Coding And Billing - Beaumont Health System

Rita Shugart, RN, RVT, FSVU
Shugart Consulting
February 7, 2015
No Conflicts
Attendees are encouraged to review the specific
statutes, regulations, and other interpretive
materials referred to in this presentation for a full
and accurate statement of their contents, and to
check these resources frequently for changes,
updates, and revisions.
CPT is a registered trademark of the American
Medical Association
Process
(Coding)
Policy
(LCD, Orders)
Documentation
(Report)
APPROPRIATE
VASCULAR LAB
REIMBURSEMENT
LCD’s
Medicare contractor policies that identify
circumstances under which services will be (or will
not be) considered covered, correctly coded, and
possibly reimbursed
The single most important factor in proper
coding, billing, & reimbursement
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One NIVT LCD
Applies to all testing settings –
hospitals, offices, IDTF’s
Private insurance often follows same
provisions
SIGNIFICANT CHANGES PROPOSED!!!
WPS NIVT LCD includes:
 Technical staff/Physician qualifications
 Facility accreditation
 Type of exams covered
 Type of exams not covered
 Frequency of repeat, surveillance exams
 Documentation requirements
 Diagnosis codes considered “medically necessary”
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Tech certification or Lab accreditation required (with exceptions)
Carotid duplex frequency:
20-39%
Annually
40-69%
70-99%
Post CEA
Post stent
q 6 mo
as needed
when clinically necessary
not mentioned
Post op ABI’s (routine surveillance):
6 weeks
q 6 months X 2 years
then annually
Duplex frequency not mentioned
Local Coverage Determination (LCD): Non-Invasive Vascular Testing (N.I.V.T) (L28586)
Coding Information
ICD-9 Codes that Support Medical Necessity
Group 1 Paragraph: Cerebrovascular Studies
1. Non-invasive Physiologic Studies (93880-93882)
a. Visual Disorders
Group 1 Codes:
362.30 - 362.37 opens in new window
362.81
362.84
368.10
368.11
368.12
368.40
368.41 - 368.47 opens in new window
377.41
377.43
RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS
ENGORGEMENT OF RETINA
RETINAL HEMORRHAGE
RETINAL ISCHEMIA
SUBJECTIVE VISUAL DISTURBANCE UNSPECIFIED
SUDDEN VISUAL LOSS
TRANSIENT VISUAL LOSS
VISUAL FIELD DEFECT UNSPECIFIED
SCOTOMA INVOLVING CENTRAL AREA - HETERONYMOUS
BILATERAL FIELD DEFECTS
ISCHEMIC OPTIC NEUROPATHY
OPTIC NERVE HYPOPLASIA
Group 2 Paragraph: b. Extracranial Artery Disorders
Diagnosis code 785.9 Other symptoms involving cardiovascular system; needs to be used when
submitting a claim for the indication pulsatile tinnitus
Group 2 Codes:
433.00 - 436 opens in new window
437.0 - 437.9 opens in new window
438.10 - 438.19 opens in new window
438.81 - 438.89 opens in new window
442.81
442.82
443.21
443.24
443.29
444.89
459.9
785.9
OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT
CEREBRAL INFARCTION - ACUTE BUT ILL-DEFINED
CEREBROVASCULAR DISEASE
CEREBRAL ATHEROSCLEROSIS - UNSPECIFIED
CEREBROVASCULAR DISEASE
SPEECH AND LANGUAGE DEFICIT UNSPECIFIED - OTHER
SPEECH AND LANGUAGE DEFICITS
APRAXIA CEREBROVASCULAR DISEASE - OTHER LATE
EFFECTS OF CEREBROVASCULAR DISEASE
ANEURYSM OF ARTERY OF NECK
ANEURYSM OF SUBCLAVIAN ARTERY
DISSECTION OF CAROTID ARTERY
DISSECTION OF VERTEBRAL ARTERY
DISSECTION OF OTHER ARTERY
EMBOLISM AND THROMBOSIS OF OTHER ARTERY
UNSPECIFIED CIRCULATORY SYSTEM DISORDER
OTHER SYMPTOMS INVOLVING CARDIOVASCULAR SYSTEM
Commonly used ICD 9:
WPS LCD includes ONLY:
585. Chronic Kidney Disease,
unspecified
585.6 End Stage Renal Disease
438.85 Vertigo
386.2 Vertigo of central origin
V58.73 Aftercare following surgery
of circulatory system
V58.49 Other specified aftercare
following surgery
441.9 Aortic aneurysm of
unspecified site, without rupture
441.4 Abdominal aneurysm without
rupture
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All tests must have a signed order
Order should include type of test and a
diagnosis/indication/reason for test
Ordering MD should document intent to order and the
reason for the test in office or progress notes
The Order may conditionally request an additional
diagnostic test if the result of the initial test yields to a
certain value
May not perform an un-ordered test until a new order has
been received (but some exceptions)
Standing orders/internal protocols not permitted
Maintain copies of orders in case of audit
Medicare Benefit Policy Manual, Chapter 15
Category III Code 0126T IMT > Category I Code:
93895 Quantitative Carotid Intima Media Thickness
and Carotid Atheroma Evaluation, Bilateral
93985 Non-Covered by Medicare and most
(maybe all?) payers
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Know the definition of the selected CPT Code
All components of the CPT Code must be
included in the exam
If the exam does not meet the definition of the
CPT Code, select another CPT code (or attach a
modifier)
The CPT Code on the claim must be fully
supported by the Report
Incorrect:
Billing CPT Code 93924 (Exercise Exam) for TOS
exam or LE Exercise exam with “toe-ups” or walking
in hallway
93924 is an LE exam only and must include exercise
