assistant (PA), nurse practitioner, or clinical nurse specialist. If the Medicare Physician Fee Schedule lists a 1 or a 9 in Column U ( ASST SURG ), you cannot report a surgical assistant s claim for that particular procedure. For example, a 1 in the fee schedule Column U for code (Closed treatment of hip dislocation, traumatic; without anesthesia) means that even if the PA is there assisting, it cannot be separately paid by Medicare. If Column U Bears a 2, Assist Is OK If the fee schedule lists a 2 in Column U, you can bill a surgical assist. For example, Medicare lists the liver resection codes ( ) as being billable for an assistant at surgery. If Column U bears a 0, your documentation will make or break your assistant s reimbursement odds. When this column lists a 0, reimbursement for assistants at surgery cannot be paid unless supporting documentation is submitted to establish medical necessity. You should submit your operative report with these claims to demonstrate why the surgeon required an assistant. Medicare assigns the 0 indicator to the tenotomy codes , so you should only bill for a surgical assistant during these procedures if the surgeon is certain that he can demonstrate medical necessity to the patient s insurer. Step 2: Append AS for Medicare Patients Suppose your surgeon performs an ethmoid sinus removal (31205, Ethmoidectomy; extranasal, total) and asks your PA to serve as first assistant. Your surgeon reports 31205, and your PA reports (Assistant surgeon). Medicare pays the surgeon s service but denies the PA s claim, even though bears a 2 in Column U, indicating that the assistant should be paid. Your error: You should append modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) to your surgical code when you bill Medicare for your PA s assist. Some companies will not accept the HCPCS modifier AS, and some will. Medicare always wants the AS, but when you submit your claims to private payers, you may be required to use modifier 80 instead codinginstitute.com 43

49 Non-Physician Practitioner Handbook MISCELLANEOUS Remember: You should still append modifier 80 to your Medicare patient s surgical assist claims if a physician perform the assist. Modifier AS only applies when you bill nonphysician practitioner claims to a Medicare carrier. Tip: A best practice is to query your top 20 payers regarding how you should report PA s assists, create a file for each payer and keep their modifier preferences with each payer s contract. Step 3: Bill PA s Teaching-Hospital Assist Only if Residents Are Unavailable Although Medicare considers PAs covered providers in all hospitals, the surgical-assisting rules differ in teaching hospitals. Any hospital with an approved residency program cannot have other parties such as other physicians or PAs provide services and bill Medicare, because Medicare has already reimbursed the hospital via its residence funding. Caveat: If a qualified resident isn t available to assist, Medicare will reimburse your PA s assist. For example, suppose a hand surgeon performs a thumb fusion with graft on a Medicare patient in a teaching hospital. The hospital does not offer a hand surgery residence training program, so the surgeon brings the practice s PA to assist him. The surgeon should report (Fusion in opposition, thumb, with autogenousgraft [includes obtaining graft]), and the PA should report AS. Don t forget: Carrier preference reigns when it comes to modifiers. Some payers prefer that you append modifier 82 (Assistant surgeon [when qualified resident surgeon not available]) in these situations. Step 4: Not All Payers Follow Medicare Guidelines Although Medicare generally holds firm to its guidelines, private payers may publish completely different rules for surgical assistants and some payers may follow Medicare s lead instead of forging their own paths. Regence Blue Shield of Oregon, for instance, requests modifier AS for nonphysician surgical assistants, whereas the policy of Blue Cross and Blue Shield of Mississippi expands its scope for modifier AS beyond PAs and NPs, noting that it will provide benefits for assistant at surgery services when rendered by registered nurse first assistants (RNFA) with a CNOR certification, as well as certified registered nurse first assistants (CRNFAs). v codinginstitute.com

50 MISCELLANEOUS Non-Physician Practitioner Handbook Avoid Becoming a CERT Statistic and Paybacks Use the tips given below to find out when NPP, physician can combine forces. You have to report split/shared visits properly to avoid paybacks or underpayments. Check out when you must report an encounter with the physician s NPI and when only the NPP s NPI can be used. In the office setting: Incident-to billing is a vital part of the practice s reimbursement machine. Under incident-to rules, qualified non-physician practitioners (NPPs) can treat certain patients and still bill the visit under the physician s National Provider Identifier (NPI). The hospital setting, however, is a different story, since incident-to billing is not allowed in the hospital. But shared/split visit billing is an option. Shared-visit billing is not exactly incident-to, but it is a way to bill for services that are provided jointly by the physician and a qualified NPP. If the encounter meets shared-visit guidelines, you ll be able to report the entire visit under the physician s NPI thereby garnering you 15 percent more pay for the same service. Face-to-face Time Is a Must In a nutshell: The following example demonstrates how the typical shared visit works: The NPP visits and examines a patient. The NPP documents her work establishing medical necessity. At a different time, the doctor sees the patient. The physician documents her work. This can be immediately after or even before the NPP s visit, but it has to be on the same day. Then, you can add the documentation together to establish a billing level. Benefit: In many shared visits, the NPP conducts the preliminary interview and exam, and then the physician sees the patient. To bill a shared visit under the physician s NPI, he must provide and document a face-to-face service. According to CMS Transmittal 1875, When a hospital in-patient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician s or the NPP s NPI number. However, if there was no face-to-face encounter between the patient and the physician, the service may only be billed under the NPP s NPI codinginstitute.com 45

51 Non-Physician Practitioner Handbook MISCELLANEOUS When? There might be instances where the MD s note may not include the face-to-face encounter that is required. Maybe he only writes that he looked at the CT scan and made recommendations. Because the note doesn t fully illustrate the physician s contact with the patient, you should bill this visit under the NPP s NPI. Shared billing is an option only for select hospital E/M services you cannot bill shared visits for critical care. Make Sure Physician Is Available Under shared-visit rules, the NPP can treat patients in the hospital in accordance with his scope of practice and hospital privileges granted. During these visits, general supervision requirements apply. The physician must be accessible at all times by telephone or some other means of communication. When submitting your shared-service claims, be sure that you remember to clearly identify both providers in the medical record link the physician s encounter notes to the NPP s include legible signatures from the physician and the NPP. Tip: The documentation must prove the doctor provided at least one element of the encounter for you to bill under the physician s NPI. Examples: CMS offers the following two examples of a shared visit in Transmittal 1875: The NPP sees a hospital inpatient in the morning and the physician follows with a later face-toface visit with the patient on the same day, the physician or the NPP may report the service. In an office setting, the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the incident-to requirements are met, the physician reports the service. If the incident-to requirements are not met, the service must be reported using the NPP s NPI. v Take 8 Steps to Avoid PECOS Rejections PECOS edits are finally switched on. Just when healthcare providers were beginning to think that Phase 2 of the PECOS edits was going to be canned, CMS went live with it on Jan. 6, Rejections have been quick to follow. Here s what you can do to avoid being part of the losing end of this development. Background: In today s Medicare environment, you certainly can t afford to have payments denied or rejected, but effective Jan. 6, if your physician performs a service as the result of an order or referral, your claim must include the ordering or referring practitioner s NPI, and that number must be in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) or the payer s computer system. If you submit claims for services or items ordered/referred and the ordering or referring physician s information is not in the MAC s claims system or in PECOS, your practice will find those claims denied codinginstitute.com

52 MISCELLANEOUS Non-Physician Practitioner Handbook Reminder: In Part B as well as home health, MACs will take two steps before denying your claims. First, the carrier will check whether the ordering/referring physician is in PECOS. If not, the MAC will try to find the provider in the Claims Processing System Master Provider File. If the physician is in neither system, the claim will be rejected. If you want to ensure that your claims continue to process smoothly, follow these eight steps that can lead you to payment bliss. 1. Know Who Is Affected: An ordering physician refers to a physician or non-physician practitioner (NPP) who orders services for a beneficiary, including diagnostic or clinical lab tests, durable medical equipment, prosthetics, orthotics, and supplies. A referring physician is the physician who requests the item or service. Consider this: You ll have to submit the ordering/referring provider s NPI for all Medicarecovered services and items resulting from a physician s order or referral. This applies not only to physicians who submit claims to Medicare, but even to physicians and other eligible NPPs who do not and will not send claims to a MAC for the services they furnish, CMS says in its document, Medicare Enrollment Guidelines for Ordering/Refer ring Providers. CMS permits such physicians and other eligible NPPs to enroll for the sole purpose of ordering/referring items or services for Medicare beneficiaries. 2. Include Incident-To, X-Ray Orders in Rule: Although some practices consider the ordering/referring edits to be only applicable to those practices that deal with DME, they are grossly misinformed. Claims for imaging services including x-rays, radiation therapy, mammography, and other services will have to meet the requirements of the PECOS edits, CMS says in MLN Matters article SE1305. Needless to say, the inclusion of the referring doctor s NPI does not guarantee payment you ll also have to meet the other requirements of each specific service based on Medicare guidelines. 3. Know Where to Place the NPI: When you fill out a paper CMS-1500 form, you ll put the first and last name of the ordering/referring physician in Item 17 of the form, CMS says in MLN Matters article SE Don t Add Credentials: When you enter the name of the ordering or referring physician or NPP on your paper or your electronic claim, do not include titles such as doctor or MD, CMS stresses. In addition, Do not enter nicknames or middle names (initials) in the Ordering/Referring name field, as their use could cause the claim to fail the edits, CMS says in article SE Make Caps Lock Your Friend: Be sure to use all uppercase letters when reporting the ordering/referring provider s name on electronic claims. The information from PECOS is provided to the Common Electronic Data Interchange (CEDI) using only upper case characters, said Part B MAC NHIC Corp. in a notification to practices. The alpha character on the claim for the ordering/referring provider must be in upper case in order to validate the name against the PECOS file. 6. Don t Rely on ABNs: If you can t get the referring/ordering physician s NPI, you should not simply ask the patient to sign an advance beneficiary notice (ABN) and expect the patient to pay for the service. Claims from billing providers and suppliers that are denied because they failed the ordering/referring edit shall not expose a Medicare beneficiary to liability, CMS says in SE1305. Therefore, an advance beneficiary notice is not appropriate in this situation codinginstitute.com 47

53 Non-Physician Practitioner Handbook MISCELLANEOUS 7. Make Sure You Are in PECOS: Some practices have spent so much time researching whether their referring/ordering providers are in PECOS that they haven t yet confirmed whether they are in the system themselves. If you can t find your PECOS record in the CMS file (see #8 below for information on how to find it), contact your provider relations center for help. 8. Bookmark the List: To ensure that physicians and NPPs from whom you accept orders and referrals are of the type and specialty eligible to order and refer under Medicare, and have current enrollment records in PECOS, check the PECOS file at Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/InternetbasedPECOS. html. v Collect What You Deserve With This 4 Step Approach Deal with unexpected denials by first checking the regs. You can t afford to write off deserved reimbursement every time you are faced with a denial. Take control and apply these basic strategies to recover your pay. Tip: Take a hard look at incident-to requirements and the carrier s rules for mid-level providers to avoid having to eat the balance. Case in point: A subscriber wrote to report that she billed a claim to Medicare with a physician s assistant (PA) listed on the claim as the provider. The secondary insurer denied the claim since they do not recognize PAs. She wondered whether she can change the original claim billing provider (the PA) to the supervising physi cian (MD) and submit to the secondary insurance carrier, or whether that would appear fraudulent. Expert insight: Determining how to rectify this issue involves a multi-pronged process, advises Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. The following steps will help you figure out how to handle this type of denial. Step 1: Get the Regs in Writing I recommend contacting the secondary provider and finding out their rules for mid-level providers, Cobuzzi says. We cannot assume that non-medicare payers follow Medicare s written incident-to guidelines and their rules for billing mid-level providers. This includes your state s Medicaid, which may have its own rule set, she adds. There is a good chance, (but not definitive) that the PA was billed under his or her own number because incident-to rules for supervision and/or established plan of care were not met, Cobuzzi says. The provider needs to find out in writing whether the secondary provider will allow the PA to be billed incident-to if those conditions have not been met, and make it clear that they could bill Medicare under the PA s NPI under these conditions codinginstitute.com

54 MISCELLANEOUS Non-Physician Practitioner Handbook Step 2: Check Internal Policies Some practices bill their mid-level providers services under their own NPIs all the time, no matter whether they meet the incident-to requirements or not, Cobuzzi says. In this case, if the secondary payer pays for the mid-level provider only if supervision and plan of care requirements are met, then you can only bill the PA by changing the provider to the supervising provider and submitting it to the secondary if the mid-level met the incident-to requirements. If, however, the payer does not require supervision and/or the plan of care to be met, the provider can be changed no matter the conditions under which the mid-level provided the care, Cobuzzi adds. In this case, keep in mind that the secondary payer may not be able to process the claim under the supervising doctor and the Medicare EOB under the mid-level provider. Step 3: Face the Music If the secondary payer cannot process the adjusted claim because they cannot reconcile the supervising NPI on the claim to the mid-level provider s NPI on the EOB, or if conditions are such that you can t submit the secondary claim under the mid-level provider s NPI, you will end up eating the balance owed, unfortunately, Cobuzzi says. Step 4: Prepare for the Future If you ve had to eat the cost of such a visit, consider your lesson learned, but don t let it happen again. Going forward, get your Medicare and secondary payer policies in writing, and keep a notebook showing which payers will allow claims with mid-level providers such as PAs and nurse practitioners as the provider of service, and which will allow incident-to claims. Keep copies of each payer s incident-to requirements so you can refer to them for all types of practitioners, including dietitians and therapists, as well as other mid-level providers. v Follow These Q&As to Keep Your Mid-Level Provider's Service Reporting Incident Free Ask 3 questions to hone in on details. Billing incident-to for services your non-physician practitioners (NPPs) provide can help you collect the entire assigned physician fee for your NPP if you handle things correctly. Let our answers to three top incident-to questions help you keep on the right track. Question 1: What Is Incident-To Billing? Incident-to is the term for services that the NPP provides under a supervising physician s authority and billed under the supervising physician s NPI (national provider identification) number). It s one way to bill services to Medicare codinginstitute.com 49

55 Non-Physician Practitioner Handbook MISCELLANEOUS Before billing incident-to, you must meet several criteria set forth by CMS: The service is furnished by an NPP who qualifies as an employee of the physician (the provider can be an employee, leased employee, independent contractor of the physician, etc.). The treatment plan is initiated by the physician. The NPP can provide care once the plan is established and the physician remains active in the patient s care and management. The service is provided under the physician s direct personal supervision. The NPP provides the service in the physician s office. The NPP performs the service within the scope of her practice and in accordance with state law. The service can be categorized as one that is commonly furnished in the physician s office or clinic (not in an inpatient setting). Note: The NPP cannot bill incident-to for evaluation of a new patient. Incident-to also does not apply when the NPP sees an established patient for a new problem or when an established patient has a change in his treatment or plan of care. Private payers: The above rules are set out by Medicare, but some private payers follow the same guidelines when creating their own incident-to criteria. Cigna s policy, for example, states, For services to be considered as incident to a physician s professional service, 1) they must be rendered under the physician s immediate personal supervision by his/her employee, 2) they must be an integral, although incidental part of a covered physician s service, 3) they must be of kinds commonly furnished in physician s offices, and 4) the services of nonphysicians must be included on the physician s bills. Important: Make sure you get from your private payers and your other non Medicare payers, such as Medicaid what their rules are for NPP billing and incident to services in writing to assure that you are providing following exactly what they expect from your practice. For example, Kansas Medicaid does not allow incident to billing for NPP services and they require the NPPs bill directly under their own NPI. Kansas Medicaid allows 75 percent of their fee schedule for NPP services. Remember: Physicians cannot bill incident-to another physician because you cannot bill services provided by one physician under another physician s name or number. Billing under the name of a physician who did not perform the service could lead to allegations of false claims submissions. Question 2: What Qualifies as Direct Supervision? In terms of incident-to, the physician whose NPI will be used for billing must be present in the office suite and immediately available to provide assistance and direction as necessary. The physician providing the direct supervision, the physician you bill under, however, might not always be the patient s regular physician or the physician who developed the problem s plan of care. Scenario: Dr. A saw Mrs. Jones and established a plan of care for ongoing treatment of her tinnitus (388.30). She returns for her follow-up visit in two weeks. She sees the nurse practitioner, who continues the planned treatment. Dr. A is at the hospital performing surgery that codinginstitute.com

