CONNECTIONS DELAY IN ICD-10 IMPLEMENTATION

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1 DELAY IN ICD-10 IMPLEMENTATION The government recently passed legislation to change the date from October 1, 2014, to October 1, 2015, for mandatory adoption of ICD-10 codes. PHP intends to preserve the significant progress we have made to prepare for implementation of ICD-10, and we are adjusting our plans to accommodate the new deadline. When PHP adopts the new coding system, there will be no grace period allowed for the transition. The transition date will be based on dates of service. Claims for services provided on or after October 1, 2015 must be billed with ICD-10 diagnosis codes or ICD-10 inpatient procedure codes. Claims for services provided before October 1, 2015, must be billed with ICD-9 diagnosis codes and ICD-9 inpatient procedure codes. To learn more, read PHP's FAQs on ProvLink or visit CMS's ICD-10 website. CMS s ehealth University also offers several resources to help providers comply with the new coding system. May-June 2014 In This Issue Delay in ICD-10 Implementation CPT Code Not Allowed as Bilateral Procedure IMRT Planning Includes Simulation Field Settings CPT codes and (REPEAT) Date of Service (DOS) for X-ray and Lab Interpretations PHP Clinical Editing Explanation Codes What To Do If You Have Questions Payment Rules Electronic Contract Delivery 1

2 CPT CODE NOT ALLOWED AS BILATERAL PROCEDURE PHP Payment Policy 14.0 (Bilateral Procedures) states, Only those procedures which qualify for the bilateral surgery payment adjustment on the Medicare Physician Fee Schedule (MPFS) (bilateral surgery indicator of 1 ) may be billed with modifier -50. For codes where CPT guidelines differ from CMS guidelines, PHP follows CMS guidelines for bilateral procedures. One code where CMS guidelines differ from CPT guidelines is CPT code (Removal impacted cerumen requiring instrumentation). In 2013, the description for CPT code included the phrase, one or both ears. In 2014, the CPT description changed from one or both ears to unilateral and included instructions, For bilateral procedure, report with modifier 50. However, CMS issued a memorandum explaining that the relative value for was based on the procedure being performed bilaterally. Therefore, CMS has assigned a bilateral surgery indicator of 2 to code 69210, which means this code may not be reported with multiple units, modifier -50, or RT and LT modifiers. In accordance with CMS guidelines and PHP Payment Policy 14.0, PHP has assigned a daily maximum of one unit to CPT code Additional payment will not be allowed if this code is billed with multiple units, modifier -50, or RT and LT modifiers. IMRT PLANNING INCLUDES SIMULATION-AIDED FIELD SETTINGS CPT codes 77280, 77285, 77290, and may not be reported with CPT code 77301, even if simulation-aided field settings ( ) are performed on a different date from intensity modulated radiotherapy (IMRT) planning (77301). The 2014 National Correct Coding Initiative (NCCI) Policy Manual, Chapter IX, Section F, Number 11, says, Intensity modulated radiotherapy (IMRT) plan (CPT code 77301) includes therapeutic radiology simulation-aided field settings. Simulation field settings for IMRT should not be reported separately with CPT codes Although procedure-to-procedure edits based on this principle exist in NCCI for procedures performed on the same date of service, these edits should not be circumvented by performing the two procedures described by a code pair edit on different dates of service. 2

3 CPT CODES AND NOT ACCEPTED BY PHP In 2014, the CPT Editorial Panel revised existing immunohistochemistry CPT code and created a new add-on code, CPT code The description for CPT code is, Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide, and CPT code is used to report, each additional separately identifiable antibody per slide. The 2013 coding requirements allowed CPT code to be billed once per specimen for each antibody, but the revised CPT codes and descriptors allow the reporting of multiple units for each slide and each block per antibody (88342 for the first antibody and for subsequent antibodies). CMS believed this coding would encourage overutilization by allowing multiple blocks and slides to be billed. To ensure that the services are only reported once for each antibody per specimen, CMS created HCPCS codes G0461 (Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain) and G0462 [Immunohistochemistry or immunocytochemistry, per specimen; each additional single or multiplex antibody stain (List separately in addition to code for primary procedure)]. PHP is following CMS guidelines for billing immunohistochemistry tests by requiring providers to use HCPCS codes G0461 and G0462 to report these services. Effective June 1, 2014, CPT codes and will no longer be accepted by PHP. These codes will be denied advising providers to rebill with a valid CPT/HCPCS code, i.e., G0461 and G0462. DATE OF SERVICE FOR X-RAY AND LAB INTERPRETATIONS Physicians are expected to use the actual date of service to report interpretation of laboratory tests or radiology examinations, even if the date of the interpretation is different from the date the test was performed. If both the technical and professional components of the lab or x-ray examination are performed by the same provider on the same date, bill the appropriate code once with no modifiers. If different providers perform the separate components, or if the same provider performs both components of the test but on different dates, bill the technical component with modifier -TC and the professional component with modifier -26, using the actual date of service for each component. 3

