Medicare updates influenza vaccine payment allowances
Fall is typically the season for administering influenza vaccine. Accordingly, the Centers for Medicare & Medicaid Services (CMS) recently published its annual update of influenza vaccine payment allowances.
The allowances printed in the update are for dates of services beginning Aug. 1, 2013, and ending July 31, 2014. Medicare administrative contractors have until Oct. 25, 2013, to implement the new payment allowances in their claims processing systems. The payment allowances apply when Medicare payment is based on 95 percent of the average wholesale price, except when furnished in a hospital outpatient department, a Rural Health Clinic, or a Federally Qualified Health Center for which payment is based on reasonable cost.
The update covers a variety of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes used to report influenza vaccine. These include some CPT codes that are new for 2014 and at least one, 90687 (Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 months of age, for intramuscular use), for which Food and Drug Administration approval is still pending. You can find a list of the new CPT vaccine codes on the American Medical Association’s web site. As the information becomes available, CMS will post payment limits for influenza vaccines that are approved after the update’s release date, including CPT codes 90687 and 90688 (Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use), on the CMS Seasonal Influenza Vaccines Pricing webpage.
When billing for an influenza vaccine administered to a Medicare patient, don’t forget to also report the HCPCS administration code, G0008 (Administration of influenza virus vaccine).
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
UnitedHealthcare jumping on vaccination bundling bandwagon
One of the nation's largest insurers is piggybacking on new restrictions that complicate physicians getting paid for performing vaccinations.
UnitedHealthcare (UHC) announced in its July 2013 Network Bulletin that it will align with Correct Coding Initiative (CCI) edits that went into effect Jan. 1, 2013. These changes, detailed in a February blog, affect evaluation and management (E/M) services and immunization administration codes.
UHC said that beginning in the third quarter of 2013 it will deny Current Procedural Terminology (CPT) codes 99201-99380 and 99401-99499 when reported on the same date of service as an immunization administration service (CPT codes 90460-90461 and 90471-90474). However, if the E/M code is reported with modifier 25, indicating it is a significant and separately identifiable service provided on the same day, UHC will pay for both codes. On the plus side, this policy change will not apply to preventive medicine E/M services (CPT codes 99381-99397 and Healthcare Common Procedure Coding System code G0402), which is often the type of E/M service during which vaccines are administered.
No word yet on what other payers may also be following suit, but it’s a safe bet that UHC is not alone and will not be the last.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Decoding the new transitional care management rules
Ever since their introduction at the beginning of the year, the new transitional care management (TCM) codes have caused confusion.
The Getting Paid blog described the new codes when they were first announced last fall. But the questions have continued, and the codes are getting additional attention after the CPT Editorial Panel clarified in January that transitional care management involving new patients, and not just ones that a physician has seen within the previous 12 months, could be billed using the TCM codes.
Here are some of the more common questions:
Q. When should I bill for TCM?
A. You should submit your bill on the 30th day after discharge. TCM covers 30 days of management services with one evaluation service bundled into the code. The date of service on the claim would be the 30th day after the discharge.
Q. What happens if the patient is re-admitted before the 30 days are up?
A. The face-to-face visit would become the appropriate level evaluation and management code for the service that was rendered. You would restart your 30 days of service on the TCM once the patient was discharged.
Q. Does a discharge visit count as the post discharge contact?
A. No, a discharge visit does not count. The initial contact must be made after the patient leaves the hospital. This is to make sure that the patient has the support necessary until they have their face-to-face visit. The initial contact can be phone, e-mail, text, or face-to-face. It can involve the patient and/or the patient's caregiver.
Q. If the patient needs an unrelated evaluation and management (E/M) visit during the 30 days can I bill for this?
A. Yes, although there are some restrictions on what you can bill, such as anticoagulation management and home health care certification.
We’ve yet to hear how these codes are getting paid since the earliest billing date would have been Jan. 30, 2013. We are also waiting on the Centers for Medicare & Medicaid Services (CMS) to release guidelines on the codes, which we expect to receive by the end of February.