56 MISCELLANEOUS Non-Physician Practitioner Handbook day and Dr. B is the in-office physician. You would bill the visit as incident-to under Dr. B s NPI since he was physically present and able to provide direct supervision. If you billed under Dr. A., it would be considered fraud (billing for services not provided) because Dr. A did not supervise the NPP when the services were provided to Mrs. Jones. So, even though Mrs. Jones received the service, she did not receive it from Dr. A, and as such, billing under Dr. A is considered fraudulent Medicare billing. Question 3: What Kind of Documentation Is Needed? The more detailed your documentation related to incident-to services can be, the better. Keep these points in mind: Ensure that the documentation clearly notes who performed the service. Even if your claim has the doctor s number on it, the actual medical record should be signed by the NPP and note that the NPP was the practitioner. Verify that you have proof that a supervising physician was actually on site on the date and time of service. More than one incident to claim has been denied because auditors realized a physician was on vacation while he was purported to be overseeing several NPPs. Although many practices have proven the physician was present via the schedule for that day, it is highly recommended that NPPs start out incident to notes with the following documentation: Dr. B in the office supervising today. With this documentation present, there will be no question as to who was present in the office providing direct supervision on the date of service. Pay out: Billing incident-to has numerous requirements, but can boost your bottom line when done correctly. When the claim meets incident-to criteria, Medicare will reimburse at 100 percent of the Medicare Physician Fee Schedule (MPFS) allowable for that service. If you don t meet all the incident-to criteria and the NPP bills Medicare directly with his or her own name and NPI on the claim form, the payment is reduced to 85 percent of the MPFS allowable by Medicare. All non-medicare payers will have their own reimbursement rules as demonstrated above with Kansas Medicaid. v Get the Latest Scoop on Hydrocodone Combo Prescriptions Ensure that your providers meet these criteria for Rx. States have very specific rules regarding prescribing controlled substances, which means you should always make sure your providers are compliant with current regulations. Keep in mind: Each state decides who has the authority to prescribe controlled substances within that state, provided the state s regulations don t conflict with federal law codinginstitute.com 51

57 Non-Physician Practitioner Handbook MISCELLANEOUS Case in point: The Drug Enforcement Agency (DEA) recently took emergency action to reclassify combination analgesics containing hydrocodone and acetaminophen or aspirin (such as Vicodin, Lortab, or Norco) from Schedule III to Schedule II status. The DEA cited over-prescribing and underestimating of addiction potential as its reason for the shift. The change which was effective Oct. 6, 2014 has significant implications for pain management specialists. Three top results of the action include: You can no longer call hydrocodone combination drugs in to pharmacies, except under very limited emergency situations. Providers must limit written prescriptions for hydrocodone combination drugs to a 30-day supply. Providers cannot allow for refills when they write prescriptions for hydrocodone combination drugs. Another potential issue with this change affects NPs and PAs that work in states that allow NPPs (non-physician providers) to write prescriptions for Schedule III controlled substances, but not Schedule II, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Co. They previously could prescribe these drugs but after Oct. 6 will no longer be able to. Their practices will need to address this change. Take action: Familiarize yourself with the rules and regulations surrounding this change, including a review of guidelines regarding substantive requirements in the Federal Controlled Substances Act 21 CFR Specifically, the Act sets forth these requirements when prescribing controlled substances: A valid physician-patient relationship Prescription services must be within the scope of the physician's practice Guidelines based on generally accepted medical standards of care Supporting documentation for the prescription risk assessment. Many providers interpret these standards to mean that a physician must meet all five requirements as well as other substantive requirements in the Act before prescribing controlled substances for their patients. Because of the reclassification of hydrocodone combination products, patients who need additional medications will need to obtain a new written prescription for each 30-day supply. v codinginstitute.com

58 MISCELLANEOUS Non-Physician Practitioner Handbook Focus on Terminology to Navigate the NPP Maze Take note of an NPP s background to best take advantage of her skills. The first step in understanding how to bill for incident-to services is to understand which members of your office staff fall under the category of non-physician practitioner (NPP), also referred to as or non-physician provider. Learning the lingo in this area is a real challenge, says Duane C. Abbey, Ph.D., president of Abbey & Abbey, Consultants, Inc. in Ames, Ia., during his recent audioconference Effective Utilization of Non-physician Practitioners, sponsored by The Coding Institute affiliate AudioEducator.com. You are going to have to take the time and trouble to step back and make sure that when you are reading a regulation or meeting with a group of folks or credentialing someone, that you understand exactly who they are and what they are, and that s not always easy. Review the key words you need to know to help ensure proper incident to billing, and effective use of NPPs to increase your patient base and bring in extra revenue. Differentiate Practitioner From Provider From Physician As noted above, the acronym NPP can refer to the terms non-physician provider or non-physician practitioner. So what is the difference? Well, one is a subset of the other, Abbey explains. A non-physician provider is simply a healthcare provider that provides healthcare services, that is not a physician. Generally, when you are referring to non-physician practitioners, you are referring to non-physician healthcare providers who are allowed to bill professionally to Medicare, he adds. If the common factor is that the NPP is not a physician, you then need to know who fits in the role of practitioner and who qualifies as a physician. Defining exactly what a physician is, is not exactly that straightforward, Abbey cautions. He points to the Code of Professional Regulations, Title 42, Chapter IV, Subchapter B, Part 405 (42 CFR ), for the definitions you should learn: Physician means a doctor of medicine; doctor of osteopathy; doctor of dental surgery or of dental medicine; doctor of podiatric medicine; or doctor of optometry who is legally authorized to practice medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, or optometry by the State in which he performs such function and who is acting within the scope of his license when he performs such functions. Practitioner means a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, clinical psychologist, clinical social worker, registered dietitian or nutrition professional, who is currently legally authorized to practice in that capacity by each State in which he or she furnishes services to patients or clients codinginstitute.com 53

59 Non-Physician Practitioner Handbook MISCELLANEOUS Resource: You can review these and other definitions in the CFR at Reviewing these definitions brings about the question of what category podiatrists, chiropractors, physical therapists, occupational therapists, respiratory therapists, dieticians, medical nutrition professionals, and others fit in, Abbey says. Check Various Scope of Practice and Qualifications NPPs are growing in number because they are a lot less expensive to employ than are physicians. I see a new type of NPP every time I travel, Abbey comments. However, the scope of practice for an NPP is often different from that of a physician. Before your practice hires a new NPP, you need to assess what the NPP can actually do in your practice, from both a scope of practice and a qualification perspective, at a variety of levels, as follows, Abbey says: National professional Check with national professional organizations National Medicare Check the CFR, Federal Register, and appropriate manuals to see what the NPP can actually do State law/rule Check state statutes and administrative law Employer/institution Check the actual job descriptions, policies and procedures your practice or facility has in place Service area Review the service activities and physician agreements in your practice to see what the NPP is allowed to perform Personal Finally, review the NPP s personal competencies and training. Questions: The Medicare program recognizes a number of different non-physician practitioners for separate payment, but the list of NPPs in a given service area can be quite different, Abbey explains. There are several questions you ll need to find answers to, including: Which NPPs can provide telehealth services? Which NPPs can provide assistant at surgery? Which NPPs can set up their own private or independent practices? What NPPs can bill through incident-to billing? Again, the biggest challenge we all have is terminology Abbey says. Best bet: Your practice needs to review all the information available, including federal regulations, state laws, and individual payer policies to ensure your NPP coding, billing, and reimbursement stays compliant and successful. v codinginstitute.com

60 READER QUESTIONS Non-Physician Practitioner Handbook READER QUESTIONS Match POS Code and Provider Type Question: I am receiving denial C0-170 (Payment is denied when preformed/billed by this type of provider) from Medicare when I bill for an initial nursing facility visit our physician assistant (PA) did. I am using place of service code 31 (Skilled Nursing Facility) and provider type 38 (Physician assistant). Why am I getting this denial? Alabama Subscriber Answer: You cannot bill an initial visit in a skilled nursing facility (SNF) or nursing facility (NF) using (Initial nursing facility care, per day, for the evaluation and management of a patient...) under a physician assistant (PA), per Medicare rules. Medicare says that a physician must perform this type of service, per 42 Code of Federal Regulations (42 C.F.R [c] [4]). According to CMS, the Social Security Act states in Section 1819(b)(6)(A) that the medical care of every resident must be provided under the supervision of a physician. This means non-physician practitioners, including PAs, cannot perform the initial comprehensive visit in SNFs. Remember: CMS defines the initial visit is defined as the initial comprehensive assessment visit during which a physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident. Additionally, per the Long Term Care regulations (42 CFR [c][4] and [e][2]), the physician may not delegate a task that the physician must personally perform. Therefore, the physician may not delegate the initial visit in a SNF to your PA. Keep in mind: This rule also applies to the NF (POS 32) with one exception: A qualified NPP, who is not employed by the facility, may perform the initial visit in the NF setting when the state law permits. Learn more: You can read more about Medicare s billing regulations for NPPs in the SNF and NF setting by reading the Medicare Claims Process Manual, Chapter 12, Section ( or MLN Matters article SE0418 ( v Billing Same-Day Physician/Nurse Practitioner Services Question: Our nurse practitioner (NP) is working with our internal medicine physician in the same clinic. We are planning to see new patients two days a month. The physician will have her own visit and cover certain topics with each patient, and our NP will then see the patient on the same day and cover additional topics that the physician will not be covering. Our NP will mainly cover health maintenance issues. Are we able to bill for the NP service if it occurs on the same day as the patient sees our physician if the NP is covering an entirely different subject? The visit with the NP will be 45 minutes and is primarily counseling. Michigan Subscriber 2015 codinginstitute.com 55

61 Non-Physician Practitioner Handbook READER QUESTIONS Answer: In general, when your physician and an NP both have a face-to-face evaluation and management (E/M) encounter with the same patient on the same day, you should only report one E/M service reflecting the totality of the encounter, especially if the services are connected in any way. The notes of both practitioners can be combined to decide on the level of service and one bill generated under the physician s name and PIN. In the scenario you describe, the combined face-to-face time will likely exceed 60 minutes for both your physician and your NP contacts with the majority of time spent in counseling. As such, you may be able to report the level of E/M service based on time. If so, documentation should describe the content of the counseling provided and/or activities to coordinate care. There must also be sufficient detail to support the service billed. So, if time is documented and the medical necessity supports both services, the practice could bill up to a level 5 service (99205, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components Counseling and/ or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem[s] and the patient s and/or family s needs. Usually, the presenting problem[s]are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family). If the total face-to-face time exceeds 90 minutes, then you may add a prolonged services charge (99354, Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]). Remember: Before following this route, the physician and NP must be employees of the same practice. In any shared service, both the physician and the NP must provide their portion of the services face to face. The incident-to rules are all still in effect. You must document medical necessity and what you actually did during the encounter. Caution: Per section B of chapter 12 of the Medicare Claims Processing Manual, a shared/split encounter between a physician and a non-physician practitioner, such as an NP, the service is considered to have been performed incident to if the requirements for incident to are met and the patient is an established patient. If incident to requirements are not met for the shared/split E/M service, the service must be billed under the NPP s provider number, and payment will be made at the appropriate physician fee schedule payment. Thus, in your example, it may not be possible to bill Medicare for these shared visits under the physician s provider number if the patient is new, as indicated. Instead, you will need to report the encounter to Medicare under the NP s name and number, which Medicare will pay at a discounted rate. Possible exception: If the services provided by the physician and the NP could be separately reported if provided by a single physician or NP, then it may still be possible to report them separately in this scenario. For example, if one of them provided a preventive medicine visit and the other provided a problem-oriented encounter, both services could be reported, with the appropriate use of modifier 25. v codinginstitute.com

62 READER QUESTIONS Non-Physician Practitioner Handbook Multi-Provider Visit Could Be Shared Service Question: My physician and a physician s assistant visited the same patient in the hospital on the same day. Can I bill this as a shared service? North Dakota Subscriber Answer: The answer is yes if the documented services meet the Medicare rules for collaborative shared services. This means that the NPP provided the history, exam and MDM and the physician then also provided face-to-face service while documenting a critical portion of the service related to the patient s chief complaint. Example: The service provided by the NPP was part of a pre-round for the physician. Then the physician can focus on the problem when she has her face-to-face with the patient. Following CMS s shared-visit rules, you can bill claims under the physician s NPI number as long as the physician provided face-to-face time with the patient and documents a significant component of the service. If no face-to-face time is provided by the physician, the service can only be billed under the NPP s number, lowering the reimbursement. A shared-visit claim needs to provide the following details: A medical record that identifies both providers. A connection between both providers encounter notes. Legible signatures of both providers. Proof that the physician provided at least one element of the encounter. Keep in mind: The documentation must show that the physician was personally involved in some way by conducting an exam and/or planning the care of the patient. v Focus on Incident-to Rules Question: The following scenario occurred in our practice: Physician A covered an established patient office visit for physician B who was across the street with a patient in the hospital. They want me to bill the office visit incident-to physician B even though he was not in the office at the time. Can I do that? Answer: You should not report this service incident to physician B. SuperCoder.com Subscriber Incident-to billing doesn t apply between two physicians. You cannot bill services provided by one physician under another physician s name or national provider identifier (NPI). Billing under the name of a physician who did not perform the service could lead to allegations of false claims submissions. Incident-to billing may apply when a mid-level provider or non-physician practitioner (NPP), such as a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist, provides a service under the direct supervision of a physician. If the service meets incident to criteria, you can bill the service under the physician s NPI rather than the NPP s. In this case, physician A should bill for the service. v 2015 codinginstitute.com 57

63 Non-Physician Practitioner Handbook READER QUESTIONS Avoid NP Billing Snafus With This Advice Question: If one of our NPs does an outpatient procedure, and the physician is present during the procedure, should I bill it under the NP or the physician? Nevada Subscriber Answer: It depends. You will bill it according to the exact coverage of the Health plan in question as the rules of billing and reimbursing for the services of Nursing Practitioners (NP), Clinical Nurse Specialists (CNS), Non-Physician Practitioners (NPP) and Practice Assistants (PA) vary from one plan to another. While some plans allow NP services to be billed under their own provider numbers, other plans do not and healthcare providers have to bill for the same services using the physician s name and provider number on the claim. Medicare terms this arrangement as incident-to billing. Therefore, you have to carefully go through the policy of each health plan with which the patient has contracted for the billing policy, or identify the terms of agreement negotiated between the practice and the payer. Even though NPs and CNS may obtain their own Medicare billing numbers, you will bill the Medicare services under physicians for outpatient services provided by the NP only if the following conditions have been fulfilled: The NP must be an employee of the physician. (The NP can be either a routine employee or leased employee from another agency; he or she must not be an independent contractor.) The physician sees the patient in the initial visit. (This means the physician has to repeat essential elements of the physical exam and review the history. He or she needs to make a separate note in the chart. There cannot be just repetition for formality.) The physician has an active and ongoing involvement in the patient s care. (Nothing specific is defined, but generally, this implies that the physician sees the patient for any new significant problem and, otherwise, every third to fifth office visit.) The physician directly supervises the NP. (It is not necessary for the physician to see the patient, but the physician should be in the office suite at the time the service is being rendered and available to render immediate assistance if required. Just being present in the building is not sufficient.) The services are allowed to be performed as an incident-to service (otherwise, it will have to be reported under the NP name to those payers that allows this). The service takes place if an office setting (Place of Service 11) (otherwise, it will have to be reported under the NP name to those payers that allows this). Note: Billing Medicare for services provided by NPs under the physician s name as incident to is a risky practice unless the physician is always present in the office suite when the NP sees patients. This type of billing does not apply to inpatient situations and only applies to ambulatory care in a private office setting. Incorrect billing can lead to significant financial penalties, and a consistent pattern of improper billing can lead to criminal charges of fraud. This is not a matter to take lightly. v codinginstitute.com

64 READER QUESTIONS Non-Physician Practitioner Handbook Here s Who Can Perform Spirometry, Oximetry Question: Is there a valid code (accepted and PAID) for the interpretation of spirometries and overnight oximetries performed by a PA? If so, must the test be performed under physician supervision or not? California Subscriber Answer: Yes. A spirometry or oximetry procedure can be performed either by a nurse, respiratory therapist, NPP (nurse practitioner, physician s assistant) or in some cases the physician. However, spirometry requires an interpretation of results by a qualified provider of services (i.e., physician or NPP).Oximetry are technical only codes and do not require a physician interpretation. You should report (Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring [separate procedure]) for the overnight oximetry. This is not performed by the staff. This requires the patient to wear the oximeter overnight. It is an active code, and you would submit it under the physician s name. There is no need to report this service under the NPP. However, it must meet all the coverage criteria in order for the service to be reimbursed: The patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations. The patient has a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen. For the spirometry, you can report (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation).code only requires the general supervision of the physician (i.e., available by phone or beeper). Please note that other spirometry service may require a higher level of physician supervision. In other words, should only be reported by the interpreting provider. If an NPP performs and interprets the spirometry, and the NPP is enrolled with the payer, the NPP should appear on the claim. If not enrolled, the claim should be submitted per the contractual arrangement with the payer. If the service is performed incident-to the physician (see below), it will go out under the physician s name, as permitted by the payer. What it is: Spirometry (94010) is the most common of pulmonary function tests, measuring lung function, volume, and speed of air inhaled or exhaled. The patient is asked to inhale and exhale air through the sensors of the device. The speed and volume of the air is measured and the result is displayed on a graph. Payment: Do not report or when the physician performs any other payable service on the same day, as payers will bundle the pulse oximetry code without separate payment Warning: Don t get confused by other oximetry codes. For the noninvasive ear or pulse oximetry, you would use (Noninvasive ear or pulse oximetry for oxygen saturation; single determination). v 2015 codinginstitute.com 59

