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AAPC – Omaha Chapter January 18, 2005 7:00 am Presented by: Cynthia A. Swanson, RN, CPC Paula L. Smith, RN, CPC, CCS-P Seim, Johnson, Sestak & Quist, LLP.

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Presentation on theme: "AAPC – Omaha Chapter January 18, 2005 7:00 am Presented by: Cynthia A. Swanson, RN, CPC Paula L. Smith, RN, CPC, CCS-P Seim, Johnson, Sestak & Quist, LLP."— Presentation transcript:

1 AAPC – Omaha Chapter January 18, :00 am Presented by: Cynthia A. Swanson, RN, CPC Paula L. Smith, RN, CPC, CCS-P Seim, Johnson, Sestak & Quist, LLP 8807 Indian Hills Drive, Suite 300 Omaha, NE CPT 2005 Changes and Medicare Update

2 2 AGENDA 2005 CPT Overview of CPT Code Changes Category II Codes Category III Codes Medicare 2005 Changes Other Issues/Discussion Disclaimer A presentation can neither promise nor provide a complete review of the myriad of facts, issues, concerns and considerations that impact upon a particular topic. This presentation is general in scope, seeks to provide relevant background, and hopes to assist in the identification of pertinent issues and concerns. The information set forth in this outline is not intended to be, nor shall it be construed or relied upon, as legal advice. Recipients of this information are encouraged to contact their legal counsel for advice and direction on specific matters of concern to them. CPT is a trademark of the American Medical Association. CPT codes, descriptions and modifiers are copyright 2004 CPT American Medical Association.

3 3 Overview of Changes for CPT 2005 Number of Annual CPT Coding Changes ,

4 4 Overview of Changes for CPT 2005 Code changes o New Codes – 170 o Revised – 61 o Deleted – 46 o Hundreds of “other changes” related to guidelines, introductory notes, explanatory text, headings, and cross-references o Total codes for CPT 2005 = about 8,492 compared to 8,368 in 2004

5 5 Overview of Changes for CPT 2005 No longer a grace period for new codes – must be used for services on or after January 1, 2005 National Standard Code Set/HIPAA AMA Publication CPT™ Changes 2005–An Insider’s View CPT Editing Marks The Symbols

6 6 Overview of Changes for CPT 2005 CPT Symbols ● -________________________  -________________________ + -________________________  -________________________  -________________________ Fill in the descriptions for these symbols Color coding scheme

7 7 Overview of Changes for CPT 2005 CPT Symbols A new symbol was added Conscious sedation “bulls-eye” symbol has been added for 2005 Intended to indicate those procedures in which the provision of conscious sedation services is considered to be inherent Not separately reported by the same physician performing the primary service Appendix G

8 8 CPT 2005 Coding Manual Appendix A –Modifiers Appendix B –Summary of Additions, Deletions, and Revisions Appendix C – Clinical Examples Appendix D – Summary of CPT Add-on Codes Appendix E –Summary of CPT Codes Exempt from Modifier 51

9 9 CPT 2005 Coding Manual Features Four New Appendixes Appendix F –Summary of CPT Codes Exempt from Modifier 63 Appendix G –Summary of CPT Codes which Include Conscious Sedation Appendix H –Alphabetic Index of Performance Measures by Clinical Condition or Topic Appendix I –Genetic Testing Code Modifiers

10 10 Evaluation and Management (E/M) Services - continued Excluding minor editorial modifications, revisions to the E/M section for CPT 2005 consist solely of clarification of the neonatal age Consistency between diagnostic (ICD-9-CM) and procedural (CPT) code sets

11 11 Evaluation and Management (E/M) Services - continued Editorial revision made to the neonatal and pediatric critical care codes  99293,  99294,  99295,  Most commonly utilized definition of the neonatal period is beginning at birth and lasting through the 28 th day following birth Formerly, CPT utilized 30 days of age or less A critically ill patient of 29 days of age was reported using a neonatal CPT code and a non-neonatal ICD-9- CM code Resolution of discrepancy

12 12 Evaluation and Management (E/M) Services - continued E/M Documentation Guidelines Nothing new to report The 1995 or 1997 E/M Documentation Guidelines are still in effect Medicare – Can continue to use either set of guidelines

13 13 Anesthesia Minimal revisions Addition of a single code ●00561 – Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, under one year of age  (Do not report in conjunction with 99100, and 99135) 

14 14 Anesthesia (continued) Revision of the Anesthesia guidelines in tandem with the addition of Appendix G Summary of CPT Codes Which Include Conscious Sedation