AAFP has created a form to help you document the requirements of TCM visits and made available for download a list of frequently asked questions. TCM was also discussed as part of an AAFP/TransforMED webinar, “What’s new in Medicare and Medicaid payment in 2013,” which is archived on TransforMED's Delta Exchange site and accessible to AAFP members upon login.
–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians
'Tis the season...influenza season, that is
The Centers for Medicare & Medicaid Services (CMS) released its annual update to influenza vaccine payments in early October, effective for dates of service on or after Aug. 1, 2012. Here’s an overview of what your Medicare contractor should be paying you.
CMS has payment allowances for several CPT and HCPCS codes for seasonal influenza virus vaccines. These allowances are typically based on 95 percent of the average wholesale price. However, when physicians furnish the vaccine in a hospital outpatient department, rural health clinic, or federally qualified health center, payment is based on reasonable cost and other allowances may apply.
The following table shows the payment allowances (based on 95 percent of the average wholesale price) for the most common codes:
Influenza virus vaccine, split virus, preservative free, when administered to children 6 to 35 months of age, for intramuscular use
Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
Influenza virus vaccine, split virus, when administered to children 6 to 35 months of age, for intramuscular use
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular (Afluria)
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Note that CMS has permitted payment allowances for some influenza vaccines to be set by the local claims processing contractor. Specifically, local contractors set the payment amounts for Q2034, Influenza virus vaccine, split virus, for intramuscular use (Agriflu), and Q2039, Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified).
Medicare payment for some other influenza vaccine codes is available only after the local claims processing contractor determines that the vaccine in question is medically reasonable and necessary for the beneficiary. These include:
• 90654 – Influenza virus vaccine, split virus, preservative-free, for intradermal use (Fluzone ID); Part B allowance of $18.981,
• 90660 – Influenza virus vaccine, live, for intranasal use (FluMist); Part B allowance of $23.456,
• 90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (Fluzone High-Dose); Part B allowance of $30.923.
The additional scrutiny that Medicare is giving these codes is probably due in part to their costs compared with the traditional injectable influenza vaccine. Beyond that, code 90654 is a new code reflecting a new route of administration (i.e., intradermal), and the “enhanced immunogenicity” represented by code 90662 is probably not universally needed, leading Medicare to make sure that those who receive it do so appropriately. Finally, an article published by the Medicare contractor in Florida suggests that 90660 is only indicated for healthy individuals between 2 to 49 years of age, again leading Medicare to ensure that those who receive it do so appropriately.
In closing, it is worth pointing out that the allowances above are effective with dates of service on or after Aug. 1, 2012; however, Medicare contractors have until Dec. 28, 2012, to implement these allowances, so it is possible that some of your influenza vaccine claims may not be paid at the correct rate in the interim. Medicare contractors will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, contractors will adjust claims brought to their attention, so if you submitted a claim that is not paid at the correct allowance, you need to bring that claim to the contractor’s attention for adjustment.
For more information, check out the MLN Matters article (MM8047) "Influenza Vaccine Payment Allowances: Annual Update for 2012-2013 Season.”
–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Putting E/M services on the RAC
In July, I posted about a report from the U.S. Department of Health & Human Services Office of the Inspector General (OIG) which found that from 2001 to 2010, physicians increased their billing of higher level evaluation and management (E/M) codes in all types of E/M services. In that post, I encouraged you to make sure that your documentation supports the level of E/M services that you are billing. With the OIG paying attention, the Centers for Medicare & Medicaid Services (CMS) were likely to follow suit, and you needed to be prepared.