on a motorized treadmill
Incorrect:
Billing CPT Code 93990 for duplex scan of a
hemodialysis access site only
93990 Duplex scan of hemodialysis access must
include evaluation of arterial inflow, body of
access, and venous outflow
Incorrect:
A Vein Mapping of the bilateral cephalic veins is
performed, and the CPT Code 93970 Venous Duplex,
Complete bilateral study is billed
Correct:
Although bilateral, this is not a complete exam; should
be billed as 93971, Venous Duplex, unilateral or
limited
Incorrect:
Report reads only “no evidence of intracranial ICA
dissection” and CPT Code 93886 TCD complete is
billed
Correct:
CPT Code 93886 requires evidence that the bilateral
anterior and posterior circulation were evaluated
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93922 (ABI’s w/waveforms) performed incorrectly:
Done with duplex imager
• Done with PPG
• No waveforms documented
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93924 (LE Exercise)- done w/o treadmill
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TOS billed as Exercise study
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Superficial Vein Mapping billed as UE or LE Venous
Duplex Complete (93970), when only limited exam
performed
Dialysis Access (93990) study does not include
inflow, outflow
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-59: “Distinct procedures/services not normally reported
together, but appropriately billable under the circumstances”
4 new, more specific Modifiers will eventually replace -59
 XS - Separate Structure, A Service That Is Distinct Because It
Was Performed On A Separate Organ/Structure
 XE - Separate Encounter
 XP - Separate Practitioner
 XU - Unusual Non-Overlapping Service
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CMS will initially accept either a -59 modifier or the more
selective -X modifiers as correct coding
MAC’s may begin requiring use of -X modifiers as desired
For more info: http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R1422OTN.pdf
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Code the diagnosis, symptoms, conditions or reasons for
ordering the test
Use LCD Cheat Sheets to assist in diagnosis code selection
Do not use the initial “referral” indication if it is known to
be inaccurate
There are no codes in LCD that include “rule out”,
“suspected”, “probable”, or “questionable”
- try to get symptoms or signs on Orders
May code a confirmed or definitive diagnosis
documented by the diagnostic test
Choose the diagnosis code that provides the highest
degree of accuracy and completeness
Test: Duplex abdominal aorta 93978
Indication: Family history of AAA
Report: “no evidence of AAA”
Incorrect ICD-9 Code Billed on claim:
441.4 Aneurysm Abdominal Aorta, not ruptured
Test: Cerebrovascular Duplex Complete 93880
Indication: Headache
Report: “no evidence of ICA stenosis bilaterally”
Incorrect ICD-9 Code Billed on claim: 435.9 TIA
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ICD 10 MUST be used for studies performed starting
10-1-2015
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EVERY diagnosis code will change
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From 17,000 diagnosis codes to 150,000
Pressure ulcers
• Angioplasty
• Fractures
• Diabetes
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ESRD
1 >>> 125
1 >>>> 854
747 >>> 17,099
69 >>> 239
11 >>> 5
No effect on CPT CODING
New Concepts:
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Stratification
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Laterality
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mild
mild intermittent
mild persistent
moderate persistent
severe
Right side = character 1
Left side = character 2
Bilateral = character 3
Unspecified side = character 0 or 9
Co-Morbidities
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history of tobacco use (Z87.891)
occupational exposure to environmental tobacco smoke (Z57.31)
tobacco dependence (F17.-)
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tobacco use (Z72.0)
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Current: 433.10 Occlusion and stenosis of carotid artery
without cerebral infarction
ICD 10:
• 165.21
• 165.22
• 165.23
• 165.29
Occlusion and stenosis of right carotid artery
Occlusion and stenosis of left carotid artery
Occlusion and stenosis of bilateral carotid arteries
Occlusion and stenosis of unspecified carotid artery
Current: 440.21 Atherosclerosis of native arteries of the
extremities with intermittent claudication
ICD 10:
• 170.211 Atherosclerosis of native arteries of extremities with
intermittent claudication, right leg
• 170.212 Atherosclerosis of native arteries of extremities with
intermittent claudication, left leg
• 170.213 Atherosclerosis of native arteries of extremities with
intermittent claudication, bilateral legs
• 170.218 Atherosclerosis of native arteries of extremities with
intermittent claudication, other extremity
• 170.219 Atherosclerosis of native arteries of extremities with
intermittent claudication, unspecified extremity
THERE’S A CODE FOR THAT!