4 PHP CLINICAL EDITING EXPLANATION CODES EX Code CDD a01 a02 a03 a04 a05 a10 a11 a13 a14 a15 a29 a31 b01 b02 d01 d02 d07 N01 N02 N04 N05 N06 N14 N15 N51 N52 N54 N55 N58 N58 N91 N92 N93 N94 Explanation Duplicate claim Add-on code billed without an appropriate parent code Co-surgeon or team surgeons not appropriate for code Charges included in global OB payment Postoperative visit included in global surgery payment New patient visit frequency exceeded per CPT guidelines Pharmacy codes currently invalid Lifetime maximum for procedure exceeded Bundled/global services, services are never paid separately Chemotherapy administration code not allowed with this drug Service not allowed at this POS (place of service) Clinical daily maximum exceeded for this service Denied per medical policy Experimental/investigational procedures not covered Cosmetic procedures not covered Services not allowed from this provider specialty Services not allowed at this place of service Service not authorized per provider contract Procedure is incidental to another procedure Procedure is mutually exclusive to another procedure Postoperative care is included in global surgical payment Preoperative care is included in global surgical payment Assistant surgeon not allowed for this procedure Invalid gender for procedure Age does not fit within range described by procedure Rebundle edit occurred with a claim in history Duplicate unilateral or bilateral procedure Daily maximum for this procedure has been exceeded Procedure(s) on current claim combined with procedure(s) on claim in history exceed daily maximum Mutually exclusive edit with claim in history Incidental edit with claim in history CCI edit, procedure is incidental to another procedure CCI, current claim denied as incidental to claim in history CCI edit, procedure mutually exclusive to another procedure CCI, current claim denied as mutually exclusive to claim in history 4

5 WHAT TO DO IF YOU HAVE QUESTIONS Inquiry Locate the Clinical Edit Fax Inquiry form on ProvLink. (Click on Forms in the tool bar on the left side of the home page.) Complete the form and send all required documentation as indicated on the form to our dedicated inquiry fax line (s). Note: This form is used only for clinical edits as listed on the previous page of this newsletter. A review of the coding applications will be initiated. Service may be allowed and the claim reprocessed. Service denial may be upheld and an explanation of the rationale for the edit will be forwarded to you. Appeal If you do not agree with the edit or payment rule logic, a formal appeal may be submitted in writing. If you are familiar with the edit logic or payment rule and still wish a formal appeal, indicate this to your Provider Relations Representative. Our Medical Coding Administration Department and/or Medical Department will review the appeal and will reply by letter if the denial is upheld. Edit Reviews When there is a high volume of inquiries or appeals about a specific edit combination, PHP Medical Directors will review the edit combination. If the decision is made to reverse the edit, PHP will implement within 7 days. If the decision is made to uphold the edit, we will publish the information in Newsletter. If an edit combination is upheld, we will ask that you not continue to submit individual claims for review unless there is a clear and distinct exception clearly documented. 5

6 PAYMENT RULES Payment Rules are located on ProvLink. Please review these, as they may explain many of the payment applications that affect your claims payment. It is our policy to notify providers via Connections newsletter prior to implementing new payment rules. ELECTRONIC CONTRACT DELIVERY Providence Health Plan offers secure electronic contract delivery. If you have not already done so, please provide your Providence Health Plan Provider Relations Representative with an address for the person in your organization who should receive contract negotiation and contract update information. Please note that if the contracting contact in your organization changes, it will be important to communicate the new name and to your Providence Health Plan Provider Relations Representative. 6