2017 Coding and Reimbursement Newsletter

Transcription

1 2100 Gateway Centre Bulevard, Suite 310 Mrrisville, NC ASEch.rg 2017 Cding and Reimbursement Newsletter The ASE Cding and Reimbursement Newsletter is a resurce fr cardivascular ultrasund prcedures prvided in the facility and ffice settings. The Newsletter is prvided exclusively t members f ASE Physician Fee Schedule (PFS) Cardivascular Ultrasund Services In General: Medicare payments fr physicians services (including payment fr the interpretatin f cardivascular ultrasund studies (prfessinal cmpnent r PC )) and payment fr physicians ffice verhead, clinical staff, equipment and supplies in nn-facility settings (technical cmpnent r TC )) are determined by the relative value units (RVUs) accrded t each service, multiplied by the natinal cnversin factr, adjusted based n the Gegraphic Practice Cst Indices, and further mdified under varius billing and payment plicies. Relative Value Units (RVU): Fr each prcedure/service represented by a cde, three RVU cmpnents are assigned t accunt fr the relative resurce csts used t prvide a service/prcedure. Physician wrk: Reflects relative levels f physician time/ intensity assciated with furnishing a service Practice expense (PE): Reflects practice csts (e.g., ffice space, supplies and equipment, and staff) Malpractice expense (MP): Represents payment fr the prfessinal liability expenses Cnversin Factr (CF): The CF is a dllar amunt used t cnvert RVUs int a payment amunt. Fr the perid frm January 1, 2017 thrugh December 31, 2017, the CF is $ Gegraphic Practice Cst Indices (GPCI) accunt fr the gegraphic differences in the cst f practice acrss the cuntry. CMS calculates an individual GPCI fr each f the RVU cmpnents. Natinal Average Physician Fee Schedule Payment Amunts: The natinal average Medicare Physician Fee Schedule amunts are the prduct f three factrs: Ttal RVUs x Cnversin Factr (CF) = Natinal Average Payment. See Table 1 fr the natinal average Medicare PFS amunts thrugh December 31, Please nte that the payment amunts prvided n Table 1 are nt gegraphically adjusted. What s New fr 2017: Medicare payment fr the prfessinal and technical cmpnents f mst echcardigraphy services under the Physician Fee Schedule will remain essentially unchanged in 2017, except that the Medicare allwances fr TEE will n lnger include payment fr mderate sedatin, which will be separately billable under new CPT cdes. "CPT cpyright 2015 American Medical Assciatin. All rights reserved. CPT is a registered trademark f the American Medical Assciatin."

2 If yu perfrm mderate sedatin in cnjunctin with the TEE r ther prcedures that yu prvide, use the fllwing new CPT cdes, as applicable: CPT 1 / HCPCS PFS Rate (nnhspital) Descriptin Mderate sedatin services prvided by the same physician r ther qualified health care prfessinal perfrming the diagnstic r therapeutic service that the sedatin supprts, requiring the presence f an independent trained bserver t assist in the mnitring f the patient s level f cnsciusness and physilgical status; initial 15 minutes f intra-service time, patient yunger than 5 years f age $78.23 $ PFS Rate (hspital) Mderate sedatin services prvided by the same physician r ther qualified health care prfessinal perfrming the diagnstic r therapeutic service that the sedatin supprts, requiring the presence f an independent trained bserver t assist in the mnitring f the patient s level f cnsciusness and physilgical status; initial 15 minutes f intraservice time, patient yunger than 5 years f age $52.04 $12.56 Mderate sedatin services prvided by the same physician r ther qualified health care prfessinal perfrming the diagnstic r therapeutic service that the sedatin supprts, requiring the presence f an independent trained bserver t assist in the mnitring f the patient s level f cnsciusness and physilgical status; each additinal 15 minutes f intra- service time (List separately in additin t cde fr primary service) $11.12 NA If an anesthesilgist r a physician ther than the physician perfrming the prcedure prvides the anesthesia, that physician will bill separately using different new CPT cdes. (new CPT cdes 99155, 99156, r 99157, as applicable.) In 2017, a number f payment adjustments may apply t Medicare payment under the Physician Fee Schedule, depending n the physician s (r his r her grup s) perfrmance under Medicare incentive prgrams.