65 Non-Physician Practitioner Handbook READER QUESTIONS Giving a Helping Hand Is a Shared Service Question: My physician and a physician s assistant visited the same patient in the hospital on the same day. Can I bill this as a shared service? North Dakota Subscriber Answer: The answer is yes if the service given by the non-physician practitioner (NPP) was just to give a helping hand to the physician in an inpatient setting by performing a portion of the E/M service, such as the history and initial examination, and the physician then also provided face-to-face service. Example: The service provided by the NPP was part of a pre-round for the physician. Then the physician can focus on the problem when she has her face-to-face with the patient. Following CMS s shared-visit rules, you can bill claims under the physician s NPI number as long as the physician provided face-to-face time with the patient. If no face-to-face time is provided by the physician, the service can only be billed under the NPP s number, lowering the reimbursement. A shared-visit claim needs to provide the following details: A medical record that identifies both providers. A connection between both providers encounter notes. Legible signatures of both providers. Proof that the physician provided at least one element of the encounter. Keep in mind: The documentation must show that the physician was personally involved in some way by conducting an exam and/or planning the care of the patient. v Capturing PAs Work For Initial Nursing Facility Visits? Not so Fast Question: I am receiving denial C0-170 (Payment is denied when preformed/billed by this type of provider) from Medicare when I bill for an initial nursing facility visit our physician assistant (PA) did. I am using place of service code 31 (Skilled Nursing Facility) and provider type 38 (Physician assistant). Why am I getting this denial? Alabama Subscriber Answer: You cannot bill an initial visit in a skilled nursing facility (SNF) or nursing facility (NF) using (Initial nursing facility care, per day, for the evaluation and management of a patient...) under a physician assistant (PA), per Medicare rules. Medicare says that a physician must perform this type of service, per 42 Code of Federal Regulations (42 C.F.R [c] [4]). According to CMS, the Social Security Act states in Section 1819(b)(6)(A) that the medical care of every resident must be provided under the supervision of a physician. This means nonphysician practitioners, including PAs, cannot perform the initial comprehensive visit in SNFs. Remember: CMS defines the initial visit is defined as the initial comprehensive assessment visit during which a physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident codinginstitute.com

66 READER QUESTIONS Non-Physician Practitioner Handbook Additionally, per the Long Term Care regulations (42 CFR [c][4] and [e][2]), the physician may not delegate a task that the physician must personally perform. Therefore, the physician may not delegate the initial visit in a SNF to your PA. Keep in mind: This rule also applies to the NF (POS 32) with one exception: A qualified NPP, who is not employed by the facility, may perform the initial visit in the NF setting when the state law permits. Learn more: You can read more about Medicare s billing regulations for NPPs in the SNF and NF setting by reading the Medicare Claims Process Manual, Chapter 12, Section ( or MLN Matters article SE0418 (www. cms.gov/mlnmattersarticles/downloads/se0418.pdf). v Check Payer Policies When Billing Incident-to Services Question: If one of our NP s does an intubation or other procedure and the physician is present during the procedure, which one do I bill under? The physicians are putting it under their billing. Cincinnati Subscriber Answer: Health plans are free to set their own policies for credentialing NPPs and providing reimbursement for their services. Some plans credential NPPs and allow their services to be billed under the NPPs provider numbers. Other plans do not and instruct practices to bill for services provided by NPPs as if the physician had provided them, using the physician s name and provider number on the claim. Medicare refers to this arrangement as incident-to billing and has a set of rules that apply to it that will be explained later. Health plans that allow this type of billing may do so with fewer restrictions than Medicare. Unfortunately, this leaves you needing to determine the policy of each health plan with which you contract. So, you will have to get in touch with the each payer and see what their policies are for covering the services provided by the NPPs in the presence of your physician. If the payer policy allows your NPP to bill out the intubation procedure under the particular NPP s provider number, you can bill it so or else you will have to report the services under the physician s name and provider number. v Can the Attending Bill For A NP s Procedure? Give Credit Where Credit is Due Question: An NP employed by the hospital wants to do sutures repairs in the ED and believes the ED group may bill for it if they are in attendance during procedure. Is this possible? What about for a PA when the chart is signed by the attending? Texas Subscriber Answer: No. There is no mechanism for an attending physician to bill Medicare for a procedure performed by a NP in a facility setting. Don t be confused about applying the shared service visits concept for an attending supervising a NPP and after documenting a face-to-face encounter, reporting the service under the attending s NPI. Remember that concept, as directed by Medicare Carrier transmittal 1780, only applies to E/M services, not to procedures. v 2015 codinginstitute.com 61

67 Non-Physician Practitioner Handbook Clip and Save Tools Clip and Save Tools Quickly Determine If You Can Bill Your NPPs Service Incident to the Physician Incident-to billing can help you maximize your practice s reimbursement by leveraging the help of non-physician practitioners (NPPs) but only if you follow the rules. Use this handy tool, created by Barbara Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, Tinton Falls, N.J. to help you determine when you can bill services incident-to and when you can t. v No Use the non-physician practitioner s provider number on the claim -- not the physician s. Allow fees at 85 percent of the fee schedule. Non-physician practitioner provides service Was the physician in the suite? Yes Yes Was the problem new? No The service should qualify for incident-to billing Use the physician s provider number on the claim and bill the charge at 100 percent of the fee schedule fee codinginstitute.com

68 Clip and Save Tools Non-Physician Practitioner Handbook Avoid Substitute Physician Billing Challenges With These 13 Tips Be sure you know the difference between modifiers Q5 and Q6. At some point your physician will need time off, whether for vacation, maternity leave, or illness. Avoid unnecessary complications and delayed payments by knowing the ins and outs of locum tenens billing before you hire a substitute physician for your office. Keep this clip-and-save checklist handy for quick how-to advice on billing during your urologist s absence. 1. Know What Reciprocal Billing Means. Remember that reciprocal billing allows an absent physician to submit claims and receive Medicare payments for services that have been arranged for a substitute physician to provide on an occasional, reciprocal basis. 2. Get to Know Modifier Q5. To appropriately report services a physician performs under a reciprocal billing agreement, use modifier Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement). The physician providing reciprocal services does not receive any payment from the absent physician or his office. 3. Nail Down Locum Tenens Specifics. Locum tenens allows your doctor to receive payment for services another physician performs. But a locum tenens physician cannot work for another practice, and your physician cannot restrict the locum s services to your office. 4. Consider Per-Diem Pay Requirements. The absent physician pays a locum tenens physician on a per-diem or fee-for-time basis. 5. Make Q6 Your Locum Tenens Go-to Modifier. When reporting locum tenens physician services, always use modifier Q6 (Service furnished by a locum tenens physician). 6. Keep Track of Days on Your Calendar. Medicare will not pay for reciprocal billing or locum tenens services for more than 60 continuous days, although reciprocal care is often for much shorter periods of time. 7. Make Sure Doc Isn t On-Site. To use modifiers Q5 and Q6, your doctor must be unavailable to provide services. This means that your physician should be out of the office while the substitute physician provides services. 8. Keep Intent in Mind. The Medicare patient must have arranged or sought to receive your vacationing physician s services. 9. Make Recordkeeping a Priority. The patient s regular physician must maintain all of the substitute physician s service on record, along with the substitute physician s NPI number. You can make an extra copy of each of the locum s claims and keep the copies in a separate paper file for the locum tenens, or you can use your computer system to track the locum tenens services codinginstitute.com 63

69 Non-Physician Practitioner Handbook Clip and Save Tools 11. Know Your Payer. Locum tenens applies only to Medicare. Most other payers (such as TRICARE, managed care, traditional indemnity insurance, etc.) do not recognize the locum tenens guidelines or reimburse for substitute physicians. Therefore, you must bill these payers using the name of the physician rendering the service. 12. Avoid Locum Tenens for NPPs. Locum tenens applies only to physicians not to non-physician practitioners such as nurse midwives, nurse practitioners, or physician s assistants. 13. Keep Modifiers Straight. Differentiate locum tenens from reciprocal billing. When you report locum tenens services, don t confuse modifier Q6 with modifier Q5. You use modifier Q5, for example, when your physician arranges with another doctor to cover each other s patients on weekends. In this situation, Doctor A will see Doctor B s patients and then Doctor B will bill under his NPI using modifier Q5. The physicians don t exchange any money because the services eventually even out over time. v codinginstitute.com

70 Clip and Save Tools Non-Physician Practitioner Handbook Incident-to Audit Checklist AUDIT CHECKLIST: INCIDENT-TO Month: Physician: Met criteria: Patient: Reviewer: Payer: If the answer is no to any of the questions, it is not appropriate to bill the service incident-to the physician. DOCUMENTATION TASK YES NO Location Employment relationship Supervision Services performed Auxiliary staff services NPPs Qualified Staff Scribing Incident-to? 100% of feesch. Does the place of service (POS) fall within the definition of an office or a physician directed clinic? The service is not performed in the instiutional setting (i.e. hospital or skilled nursing facility)? Incident-to service cannot be performed in the emergency room, hospital outpatient department or provider based physician office (POS 22). Does the physician or group incur an expense and meet the employment requirements for the auxiliary staff? -OR- Does the aquiliary staff include employees, leased employees, or independent contractors of the physician or the entity that employs or contracts with the physician? Did the physician perform direct supervision? (Present in the office suite to assist, if necessary. The physician does not need to be physically present in the patient s treatment room for these services.) Is there a documentation link between auxiliary staff and the physician when the incident-to service was performed? (Archived records of when the supervising physician was in the office suite, i.e. physician schedules, etc or documentation in the medical record by the physician.) Did the physician personally perform the initial service and develop the plan of care? (Non-physician practitioners (NPPs) cannot see new patients or established patients with new problems incident-to). Is the service a part of the patient s normal course of treatment? Is the physician actively involved in the course of treatment? Is the physician s involvement documented in order to prove physician involvement on an active level? If service is performed by auxiliary staff, who are not NPPs, is only a level 1 visit (CPT 99211) billed? If the review of systems (ROS) and past family and social history (PFSH) were performed by auxiliary staff is there documentation to support that the physician and/or NPP personally reviewed this documentation by confirming and/or supplementing to it in the medical record? Are auxiliary personal performing physician services qualified non-physician practitioners (NPP)? This includes Physician Assistant, Nurse Practitioners, and clinical Nurse Specialists. Is the NPP licensed and Certified to practice in the state in which they are practicing? The NPPS salary and benefits are excluded from the facility s cost report? If a scribe was used, did/she only document what was dictated to them by the physician and is the scribe identified as such? (Suribes do not act on their own) Yes or Nö? If incident-to requirements are not met, the services may be billed under the NPP s own provider number and paid at 85% of the Medicare physician fee Schedule codinginstitute.com 65

71 Non-Physician Practitioner Handbook 2015 Coding Updates 2015 Coding Updates Update Your 2015 Anesthesia Coding Don t miss how joint injections and TAP blocks will be reported. Whether you code strictly for anesthesia procedures or also for pain management, CPT 2015 brings numerous changes your office needs to know. Read on for the basics. Say Goodbye to 3 Anesthesia Codes Only three codes from CPT s anesthesia section changed effective Jan. 1, The new code book deleted: Anesthesia for procedures on clavicle and scapula; radical surgery Anesthesia for procedures on thoracic spine and cord; thoracolumbar sympathectomy Anesthesia for procedures in lumbar region; chemonucleolysis. Other high points that could affect your anesthesia coding include: Changes to joint injection codes to specify whether the physician used ultrasound guidance. The current codes (20600, 20605, and 20610) will specify without ultrasound guidance, and you ll have three new codes for the same injections using US guidance. Four new codes for TAP (transversus abdominis plane) block that differentiate between and injection or continuous infusion and whether the provider administered a unilateral or bilateral injection. A new, comprehensive code for transesophageal echocardiography (TEE) monitoring that includes real-time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D. The new code will represent a more comprehensive service than the code currently allowed for anesthesiologists, (Echocardiography, transesophageal [TEE] for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing [continuous] assessment of [dynamically changing] cardiac pumping function and to therapeutic measures on an immediate time basis). Watch for Pain Management Changes If you also code for pain management services, you ll be reporting kyphoplasty and percutaneous vertebroplasty services differently in Six new codes represent the services based on the number of vertebral bodies treated and the spinal area codinginstitute.com

72 2015 Coding Updates Non-Physician Practitioner Handbook Each code still represents either unilateral or bilateral injections. The biggest change is the addition of inclusive of all imaging guidance to the descriptors. Because of the updated descriptors, the associated radiology codes for guidance were deleted. You are no longer able to report the following codes as part of your vertebroplasty or kyphoplasty claim: Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance under CT guidance. Spinal myelography codes also underwent changes that will help you code procedures in more detail. Code was revised to represent the lumbar area rather than its current, wider range spinal designation. The new descriptor reads, Injection procedure for myelography and/or computed tomography, lumbar (other than C1-C2 and posterior fossa). You also have four new code choices for myelography via lumbar injection. Three of the codes specify spinal region (cervical, thoracic, or lumbar) and the fourth represents the procedure in two or more regions (lumbar/thoracic,cervical/thoracic, lumbar/cervical, lumbar/ thoracic/cervical). v Get to Know the Changes to TAP Block and TEE Monitoring Codes 2015 brought several new options specific to anesthesia providers. You can no longer report three codes from CPT s anesthesia section in 2015 because they were deleted: Anesthesia for procedures on clavicle and scapula; radical surgery Anesthesia for procedures on thoracic spine and cord; thoracolumbar sympathectomy Anesthesia for procedures in lumbar region; chemonucleolysis. When the deletions go into effect, coders will simply report the highest based procedure that matches anatomically, says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. For example, you ll report (Anesthesia for procedures on thoracic spine and cord; not otherwise specified) to a not otherwise specified/nos location; (Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; not utilizing 1 lung ventilation) for an anterior approach not using one lung ventilation; ( utilizing codinginstitute.com 67

73 Non-Physician Practitioner Handbook 2015 Coding Updates lung ventilation) for using one lung ventilation; or (Anesthesia for extensive spine and spinal cord procedures [e.g., spinal instrumentation or vascular procedures]) if the thoracic spinal procedure involved multiple levels (as described in the comments section or instrumentation). Learn Your New TAP Block Coding Options Providers sometimes use transverses abdominis plane (TAP) catheters as an alternative to epidural analgesia after upper abdominal surgery or as an adjunct to anesthesia during an abdominal laparoscopic procedure. CPT didn t include a code specifically for a TAP catheter, so you report the service with (Unlisted procedure, nervous system) and submit a copy of the procedure report. That changed in 2015; now you have access to four new codes that differentiate between an injection or continuous infusion and whether the provider administered a unilateral or bilateral injection. The new options are: Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed) by continuous infusion(s) (includes imaging guidance, when performed) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed) by continuous infusions (includes imaging guidance, when performed). I expect the confusion regarding TAP block coding go away since we ll now have specific codes, Dennis says. Add Another Choice for TEE Monitoring Anesthesiologists sometimes use TEE (transesophageal echocardiography) for monitoring during cardiac procedures. If your provider s documentation supports the criteria, you can sometimes report (Echocardiography, transesophageal [TEE] for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing [continuous] assessment of [dynamically changing] cardiac pumping function and to therapeutic measures on an immediate time basis) for the service. Change: Beginning in 2015, you have an additional, more comprehensive code for TEE monitoring. Code represents Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great vessel(s) structural intervention(s) (e.g.,tavr, transcathether pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure) (peri-and intra-procedural), real-time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D codinginstitute.com

74 2015 Coding Updates Non-Physician Practitioner Handbook Remember: Medicare does not pay for TEE monitoring. Dennis advises coders to look for documentation that shows who performed the service and fully explains the procedure and service (diagnostic, monitoring, Doppler echocardiography with or without color flow, etc.). Watch for Kyphoplasty, Vertebroplasty Code Overhaul If you code for pain management services, your provider will report kyphoplasty and percutaneous vertebroplasty services differently in That s thanks to six new codes that represent the services based on the number of vertebral bodies treated and the spinal area: Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic lumbosacral each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic lumbar each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure). Important: Note that each code will continue to represent both unilateral and bilateral injections. It s important to see that the new vertebroplasty code, 22510, also includes the cervical spine region, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Co. If a provider performs a cervical vertebroplasty in 2014, you can only report it with (Unlisted procedure, spine). It will be good that pain management providers will be able to report the cervical procedure with the new code. These codes will replace your 2014 options, The biggest change is the addition of inclusive of all imaging guidance to the descriptors. Each of the new codes also includes the bulls-eye symbol designation, which means the associated RVUs and service include moderate sedation. This is new for kyphoplasty in The 2014 codes ( ) did not include moderate sedation, so you could bill it separately. Because of the updated descriptors, the associated radiology codes for guidance will be deleted. You ll no longer be able to report the following codes as part of your vertebroplasty or kyphoplasty claim: Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance under CT guidance. v 2015 codinginstitute.com 69