15 15 Surgery Notable changes in the surgery section this year include: Six new transplant series of codes and guidelines Conversion of Category III codes to Category I codes Addition of 10 Category I codes Guideline additions New codes for skin debridement for necrotizing infections New codes for gastric restrictive procedures Revisions and additions to the bronchoscopy codes

16 16 Surgery/Integumentary System - Codes ●11004 – ●11006 were added to identify extensive debridement procedures - High risk patients, soft tissue infections such as Fournier’s gangrene - In addition to the risk and extensiveness involved in the performance of debridement procedure, transplantation or removal of organs, hernia and/or intestinal repair, or fistula repair may be necessary

17 17 Surgery/Integumentary (continued) Add-on code  ●11008 has been established to identify concurrent removal of a mesh or prosthetic device Includes parenthetical notes to identify procedures that should be separately reported and a list of exclusionary codes

18 18 Surgery/Integumentary System (continued) o Three codes added to the Breast Introduction Section ●  ●  ● o Describe catheter placement and subsequent catheter removal for interstitial radioelement application in the breast following partial mastectomy

19 19 Surgery/Integumentary System (continued) Clarify reporting of spinal procedures related to: - Exploration of spinal fusion - Revision of previously placed instrumentation Introductory language has been revised and expanded

20 20 Surgery – Musculoskeletal Clarify reporting of spinal procedures related to: Exploration of spinal fusion Revision of previously placed instrumentation Introductory language of the Spinal Arthrodesis and Spinal Instrumentation subsections has been revised and expanded

21 21 Surgery – Musculoskeletal (continued) Exploration Subsection - Instructs the appropriate method of reporting arthrodesis procedures which would be performed at the same session as the definitive spinal procedure - Clarifies the use of 51 modifier

22 22 Surgery – Musculoskeletal (continued) Deletion of Category III codes 0012T, 0013T, 0014T Five codes and nine cross-references were established to report techniques to provide hyaline or hyaline-like repair for articular knee defects New codes ●27412 – Autologous chondrocyte implantation, knee ●27415 – Osteochondral allograft, knee, open

23 23 Surgery/Respiratory System Codes ●31545 & ●31546 were added to describe direct operative laryngoscopy with removal of non-neoplastic lesion(s) of the vocal cord Revisions to the bronchoscopy section to distinguish airway stents placed in the trachea versus the bronchus or bronchi

24 24 Surgery – Transplantation Services Transplantation Background Transplantation Procedures Donor Backbench Codes Rationale for Changes

25 25 Surgery/Respiratory System Lung Transplantation Three distinct components of physician work 1) Cadaver donor pneumonectomy(s) 2) Backbench work 3) Recipient lung allotransplantation Two new codes (●32855 and ●32856) for backbench preparation of cadaver donor lung allograft prior to transplant

26 26 Surgery/Cardiovascular System Heart/Lung Transplantation Codes ● and ● were added to describe backbench preparation of cadaver donor heart/lung allograft prior to transplantation

27 27 Surgery/Cardiovascular System (continued) o Four new codes added to report endovenous ablation therapy for incompetent veins o ●36475, ●36476, ●36478 and ●36479 o Add-on code to each of the initial codes intended to report performance of ablation for each additional vein after the first vein

28 28 Surgery/Digestive System o Several new gastric restrictive surgery codes were added to reflect the rapidly expanding field of bariatric surgery ● and ●43645 – laparoscopic techniques ●43845 – added to describe biliopancreatic diversion with duodenal switch  – editorial revision to existing open Roux-en-Y gastric bypass for morbid obesity (150 cm or less) For greater than 150 cm, use 43847

29 29 Surgery/Digestive System o New codes for backbench work o Intestine Transplant New codes (●44715 – ●44721) o Liver Transplant New codes (●47143 – ●47147) o Pancreas Transplant New codes (●48551 – ●48552) o Kidney Transplant New codes (●50323 – ●50329)

30 30 Surgery/Nervous System Two new codes have been added to describe laminoplasty procedures ● ● Laminoplasty is an alternative approach for posterior decompression of the cervical spinal cord

31 31 Radiology New Coding Tool Clinical Examples in Radiology Newsletter Authors: American Medical Association, American College of Radiology Quarterly case-orientated format

32 32 Radiology o Guideline additions to the Radiology Section o Provide greater clarity in coding o Guidelines for reporting diagnostic angiographies in the Aorta and Arteries, Veins and Lymphatics, and Transcatheter Procedures subsections of Radiology o Guidelines for ultrasound imaging services in the Abdomen and Peritoneum and Non-Obstetrical subsections of Radiology

33 33 Radiology (continued) o New codes for fetal ultrasound services ● ● o Revisions in the Therapeutic Nuclear Medicine subsection o Tumor Imaging

34 34 Radiology (continued) Six new ( ● – ● 78816) codes for reporting tumor imaging by positron emission tomography (PET) and computed tomography (CT) procedures have been added to the Nuclear Medicine Diagnostic subsection of CPT.