3 In 2017, a penalty f 2% f Medicare PFS allwances may apply if the physician (r grup) failed t meet Medicare s Physician Quality Reprting System requirements in Fr infrmatin n the 2015 PQRS Feedback Reprts and hw t request them, individual EPs and grup practices shuld visit the PQRS Analysis and Payment webpage and access the "2015 PQRS Feedback Reprt User Guide" and the "Quick Reference Guide fr Accessing 2015 PQRS Feedback Reprts". In 2017, a penalty f -2% f Medicare allwances may apply if the physician failed t meet requirements related t Meaningful Use f Electrnic Health Recrds (EHR), during an EHR reprting perid in In CY 2017, Medicare will apply the Value Mdifier t physician payments under the Medicare Physician Fee Schedule fr all physicians, regardless f practice size. Under this prgram, in rder t avid an autmatic negative tw percent (-2.0%) (fr sl physicians and physician grups with between 2 t 9 physicians r ther eligible prfessinals) r negative fur percent (-4.0%) (fr physician grups with 10 r mre eligible prfessinals) adjustment in CY 2017, physicians must have participated satisfactrily in the PQRS in CY Quality-tiering is mandatry fr grups and sl practitiners subject t the Value Mdifier in CY Grups with 10 r mre EPs are subject t upward, neutral, r dwnward adjustment under quality-tiering, and sl practitiners grups with fewer than 10 physicians and eligible prfessinals EPs are subject t nly upward r neutral adjustment in CY will serve as the perfrmance year fr PFS payment adjustments that will be implemented in 2019, under the Medicare Access and CHIP Reauthrizatin Act f 2015 (MACRA). Under MACRA, the payment adjustment that will apply will depend upn whether yu qualify fr the Advanced Alternative Payment Mdel (AAPM) r Merit-based Payment System (MIPS) track. Fr the 2017 perfrmance year, virtually all ASE members likely will fall under the MIPS payment track Under MIPS, Medicare PFS adjustments fr physicians and certain ther clinicians are adjusted up r dwn based n hw they perfrm with respect t fur perfrmance categries: Quality (currently PQRS), Advancing Care Infrmatin (ACI)(currently Meaningful Use f Certified Electrnic Health Recrds (CEHRT)), Clinical Practice Imprvement Activities (CPIA) (new), and Cst (currently Value-Based Mdifier). Hwever, fr the 2017 perfrmance year, special MIPS transitin rules will be in effect. Under these rules: MIPS-eligible clinicians wh fail t reprt int the new system at all will incur a payment reductin in 2019 (based n 2017 perfrmance) (-2%). Clinicians wh reprt ne measure in the quality perfrmance categry OR ne activity in the imprvement activities perfrmance categry; OR reprt the required measures f the advancing care infrmatin perfrmance categry can avid a negative MIPS payment adjustment in Thse wh reprt mre than ne measure fr the full 90 day reprting perid will be eligible fr psitive adjustments.