75 Non-Physician Practitioner Handbook 2015 Coding Updates Get Ready for Extra Scrutiny of Modifier AA Claims in 2015 Plus: Incorrect place of service coding could also get you in trouble. Anesthesia coders and providers, be warned: Modifier AA (Anesthesia services performed personally by anesthesiologist) use is on the hot list for the Office of Inspector General (OIG) in Background: The OIG Work Plan details issues that the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General will address during the fiscal year. The agency published its latest document on Oct. 31, which outlines the target areas it will be reviewing in Differentiate AA From QK Modifier Claims for personally-performed anesthesia services will be closely watched next year, according to the Work Plan. We will also determine whether Medicare payments for anesthesiologist services reported on a claim with the AA service code modifier met Medicare requirements, the OIG states in the Work Plan. Reporting an incorrect service code modifier on the claim as if services were personally performed when they were not will result in Medicare s paying a higher amount. Translation: The OIG believes that Medicare might be overpaying for anesthesia services due to misuse of modifier AA. If the anesthesiologist does not personally perform the anesthesia, you should not bill as if he did, and you shouldn t append modifier AA to the service code. Get ahead: If your anesthesiologist personally performs a case, you must know where he is for the entire procedure and report modifier AA with the procedure code. The payer will reimburse him for the entire case. Know Your Place of Service If your physicians perform a considerable number of services at ASCs or hospital outpatient departments, double and triple-check your place of service (POS) coding to ensure that you didn t erroneously lead your payer to believe that you performed the service in your office. Prior OIG reviews determined that physicians did not always correctly code nonfacility places of service on Part B claims submitted to and paid by Medicare contractors, the OIG says in the Work Plan. Translation: Because CMS reimburses more money for procedures performed in your office than those performed in hospitals, you re getting overpaid for services that you misidentify with POS 11 (Office) if the service actually took place elsewhere. Get ahead: If you perform services in an outpatient hospital setting, you should use place of service 22 instead of 11. If the service took place in an ASC, you should instead use POS code codinginstitute.com

76 2015 Coding Updates Non-Physician Practitioner Handbook Remember: Even if your physician performs 80 percent of his procedures in the hospital, it s possible that some will take place in the office, so you can never assume that you know the POS when you read a chart. Therefore, you should always be sure to confirm where a procedure was performed before you file the claim with the POS code. Resource: To read the entire 2015 OIG Work Plan, visit v Open Up Carotid Artery Stent Coding Options Don t separately code angioplasty. When your cardiologist places an intravascular stent in the carotid artery, you have more options for reporting the service under CPT 2015 than you ve ever had before. But you also face more restrictions on the services based on newly-stated bundling rules. Let our experts guide you through the code revisions and additions to make sure you capture appropriate pay for your cardiologist s work, and avoid coding errors that could lead to costly denials. Distinguish Carotid Artery Site Stents can go many places in the carotid artery, so you need to know the exact operative site if you want to accurately describe your cardiologist s work. You currently have three codes to describe carotid artery stenting, the first two of which have revised definitions in CPT 2015, as follows: Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection without distal embolic protection Transcatheter placement of intravascular stent(s), intracranial (e.g., atherosclerotic stenosis), including balloon angioplasty, if performed. Codes describe stent placement in the cervical portion of the extracranial carotid artery. The intended site of these codes is the carotid bifurcation in the neck. On the other hand, you ll use for a stent in the intracranial internal carotid artery. Now CPT 2015 adds a new code for another carotid artery stent location the intrathoracic common carotid artery or the innominate artery, specifically with an antegrade surgical approach. The code is (Transcatheter placement of intravascular stent[s], intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation). Parallel: Notice that 37218is similar to the 2014 code added for retrograde services: (Transcatheter placement of an intravascular stent[s], intrathoracic common carotid artery or 2015 codinginstitute.com 71

77 Non-Physician Practitioner Handbook 2015 Coding Updates innominate artery by retrograde treatment, via open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation). Also, CPT 2015 makes minor revisions to 37217, deleting an before intravascular and via before open to standardize the wording of codes and Clarify What s Included Existing codes and have always included the catheter placement for selective carotid access, and the radiological supervision and interpretation, per CPT instruction, says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash. Now revisions to and in 2015 add language to make this bundling more explicit. Don t miss: The code revisions also bundle angioplasty with the stent codes, which was not an overt bundling rule prior to the change. Open up: The existing and definitions stated that the codes described percutaneous procedures, but the 2015 code revision allows you to use the codes to describe open procedures. The changes made to and make them more consistent with all other endovascular bundled coding, says Christy Hembree, CPC, a coder with a private practice in Cartersville, Ga. Bottom line: These codes now include angioplasty, and supervision and interpretation, and can now be used for open or percutaneous procedures, Hembree says. Study This Clinical Example Look at the following example to get a better idea of how you should use the carotid artery stent codes in Case: Using femoral access and common carotid placement, the cardiologist images the right common carotid and right internal carotid. The cardiologist documents normal anatomy and states there are no abnormalities in the internal carotid, but she finds stenosis in the cervical common carotid. The cardiologist inserts a catheter and places an embolic protection device distal to the stenosis to trap plaque or thrombi. The cardiologist advances a stent to the cervical common carotid artery stenosis. Solution: You should report this case using 37215, because the site of the stent is the cervical carotid artery, and the cardiologist places a distal embolic protection device. You should not additionally report (Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family) for placing the catheter in the right carotid artery, because that service is bundled into v codinginstitute.com

78 2015 Coding Updates Non-Physician Practitioner Handbook Replace Your Old Cat. III Codes for S-ICDs With New and Old Cat. I Options in 2015 Don t miss how system insertion/replacement coding changes in the new year. You have new Category I codes for subcutaneous implantable defibrillator (S-ICD) services as of Jan. 1, The Cat. I codes are similar to the Cat. III options available in 2014, but there are some key differences you ll need to watch. Start Here for an S-ICD and Code Crosswalk Overview S-ICD explained: An S-ICD has a pulse generator and an electrode. The physician implants the pulse generator under the patient s skin, typically under the armpit on the side of the chest. The physician implants the electrode so that this component attaches to the generator and extends under the skin to the target site, usually reaching from the generator and along the rib until the component reaches the breastbone. The S-ICD works by detecting the patient s heart rhythms and delivering an electric shock (defibrillation) to correct abnormal heart rhythms to 2015 crosswalk: CPT 2015 includes a crosswalk instruction that in place of 2014 Category III codes 0319T-0328T for S-ICDs, you ll use Category I codes 33240, 33241, 33262, , 93260, 93261, and Having Cat. I codes for S-ICDs should make it easier to report these procedures and remove a lot of confusion, notes Kristine Leseman, CPC, CCC, Revenue Integrity Specialist II for a hospital in Tacoma, Wash. Having Cat. I codes rather than Cat. III codes may also make reimbursement for these services more likely, she adds. Here s a closer look at how you ll apply these codes. Apply 3 Existing Pulse Generator Codes to S-ICDs in 2015 The first three Cat. I codes in the 2015 crosswalk instruction are 33240, 33241, and : These three codes existed in 2014, but CPT 2015 revises the descriptors by deleting pacing cardioverter- from in front of defibrillator and by adding implantable to the definitions. Below are the 2015 definitions: Insertion: 33240, Insertion of implantable defibrillator pulse generator only; with existing single lead Removal: 33241, Removal of implantable defibrillator pulse generator only Replacement: 33262, Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system. In 2015, you continue to apply 33240, 33241, and to insertion, removal, and replacement services for pulse generators that attach to transvenous leads, just as you did in But you also apply these codes to pulse generator services for generators that attach to subcutaneous electrodes. Also note that the crosswalk includes and 33262, which are specific to single lead systems. S-ICDs connect to a single electrode that the physician places under the skin codinginstitute.com 73

79 Non-Physician Practitioner Handbook 2015 Coding Updates 2014: In 2014, you used Category III codes for the generator services when related to an S-ICD. CPT 2015 deletes these codes: Insertion: 0321T, Insertion of subcutaneous implantable defibrillator pulse generator only with existing subcutaneous electrode Removal: 0322T, Removal of subcutaneous implantable defibrillator pulse generator only Replacement: 0323T, Removal of subcutaneous implantable defibrillator pulse generator with replacement of subcutaneous implantable defibrillator pulse generator only. Include EP Evaluation in Insertion/Replacement in 2015 The next code in the 2015 crosswalk is new code 33270, which covers multiple services: 33270, Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed. You ll use when the physician inserts or replaces the complete system, including the electrode, at the same session. The code also includes defibrillation threshold evaluation, arrhythmia induction, sensing evaluation, and programming or reprogramming when the physician performs those services at the same session as the insertion or replacement. 2014: New code replaces the following codes, which CPT 2015 deletes: 0319T, Insertion or replacement of subcutaneous implantable defibrillator system with subcutaneous electrode 0326T, Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters). Key pointer: In 2014, you used one code for system insertion/replacement and another code for the electrophysiologic (EP) evaluation performed at the same session. In 2015, single code covers both the insertion/replacement and the EP evaluation. Terms you may see related to the EP evaluation include threshold testing and DFT testing, which stands for defibrillation threshold testing. Need to Code Only an Electrode Service? See The next group of codes in the 2015 crosswalk is These codes apply when the physician inserts, removes, or repositions only the S-ICD electrode: Insertion: 33271, Insertion of subcutaneous implantable defibrillator electrode Removal: 33272, Removal of subcutaneous implantable defibrillator electrode Repositioning: 33273, Repositioning of previously implanted subcutaneous implantable defibrillator electrode codinginstitute.com

80 2015 Coding Updates Non-Physician Practitioner Handbook Codes cross almost exactly to the 2014 codes you used, which CPT 2015 deletes, although the 2014 repositioning code applied to both electrode and generator repositioning: Insertion: 0320T, Insertion of subcutaneous defibrillator electrode Removal: 0324T, Removal of subcutaneous defibrillator electrode Repositioning: 0325T, Repositioning of subcutaneous implantable defibrillator electrode and/or pulse generator. Turn to 93xxx Codes for Evaluation Options The final three codes in the 2015 crosswalk will be in the Medicine section of CPT, unlike the previous codes, which will appear in the Surgery section. Programming: In 2015, you ll use the following code for in-person S-ICD programming device evaluation: 93260, Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable subcutaneous lead defibrillator system. Code clarifies that it includes review and report by a physician or other qualified health care professional. This phrase wasn t present in the 2014 code it replaces, 0328T (Programming device evaluation [in person] with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, implantable subcutaneous lead defibrillator system). Interrogation: In 2015, you ll use for in-person S-ICD interrogation device evaluation: 93261, Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system. Code adds by a physician or other qualified health care professional, but otherwise has the same descriptor as the code it replaces, 0327T (Interrogation device evaluation [in person] with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable subcutaneous lead defibrillator system). Electrophysiologic: In 2015, you ll use for S-ICD EP evaluation performed at a different session than implant/replacement: 93644, Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters) codinginstitute.com 75

81 Non-Physician Practitioner Handbook 2015 Coding Updates Code replaces 0326T (Electrophysiologic evaluation of subcutaneous implantable defibrillator [includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters]). Keep in mind: The descriptors for and 0326T are the same, but you will not use them in the same way. An instruction for 2014 code 0326T told you to report it separately during device insertion, replacement, or for follow-up device testing, when performed. But in 2015, the code for system insertion/replacement, 33270, includes the EP evaluation. So you should not use for evaluation at the insertion/replacement session. v See What s New for Chronic Care Management and Advance Care Planning in the New Year Make the most of new bullet points for to meet documentation requirements. Review the following changes to chronic care management (CCM), including helpful new bullet points, and the changes to new time-based codes for advance care planning. Embrace the Chronic Care Management Improvements Changes to five codes may make your CCM services coding less of a chore. You ll find that CPT 2015 revises the descriptor for with new bulleted detail as shown below: 2014: 99487, Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month 2015: 99487, Complex chronic care management services, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; Establishment or substantial revision of a comprehensive care plan; Moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month codinginstitute.com

82 2015 Coding Updates Non-Physician Practitioner Handbook Adding the elements is definitely a positive; it gives the provider community a set of guidelines to follow to meet the documentation requirements of the codes, says Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC, director of coding operations-him at Allegheny Health Network in Pittsburgh, Pa. Often we find that the providers are performing the services, but aren t necessarily illustrating them as the payer would like to see in the documentation. In addition, you ll see that CPT 2015 deletes (Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month). Don t miss: For each additional 30 minutes of chronic care management your physician provides, you will still be able to report revised add-on code ( each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month [List separately in addition to code for primary procedure]). Bonus: You will also have another new CCM code to use when the CCM does not meet the requirements for the complex CCM codes: 99490, Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline, Comprehensive care plan established, implemented, revised, or monitored. Add Time Carefully for Advance Care Planning Coding Two new advance care planning codes represent the work of a physician or other qualified professional, including discussions with the patient or his representative and completing any required forms. Code covers the first 30 minutes in direct contact with the patient or representative, and represents each additional 30 minutes after that. The code descriptors are below: 99497, Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate , each additional 30 minutes (List separately in addition to code for primary procedure). v 2015 codinginstitute.com 77

83 Non-Physician Practitioner Handbook 2015 Coding Updates Look for Changes to Ultrasound Guided Arthrocentesis, Breast Ultrasound, and Care Management E/M Language And see how new rib fracture treatment alters your closed rib fracture coding. CPT 2015 went into effect in January. Take a look at our expert overview of your top ED-relevant changes that are in the works for this year. Joint Arthrocentesis Codes Now Reflect With Or Without Ultrasound Guidance Three new codes join revised codes in the family of ultrasound guided arthrocentesis of small, intermediate, and large joints. The previously existing codes, 20600, and now include the phrase without ultrasound guidance and each is now partnered with a new code (20604, 20606, and that reads with ultrasound guidance, with permanent recording and reporting, says Michael Granovsky, MD, FACEP, CPC, President of Logixhealth a national coding and billing company based in Bedford, MA. See below for specifics on the changes for each revised code followed by a new code describing the procedure with ultrasound guidance: (Arthrocentesis, aspiration and/or injection, small joint or bursa [e.g., fingers, toes]; without ultrasound guidance) Code added (with ultrasound guidance, with permanent recording and reporting) (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]; without ultrasound guidance) Code added (with ultrasound guidance, with permanent recording and reporting) (Arthrocentesis, aspiration and/or injection, major joint or bursa [e.g., shoulder, hip, knee, subacromial bursa]; major joint or bursa] without ultrasound guidance) Code Added (With ultrasound guidance, with permanent recording and reporting) ED Connection: Here s Why Care Management E/M Language Changes Matter As you ve noticed, over the past few years, the AMA has engaged in an extensive rewrite of what is now known as the care management services section of the evaluation and management code chapter. This section includes chronic care management, complex chronic care management, the transitional care management series and advance care planning codinginstitute.com

84 2015 Coding Updates Non-Physician Practitioner Handbook ED relevance: While ED physicians are unlikely to report the care management codes, because they can only be reported once per month, and only by a single provider, typically the primary care physicians or whoever is running the medical home for that patient, knowing about them can enhance your payment savvy. The skinny: As payment methodologies continue to evolve towards episodes of care, ED coders need to be aware of these specific code descriptors to gain a big picture understanding of the code sets and how they may impact larger payment methodologies, says Michael Granovsky, MD, FACEP, CPC, President of Logixhealth a national coding and billing company based in Bedford, MA. Don t Look for Uncomplicated Rib Fracture Treatment Code The rib fracture code (Closed treatment of rib fracture, uncomplicated, each) has been deleted from CPT because of changes in the standard of care for rib fractures, so that is no longer separately reportable. Rationale: Historic strapping and support are no longer typically performed to the extent that CPT felt the treatment is separately identifiable from an E/M service. As such, this code was deleted from the book starting in 2015, Granovsky explains. Stay Abreast of These Additional Ultrasound Changes A rewrite of the codes describing ultrasound of the breast results in one code being deleted and replaced by two new codes starting January (2014 code for US breast unilateral or bilateral) has been deleted is a 2015 new code (Ultrasound breast unilateral complete) is a 2015 new code (Ultrasound breast unilateral limited) Prick Up Your Ears For Vaccine And Immunization Changes Many influenza vaccine codes already are present in CPT, but new for 2015 is (Influenza vaccine quadrivalent, split virus, preservative free, for intradermal use) The FDA has approved an additional influenza vaccine formulation which has its own unique CPT code (Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for intramuscular use) Revised codes in the vaccine section include these three, which have been updated to reflect the most current strains or minor rephrasing of prior language as shown below using underline for new language and strikethrough for deleted terms, Granovsky explains Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, for intradermal use Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-HIB) for intramuscular use 2015 codinginstitute.com 79