35 35 Pathology and Laboratory Codes and cross-references added to report Helicobacter pylori testing/interpretation Additions and revisions made to the morphometric analysis codes in the Surgical Pathology subsection Guidelines added to the Molecular Diagnostics and Cytogenetics subsections

36 36 Medicine Revisions to:  Vaccine administration procedure codes  Gastric testing codes  Acupuncture codes  Neurostimulator codes  Echocardiography guidelines

37 37 Medicine (continued) Immunization Administration for Vaccines/Toxoids Series of new codes ( ● – ● 90468) for immunization administration which incorporates the work of physician immunization counseling for young children (under 8 yrs. of age)

38 38 Medicine (continued) Gastroenterology Five new codes (●91034 – ●91040) to report esophagus reflux testing, esophageal function testing and esophageal balloon distension provocation study New testing methods in recent years

39 39 Medicine (continued) Active Wound Care Management Updated section includes revised introductory guidelines Revised codes to report selective debridement based on total surface area of wound(s) size New procedures to describe negative pressure wound therapy techniques based on total surface area wound(s) size

40 40 Medicine (continued) Acupuncture Codes and were deleted Codes ●97810 –  ●97814 were established to more clearly describe acupuncture and electroacupuncture services Codes based on 15 minute increments of personal contact with the patient

41 41 Category II Codes A new section of Category II (Performance Measurement) CPT codes and introductory notes was added to CPT 2004 All of the 2004 Category II codes have been deleted and renumbered Four new codes have been added to represent Maternity Care Management Eight new categories added for future expansion

42 42 Category III Codes Emerging Technology, Services and Procedures CPT Codes – Alphanumeric identifier with a letter (T) in last field 27 new codes added Many Category III codes have been converted to Category I codes for 2005

43 43 Category III Codes Series of codes added for reporting Percutaneous transcatheter placement of extracranial vertebral or intrathoracic carotid artery stents Ultrasound ablation of uterine leiomyomata Acoustic heart sound recording and computer analysis Computed tomographic colonoscopy Percutaneous intradiscal annuloplasty

44 44 MMA 2003 Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Largest change to the Medicare program since its inception Huge social debate Medicare 1964 – Disease Specific benefit Movement to preventive medicine benefit with a co-pay

45 45 MMA 2003 (continued) Other Changes - Regulation - Managed Care - Fee Schedule Changes - Demonstration Projects

46 Medicare Changes MMA provision replaced a 4.5% reduction with a 1.5% increase for 2004 and a 3.3% reduction with a 1.5% increase for 2005

47 Medicare Changes (continued) Medicare Physician Fee Schedule Conversion Factor Conversion Factor $ Conversion Factor $ Anesthesia Conversion Factor Conversion Factor $ Conversion Factor $

48 48 Medicare Changes 2005 (continued) Venipuncture HCPCS Code G0001 is deleted for 2005 Report venipuncture service with CPT code In the final rule, the status indicator for CPT code reflects “I” – Invalid for Medicare. This is an error and it should be a “C” – Carrier priced. Medicare reimbursement remains at $3.00 for 2005

49 49 Medicare Changes 2005 (continued) New Medicare Preventive Services 1) Initial preventive physical examination (HCPCS “G” codes) 2) Cardiovascular screening blood tests 3) Diabetes screening tests Specific coverage provisions apply for each of these new benefits

50 50 Medicare Changes 2005 (continued) Preventive Physical Examination Eligible beneficiary An initial preventive physical examination Medical history Physician Qualified NPP Social History Review of individual’s functional ability and level of safety Performance and interpretation of ECG

51 51 Medicare Changes 2005 (continued) Initial Preventive Physical Examination (IPPE) G Codes G0344 IPPE; face to face visit services limited to new beneficiary during the first six months of Medicare enrollment G0366 EKG, routine EKG with at least 12 leads with interpretation and report, performed as a component of the IPPE Report IPPE and the applicable EKG (G code)

52 52 Medicare Changes 2005 (continued) G0367tracing only, without interpretation and report, performed as a component of the IPPE G0368 interpretation and report only, performed as a component of the IPPE

53 53 Medicare Changes 2005 (continued) Diabetes Screening The term “diabetes screening tests” is defined in Section 613 of the MMA as testing furnished to an individual at risk for diabetes and includes a fasting blood glucose test and other tests Not a benefit if previously diagnosed diabetic