Well, it appears that CMS was paying attention, or at least its recovery audit contractors (RACs) were. This week, CMS alerted the American Medical Association (AMA) that it has approved the Medicare Region C RAC. The contractor for Region C, Connolly, is to begin conducting audits of coding for E/M services in physician offices, specifically CPT code 99215. According to the AMA, in the next several weeks Connolly will begin a complex medical review of code 99215 and will be permitted to extrapolate their findings based on a statistical sample of such claims. Connolly is the Medicare fee-for-service RAC contractor who conducts RAC audits in the following states:
- Puerto Rico
- U.S. Virgin Islands
However, it has not yet been announced if all or only a subset of these states and territories will be under review. As of this writing, Connolly has not posted this information and other details of the review on its website. These reviews are expected to begin imminently in Region C and, according to CMS, are likely to be approved in other Medicare regions in the near future.
The American Academy of Family Physicians, the AMA, and 100 other state and specialty societies sent a letter to CMS in March 2009 strongly opposing RAC audits of E/M services. However, the OIG report apparently encouraged CMS, through its RAC auditors to do otherwise.
So, what's a family physician to do? I would argue that the advice given in my July post still applies: make sure that your documentation supports the level of E/M services that you are billing to Medicare. If you are subjected to a RAC audit, take some solace in the fact that, according to CMS' FY 2010 Recovery Auditor Report to Congress, 46 percent of the Medicare RAC determinations that were appealed were decided in the provider's favor. That means you have almost a 50/50 chance of prevailing in the long run. Of course, as John Maynard Keynes once observed, "In the long run, we are all dead." Hopefully, the prospects for physicians in this case are a bit more optimistic.
The old "new patient" conundrum
In its most recent Medicare Quarterly Provider Compliance Newsletter (PDF download) the Centers for Medicare and Medicaid Services (CMS) highlighted an issue that apparently continues to be a problem for some physicians. Namely, when is a patient "new" for purposes of billing evaluation and management (E/M) services?
CMS defines a "new" patient in Chapter 12 Section 30.6.7 (PDF download) of the Medicare Claims Processing Manual as "a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years." This is essentially the same definition as in Current Procedural Terminology (CPT), which states, "A new patient is one who has not 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." CPT defines "professional services" as "those face-to-face services rendered by a physician and reported by a specific CPT code(s)."
A simple way to determine if a patient is new is to ask yourself this question: "Have I (or another physician of my specialty within our group practice) provided a face-to-face service to this patient within the past 3 years?" If the answer is no, then the patient is new to you for purposes of coding and billing the E/M service that you are providing to him or her. If the answer is yes, then you must consider the patient established. Determination of whether the patient is new or established should not be made solely on whether the chart presented was new. Coding or charge entry staff should search for past billing records using the patient's social security number and date of birth, and if a billing record is found, contact the appropriate staff to compare the charts and determine if the patient is established.
While some of your patients may be new, this issue is not, and apparently, it continues to sufficiently confuse some physicians that CMS felt it necessary to remind folks about the definitions involved. CMS issues the Medicare Quarterly Provider Compliance Newsletter to help physicians and their billing staffs understand the claims submission problems found by Medicare contractors and how to avoid certain billing errors and other improper activities when dealing with the Medicare. In light of that, you may want to check your own understanding of the new patient issue and related coding and billing practices, lest this become a compliance issue in your practice.
Drug screening codes have changed
There are now two drug screening codes for reporting use of a multiplexed screening kit that tests for multiple drugs or drug classes. The Centers for Medicare & Medicaid Service published new HCPCS code G0434 for the multiplexed drug screening to differentiate these tests from those that are more complex. CPT followed with new code 80104 for the same purpose. The descriptors for these new codes follow:
• G0434, "Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter (add modifier QW if you have CLIA certificate of waiver)"
• 80104, "Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure"
Use the G code for Medicare claims, and use the CPT code for other claims. The Medicare Clinical Laboratory Fee Schedule shows an average fee of $20.67.