85 Non-Physician Practitioner Handbook 2015 Coding Updates Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and inactivated poliovirus vaccine, inactivated (DtaP-HepB-IPV) for intramuscular use Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), quadrivalent, for intramuscular use Do you Have A Pediatric ED? Brush Up on the Coding Continuum for Very Sick Kids You may be interested in changes in the Inpatient Neonatal and Pediatric Critical Care code preamble. Details: The new language clarifies the code choice is based on the initial or subsequent day of treatment, the age of the patients (28 days or under, 29 days to 6 years) and the site of service (neonatal or pediatric critical care unit). There is also new language limiting the code use to only one provider and only once per day. Remember that children age 6 years or older requiring critical are service would have those services reported using the regular critical care codes, and 99292, as needed, Granovsky warns. v Get Ready to Inject Your 2015 Vaccine Claims With New, Revised CPT Codes If you have been wondering at what new changes you will be facing with CPT 2015, here is a look at what you can expect. You will see some new codes for vaccinations, arthrocentesis, and chronic care management while having to take into account some descriptor changes to old codes. Observe Changes to Vaccination Codes As with every year, you see some changes to vaccination codes in CPT You have to add two new vaccine codes to your cache while making note of many changes to the descriptors of old codes. The two new codes that you have in 2015 include: (Influenza virus vaccine, quadrivalent [IIV4], split virus, preservative free, for intradermal use) (Human Papilloma virus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent [HPV], 3 dose schedule, for intramuscular use) In addition, you will see the following descriptor changes in CPT 2015: (Influenza virus vaccine, trivalent [IIV3], split virus, preservative-free, for intradermal use) (Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib)[DTaP/Hib], for intramuscular use) (Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitishepatitis B, and inactivated poliovirus vaccine, inactivated (DtaP-HepB-IPV) [DTaP-HepB-IPV], for intramuscular use) codinginstitute.com

86 2015 Coding Updates Non-Physician Practitioner Handbook (Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), quadrivalent, for intramuscular use) Note: The new codes, and 90651, carry the lightning bolt (~) sign that indicates that these codes are still awaiting FDA approval. The revisions to the existing codes are primarily editorial or otherwise made to distinguish the existing codes from new codes that will appear in 2015, observes Kent Moore, senior strategist for physician payment with the American Academy of Family Physicians. For instance, the addition of the word trivalent to is primarily for the purposes of distinguishing it from new code 90630, which is a quadrivalent vaccine, Moore adds. v Non-Incisive Diverticulitis Drives New Esophagoscopy Changes Bipolar cautery description gets a boot out of descriptor. Last year, you saw a lot of new inclusions and revisions in esophagoscopy codes. As of January 1, 2015, CPT has decided to refine the codes introduced earlier and also added a new code to deal with diverticulectomy. Esophagoscopy Welcomes a Single New Member Last year, CPT added new codes in the series from (Esophagoscopy, rigid, transoral ). This time, CPT 2015 introduces a new code for rigid esophagoscopy (43180, Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus [eg, Zenker s diverticulum], with cricopharyngealmyotomy, includes use of telescope or operating microscope and repair, when performed). This code will enable gastroenterologists or other specialists to identify the emerging procedure used for non-surgical and non-incisive removal and repair of Zenker s diverticulum. The procedure is also variously known as endoscopic transoral stapling of Zenker s diverticula, transoral resection of short segment Zenker s diverticulum, endoscopic cricopharyngealmyotomy, transoral repair of Zenkers diverticulum, etc. Minor Descriptor Changes Round Off Esophagoscopy Updates The other code updates in the esophagoscopy family include descriptor changes. CPT 2015 has updated the descriptors for codes (Esophagoscopy, rigid, transoral; with removal of foreign body) and (Esophagoscopy, flexible, transoral; with removal of foreign body) by including removal of multiple bodies. That effectively means that from next year onward, you will be report the above two codes only once even if the physician removed multiple bodies in the same session. So the new codes will be (Esophagoscopy, rigid, transoral; with removal of foreign body[s]) and (Esophagoscopy, flexible, transoral; with removal of foreign body[s]) 2015 codinginstitute.com 81

87 Non-Physician Practitioner Handbook 2015 Coding Updates In recent years, the CPT Editorial Panel has been replacing the terminology with or without in codes with including, when performed in an effort to standardize the language and make the code descriptors more accurate. Under this umbrella, the descriptor for code has been refined with the term includes changing to including. The code descriptor will now read Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure). However, code gets a major makeover from 2015 with the provision for bipolar cautery being removed from the descriptor. The definition of lesion in the older description also sees a change as CPT 2015 has added all kinds of lesions, polyps and tumors under one descriptor. The code (Esophagoscopy, flexible, transoral; lesion removal by hot forcep or bipolar cauter) gets updated to (Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps). That means that you will not be able to report this code if your provider has removed lesion(s) by any kind of cauterization. Descriptor Edits Changes the Way You Will Report GI Procedures The CPT Editorial Panel continues to standardize the language and make the code descriptors more accurate in lower GI endoscopy procedures. This will affect codes across the lower GI spectrum with changes in: Base codes: The panel has continued with the standardization of the code descriptor by replacing the terminology with or without in the codes with including, when performed. This is similar to what was done to upper GI procedures. This particular change is applicable for the base codes of endoscopy families. Code gets updated from Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) to Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Similarly, code will read as Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Code will be described as Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) for stomal colonoscopy will now read as Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Code updates to Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) will read as Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) codinginstitute.com

88 2015 Coding Updates Non-Physician Practitioner Handbook Keep in mind that the changes in descriptor language do not affect the usage the above codes in any way. The changes are just a continuation in standardization of the language. Foreign body removal: You also have to implement descriptor changes for removal of foreign body, which effectively specifies that from next year onward, you will be reporting foreign body removal only once even if the physician removed multiple bodies in the same session. Code will change to Sigmoidoscopy, flexible; with removal of foreign body[s]. Similar changes will affect (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of foreign body[s]), (Colonoscopy through stoma; with removal of foreign body[s]), and (Colonoscopy, flexible; with removal of foreign body[s]). Control of bleeding: The panel has replaced all previous code descriptors for control of bleeding codes (such as injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, and plasma coagulator) with a single term any method. For example, will change to Colonoscopy through stoma; with control of bleeding, any method. Similarly updated codes are (Sigmoidoscopy, flexible; with control of bleeding, any method) and (Colonoscopy; with control of bleeding, any method). Stent placement: The new lower GI endoscopy codes for placement of endoscopic stents will now include pre-dilation, post-dilation, and guide wire passage, whereas you currently consider only pre-dilation. You will not report modifier 52 (Reduced services), even if the GI does not perform all the three components during the same session and you will not be allowed to report these separately also. All old stent related codes stand deleted and new codes reflecting the change have been introduced instead. For instance, CPT deletes and replaces it with new code (Ileoscopy, through stoma; with placement of endoscopic stent [includes pre- and post-dilation and guide wire passage, when performed]) takes its place. Similarly, will replace (Colonoscopy through stoma; with transendoscopic stent placement [includes predilation]); will replace (Sigmoidoscopy, flexible; with transendoscopic stent placement [includes predilation]); and new code replaces (Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement [includes predilation]). Ablation: New codes for ablation procedures follow the same changes done to stent procedures and will include pre- and post-dilation and guide wire passage, when performed. Separate reporting of pre- or post-dilation or guide wire passage will be rejected due to bundling. For instance, you will delete 44393, and you ll add new code (Colonoscopy through stoma; with ablation of tumor [s], polyp[s], or other lesion[s] [includes pre-and post-dilation and guide wire passage, when performed]). Similarly, new codes and replace (Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) and (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) respectively. Bipolar cautery: CPT 2015 has also modified tumor removal codes by taking out the reference to bipolar cautery. For example, will become Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps in accordance with 2015 codinginstitute.com 83

89 Non-Physician Practitioner Handbook 2015 Coding Updates the latest techniques being used for growth removal. Similar modifications can be seen to (Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps) and (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps). Therefore, from January onward, you will have to use codes for unlisted procedures to report use of bipolar cautery. New Introductions in Colonoscopy Codes Expands the Family The CPT Editorial Panel has now defined colonoscopy as the examination of the whole colon because CPT 2015 removes the phrase proximal to splenic flexure from the official descriptor for code (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression [separate procedure]), which indicates the procedure applies to the entire colon, rather than just a specific portion. Other than changing the descriptors of the existing codes, CPT 2015 introduces new codes for transendoscopic balloon dilation and endoscopic mucosal resection. So, if your physician performs a simple endoscopy and has to use balloon dilation for the simple purpose of better visualization, you will be able to report this new code (Ileoscopy,through stoma; with transendoscopic balloon dilation). CPT 2015 has introduced a similar code for colonoscopy (Colonoscopy through stoma; with transendoscopic balloon dilation). Get ready for new codes describing endoscopic mucosal resection (EMR) including injectionassisted, cap-assisted, and ligation-assisted techniques. CPT has now bundled sub-mucosal injection, banding, or snare polypectomy for the same lesion into the code for EMR. Moreover, you will not report a biopsy if your gastroenterologist performs it on the same lesion as the EMR. The new codes are (Colonoscopy through stoma; with endoscopic mucosal resection), (Sigmoidoscopy, flexible; with endoscopic mucosal resection), and (Colonoscopy, flexible; with endoscopic mucosal resection). Colonoscopy via stoma has been brought at par with flexible colonoscopy with new codes for area-specific ultrasound procedures (with/without fine needle aspiration/biopsy). The new code for colonoscopy via stoma is ( with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures). The corresponding flexible colonoscopy code has been updated to with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures. CPT 2015 has recognized decompression procedures in endoscopies by adding new codes in colonoscopy (flexible and through stoma) and modifying an existing one in sigmoidoscopy. The new codes are (Colonoscopy through stoma; with decompression [for pathologic distention] [eg, volvulus, megacolon], including placement of decompression tube, when performed) and (Colonoscopy, flexible; with decompression [for pathologic distention] [eg, volvulus, megacolon], including placement of decompression tube, when performed). The modified sigmoidoscopy code will be used as Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed codinginstitute.com

90 2015 Coding Updates Non-Physician Practitioner Handbook Provision for Unlisted Procedures Keeps Space for Emerging technology CPT 2015 has kept a provision for unlisted procedures for procedures not yet coded. You will find that (Unlisted procedure, small intestine) will now be much more specific with the code being confined to the small intestine. A similar area-specific unlisted procedure has been added with (Unlisted procedure, colon). v Adds Carotid Stent Coding Option Bundle angioplasty and more to match code revisions. Both opportunities and restrictions come your way in 2015 for intravascular stent coding, compliments of CPT 2015 code changes for transcatheter placement codes Read on to make sure you re ready to capture appropriate pay for your general surgeon s stent placement services, and to avoid coding errors that could lead to costly denials as you implement the new and revised codes. Distinguish Carotid Artery Site Stents can go many places in the carotid artery, so you need to know the exact operative site if you want to accurately describe your general surgeon s work. You currently have three codes to describe carotid artery stenting, the first two of which have revised definitions in CPT 2015, as follows: Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection without distal embolic protection Transcatheter placement of intravascular stent[s], intracranial [e.g., atherosclerotic stenosis], including balloon angioplasty, if performed. Codes describe stent placement in the cervical portion of the extracranial carotid artery. The intended site of these codes is the carotid bifurcation in the neck. On the other hand, you ll use for a stent in the intracranial internal carotid artery. Now CPT 2015 adds a new code for another carotid artery stent location the intrathoracic common carotid artery or the innominate artery, specifically with an antegrade surgical approach. The code is (Transcatheter placement of intravascular stent[s], intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation). Parallel: Notice that 37218is similar to the 2014 code added for retrograde services: (Transcatheter placement of an intravascular stent[s], intrathoracic common carotid artery or innominate artery by retrograde treatment, via open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation) codinginstitute.com 85

91 Non-Physician Practitioner Handbook 2015 Coding Updates Also, CPT 2015 makes minor revisions to 37217, deleting an before intravascular and via before open to standardize the wording of codes and Clarify What s Included Existing codes and have always included the catheter placement for selective carotid access, and the radiological supervision and interpretation, per CPT instruction, says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash. Now revisions to and in 2015 add language to make this bundling more explicit. Don t miss: The code revisions also bundle angioplasty with the stent codes, which was not an overt bundling rule prior to the change. Open up: The existing and definitions stated that the codes described percutaneous procedures, but the 2015 code revision allows you to use the codes to describe open procedures. The changes made to and make them more consistent with all other endovascular bundled coding, says Christy Hembree, CPC, a coder with a private practice in Cartersville, Ga. Bottom line: These codes now include angioplasty, and supervision and interpretation, and can now be used for open or percutaneous procedures, Hembree says. Study This Clinical Example Look at the following example to get a better idea of how you should use the carotid artery stent codes in Case: Using femoral access and common carotid placement, the surgeon images the right common carotid and right internal carotid. The surgeon documents normal anatomy and states there are no abnormalities in the internal carotid, but she finds stenosis in the cervical common carotid. The surgeon inserts a catheter and places an embolic protection device distal to the stenosis to trap plaque or thrombi. The surgeon advances a stent to the cervical common carotid artery stenosis. Solution: You should report this case using 37215, because the site of the stent is the cervical carotid artery, and the surgeon places a distal embolic protection device. You should not additionally report (Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family) for placing the catheter in the right carotid artery, because that service is bundled into Nor should you separately report (Angiography, carotid, cervical, unilateral, radiological supervision and interpretation), because states that the code includes radiological supervision and interpretation. v codinginstitute.com

92 2015 Coding Updates Non-Physician Practitioner Handbook Refine Recent Esophagoscopy Overhaul With New/ Revised Codes Use notes to clarify coding bundles, too. Hopefully you re used to the esophageal endoscopy coding paradigm instituted in 2014, because CPT 2015 is at it again. With one new code, four revised codes, and a host of new instructions in the range (Esophagoscopy ), you have a lot to learn. Let us give you the lowdown on how your esophagoscopy coding changed starting Jan. 1. Welcome Zenker s Diverticulum Fix When your surgeon performs an open surgical procedure to resect a Zenker s diverticulum, you have to report the procedure (Diverticulectomy of hypopharynx or esophagus, with or without myotomy ), with the codes distinguishing a cervical or thoracic approach. But you haven t had a code to report a common endoscopic alternative Zenker s diverticulum treatment until now. CPT 2015 adds (Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus [e.g., Zenker s diverticulum], with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when performed) to describe the procedure. The good news is that physicians finally have gotten a code for doing endoscopic repair of Zenker s diverticulum, says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. Coders will no longer have to use an unlisted code to report this service. You may see the procedure referred to by various names, such as endoscopic transoral stapling of Zenker s diverticula, transoral resection of short segment of Zenker s diverticulum, endoscopic cricopharyngealmyotomy, or transoral repair of Zenker s diverticulum. Terminology: Zenker s diverticulum is a pocket that occurs at the junction of the pharynx and esophagus. The condition often occurs in older patients, trapping food in the back of the throat and causing difficulty swallowing, regurgitation, and possibly aspiration pneumonia. Greet Code Revisions, Too Despite the fact that CPT 2014 showered the esophagoscopy section with 12 new and 14 revised codes that you ve been using this year, you won t find the section unchanged this year. What s the same: CPT 2015 keeps the basic structure of the section intact, with codes distinguished by rigid or flexible scopes, and by transnasal or transoral approach. Within these larger divisions, CPT provides individual codes for specific services such as biopsy, injections, foreign body removal, and so on codinginstitute.com 87

93 Non-Physician Practitioner Handbook 2015 Coding Updates What s different: CPT 2015 makes minor revisions to four codes. The following two codes changed slightly to clarify that the service includes removing one or more foreign bodies, not just a single foreign body: Esophagoscopy, rigid, transoral; with removal of foreign body(s) Esophagoscopy, flexible, transoral; with removal of foreign body(s). CPT 2015 also removes bipolar cautery as part of the descriptor for ( with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps). The change reflects the fact that most surgeons now avoid bipolar cautery due to increased bleeding risk. If your surgeons still use bipolar cautery, you should no longer report 43216, but should instead turn to another code depending on the procedure, such as (Esophagoscopy, flexible, transoral; with biopsy, single or multiple) or (Esophagoscopy, flexible, transoral; with ablation of tumor[s], polyp[s], or other lesion[s] [includes pre- and post-dilation and guide wire passage, when performed]), or possibly an unlisted code, says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash. Finally, CPT 2015 tweaks the definition to standardize language by changing includes to including, but the change makes no difference in how you should use the code (43197, Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]). Don t Ignore Notes Perhaps the biggest change to the esophagoscopy section is the large number of new and revised text notes following many of the codes. Learn code restrictions: CPT 2015 adds instructions for numerous codes in the range that state, Do not report [code number] in conjunction with [other code number(s)]. These notes essentially serve as CPT bundling instructions, Bucknam explains. In other words, the notes tell you which esophagoscopy and other codes you should not report together for various reasons, she says. For instance: The instructions may bundle the codes because they re mutually exclusive, such as for flexible transnasal diagnostic esophagoscopy and (Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]). These codes are the same except for the approach transoral or transnasal so the surgeon performs one or the other. Or the instructions might bundle the codes because one code is a component of another, such as (Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen[s] by brushing or washing when performed [separate procedure]) and ( with directed submucosal injection[s], any substance). Code includes the diagnostic scope described by codinginstitute.com

