CONNECTIONS CHANGES TO CODE DESCRIPTIONS IN 2013

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1 CHANGES TO CODE DESCRIPTIONS IN 2013 For 2013, the American Medical Association revised the description of 82 evaluation and management (E&M) codes in the CPT book within the range to specify that these E&M services may be reported by a physician or other qualified health care professional. It is understood that the other qualified health care professional must be acting within the scope of their license, and PHP has two payment policies that address which E&M codes may be reported by non-physician practitioners. Nurse Practitioners (NP) and Physician Assistants (PA) who are licensed by the state and are credentialed by PHP may bill under the physician s name using the incident to guidelines. (See Payment Policy 62.0, Incident-To. ) These practitioners may also bill independently. (See Payment Policy 40.0, Physician Extenders. ) Whether billing incident to or billing independently, an NP or PA is not restricted to specific E&M codes. Coverage of services rendered by auxiliary personnel who are not licensed by the state to practice independently is limited to those services performed while in the employment of a physician and under the immediate supervision of a physician or physician extender. The only E&M code which may be billed by auxiliary personnel is CPT code March-April 2013 In This Issue Changes to Code Descriptions in 2013 Payment Policy Updates Always Use Current Codes Zostavax Coverage Changes Autologous Fat Grafting Cardiac Catheterization Add-On Codes Facet Joint Injections Ultrasound for IUD Insertion PHP Clinical Editing Explanation Codes What To Do If You Have Questions Payment Rules Electronic Contract Delivery 1

2 PAYMENT POLICY UPDATES Payment Policy 06.0 (Multiple Surgery Reduction) was revised to show only codes with an indicator of N on CMS s schedule of ASC Covered Surgical Procedures are exempt from the multiple surgery reduction. This change applies to facilities who contract for payment using CMS payment methodology. (See Payment Policy 74.0 ASC Payment System for additional information.) There were multiple codes added to Payment Policy 13.0 (Bundled or Adjunct Services) and one code removed from the policy. Code (Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance) was removed from Payment Policy PHP will now allow payment for this service if it is the only service provided on that day. The code will not be paid in conjunction with any other service. PHP considers payment for this service to be included in any other services performed on the same day. Codes (supervision of interfacility transport) were added to Payment Policy Codes (complex chronic care coordination services) were added to Payment Policy Codes 92921, 92925, 92929, 92934, 92938, and were added to Payment Policy (See related article in this issue.) Code (pharmacologic management with psychotherapy services) was added to Payment Policy Payment Policy 58.0 (Documentation Guidelines for Medical Services) was revised to show that the time spent for each modality must be recorded for timebased therapy codes. Payment Policy 85.0 (Documentation Guidelines for Physical Therapy, Speech Therapy, and Occupational Therapy Services) is a new policy clarifying PHP s documentation requirements for physical therapy, speech therapy, and occupational therapy services. See also Payment Policy 58.0 (Documentation Guidelines for Medical Services). 2

3 ALWAYS USE CURRENT CODES Providers may use only the most current code sets for billing PHP. PHP Payment Policy 19.0 (Service Code Policy) states, Providence Health Plan will use the most current published service codes for coverage issues and pricing. These service codes are published in the Current Procedural Terminology (CPT), ICD-9 CM, HCPCS (National Level II codes) and Diagnostic Related Groupings (DRG) books. Systematic implementation of approved service codes and rates is effective January 1. Per HIPPA guidelines, the most current code sets must be used for billing services. As it does every year, PHP began accepting the current codes on the first of January. The 2013 CPT codes may be used for dates of service on or after January 1, Codes that are new this year will be retrofitted for contracts that use the previous year s relative value schedule for setting payment rates. ZOSTAVAX COVERAGE CHANGES For Medicare members aged 50 years and older with Part D prescription benefit, PHP will cover herpes zoster vaccine (Zostavax). Previously, coverage applied to Medicare members aged 60 and older. This change follows CMS (Centers for Medicare and Medicaid Services) coverage recommendations according to the FDA labeled indication. For Commercial members, PHP follows ACIP (Advisory Committee on Immunization Practices) recommendations. ACIP recommends Zostavax for adults aged 60 years and older. PHP will continue to cover Zostavax for Commercial members aged 60 years and older. With prior authorization, PHP will cover Zostavax for Commercial members aged 50 to 59 years with consideration to factors cited in ACIP supplemental recommendations: Poor anticipated tolerance of herpes zoster Post-herpetic neuralgia symptoms For example, patient having factor(s) above attributable to preexisting chronic pain, severe depression, or other comorbid conditions; patient s inability to tolerate treatment medications because of hypersensitivity or interaction with other chronic medications. ACIP supplemental recommendations are outlined on the following link: 3