CMS explained in MLN Matters publication SE1105 (PDF download) that refining the drug screen testing codes and revising the descriptors was done to avoid unnecessary or excessive utilization of code G0431 for relatively simple point-of-care tests that screen for multiple substances. In addition to introducing code G0434, code G0431 was changed from “Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class” to “Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter.” If your practice has received denials for claims with dates of service on or after Jan. 1, 2011, that use code G0431QW for tests conducted with the kits listed in MLN Matters publication MM7266 (PDF download), corrected claims should be submitted with code G0434QW. For dates of service on or after April 1, 2011, claims that use code G0431QW will be denied.
Also effective Jan. 1, 2011, code G0430 has been deleted and replaced with code G0434. Therefore, the code G0434QW replaces G0430QW.
G0434 should be used to report very simple testing methods, such as dipsticks, cups, cassettes and cards, that are interpreted visually or with the assistance of a scanner, or that are read utilizing a moderately complex reader device outside the instrumented laboratory setting (i.e., non-instrumented devices). This code should also be used to report any other type of drug screen testing using test(s) that are classified as Clinical Laboratory Improvement Amendments (CLIA) moderate complexity test(s), keeping the following points in mind:
• G0434 includes qualitative drug screen tests that are waived under CLIA as well as dipsticks, cups, cards, cassettes, etc., that are not CLIA-waived.
• Laboratories with a CLIA certificate of waiver may perform only those tests cleared by the Food and Drug Administration (FDA) as waived tests. Laboratories with a CLIA certificate of waiver should bill using the QW modifier.
• Laboratories with a CLIA certificate of compliance or accreditation may perform non-waived tests. Laboratories with a CLIA certificate of compliance or accreditation should not append the QW modifier to claim lines.
• Only one unit of service for code G0434 can be billed per patient encounter regardless of the number of drug classes tested and irrespective of the use or presence of the QW modifier on claim lines.
Note that the "per encounter" reporting for G0434 doesn't prevent reporting when a patient is tested in two different settings, such as when a patient tested in the physician's office in the morning later reports to the emergency department and receives a second test.
The MLN Matters publication mentioned earlier (MM7266) also provides a listing of the drug kits that should be reported using the new code G0434 with the QW modifier to signify the test's waived status. Each quarter CMS publishes a list of all test products with CLIA-waived status. Providers may use this list to determine if a particular test product can be appropriately performed by a laboratory with a CLIA waiver and is eligible to be billed using the QW modifier. However, the currently displayed list is from Jan. 5, 2010. You can view the most recent list as provided to the Medicare contractors in Medicare CR7266 (PDF download).
If you are unsure about Medicare coverage of drug screening tests, this information is available from the Medicare Coverage Database and the Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report dated January 2011. I found local coverage determinations for qualitative drug screens posted by National Governments Services Inc., First Coast Service Options Inc., and Palmetto GBA by searching the term "drug screen" in the Medicare coverage database.
I may have just set the record for the most links in a Getting Paid blog, but I'm sure my drug screen would come out clean. I just like to provide the sources for further information and to help you and your staff keep up with these ever-changing codes and coverage decisions.
Like a shot in the arm – or not
Jan. 1, 2011 brought quite a few changes to primary care. Some are good. Others that should be good are overly complex (if you have looked at the Medicare annual wellness visit requirements, you know what I mean) or lack acceptance among payers, which is the problem with the new pediatric vaccine administration codes, the subject of this post.
The new pediatric vaccine administration codes were developed to recognize the physician work of counseling patients about each component of combination vaccines. I provided details about these codes in a previous blog. I have heard from some practices that they have seen increased payment for the vaccine administrations from some payers. Unfortunately, other payers are not yet on board with the need to make provision of childhood vaccines an affordable endeavor.