94 2015 Coding Updates Non-Physician Practitioner Handbook Handy tool: The following table summarizes the text notes added or revised in the esophagoscopy section of CPT 2015, most of which involve bundling restrictions. v Code Bundled with Comment, CPT (rigid therapeutic) (rigid dx), (flex transnasal dx), (flex transnasal biopsy) (flex transoral therapeutic) (flex transnasal ultrasound) ,43217,43211, (flex transnasal dx), (flex transnasal biopsy), (flex transoral dx) Part of the above 18 codes with new bundles Various, existing bundles form CPT 2014 New bundles in new text notes for five codes New Bundles in new or revised text notes for 18 codes New text note, Do not report [code] more than once per session added phrase to existing bundles: for the same lesion (rigid dx) , New Text note for bundled codes (flex transnasal dx) 31575, , 43198, , , 43266, 43270, (flex transnasal biopsy) 31575, , 43197, , , 43266,43270, Revised text note _ added underlined codes to list of bundled codes Revised text note _ added underlined codes to list of bundled codes (flex transoral dx) 43197, 43198, New Text note for bundled codes Prep for Upcoming Global Period Changes Drastic coding changes will put you on the auditor target list. If you were hoping that the CMS proposal you read about in to do away with 10- and 90-day global surgical packages in the next few years was a hoax, we have bad news. CMS has confirmed in the 2015 Physician Fee Schedule Final rule that it will phase out global periods. The good news is that we have the need-to-know info about how your practice can prepare, so you are ready when the implementation comes around. Look for Re-Valuation The proposal to make all surgeries 0-day affairs means that CMS would not continue to pay for the affected codes at the same rate. Under the mis-valued code initiative, the surgical code would be re-valued to include only those services provided on the day of surgery, and to pay separately for visits or services actually furnished after the day of the procedure, explains Joann Baker, CCS, CPC, CPC-H, owner of Precision Coding and Compliance, LLC in Hackettstown, N.J. That could mean you will receive a lower surgical fee, and must file additional claims for pre-op or follow-up E/M services. Since the base procedure valuation may change, preparing for the adjustment in revenue and an increase in claim reporting volume may need to be assessed while all visits and services to the patient are completed and billed, Baker says codinginstitute.com 89

95 Non-Physician Practitioner Handbook 2015 Coding Updates Timeline: Under the proposal, the current 10-day global codes will transition to 0-day in 2017, and the 90-day will change to 0-day in The actual dates will depend on when CMS completes the analysis for updating the global code values. Understand Pros and Cons CMS identified global surgical packages as a problem to be fixed based on OIG reports. The OIG has identified a number of surgical procedures that include more visits in the global period than are being furnished, CMS states in the proposal. Solution: CMS explains that it believes by moving to only 0-day global codes, there will be positive outcomes, including: Increased accuracy of fee schedule payments by more accurately basing the rates on the resources used in the procedures Fewer duplicated payments when a patient receives post-op care from a different provider Elimination of payment discrepancies between E/M services provided in and outside of global periods Retention of the pre- and post-operative services performed on the same day in the 0-day global More accurate data for new payment models and research. Upside: I do think surgeons will welcome this change because it simplifies office billing procedures, says Freda Brinson, CPC, CPC-H, CEMC, compliance auditor at St. Joseph s/ Candler Health System in Savannah, Ga. No longer will surgical dates have to be remembered, counted, and calculated as to when a visit can be billed; no longer will there be the need to stress out over is this really related to the procedure. Downside: One concern about the change to 0-day is a possible negative impact on patient care. More complex surgical cases may entail more post-op care visits, which mean more co-pays. Patients who are concerned about their out-of-pocket expenses may elect not to go for the appropriate follow-up care. Don t Change Your Follow-Up Patterns Another concern expressed by CMS is that allowing separate payment for E/M visits during post-operative periods will promote unnecessary office visits, and an increase in E/M services overall. Because of this concern, CMS has stated its intention to monitor any changes in the use of E/M visits associated with surgical procedures. Do this: Perform an internal audit now to elucidate and document your urologist s patterns of pre- and post-op visits associated with the most common surgical procedures performed in your practice. In that way, you will have a baseline to monitor your billing practices after the globalpackage change goes into effect and documentation to lean on if a CMS auditor comes calling. Resource: You can review the relevant Federal Register notice in its entirety at www. federalregister.gov/articles/2014/07/11/ /medicare-program-revisions-to-paymentpolicies-under-the-physician-fee-schedule-clinical-laboratory. v codinginstitute.com

96 2015 Coding Updates Non-Physician Practitioner Handbook X May Soon Mark the Spot for Successful Same-Day Procedure Claims Caution: Modifier 59 won t be your CCI catch-all. When you hear Correct Coding Initiative (CCI) or bundled you probably think of modifier 59 (Distinct procedural service). Most coders know that modifier 59 can separate CCI edits, but it is not meant to be utilized solely for that reason. If you rely too heavily on what CMS describes as the most widely used HCPCS modifier, you are asking for an audit. Good news: CMS intends to stop modifier 59 misuse by introducing four new modifiers to take its place in specific circumstances, and these modifiers may make your job a bit more straightforward. Review the Issues With 59 CMS says in Transmittal R1422 (issued on Aug. 15) that many providers misuse modifier 59 with CCI bundles, leading the modifier to be the source of a projected one-year error rate of $770 million. CMS points out the following three common reasons that people use modifier 59, along with the associated error odds, according to MLN Matters article MM8863, issued on Aug. 15: Infrequently used to identify a separate encounter, typically used correctly Less commonly utilized to define a separate anatomic site, less often used correctly Commonly used to define a distinct service, but frequently done so incorrectly. Say Hello to EPSU Modifiers In light of the problems that CMS has faced when dealing with modifier 59, CMS felt the need to find a solution. The 59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place, the MLN Matters article says. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment. To that end, CMS has debuted the following new modifiers, known as the X(EPSU) modifiers: XE: Separate encounter (A service that is distinct because it occurred during a separate encounter) XS: Separate structure (A service that is distinct because it was performed on a separate organ/structure) XP: Separate practitioner (A service that is distinct because it was performed by a different practitioner) XU: Unusual non-overlapping service (The use of a service that is distinct because it does not overlap usual components of the main service) codinginstitute.com 91

97 Non-Physician Practitioner Handbook 2015 Coding Updates The new modifiers should not negatively affect claim success, says Jonathan Rubenstein, MD, director of coding and physician compliance for Chesapeake Urology Associates in Baltimore. It is just extra work for the coders and billers, thereby increasing costs to providers. If it does do it s intended job, the further descriptors will only reduce reimbursement to fraudulent claims that should not have been paid anyways for providers who are following appropriate coding and billing rules. It may actually reduce the risk of audits when used correctly. Don t Skip 59 Entirely Although the new modifiers will replace modifier 59 in specific instances, CMS won t cease accepting 59 in CMS will continue to recognize modifier 59, which does indicate that a code represents a service that is separate and distinct from another bundled service. The X(EPUS) modifiers are more selective versions of modifier 59 to help clarify billing, so some procedures that are at high risk for incorrect billing will require one of the X(EPUS) modifiers. Either modifier 59 or X(EPUS) will be acceptable for payment purposes, but it would be incorrect to include both on one line. Official guidance: CMS will not stop recognizing the 59 modifier but notes that CPT instructions state that the 59 modifier should not be used when a more descriptive modifier is available, says the Transmittal, which has an effective date of Jan. 1, CMS will continue to recognize the 59 modifier in many instances but may selectively require a more specific X(EPSU) modifier for billing certain codes at high risk for incorrect billing. The transmittal said that these new modifiers do not cover all aspects when the 59 might be used so you can still use the 59 modifier if you think that you have a situation that is applicable to the 59 modifier but not applicable to these four alternatives, says Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CPCO, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. Again, it makes you think and make sure you are meeting the definition and not just adding a 59 to get paid because the two codes are bundled. For instance, CMS is eventually going to institute edits that will allow the XE modifier to separate a specific CCI edit pair, but won t accept modifier 59 or XU to separate that particular pair. As a way of easing into the new modifiers, CMS will initially accept either modifier 59 or the X(EPSU) modifier for a service, but the rapid migration of providers to the more selective modifier is encouraged, the MLN Matters article notes. However, MACs can start requiring the more specific modifiers in place of modifier 59 at their convenience, so keep an eye out for local requirements. Keep in mind that CMS does not want you to play it safe and just add all of the modifiers to each CCI edit you re trying to separate. Therefore, you can t report both the 59 modifier and an X(EPSU) modifier on the same line item. Resource: To read the transmittal, visit Transmittals/Downloads/R1422OTN.pdf. To read the MLN Matter article, visit Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/ MM8863.pdf. v codinginstitute.com

98 2015 Coding Updates Non-Physician Practitioner Handbook Tests That Your Ob-Gyn May Order Highlight The New CPT Changes For 2015 Infertility clinics, rejoice: This category III code becomes a category I code. You won t find any riveting new ob-gyn codes for 2015, but that doesn t mean you should overlook the new CPT codes your physician may order especially if your practice includes bone density test machines or labs. Include New Codes for Breast Ultrasound and Digital Tomosynthesis Your ob-gyns won t perform these breast ultrasound procedures, but they may order them. Two new codes for breast ultrasound include the following: 76641, Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete 76642, Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited Also add the following three codes for breast tomosynthesis to your list: 77061, Digital breast tomosynthesis; unilateral 77062, Digital breast tomosynthesis; bilateral 77063, Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) New codes [like these] continue to be developed to keep up with new technologies, says Michele Midkiff, CPC-I, PCS, RCC, an interventional and neuro-interventional radiology coding consultant in Mountain View, CA. But be sure you know the coverage criteria for tomosynthesis before ordering it, as many major payers still do not cover it. Check Bone Density Study with Vertebral Fracture Assessment Another test your ob-gyn may order is the bone density test. However, some practices do have the machines and may perform this test in the office. In 2014, these practices banked upon (Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; vertebral fracture assessment) for vertebral fracture assessment. Effective 2015, this code will no longer be valid. You will have two new codes for vertebral fracture assessment. These include (Dualenergy X-ray absorptiometry [DXA], bone density study, 1 or more sites; axial skeleton [e.g., hips, pelvis, spine], including vertebral fracture assessment) where vertebral fracture assessment is done as part of bone density study and (Vertebral fracture assessment via dual-energy X-ray absorptiometry [DXA]) which is for vertebral fracture assessment alone. This is in keeping with the trend to clarify and increase specificity in coding, Midkiff says codinginstitute.com 93

99 Non-Physician Practitioner Handbook 2015 Coding Updates Add to Your Possible Ordered Test Choices Another test your ob-gyn might order is new code (Fetal chromosomal aneuploidy [e.g., trisomy 21, monosomy X] genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21). Cell free fetal DNA is a newer option that can be used as a primary screening test in women at increased risk of aneuploidy. This would include women aged 35 years or older, fetuses with ultrasonographic findings that indicate an increased risk of aneuploidy, women with a history of a child affected with a trisomy, or a parent carrying the gene that increases the risk of trisomy 13 or trisomy 21. Ob-gyns can also use this service as a follow-up test for women with a positive first-trimester or second-trimester screening test result. Highlight HPV Coding Changes in 2015 CPT 2015 reworks HPV coding by deleting (Infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus, human, direct probe technique/amplified probe technique/quantification). In place of those codes, you ll find the following three new codes: Human Papillomavirus (HPV), low-risk types (e.g., 6, 11, 42, 43, 44) Human Papillomavirus (HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed. Pathology impact: This change may be significant for payment, since many payers will cover testing for high-risk HPV types, but not low-risk HPV types under certain clinical circumstances, says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark. Infertility Labs, Take Heed of New Cryopreservation Code For infertility labs, you ll want to take note of this new code. Code (Cryopreservation, mature oocyte[s]) which replaces the deleted code 0059T (Cryopreservation; oocyte[s]). This means that this technology has now proven itself as a mainstream procedure which warrants conversion to a Category I CPT code. Observe Changes to Vaccination Codes As with every year, you will be seeing some changes to vaccination codes in CPT You will have to add two new vaccine codes to your cache while making note of many changes to the descriptors of old codes. The two new codes that you will be seeing in 2015 include: (Influenza virus vaccine, quadrivalent [IIV4], split virus, preservative free, for intradermal use) (Human Papilloma virus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent [HPV], 3 dose schedule, for intramuscular use) In addition, you will be seeing the following descriptor changes in CPT 2015: (Influenza virus vaccine, trivalent [IIV3], split virus, preservative-free, for intradermal use) codinginstitute.com

100 2015 Coding Updates Non-Physician Practitioner Handbook The revisions to the existing CPT codes are primarily editorial or otherwise made to distinguish the existing codes from new codes that will appear in 2015, observes Kent Moore, senior strategist for physician payment with the American Academy of Family Physicians. For instance, the addition of the word trivalent to is primarily for the purposes of distinguishing it from new code 90630, which is a quadrivalent vaccine, Moore adds. Master These Wound Management Codes You ve got revisions and new codes for wound management services. They are (emphasis added): Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters total wound(s) surface area greater than 50 square centimeters Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters total wound(s) surface area greater than 50 square centimeters. Check Out These Anoscopy Additions CPT 2015 has revised and added new possible codes for providers performing anoscopies. They are (emphasis added): Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) diagnostic, with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, including collection of specimen(s) by brushing or washing, when performed with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, with biopsy, single or multiple. These new codes replace these deleted Category III codes: 0226T Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); diagnostic, including collection of specimen(s) by brushing or washing when performed 0227T... with biopsy(ies). For an ob-gyn who is treating fecal incontinence, you might be interested in new code 0377T (Anoscopy with directed submucosal injection of bulking agent for fecal incontinence). v 2015 codinginstitute.com 95

101 Non-Physician Practitioner Handbook 2015 Coding Updates Brace For New and Revised TMJ Arthrocentesis Codes For 2015 Claims Note deletion of parotid relocation code in the new year. If you have been wondering at what new changes you are facing with CPT 2015, here is a first look at what you can expect. You will be seeing some new codes arthrocentesis of the temporomandibular joint (TMJ) while having to take into account some descriptor changes to old codes. Add New Arthrocentesis Code to Your CPT Arsenal You have the addition of new codes to arthrocentesis set of codes. These new codes are based on the use of ultrasound guidance during the procedure. As per this change, you have a new code when your oral surgeon performs an arthrocentesis of the temporomandibular joint with ultrasound guidance: (Arthrocentesis, aspiration and/ or injection, intermediate joint or bursa [eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]; with ultrasound guidance, with permanent recording and reporting). You also need to incorporate some descriptor changes to the previously used code for arthrocentesis of the temporomandibular joint. According to the change, you will see the following changes to CPT (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]; without ultrasound guidance). Coding tip: You now have two different codes for arthrocentesis of the TMJ depending on whether or not your clinician used ultrasound guidance for placement of the needles in the joint. So, you will have to look at documentation to ascertain the use of ultrasound guidance to arrive at the right CPT code for the procedure performed. Note that the new arthrocentesis codes with imaging guidance only refer to ultrasound guidance, says Kent Moore, senior strategist for physician payment with the American Academy of Family Physicians. If your physician uses some other sort of imaging guidance, that remains separately reportable, as it is now. Eliminate From Your CPT List You will see the deletion of the CPT code (Parotid duct diversion, bilateral [Wilke type procedure]; with excision of 1 submandibular gland) for parotid duct diversion procedure. However, the other two CPT codes, and ( with excision of both submandibular glands) remain unchanged. So, according to the new change, you will use if your oral surgeon performs parotid duct relocation or duct relocation with excision of one submandibular gland. If both the submandibular glands are excised by your surgeon during the procedure, then you will report codinginstitute.com

102 2015 Coding Updates Non-Physician Practitioner Handbook Headline: Look How Esophagoscopy Codes Will Include More Services Your biggest ENT procedure coding changes will be related to esophagoscopy. CPT 2015 includes one new code, as well as revisions to six others. New option: The new code is (Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker s diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when performed). The good news is that otolaryngologists finally have gotten a code for doing endoscopic repair of Zenker s diverticulum, says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. Coders will no longer have to use an unlisted code to report this service and for now on will use to report the endoscopic repair of Zenker s diverticulum. Most revisions to the familiar codes are minor, but still important. The revised codes (and their changes) are as follows: Esophagoscopy, rigid, transoral; with removal of foreign body(s). The designation of foreign body was changed to be either singular or plural Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure). The word includes in the previous code descriptor will change to including Esophagoscopy, flexible, transoral; with removal of foreign body(s). The designation of foreign body was changed to be either singular or plural Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps. The previous descriptor applied to removal by hot biopsy forceps or bipolar cautery. The bipolar cautery designation will be deleted for Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s). The designation of foreign body was changed to be either singular or plural Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps. As with 43216, the inclusion of bipolar cautery in this code will be deleted for Important: Codes 43215, 43216, 43247, and include a bulls-eye designation. That means the valuation of the code already includes moderate sedation. Therefore, you wouldn t report a moderate sedation code such as (Moderate sedation services [other than those services described by codes ] provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and physiological status; younger than 5 years of age, first 30 minutes intra-service time) with any of these procedures. Eliminate 3 Eustachian Tube Procedure Options Three codes for procedures related to Eustachian tube inflation and/or catheterization are no longer valid, beginning Jan. 1, They are: Eustachian tube inflation, transnasal; with catheterization without catheterization Eustachian tube catheterization; transtympanic. v 2015 codinginstitute.com 97