4 AUTOLOGOUS FAT GRAFT FOR BREAST RECONSTRUCTION Autologous fat injection is used to assist with breast reconstruction following mastectomy. This procedure utilizes a purified form of the patient s fat harvested with a syringe from another region of the body, e.g., hips or abdomen. PHP will allow coverage for autologous fat graft for breast reconstruction following total mastectomy only. Prior authorization is required. There is no CPT code for reporting harvesting of fat using a syringe. CPT codes (Graft; derma-fat-fascia) and [Tissue grafts, other (e.g., paratenon, fat, dermis)] are used to report harvesting blocks of tissue for grafting rather than suctioning fat into a syringe. CPT code (Suction assisted lipectomy; trunk) is a procedure for removing fat deposits rather than obtaining fat cells for grafting. Once authorized, the provider may report one unlisted code (CPT 19499) for autologous fat transplant. PHP will review these surgeries on a case-by-case basis to determine payment. CARDIAC CATHETERIZATION ADD-ON CODES In 2013, CPT made changes to the codes for angioplasty and atherectomy. New codes were added for atherectomy with stenting, any revascularization of a coronary artery bypass graft, and any revascularization procedure with a chronic total occlusion of any coronary artery or graft. CPT created a separate base code for each procedure for each new artery and an add-on code for each branch within that artery. When establishing relative value units (RVU s) for these new procedure codes, CMS bundled the work of each add-on code into the base code for that procedure. Consequently, CMS has assigned a B or bundled status to each of the add-on codes in this category, which include CPT codes 92921, 92925, 92929, 92934, 92938, and Payment for the add-on code is included in payment for the base code. PHP has assigned a bundled status to all of these add-on codes. The codes have been added to Payment Policy 13.0 (Bundled or Adjunct Services) and will not be paid separately, as the payment is included in the rate established for the base code. 4

5 FACET JOINT INJECTIONS CPT codes are used to report destruction by neurolytic agent of paravertebral facet joint nerves and may be reported once per facet joint. It is important to note that the number of nerves injected for a single facet joint does not affect code selection. Use of the word nerve(s) in the code description means the code may be reported once per facet joint regardless of the number of nerves injected. If both facet joints at the same vertebral level are treated, then the code may be reported with modifier -50 (Bilateral Procedure) Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) ULTRASOUND FOR IUD INSERTION PHP Medical Directors have determined that an ultrasound is generally not required for insertion of an intrauterine device (IUD), nor is this the standard of care in the community. Therefore, an edit has been established to bundle abdominal and vaginal ultrasound codes to CPT code (insertion of intrauterine device). An ultrasound may be indicated for removal of an IUD (CPT code 58301), but only in rare circumstances. A review of the procedure note showing medical necessity for use of ultrasound will be required for payment. 5

6 PHP CLINICAL EDITING EXPLANATION CODES EX Code CDD a01 a02 a03 a04 a05 a10 a11 a13 a14 a29 b01 b02 d01 d02 N01 N02 N04 N05 N06 N14 N15 N51 N52 N54 N55 N58 N58 N91 N92 N93 N94 Explanation Duplicate claim Add-on codes billed without an appropriate parent code Co or team surgeons not appropriate for code Charges are 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 Chemo admin code not allowed with this drug Clinical daily maximum exceeded for this service Experimental/investigational procedures not covered Cosmetic procedures not covered Services not allowed from this provider specialty Services not allowed at this place of service 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 6

7 WHAT TO DO IF YOU HAVE QUESTIONS Inquiry Locate the Clinical Edit Fax Inquiry form on ProvLink. Complete the form and send all required documentation as indicated on the form to our dedicated inquiry fax line (s). 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. 7

8 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. 8