54 54 Medicare Changes 2005 (continued) Diabetes Screening Individual at risk Hypertension Dyslipidemia Obesity, BMI < or = to 30 kg/m2 Previous elevated fasting glucose Two out of four risk factors  Overweight, as defined  Family history of diabetes  History of gestational diabetes mellitus or delivery of a baby weighing greater than 9 lbs  65 years of age or older

55 55 Medicare Changes 2005 (continued) Diabetes Screening Pre diabetic twice per 12 month period V77.1 diagnosis code CPT codes 82947, 82950, Watch for additional Medicare instructions regarding applicable coding and billing of these services

56 56 Medicare Changes 2005 (continued) Cardiovascular Screening Ordered as panel or individually Cholesterol – total HDL – cholesterol Triglycerides Once every five years Labs must offer lipid panel without doing LDL above certain parameters V81.0, V81.1 and V81.2 Watch for additional Medicare instructions regarding applicable coding and billing of these services

57 Medicare Changes (continued) Chemotherapy Drug Demonstration Project Goals and Objectives Review and analyze pain control management Minimization of nausea and vomiting Assess lack of energy Assess quality of life Assess patient symptoms and complaints

58 Medicare Changes (continued) Chemotherapy Drug Demonstration Project Calendar Year 2005 Chemotherapy encounter 12 new G codes for assessment Not at all A little Quite a bit Very much

59 Medicare Changes (continued) Chemotherapy Assessment G0921 – G0924 Assessment of nausea and vomiting G0925 – G0928 Assessment of pain G0929 – G0932 Assessment of lack of energy (fatigue)

60 Medicare Changes (continued) Chemotherapy Assessment Participating physicians must bill the applicable G-codes for each patient status factor assessed in each of the three categories during a chemotherapy encounter A G-code for each patient status factor must appear on the claim for payment to be made

61 Medicare Changes (continued) A patient chemotherapy encounter is defined as chemotherapy administered through intravenous infusion or push, limited to once per day An additional payment of $130 per encounter will be paid to participating providers for submitting the patient assessment data as described, during the demonstration project

62 62 Medicare Changes 2005 (continued) MMA – Drugs Paid by Average Selling Price Beginning January 1, 2005, the payment limit for Part B drugs and biologicals, not paid on a cost or prospective payment basis, will be paid based on the Average Sales Price (ASP) plus 6 percent. Drugs will be paid based on the date of service and the lower of: The submitted charge; or The ASP plus 6 percent Quarterly pricing updates

63 63 Medicare Changes 2005 (continued) Medicare Incentive Payment 5% incentive payment to physicians furnishing services in physician scarcity areas (PSA) Primary care and specialty physicians MMA defines a primary care physician as a general practitioner, family practice practitioner, general internist, obstetrician, or gynecologist Applies to the professional services including E/M, surgery, consultation, and home, office and institutional visits (technical services are not eligible) Dentists, Optometrists, Podiatrists and Chiropractors are not eligible

64 64 Medicare Changes 2005 (continued) Clinical Psychologists Supervision of Diagnostic Tests CP may supervise the performance of diagnostic psychological and neuropsychological testing services in addition to performing them

65 65 Medicare Changes 2005 (continued) Other Provisions ESRD Care Plan Oversite (CPO) Hospice Consultation CMS Replacement Drug Demonstration “G” Codes Vaccinations Increase in allowances Others that may be applicable to your practice

66 66 Other 2005 Changes CPT 2005 Errata Medicare Physician Fee Schedule HCPCS 2005 Additions, Revisions, and Deletions 2005 ICD-9-CM Diagnosis Codes Effective Oct. 1 your practice should already be using Office of Inspector General (OIG) Work Plan Fiscal Year 2005

67 67 OIG Work Plan Fiscal Year 2005 Medicare Physicians and Other Health Professionals Billing Service Companies Medicare Payments to VA Physicians Care Plan Oversight Ordering Physicians Excluded from Medicare Physician Services at Skilled Nursing Facilities

68 68 OIG Work Plan Fiscal Year 2005 (continued) Physician Pathology Services performed in the physician office Cardiography and Echocardiography Services Physical and Occupational Therapy Services Part B Mental Health Services

69 69 OIG Work Plan Fiscal Year 2005 (continued) Wound Care Services Coding of E/M Services Use of Modifier 25 “Long Distance” Physician Claims Provider-Based Entities

70 70 Considerations Practitioner/staff education on changes Available tools/resources Update of office and out of office encounter forms Fee analysis/updates Computer updates/changes

71 71 Other Issues/Concern Questions Discussion


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