103 Non-Physician Practitioner Handbook 2015 Coding Updates Prepare for Nearly 90 New, Revised, or Deleted Lab Codes You ll need to learn yet another IHC-stain paradigm shift. Forewarned is forearmed, so let us take you on a whirlwind tour of what you can expect for 2015 lab and pathology procedure coding. Update Molecular Pathology CPT 2015 creates a family of codes in the Tier 1 Molecular Pathology section for FLT3 (fms-related tyrosine kinase 3) gene analysis for conditions such as acute myeloid leukemia. Where you currently have one code for internal tandem duplication variants (exons 14, 15), CPT 2015 revises that code (81245) as the parent code and adds intended codes ( tyrosine kinase domain [TKD] variants [e.g., D835, I836]) and 81288, which is out of numerical sequence ( promoter methylation analysis). Tier 2: You ll also see some significant changes in the Tier 2 codes, notably the addition of tests for blood typing using antigen gene analysis methods instead of traditional serological techniques. These new descriptors appear under (Molecular pathology procedure, Level 4 [e.g., analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/ deletion variants of 2-5 exons]), as follows: Human erythrocyte antigen gene analyses (e.g., SLC14A1 [Kidd blood group], BCAM [Lutheran blood group], ICAM4 [Landsteiner-Wiener blood group], SLC4A1 [Diego blood group], AQP1 [Colton blood group], ERMAP [Scianna blood group], RHCE ]Rh blood group, CcEe antigens], KEL [Kell blood group], DARC [Duffy blood group], GYPA, GYPB, GYPE [MNS blood group], ART4 [Dombrock blood group]) (e.g., sickle-cell disease, thalassemia, hemolytic transfusion reactions, hemolytic disease of the fetus or newborn), common variants RHD (Rh blood group, D antigen) (e.g., hemolytic disease of the fetus and newborn, Rh maternal/fetal compatibility), deletion analysis (e.g., exons 4, 5, and 7, pseudogene) RHD (Rh blood group, D antigen) (e.g., hemolytic disease of the fetus and newborn, Rh maternal/fetal compatibility), deletion analysis (e.g., exons 4, 5, and 7, pseudogene), performed on cell-free fetal DNA in maternal blood. The addition of these test descriptors will allow coders to distinguish between blood typing tests for red blood cell groups such as Kidd, Kell, and Duffy using gene analysis techniques instead of more traditional blood-typing methods. To clarify the method differences in the codes, CPT 2015 adds the word serologic to the existing code descriptors for blood-type testing ( (Blood typing, serologic; ). Do this: Make sure to continue reporting the appropriate code from the range when your lab uses traditional serologic blood typing methods, and reserve for any of the gene analysis blood typing tests you perform beginning in 2015, advises William Dettwyler, MT AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore codinginstitute.com

104 2015 Coding Updates Non-Physician Practitioner Handbook Engage New Genomic Sequencing Section You can expect a new section in CPT 2015 for genomic sequencing procedures (GSPs) and other molecular multianalyte assays. These codes for next-generation molecular tests describe genomic sequencing analysis for conditions such as colon cancer, aortic dysfunction, nonsyndromic hearing loss, X-linked intellectual syndrome, and whole exome/genome tests such as whole mitochondrial genomic sequencing. You ll find 21 new codes in this section, ranging from to Keep Up With Microbiology Changes You ll face several microbiology changes in CPT 2015, such as minor wording changes to include reverse transcription in multiplex infectious agent codes. For instance, the new code set changes the code descriptor of several codes from multiplex reverse transcription to includes multiplex reverse transcription, when performed, Look for influenza tests, as well as respiratory virus tests to include this change in This change parallels revisions in the 2014 codes to alter reverse transcription and amplified probe technique to amplified probe technique, includes reverse transcription when performed. Because the reverse transcription step is not required for the amplified probe codes or the multiplex codes mentioned above, the new language allows coders to accurately report the codes even if the lab does not carry out the reverse transcription step. There s more: Other microbiology changes for next year are more substantial. For instance, CPT 2015 reworks HPV coding by deleting (Infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus, human, direct probe technique/amplified probe technique/quantification). In place of those codes, you ll find the following three new codes: Human Papillomavirus (HPV), low-risk types (e.g., 6, 11, 42, 43, 44) Human Papillomavirus (HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed. This change may be significant for payment, since many payers will cover testing for highrisk HPV types, but not low-risk HPV types under certain clinical circumstances, says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark. Understand IHC and ISH Unit of Service CPT 2015 brings much-needed clarification to qualitative and quantitative immunohistochemistry (IHC) coding, and coordinates the coding principles with how you should report in situ hybridization (ISH) as well. By deleting, adding, and revising codes in the range to and to (some codes out of numerical sequence), CPT 2015 establishes the unit of service as specimen, not block, and provides distinct codes for single versus multiplex stains. Look to future issues of Pathology/Lab Coding Alert for a complete explanation of how to use these codes, and what the changes will mean for your bottom line codinginstitute.com 99

105 Non-Physician Practitioner Handbook 2015 Coding Updates Back story: When code changes for qualitative IHC hit the presses for 2014, much confusion ensued, including Medicare s implementation of alternative G codes Much of the muddle surrounded the unit of service block versus specimen, and single versus multiplex stains (with or without separately identifiable antibodies ). Even with an understanding of how to use the codes, experts noted the disparities that the codes created between qualitative versus quantitative IHC. The CPT 2015 changes to these codes should add clarity and uniformity to coding and payment for these services. v Revamp Your IHC and ISH Reporting With 2015 Makeover Look for parallel construction to simplify coding. After a year of dealing with contradictions among immunohistochemistry (IHC) and in situ hybridization (ISH) codes, CPT 2015 brings some much-needed order. Take our crash course on the structure and usage of multiple revised code families to simplify your IHC and ISH coding next year. Along with Table A, the following tips should make your 2015 coding as easy as ABC. Tip A: Code Per Specimen When CPT 2014 revised qualitative IHC codes, lots of confusion surrounded terms like per block and per slide. These unit-of-service changes created an inequity between qualitative IHC versus ISH and quantitative IHC. The changes also sent Medicare down the road of requiring HCPCS Level II codes for qualitative IHC rather than paying for the stains per block. Enter CPT 2015 with a clear addition to each IHC and ISH code: per specimen. Look at Table A to see that each code contains this statement in the common part of the parent code. Regardless of how the Medicare payment pans out, the per specimen clarification is a welcome relief for pathology practices trying to create and follow coherent charge policies for these services, says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark. Tip B: See What Stays the Same CPT 2015 still distinguishes IHC and ISH codes based on whether the procedures are qualitative (88342 and code families) versus quantitative/semiquantitative, which CPT calls morphometric analysis (88360, and code families). The new code set also continues to divide the morphometric analysis codes based on whether the procedure is manual (88360, 88368) or computer assisted (88361, 88367) codinginstitute.com

106 2015 Coding Updates Non-Physician Practitioner Handbook Tip C: Identify First Single Stain Procedure Each code family in Table A begins with a parent code for the first, single stain procedure. You can see this parallel structure in each of the following revised CPT 2015 codes (emphasis added): Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure Morphometric analysis, tumor immunohistochemistry (e.g., Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual In situ hybridization (e.g., FISH), per specimen; initial single probe stain procedure Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; initial single probe stain procedure Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; initial single bepro stain procedure. Tip D: Add-On Subsequent Single Stains In addition to revised codes for initial single stain for 2015, you ll also find new, indented, add-on codes to report additional single stains in CPT 2015, as follows (emphasis added): Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) In situ hybridization (e.g., FISH), per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure). Because these are add-on codes, expect most payers to require you to bill a primary code before they ll pay for any of these codes for additional stains. Tip E: Use New Multiplex Procedure Codes Prior to CPT 2015 changes, you didn t have a consistent way to code for multiplex IHC and ISH services. These are tests that identify multiple antibodies or probes in a single procedure. For instance: A single prostate triple stain such as PIN4 contains three antibodies that differentially stain various cell types in prostate specimens. The 2014 code set attempted to provide for this and similar stains by adding (Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; each additional separately identifiable antibody per slide [List separately in addition to code for primary procedure]). But Medicare declined to pay for this code, and the other IHC and ISH codes did not address the multiplex concept. CPT deletes the code in codinginstitute.com 101

107 Non-Physician Practitioner Handbook 2015 Coding Updates Table A: CPT 2015 IH C and ISH Code Additions, Deletions, and Revisions Code Family How-To Instructions Parent Use of qualitative IHC, initial single antibody stain procedure per speciment : Deleted # : Indented Use with for each additional single antibody stain procedure on the same specimen Indented Use instead of for qualitative IHC for a single multiplex antibody stain procedure per specimen Parent Use for manual quantitative or semiquantitative IHC for a single antibody stain procedure per specimen Indented Use for computer-assisted quantitative or semiquantitative IHC for a single antibody stain procedure per specimen Parent Use for qualitative ISH initial single probe stain procedure per specimen # : Indented Use with for each additional single probe stain procedure on the same specimen Indented Use instead of for qualitative ISH for a single multiplex probe stain procedure per specimen Parent Use for computer-assisted quantitative or semiquantitative ISH for the initial single probe stain procedure per specimen # : Indented Use with for each additional single probe stain procedure on the same specimen # Indented Use instead of for computer-assisted quantitative or semiquantitative ISH for a single multiplex probe stain procedure per specimen Parent Use for manual quantitative or semiquantitative ISH for initial single probe stain procedure per specimen : Indented Use with for each additional single probe stain procedure on the same specimen # Indented Use instead fo for manual quantitative or semiquantitative ISH, for a single multiplex probe stain procedure per specimen Look to the following new CPT 2015 codes to report multiplex IHC and ISH procedures next year (emphasis added): Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure In situ hybridization (e.g., FISH), per specimen; each multiplex probe stain procedure Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe stain procedure Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure. Notice: Unlike the codes for each additional single stain, these multiplex stain codes are not add-on codes. Although CPT 2015 indents each code under a parent code, the parent and child codes have an either/or relationship. In other words, you should either use the parent code for the first single-stain procedure, or you should use the appropriate indented code for a multiplex stain procedure. v codinginstitute.com

108 2015 Coding Updates Non-Physician Practitioner Handbook : Check Out New GI Pathogen Detection Codes Capture multiple targets with one code. If your lab performs one of the new commercial panels to detect gastrointestinal (GI) pathogens, you haven t had an accurate CPT code to report the service until now. Make sure you re ready to use three new codes to report your GI pathogen nucleic acid screening tests in Count Targets to Choose Code Since CPT 2015 went into effect on Jan.1, you have the following three new codes to report the service: Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, targets. These codes describe tests to detect and identify nucleic acids from multiple bacteria, viruses, or parasites in a fecal specimen of a patient with symptoms of a GI tract infection. Distinguish the three codes based on the number of targets, which are nucleic acid sequences from specific organisms that the test seeks. Understand Multiplex New codes are in the CPT microbiology section for infectious agent detection by nucleic acid (DNA or RNA) probe, which the code set organizes alphabetically by infectious organism name. You ll find the new codes listed following the existing codes for enterovirus and enterococcus. The big difference in these new codes is that the nucleic acid probes are not for just one organism, but instead, provide targets for multiple organisms that might cause a GI infection. New codes are modelled after existing codes for respiratory viral pathogens, [Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus ]. The codes are used for multiplex panel formats that detect multiple specific pathogens with similar clinical presentations, explains Vickie Baselski, PhD, D(ABMM), F(AAM), professor of pathology and laboratory medicine at the University of Tennessee Health Science Center in Memphis codinginstitute.com 103

109 Non-Physician Practitioner Handbook 2015 Coding Updates Multiple probes: A multiplex probe technique involves a single test that simultaneously interrogates multiple nucleic acid sequences, called targets. The multiple probes may be for multiple types or subtypes of a single organism, or for multiple organisms. Reverse transcription: The terminology includes multiplex reverse transcription, when performed allows to be applicable for component assays using reverse transcription of RNA targets, as well as assay formats for DNA targets, or any other methods not requiring a reverse transcription, Baselski says. That s because the tests provide similar information a pathogen is present or not using the various molecular formats. Target Number is Key The distinguishing feature between the three new codes for GI pathogens is how many targets the panel includes. The break down is three to five targets for 87505, six to 11 targets for 87506, and 12 to 25 targets for Named pathogens: Although the code descriptors list multiple organisms Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, and Giardia these are examples only. The panel does not have to detect nucleic acids from all of these organisms, or from only these organisms, to warrant using the codes. Bottom line: Select the proper code based on the number of targets, regardless of the number of organisms or which GI infectious agents the test investigates. v Get to Know Big Changes to Your MCHAT, ADHD Evaluation Coding Your developmental screening tests will soon be split into two separate codes. Your practice probably performs many developmental screenings every day, so you re quite familiar with how to report Unfortunately, you ll soon have to adjust your thinking about this code, thanks to several big coding changes that took place Jan. 1. Get Ready for s New Use Although you used to report (Developmental screening, with interpretation and report, per standardized instrument form) for all of your developmental screening tests, it will be reserved for just development, speech and language delay testing starting in January. The code will be revised to say Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument codinginstitute.com

110 2015 Coding Updates Non-Physician Practitioner Handbook What this means: Not only can you no longer report for your ADHD screens, you must specifically have documentation that your provider evaluated a potential developmental and/ or speech or language delay before you can bill this code in the New Year. Welcome If you re wondering how you ll bill your ADHD or depression screenings as of January, it s a good time to memorize new code (Brief emotional/behavioral assessment [eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale], with scoring and documentation, per standardized instrument). Some of the standardized forms that your clinician might employ for this service will include the Vanderbilt Rating Scale, Patient Health Questionnaire-9 (PHQ-9), Zung Self-Rating Depression Scale, or the Beck s Depression inventory for assessing the patient for depression. Some such questionnaires that your clinician might use for ADHD will include Conners Parent and Teacher Rating Scale, ADHD Self-Rating Scale, or the Brown Attention Deficit Disorder Scale (BADDS). Although the code descriptor for doesn t specifically mention autism, the MCHAT screening for autism will fit more appropriately under this new code, since the MCHAT is much more than a speech and language delay screening. Because the MCHAT form asks about topics such as make-believe play, walking, and participation in movement activities in addition to its questions about language and hearing, will be the more appropriate code for these services in v Update Your CPT 2015 Arsenal With New Behavioral Assessment Code Check out the new changes to chronic care management codes. If you have been wondering at what new changes you will be facing with CPT 2015, here is a first look at what you can expect. You will be seeing some new codes for behavioral or emotional assessment and chronic care management while having to take into account some descriptor changes to old codes. Add to Your Behavioral Assessment Inventory When your psychiatrist assesses a patient for emotional or behavioral problems or for conditions such as attention deficit hyperactivity disorder (ADHD) or depression, he will administer some evaluation questionnaires. Some of the standardized forms that your clinician might employ will include the Patient Health Questionnaire-9 (PHQ-9), Zung Self-Rating Depression Scale, or the Beck s Depression inventory for assessing the patient for depression. Some such questionnaires that your clinician might use for ADHD will include Conners Parent and Teacher Rating Scale, ADHD Self-Rating Scale, or the Brown Attention Deficit Disorder Scale (BADDS) codinginstitute.com 105

111 Non-Physician Practitioner Handbook 2015 Coding Updates In CPT 2015, you will have a new code that you can use when your clinician assesses a patient for emotional or behavioral problems. As of Jan.1, you will use (Brief emotional/ behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument) for every test that your clinician administers. Note Terminology Changes to Focusing on new codes will help keep your claims compliant in 2015, but descriptor revisions or clarifications can also affect your code selection. Case in point: New wording for CPT code will replace the words, interpretation and report with scoring and documentation. The code will also include examples of developmental screening for which you can utilize this code. So, the new descriptor for will now read Developmental screening [e.g., developmental milestone survey, speech and language delay screen], with scoring and documentation, per standardized instrument. These changes appear to be primarily editorial, observes Kent Moore, senior strategist for physician payment with the American Academy of Family Physicians. The new parenthetical provides some useful examples of the kinds of developmental screening with which the code is intended to be reported. Also, the change from interpretation and report to scoring and documentation seems intended to reflect that these tests involve less of the former and more of the latter when the instrument is completed, Moore adds. Embrace the Chronic Care Management Improvements Changes to five CCM codes may make your chronic care management services coding less of a chore. You ll find that CPT 2015 revises the descriptor for with bulleted detail as follows: (Complex chronic care management services, with the following required elements: Multiple [two or more] chronic conditions expected to last at least 12 months, or until the death of the patient; Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline; Establishment or substantial revision of a comprehensive care plan; Moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month Adding the elements is definitely a positive; it gives the provider community a set of guidelines to follow to meet the documentation requirements of the codes, says Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC, director of coding operations-him at Allegheny Health Network in Pittsburgh, Pa. Often, we find that the providers are performing the services, but aren t necessarily illustrating them as the payer would like to see in the documentation codinginstitute.com