Here is some disappointing but important guidance from the CDC regarding Vaccines for Children (VFC) payment:
In the VFC program, the regional vaccine administration fee cap rates were established on a per-vaccine basis, not on a per-antigen or per-component basis. Under current interpretation of CMS policy, the administration fee for the VFC program will continue to be based on a per-vaccine basis and not on a per-antigen or per-component basis. CMS is looking closely at the VFC administration fee cap to ensure that it keeps up to date with changes in underlying costs of providing vaccines and with medical practice. CMS anticipates updating the fee cap in the near future, and is also examining the larger reimbursement structure of the VFC program. In the meantime, state Medicaid agencies can increase the amount they pay providers up to their regional cap by submitting a State Plan Amendment, as most states are currently paying providers rates that are below their state caps. In addition, a state could choose to establish different rates, up to their regional cap, for a vaccine with multiple antigens and those that are single components.
VFC-enrolled providers may not charge a vaccine administration fee to VFC-entitled children that exceeds the regional administration fee cap per dose of vaccine.
Providers are encouraged to use the new code 90460 for the administration of a vaccine under the VFC program. If code 90461 is used for a vaccine with multiple antigens or components, it should be given a $0 value for a child covered under the VFC program. This applies to both Medicaid-enrolled VFC-entitled children as well as non-Medicaid-enrolled VFC-entitled children (i.e., uninsured, underinsured, and American Indian or Alaska Native children not enrolled in Medicaid).
Also, here's what you need to know about private payers' handling of these claims: Make sure that the person who reviews your payments watches for the number of units allowed by payers. Some are substantially limiting the payment for code 90461. For some this is a system error that is to be corrected, but not for all. One payer's policy blatantly states that it will pay for only one unit per date of service for the primary vaccine administration, 90460, and only 3 units for "additional injections" using code 90461. In other words, the payer is ignoring the per-component-oriented descriptors in CPT 2011. The payer goes on to say, "Maintaining the 'per administration/injection' definition from the 2010 immunization administration codes (90465/90466, 90471/90472) will allow a budget-neutral conversion. The 2011 allowances will reflect a 1% increase." Apparently this payer has never heard that HIPAA prohibits changing the code descriptors. I wonder if the payer's premiums and profits are "budget neutral."
But I didn't write this to depress you. Be aware that the AAFP (and the American Academy of Pediatrics, which has invested extensive time and effort in acceptance and payment of the new codes) is advocating for fair and correct payment of these codes. And as mentioned previously, some payers did begin paying the codes as intended on Jan. 1. We will keep working on the rest.
Vaccine administration: A little good news for little folks and their doctors
If you provide pediatric vaccines in your practice, you have no doubt noticed the increase of combination vaccine products and a related decrease in your payment for vaccine administration services. The good news is that the CPT Editorial Panel and the Centers for Medicare & Medicaid Services (CMS) also noticed. New codes will allow reporting of the administration service for each vaccine component beginning in 2011. Even better, CMS published relative value units (RVUs) for these codes – even though they will not typically be reported for Medicare patients.
The new codes are 90460 and 90461. These codes should be reported for physician counseling (or that of another qualified health care professional) and administration of vaccines to children through age 18. Code 90460 is reported for administration of a single component vaccine and/or for the first component of a multiple component vaccine. Code 90461 is reported for each additional component of a multiple component vaccine. For example, MMR vaccine has three components, so administration of this vaccine would be reported with one unit of 90460 and two units of 90461.
CMS assigned RVUs to these codes by crosswalking them with the values of the adult vaccine administration codes 90471 and 90472. This means that new code 90460 has the same RVUs as 90471, and each unit of 90461 has the same RVUs as 90472. Beats getting one administration fee that was valued the same as 90471!
AAFP Coding Resources web pages have been updated to provide more information on these new codes and the guidelines for reporting them.
More to come on CPT code changes for 2011 in your January/February issue of Family Practice Management!
Accountable care organizations and the future of physician payment
As promised in the meeting agenda, an FTC panel debated circumstances under which independent health care providers participating in an ACO could engage in price point negotiations with private payers without running afoul of federal antitrust laws that prohibit price-fixing. Also, panel participants explored different ways in which the HHS secretary could exercise waiver authority or create new exceptions and safe harbors related to the physician self-referral law, the federal anti-kickback statute, and the civil monetary penalty law, for the purpose of encouraging the creation and development of ACOs. The AAFP submitted comments that were included in the meeting record, and the Academy will continue to track the progress of the issues discussed.