Z89.412 Acquired Absence of Left Great Toe
Who does the diagnosis coding now? Who is training them for ICD
10?
What plans is your EMR vendor making?
will they be ready before 10-1-15?
will you be able to practice with ICD 10 before 10-1-15?
will they install ICD 10 codes included in NIVT LCD’s?
will you get an alert if an ICD 10 code is entered that is not
in
LCD?
Who will help physicians, nurses, clerical staff who enter Vasc Lab
orders?
Are paper or electronic cheat sheets needed? Who will prepare?
Who will be available to help staff on 10-1-15?
Does schedule need to be adjusted for 10-1-15?
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Labs may will need to get expanded information in
Orders
Coders may will need expanded History/Indications in
Vascular Lab Reports
LCD’s with ICD 10 codes are available now
Review the ICD 10 LCD and make new Cheat Sheets!
Expect disruptions in workflow, productivity,
reimbursement
Aorta Limited
Patient: XXX
DOB: 00/00/0000
Study Date: 00/00/0000 10:26:40 AM
Referring Physician:
Account #: YYY
Study Quality:
Room: Room 0
Indications: Follow up of infrarenal AAA with maximum diameter of 5.0 cm, right
CIA 1.3 cm, left CIA 1.9 cm, on last exam of 00/00/2013.
Vel (cm/s)
Proximal Aorta 96.7
Mid Aorta
150.5
Distal Aorta
37.6
R Common iliac
L Common iliac
Diam (A-P) (cm)
2.76
5.0
1.7
125.9
77.6
Diameter (Lateral)
(cm)
2.3
4.8
1.8
2.2
2.1
Not just for results anymore
May determine reimbursement
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Indications – narrative, not only ICD-9, ICD-10 code
Include major components required by CPT code
(i.e. 93990 include space for inflow, access, and outflow)
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Don’t use Lab-specific names for Reports
(“Post ELVS” vs. “LE Venous Duplex” report with “post laser ablation” as
Indication)
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One test (CPT code) per Report is best
(i.e. LE Art Duplex ltd + LE physio ltd combined on one “Graft Scan”
Report)
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Impression – should berelated to Lab’s Diagnostic
Criteria, not restatement of ultrasound findings
States of MI, IN, IA, KS, MO, NE
4 New Draft LCD’s (ICD-9):
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Non-Invasive Cerebrovascular Studies (DL35735)
Non-Invasive Peripheral Arterial Vascular Studies (DL35741)
Non-Invasive Peripheral Venous Vascular Studies including
Hemodialysis Access (DL35745)
Non-Invasive Abdominal/Visceral Vascular Studies (DL35749)
Same 4 Draft LCD’s published for ICD-10:
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Non-Invasive Cerebrovascular Studies (DL35753)
Non-Invasive Peripheral Arterial Vascular Studies (DL35761)
Non-Invasive Peripheral Venous Vascular Studies including
Hemodialysis Access (DL35751)
Non-Invasive Abdominal/Visceral Vascular Studies (DL35755)
1.
Deletion of diagnoses previously considered
“medically necessary”
TCD testing- sickle cell
Abdominal/visceral testing – “pulsatile mass”
2.
Poorly written Credentialing/Accreditation section
1.
Arterial testing – 93922 is “non-covered” CPT Code
Current Cerebrovascular LCD for TCD testing includes
among Indications:
“Evaluating children with various vasculopathies such as
sickle cell disease and Moyamoya”
And lists ICD-9 Codes 282.60 – 282.69 and 437.5 among
codes that may meet medical necessity
Draft Cerebrovascular LCDs for TCD testing state:
“The following are considered investigational and not
medically necessary:
Evaluation of children with various vasculopathies, such
as moyamoya disease and neurofibromatosis.”