112 2015 Coding Updates Non-Physician Practitioner Handbook In addition, you ll see that CPT 2015 deletes (Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month). Don t miss: For each additional 30 minutes of chronic care management your physician provides, you will still be able to report revised add-on code (Complex chronic care coordination management services...; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month [List separately in addition to code for primary procedure]). Bonus: You will also have two new CCM codes to choose from: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline, Comprehensive care plan established, implemented, revised, or monitored each additional 30 minutes... These changes appear to be primarily in response to the Centers for Medicare & Medicaid Services (CMS) proposal to establish its own G code for chronic care management along the lines described in code 99490, Moore says. It will be interesting to see what CMS decides to do with its proposal in light of the CPT changes. v Prepare Your Coding Practice For New Codes As Technology Makes An Advance Watch for changes in vertebral fracture assessment, breast imaging, vertebroplasty procedures. The CPT radiology coding changes for 2015 are available now. These changes became effective January 1, Here are highlights of what changes you need to introduce in your practice this year. Check Bone Density Study with Vertebral Fracture Assessment In the past, you banked upon (Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; vertebral fracture assessment) for vertebral fracture assessment. Effective 2015, this code will no longer be valid. You have two new codes for vertebral fracture assessment. These include (Dual-energy X-ray absorptiometry [DXA], bone density 2015 codinginstitute.com 107

113 Non-Physician Practitioner Handbook 2015 Coding Updates study, 1 or more sites; axial skeleton [e.g., hips, pelvis, spine], including vertebral fracture assessment) where vertebral fracture assessment is done as part of bone density study and (Vertebral fracture assessment via dual-energy X-ray absorptiometry [DXA]) which is for vertebral fracture assessment alone. This is in keeping with the trend to clarify and increase specificity in coding, says Michele Midkiff, CPC-I, PCS, RCC, an interventional and neuro-interventional radiology coding consultant in Mountain View, CA. Include New Codes for Breast Ultrasound and Digital Tomosynthesis Make note of two new codes for breast ultrasound. These include the following: 76641, Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete 76642, Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited Also add the following three codes for breast tomosynthesis to your list: 77061, Digital breast tomosynthesis; unilateral 77062, Digital breast tomosynthesis; bilateral 77063, Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) These codes help to ensure your payment for use of new imaging technologies. New codes continue to be developed to keep up with new technologies, Midkiff says. Avoid Confusion in Myelography Codes You will spot new myelography codes in 2015 which include the supervision and interpretation. They are: 62302, Myelography via lumbar injection, including radiological supervision and interpretation; cervical 62303, Myelography via lumbar injection, including radiological supervision and interpretation; thoracic 62304, Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral 62305, Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more regions (e.g., lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/ thoracic/cervical) Catch the paradox: The codes and seem to represent the injection portion of the procedure. You may find it challenging to decide which of these is the most appropriate code. In this case, it will be best for you to confirm with your payer codinginstitute.com

114 2015 Coding Updates Non-Physician Practitioner Handbook Revision: Note that the existing code for myelogram injection, (Injection procedure for myelography and/or computed tomography, spinal [other than C1-C2 and posterior fossa]) has been revised. The revision is as follows: 62284, Injection procedure for myelography and/or computed tomography, spinal lumbar (other than C1-C2 and posterior fossa) Look for New Options for Vertebroplasty/Kyphoplasty If you re regularly reporting vertebroplasty and kyphoplasty procedures, then you should take note of CPT 2015 s dramatic changes. The existing codes have been deleted, and now you ll find new codes specifying imaging guidance. What happens: Both percutaneous vertebroplasty and kyphoplasty involve percutaneous injection of methylmethacrylate under imaging guidance (either fluoroscopy or CT) into a cervical, thoracic, or lumbar vertebral body lesion. Kyphoplasty also involves placement of a balloon catheter to reduce the fracture and then inject biomaterial into the cavity. The new codes are: Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic lumbosacral each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic lumbar each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) It s important to see that the new vertebroplasty code, 22510, also includes the cervical spine region, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Co. If a provider performs a cervical vertebroplasty in 2014, you can only report it with (Unlisted procedure, spine). It will be good that pain management providers will be able to report the cervical procedure with the new code. Each of the codes also includes the bulls-eye symbol designation, which means the associated RVUs and service include moderate sedation. This is new for kyphoplasty in The 2014 codes ( ) did not include moderate sedation, so you could bill it separately. The deleted codes are: Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection; thoracic lumbar 2015 codinginstitute.com 109

115 Non-Physician Practitioner Handbook 2015 Coding Updates each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); thoracic lumbar each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) Heads up: Because of the updated descriptors, the associated radiology codes for guidance will be deleted. You ll no longer be able to report the following codes as part of your vertebroplasty or kyphoplasty claim: Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance under CT guidance. Exception: You do not see a specific code for sacroplasty. If your physician does a sacral vertebroplasty then you will have two Category III codes to report that includes imaging guidance: 0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed 0201T Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed. Also: Look for the inclusive imaging guidance in these codes. Another trend in coding is bundling the imaging guidance, reducing component coding, and potentially RVUs, says Midkiff. v codinginstitute.com

116 2015 Coding Updates Non-Physician Practitioner Handbook Watch For Codes With Ultrasound and Imaging Guidance Inclusions You ll also need to update interventional radiology and RSA codes. You will face challenges if you do not revise your coding for arthrocentesis, intravascular stenting, bone and lung tumor ablation therapy, and radiostereometric analysis. To avoid denials, start learning these new changes before these changes went into effect January 1, Specify Whether Joint Aspiration Included U/S Guidance In 2015, you will find new codes for joint aspiration and/or injection which include ultrasound guidance. In addition, the existing codes will be revised to state without ultrasound guidance. You ll choose new and revised codes for arthrocentesis depending upon whether or not your physician used ultrasound guidance. New codes were added for 2015 that are all inclusive codes when ultrasound guidance is used, says Christy Hembree, CPC, team leader at Summit Radiology Services in Cartersville, GA. The new and revised codes (with changes reflected) are the following: Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); small joint or bursa without ultrasound guidance (New) with ultrasound guidance, with permanent recording and reporting Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance (New) with ultrasound guidance, with permanent recording and reporting Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (New) with ultrasound guidance, with permanent recording and reporting Note: These six codes will represent the services based on the number of vertebral bodies your physician treated and the spinal area. Each code will continue to represent both unilateral and bilateral injections. What happens: Arthrocentesis, also known as joint aspiration, is the clinical procedure in which the fluid from within the joint is removed using a needle and syringe. The skin over the aspiration site is cleaned with an antiseptic liquid. The physician then pushes a needle through the skin and into the joint and then removes the fluid with the help of a syringe attached to the needle. After the aspiration, the fluid sample may be sent to the laboratory for further examination. Watch out: Sometimes you ll see your physician performing these procedures with fluoroscopic guidance, which the new codes do not address. This section of changes can get a little confusing because according to the ACR when fluoroscopic-guided arthrocentesis is performed component coding should still be used, Hembree says. This means guidance is a huge factor in coding these procedures and coders need to be careful to not forget to code fluoro separately when it is used instead of ultrasound guidance codinginstitute.com 111

117 Non-Physician Practitioner Handbook 2015 Coding Updates Renew Intravascular Stent Coding CPT 2015 revises (Transcatheter placement of intravascular stent[s] ) to clean up some wording and clarify that the procedures include angioplasty, when performed, and also include radiological supervision and interpretation. The changes made to and make them more consistent with all other endovascular bundled coding, Hembree says. The changes read as follows (see underlined): 37215, Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection 37216, Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; without distal embolic protection Another change in 2015: Also note that next year you will use these codes for open or percutaneous approach. These codes now include angioplasty and supervision and interpretation and can now be used for open or percutaneous procedures, Hembree says. Look for a new code: Along with those revisions, you ll also have a new CPT code for placement of intrathoracic common carotid or innominate artery stent. This code includes angioplasty and imaging. In 2015, you will report (Transcatheter placement of intravascular stent[s], intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation) for intrathoracic common carotid or innominate artery stenting. As outlined in the 2015 CPT book, code is to be used in conjunction with 36216, 36217, 36225, and 36226, Hembree says. For angiography, the book directs you to code , , and For angioplasty, the book directs you to and Remember: Do not report for cranial or cerebral vessels. The ACR states that or should NOT be reported as part of diagnostic angiography of the extracranial and intracranial cervicocerebral vessels, Hembree says. They then go on to say that it may be appropriate to code and for diagnostic angiography of upper extremities and other vascular beds of the neck and/or shoulder girdle performed in the same session as vertebral angiography. Update Your Ablation Therapy Coding Ablation therapy for bone tumors: Prepare your coding for radiofrequency bone ablation to include adjacent soft tissue and radiologic guidance in the next year. The bone ablation codes have been updated to include adjacent soft tissue and radiologic guidance. This should simplify the coding process and eliminates a lot of combination coding, Hembree says. The changes in code descriptor for are marked below , Ablation therapy for reduction or eradication of 1 or more bone tumors (e.g., metastasis),radiofrequency including adjacent soft tissue when involved by tumor extension, percutaneous,including imaging guidance when performed; radiofrequency codinginstitute.com

118 2015 Coding Updates Non-Physician Practitioner Handbook In addition, you will have a new code that has been added for cryoablation of bone tumors. The new code is (Ablation therapy for reduction or eradication of 1 or more bone tumors [e.g., metastasis] including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation). What does this mean for you: Currently, you are reporting cryoablation using an unlisted code, Hembree says. In 2015, coders will be able to use to accurately report cryoablation of bone tumors. As we all know unlisted codes can be very difficult to receive payment for so the addition of the new codes in 2015 should improve reimbursement. Ablation therapy for pulmonary tumors: In 2015, you have a new category III code for cryoablation of pulmonary tumors. Add code 0340T (Ablation, pulmonary tumor[s], including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance) to your list of ablation therapy codes in CPT 0340T was a created Category III code approved at the February and May 2013 CPT Editorial Panel meetings for implementation in January However, it is new in the CPT codebook for 2015, Hembree says. Replenish Your Practice with New RSA Codes What is Radiostereometric analysis? Radiostereometric Analysis (RSA) is method for measuring micromotions in the skeleton with high precision using small spherical markers made of tantalum. Your physician may insert the markers in the patient s body either surgically or non-surgically by using an insertion device. Then your physician obtains simultaneous X-rays from two angles. Finally, your physician measures the marker projections on the film and constructs three-dimensional coordinates. The motion between different segments is calculated by comparing with results from previous RSA. List 3 new codes: In 2015, you will have three new category III codes for RSA. Category III codes are temporary codes used to report emerging technology, services, and procedures, Hembree says. Depending upon whether your physician does RSA in the spine, upper or lower limb, you select from the following codes; 0348T, Radiologic examination, radiostereometric analysis (RSA); spine, (includes cervical, thoracic and lumbosacral, when performed) 0349T, Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow, and wrist, when performed) 0350T, Radiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee, and ankle, when performed) Adopt these new codes in your practice after checking with your payer. These codes may or may not be covered by some or all payers, Hembree says. When a Category III codes best describes the services provided it must be used regardless of coverage. v 2015 codinginstitute.com 113

119 Non-Physician Practitioner Handbook 2015 Coding Updates Get to Know the 2015 Cystourethroscopy Changes CPT Brings Don t miss Kock pouch and ileal conduit updates in the surgery section. The good news is there aren t sweeping changes that will alter your urology coding, but if you miss a few key changes, you ll face denials on claims after Jan. 1, Let us give you the rundown of which changes might affect your practice so you don t have to waste precious time scouring all the new, deleted, and revised codes. Here s what you need to know in urology. Adopt 2 New Urology Codes There are two new 2015 CPT endoscopic codes for urology as follows: Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant each additional permanent adjustable transprostatic implant (list separately to code for primary procedure). Revise Your Kock Pouch Inclusions There are also changes in how you will report endoscopic evaluation of an abdominal or pelvic pouch, such as a Kock pouch or ileal reservoir. CPT 2015 alters the descriptor for and as follows (emphasis added) Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or ]) pouch; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)... with biopsy, single or multiple. These codes now clarify that the endoscopy is an examination of a particular urinary diversion, a Kock pouch or an ileal reservoir, Ferragamo explains. Look at the Surgery Updates, Too There are other changes in the surgery/digestive section of the CPT manual, which may also be of interest to urologists performing urinary intestinal diversions, Ferragamo points out. As of Jan. 1, you will find the descriptor for updated to read (emphasis added strikeout is deleted text and underline is added text): Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure). You ll use this code for endoscopy of an ileal conduit, Ferragamo explains. A new code for (Ileoscopy, through stoma; with transendoscopic balloon dilation) will be for endoscopy of an ileal conduit and dilation of a stomal stenosis, adds codinginstitute.com

120 2015 Coding Updates Non-Physician Practitioner Handbook Ferragamo. This CPT procedure code has been needed to describe a service often performed by urologists treating the common problem of stenosis of the cutaneous opening of an ileal conduit. CPT 2015 deletes ileoscopy code (Ileoscopy, through stoma; with transendoscopic stent placement [includes predilation]). In its place, you will find a new 2015 code: (Ileoscopy, through stoma; with placement of endoscopic stent [includes pre- and post-dilation and guide wire passage, when performed]). This code may be used for endoscopic placement or change of ureteral stents or catheters directly through and via an ileal conduit, Ferragamo says. You will use for either unilateral or bilateral procedures. You will also have new endoscopic coding for evaluation of a sigmoid conduit: Evaluation of a sigmoid conduit with ablation of tumor(s), polyps, or other lesions with endoscopic stent placement with endoscopic mucosal resection direct submucosal injection, any substance (for example, Botox) with transendoscopic balloon dilation (for an endoscopic dilation of a sigmoid conduit stomal stenosis). Additionally: The descriptor for the unlisted CPT code will include the word small as of January so it will read Unlisted procedure, small intestine. This unlisted code may be used for dilation of an ileal conduit stomal stenosis, Ferragamo explains. v Update Your UroLift Coding or Face 2015 Denials New codes 52441, will be your go-to answers. You haven t had a code to accurately describe the work your urologist does when he uses the UroLift system to treat a patient with benign prostatic hyperplasia (BPH) that is, until now. You have two new codes for the insertion of permanent adjustable transprostatic implants. Experts agree that those codes are your UroLift coding solution. Read on to solidify your UroLift coding know-how so you won t face denials or lost reimbursement now that the new year has begun. Focus on the Codes On January 1, CPT 2015 implemented the following two endoscopic codes for urology: Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant each additional permanent adjustable transprostatic implant (list separately in addition to code for primary procedure) codinginstitute.com 115

121 Non-Physician Practitioner Handbook 2015 Coding Updates According to a press release on the NeoTract Website, CPT codes and were approved by the American Medical Association (AMA) to describe the UroLift transprostatic implant procedure, also known as Prostatic Urethral Lift (PUL). You will use for the first implant your urologist places, explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. Then, use as an add-on code along with for any additional implants the urologist places, he adds. Old way: Prior to Jan. 1, 2015, you would report this procedure using the unlisted code: (Unlisted procedure, urinary system). If your urologist performed the UroLift procedure in a facility, the facility (for payment for the implants) reported C9739 (Cystourethroscopy, with insertion of transprostatic implant; 1 to 3 implants) for the first one to three implants and C9740 (... 4 or more implants) for any implants over three. In the office, you reported L8699 (Prosthetic implant, not otherwise specified) for the implants, Ferragamo says. New way: Now, instead of 53899, if your urologist performs the procedure in the office, you will report and for the urologist s professional fee and for the cost of the implants. If your urologist performs the procedure in a facility, such as an ambulatory surgical center (ASC) or in a hospital as an inpatient or outpatient, you will use and for the professional fee, while the facility still bills for the implants using codes C9739 and C9740. Note: You won t face an extended global surgical package with either or Because of the minimally invasive nature of the treatment, the new codes have been assigned a zero-day global period, according to NeoTract. Get to Know the Procedure When a patient has an enlarged prostate and BPH, and medications have failed, urologists often turn to surgical options. One option is the UroLift system treatment. The procedure is minimally invasive with no cutting or prostatic tissue removal, so it can typically be done under local anesthesia in the office or outpatient setting, Ferragamo explains. During the procedure, the urologist inserts the UroLift delivery device under cystoscopic visual control through the prostatic urethra. Using the device, the physician is able to place prostatic implants that pull open the prostatic urethra, reducing prostatic obstruction. Tip: The procedure does not involve the placement of a urethral stent, but it may involve placement of a postoperative Foley catheter for postoperative drainage in about a third of the cases, Ferragamo says. v codinginstitute.com

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