You might be a coding and payment geek if . . .
The arrival of the new ICD-9 manual recently reminded me that there are certain things that distinguish coding and payment geeks from otherwise "normal" people. So, for your consideration, I offer you the top 10 signs that you might be a coding and payment geek:
10. The first thing you associate with December is the arrival of the new CPT book.
9. You actually get excited when your new coding books arrive.
8. You wonder why the toy doctors bag you bought your kid doesn't include a claim form.
7. You worry your family physician is undercoding your visit.
6. You consider the Federal Register light reading.
5. You write to CMS more than to your own mom.
4. You actually understand Medicare's Sustainable Growth Rate formula.
3. You collect past issues of CPT Assistant on eBay.
2. When your family physician tells you that you have conjunctivitis, you wonder what the ICD-9 code for that is.
And the number one sign that you might be a coding and payment geek:
1. You actually understood the humor in this blog post!
Getting paid for H1N1-related services
Do you know where to obtain H1N1 vaccine for your patients and how to bill payers for its administration?
Free H1N1 vaccine kits are available through your state health agencies. The Centers for Disease Control has published a list of who to contact for information on obtaining the vaccine. If you do not wish to provide the vaccine in your practice, you can use this list to determine where to refer your patients.
Most privately insured patients will have benefits for the H1N1 vaccine administration even if their health plan does not typically cover preventive services; this is due to collaboration between the U.S. Department of Health and Human Services and payers. Medicare allows physicians to provide and bill for both H1N1 and seasonal influenza vaccines on the same date. Medicare created a new G code for administration of the H1N1 vaccine; submit code G9141 with diagnosis code V04.81. It is not necessary to report a separate code for the vaccine itself, but if you prefer to include it in your documentation, use code G9142. If billed, this code will be denied since the vaccine is provided at no cost. For the standard seasonal influenza vaccine and administration, use codes G0008 for the administration, V04.81 for diagnosis, and the appropriate CPT code for the vaccine itself (i.e., 90655, 90656, 90657, 90658 or 90660). Medicare will not pay for an office visit if the sole purpose of the visit is vaccine administration but will if a significant, separately identifiable E/M service is provided on the same date.
Your local private payers may still be deciding on the coverage and payment for the H1N1 vaccine, but most national payers have provided some guidance. The recent creation of CPT code 90470 for H1N1 vaccine administration may cause some plans to issue revised instructions. We have requested updated guidance from national health plans and will update the AAFP resources on H1N1 with this information as we receive it. As with all services, practices should check the individual patient’s benefits when scheduling the services.
Finally, it’s important to know how to code and bill for care provided to patients who are sick with the flu. New influenza diagnosis codes took effect Oct. 1, 2009. Code 488.1 is specific to influenza due to the H1N1 virus. Code 487.1 is still valid for patients with influenza not otherwise specified and other respiratory manifestations such as pharyngitis, laryngitis or URI. Code 487.0 for reporting influenza with pneumonia is also still valid. When providing in-office testing for influenza, code 87804QW represents CLIA-waived testing for influenza by immunoassay with direct optical observation. Most rapid tests do not differentiate between Influenza A and B. However, for those that do produce two separate results, payers may accept 87804QW on one claim line and 87804QW59 on a separate claim line. As always, you should check with your individual payers for specific coverage and billing guidelines.
Everything's up-to-date in Kansas City
Last week, I received a call from a doctor's office inquiring why her claim for a B-12 injection might have been denied by a particular payer. She indicated that they used Current Procedural Terminology (CPT) code 90772 to report the service.
A quick check of my 2009 CPT book identified the problem. Code 90772 has been deleted for 2009; the correct new code is 96372.