And deletes relevant ICD-9 Codes
Current Abdominal/Visceral LCD lists ICD-9 Codes 789.30 – 78939 Abdominal or Pelvic Mass or Lump among those that may meet
medical necessity for CPT Codes:
93975 Duplex scan of arterial inflow and venous outflow of abdominal,
pelvic, scrotal contents and/or retroperitoneal organs; complete study
93976 Duplex scan of arterial inflow and venous outflow of abdominal,
pelvic, scrotal contents and/or retroperitoneal organs; limited study
AND
93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass
grafts; complete study
93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass
grafts; unilateral or limited study
Draft Abdominal/Visceral LCD’s lists ICD-9 Codes 789.30 – 789-39
Abdominal or Pelvic Mass or Lump among those that may meet
medical necessity ONLY for CPT Codes: 93975, 93976
Not a new section, but needs revision/rewriting:
Vague, inaccurate language
“Recommendations” in some sections, but
contradictory “musts” in other sections
While trying to promote certified technologists
and facility accreditation, so many
loopholes are available that policy is
unenforceable
Questionable authority of MAC for some
requirements
Language Errors:
ASN Neurosonology credential
ARRT Vascular credential
Facility accreditation incorrectly called
certification
Omission:
CCI’s RPhS credential
1.a. “All non-invasive vascular diagnostic studies
must be performed meeting at least one of the
following:
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performed by a physician who is competent in
diagnostic vascular studies or under the general
supervision of physicians who have demonstrated
minimum entry level competency by being credentialed
in vascular technology, “
Means that anyone, even with no credential,
training, or experience can perform vascular tests
as long as the supervising physician is
credentialed- high school student, secretarial staff,
convicted sex offender, etc.
“If a certified technologist supervises technologists who are
not certified, the certified RVT must: provide direct supervision
and sign the record of the test along with attesting in writing to
the quality of the examination.”
No requirement in LCD that non-certified techs MUST be supervised
but, after talking with WPS, it is clear that was their intent
For compliance, Part A allows co-signature of supervising tech; Part B
requires an “attestation sentence” on the bottom of each report, plus
co-signature
CMS identifies concepts of "general, direct, and personal supervision",
but they apply only to physicians, not even to PA's and NP's. Does a
MAC have the authority to require direct supervision by a technologist?
Vascular technology credentials certify only one's competence in
testing, not in supervision of testing
Will EMR’s permit co-signature?
Potential liability issues when certified tech “attests” to quality of
study he/she has not witnessed
“Appropriate personnel certification include, but
are not limited to, …”
Negates the effect of requiring the recognized,
traditional vascular ultrasound credentials
Permits testing by those with credentials developed
specifically to circumvent LCD
certification/accreditation requirements
93922- Limited bilateral noninvasive physiologic
studies of upper or lower extremity arteries
No explanation by WPS for non-coverage decision
Non-coverage decisions typically made by CMS
Does WPS have the authority to declare a CPT Code
non-covered when CMS has decided it IS a covered
test?
If WPS does have that authority, can they make a noncoverage decision without explanation?
93922- Limited bilateral noninvasive physiologic
studies of upper or lower extremity arteries
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Many reasons that 93922 is medically necessary
Physiologic information provided by 93922 often
cannot be obtained from imaging (duplex) exam
93922 is often the only test necessary, thus reducing
costs to Medicare program
Important in evaluating status of access sites in UE,
preserving life and saving money on higher-cost
studies (higher level physiologic studies, fistulagrams,
angiograms)
Eliminating payment for 93922 may reduce access to
appropriate care for Medicare beneficiaries
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Comment Period begins 2/5/15, ends 3/21/15
Comments should come from Physician (include NPI)
Talking Points – savings to Medicare program,
Standards of Care, legal authority, access to care,
medical necessity
Include references that support your position–
Articles, Professional society guidelines, Consensus
Statements, Accreditation documents, Appropriate
Use Criteria
Cite a brief typical example of a problem, unintended
consequences, misinterpretation caused by
implementation of LCD as proposed
Do NOT refer to 93922 as “ABI’s”
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Comment Letter may be signed by multiple providers
in your group
Identify and send Comment Letters to members of the
CAC (Carrier Advisory Committee)
Comment period will likely be last opportunity to
effect change for a LONG time – ICD 10
implementation, difficult to change a Final LCD
Send comments to Dr. Ella Noel at
policycomments@wpsic.com
Email only, no postal mail
http://www.cms.hhs.gov/mcd/index_lmrp_bystate_crite
ria.asp?from2=index_lmrp_bystate_criteria.asp&
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Select state name
Select Part A (inpatient) or Part B (outpatient)
Accept License Agreement
Check the box for “ALL” policies, and review “Active,
“Draft”, and “Future” LCD’s
Draft and Future LCD’s are at the bottom of each page of
the Active LCD’s
Review the ENTIRE list of LCD’s -NIVT LCD’s may be
named differently by different MAC’s
Check frequently for updates, changes
336-339-4323
rita@shugart-consulting.com