It never ceases to amaze and amuse me when a physician's practice is not using the current versions of a CPT, Healthcare Common Procedure Coding System (HCPCS), or International Classification of Diseases, 9th Revision - Clinical Modification (ICD-9-CM) manual. It does not take too many claims denied because of out-of-date codes to equal or exceed what it would have cost the practice to buy current copies of the necessary coding manuals. Indeed, the ICD-9-CM manual is available on CD-ROM from the U.S. Government Printing Office for only $19.00, and HCPCS can be accessed freely on the Centers for Medicare and Medicaid Services web site (although I still prefer to use the manual version).
So, take a moment right now, while you're thinking about it, and pull your CPT, HCPCS, and ICD-9-CM books off the shelf. If they are not the most current versions (i.e., 2009, as I write this), then it's time to order new ones. This ounce of prevention for denied and returned claims should more than equal the pound of cure found in resubmitting or appealing such claims.
Another urban myth about coding
Recently, I received a call from a physician who had heard from a consultant that he should code his levels of evaluation and management (E/M) services based solely on the medical decision making involved. He asked me if this was true.
As I have done with other callers asking the same question, I assured him that this was incorrect information. Current Procedural Terminology (CPT) clearly states that all of the key components (i.e., history, examination, and medical decision making) play a role in selecting a level of E/M service (unless you’re coding on the basis of time because counseling and/or coordination of care dominated the encounter). For some codes (e.g., new patient office visits), all three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service. For other codes (e.g., established patient office visits), two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service. In no case does CPT state that medical decision making, by itself, determines the level of E/M service.
Medicare policy supports this interpretation. Section 30.6.1, “Selection of Level of Evaluation and Management Service,” of Chapter 12 of the Medicare Claims Processing Manual states, in part, “Instruct physicians to select the code for the service based upon the content of the service.” That content includes the history and examination.
This particular urban coding myth grows out of confusion between medical decision making and medical necessity. As the same section of the Medicare Claims Processing Manual says, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.” Using an extreme example, you can perform and document the history, examination and medical decision making necessary for a level-five office visit for a patient with a common cold, but there are not many people who would say that level of service was medically necessary in that circumstance. In any case, medical necessity is not the same as medical decision making, and medical necessity governs payment, while medical decision making plays but one part in selecting the level of E/M service.
So the next time someone tells you to code E/M services only on the basis of medical decision making, you might warn them about all the alligators living in the sewer system.
It’s annoying. You’ve submitted your claims for subcutaneous injections with code 90772 for a couple years now and all of a sudden, rejections! The code has been changed to 96372. Who's responsible for this disruption to your cash flow? It was the insurance companies, wasn’t it?
No. Insurance companies do have some influence on CPT code changes but really not that much. CPT code changes can be proposed by anyone who identifies a problem or gap in existing codes. Many originate from physician complaints made to specialty societies about payment policies that don’t align with CPT or current practices. All proposed changes are vetted and recommended for approval, modification or rejection by physician volunteers from each of the medical specialty societies that participates in the AMA's CPT process. Proposals are then approved, postponed or rejected by the AMA's 17-member CPT Editorial Panel. Most of the panel members are physicians nominated by their specialty organization and appointed by the AMA Board of Trustees. David Ellington, MD, of Lexington, Va., and the AAFP Board of Directors is a member of the panel. A handful of the panel members represent payers.
So what else has changed in CPT 2009 and how are you, a busy physician, supposed to care for your patients and your practice and keep up with all of this? You can look to Appendix M of your 2009 CPT book for a summary of the deleted codes and their replacements. Also, watch for an article in the January/February issue of FPM on the code changes most affecting family medicine. And finally, don’t hesitate to contact me (firstname.lastname@example.org) or join the AAFP e-mail discussion list for coding issues to find help with coding questions and keep up-to-date. (The discussion list is also open to non-members so that your coding and billing staff can take advantage of this free resource.)