4 2017 Hspital Outpatient Cardivascular Ultrasund Services Hspitals are paid by Medicare fr utpatient prcedures and services under the Outpatient Prspective Payment System (OPPS), which utilizes the Ambulatry Payment Classificatin (APC) system. Services are reprted with CPT cdes and/r HCPCS cdes; each payable cde is classified int an APC grup. Each APC is assigned a Medicare payment rate that applies t all f the prcedures in the APC. This APC rate is intended t cver all f the hspital resurces invlved in the prvisin f the service (such as equipment, supplies, and staff), with the exceptin f physicians services, which are separately billable and separately payable t Medicare under the Physician Fee Schedule. What s New fr 2017: Fr 2017, CMS restructured the APCs applicable t all imaging studies, including echcardigraphy. Fr the first time, many echcardigraphy prcedures are included in the same APCs as imaging studies that use imaging mdalities such x-ray, CT, and MRI. While Medicare payment fr the mst cmmnly perfrmed echcardigraphy prcedures will remain relatively stable fr 2017 (+8%), the restructured echcardigraphy APCs will result in the fllwing significant changes in the natinal 2017 APC rates, as cmpared with thse in effect in 2016: HOPPS rates fr TEE will be reduced by 36%. HOPPS rates fr cngenital echcardigraphy (CPT 93303) will be reduced by 36%. HOPPS rates fr limited echcardigraphy (CPT 93308) will increase by 47%. HOPPS rates fr cmplete bilateral duplex studies will increase by 47%, but the HOPPS rate fr limited bilateral duplex studies will be reduced by 27%. Hspitals may reprt mderate sedatin cdes (CPT , as applicable) with TEE and ther services when perfrmed in the hspital utpatient setting. Hwever, under HOPPS, mderate sedatin services are cnsidered an integral part f the primary prcedure and are nt separately paid. Special Rules applicable t ff-campus hspital utpatient facilities. The Bipartisan Budget Act f 2015, enacted at the end f 2015, includes a prvisin that will result in a 50% reductin in the HOPPS rates payable fr virtually all services (including echcardigraphy) prvided by new ff campus hspital utpatient facilities (i.e. thse lcated 250 yards r mre frm the main hspital campus r a hspital satellite). Off campus nn-emergency hspital utpatient facilities that that were nt billing Medicare as f the date f enactment f the law (Nvember 2, 2015) will incur the 50% reductin in therwise applicable HOPPS rates, effective January 1, All services (including but limited t cardivascular ultrasund) prvided by these new ff-campus hspital facilities must be billed using mdifier PN.

5 Under this same law, thse ff-campus hspital utpatient facilities that were billing Medicare as f the Nvember 2, 2015 deadline will be subject t a reductin f 50% f their HOPPS rates if they change lcatin r wnership (with certain limited exceptins). Effective January 1, CMS will package services based n hspital claim rather than the date f service. It is anticipated that this change will result in packaging f mre ancillary and ther services and a reductin in the number f services that will be separately payable; hwever, echcardigraphy and mst ther ultrasund services will remain separately payable. BOTH 2017 (PFS) AND 2017 Hspital OPPS Cardivascular Ultrasund Services ICD-10 Diagnsis Cdes went int effect n Octber 1, A crsswalk between ICD-9 and ICD-10 diagnsis cdes is available at: At the request f the ASE, the AMA CPT Panel has apprved tw new Categry III (tracking) CPT add-n cdes, fr mycardial strain imaging (published July 1, 2015, active fr reprting January 1, 2106) and mycardial perfusin cntrast echcardigraphy (published January 1, 2016, active fr reprting July 1, 2016). The cde descriptrs are: CPT +0399T: Mycardial strain imaging (quantitative assessment f mycardial mechanics using image-based analysis f lcal mycardial dynamics) Use 0339T in cnjunctin with 93303, 93304, 93306, 93307, 93308, 93312, 93314, 93315, 93317, 93350, 93351, and (Reprt 0399T nce per sessin) CPT +0439T: Mycardial cntrast perfusin echcardigraphy, at rest r with stress, fr assessment f mycardial ischemia r viability Use +0439T in cnjunctin with CPT cdes 93306, 93307, 93308, 93350, r (Reprt +0439T nce per sessin) Bth f these new cdes are Categry III r tracking cdes. This cde type is used t describe emerging technlgies. While bth Medicare and nn-medicare payers have the discretin t cver Categry III cdes, cverage generally must be sught n a payer by payer basis. ASE has discussed cverage f mycardial strain imaging with bth private payers and Medicare Administrative Cntractrs (MACs) and is seeking limited cverage fr mycardial strain imaging when it is perfrmed t aid in detectin f carditxicity in

6 patients wh are receiving ptentially carditxic chemtherapy r radiatin therapy. ASE has develped a strain cde payer tlkit which is available fr yu t use t seek payment, at ASEch.rg/Advcacy. ASE als plans t wrk with private payers and MACs in 2017 t seek reimbursement fr mycardial cntrast perfusin imaging. Categry III cdes ultimately may be reclassified as Categry I cdes (which are typically cvered by Medicare and private payers) if (1) the Categry III cde demnstrates significant utilizatin in clinical practice and (2) additinal peer-reviewed literature is published which demnstrates the utility f the new service T help btain cverage, ensure that yur ech lab staff and business department are familiar with these new CPT add-n cdes, and submit these cdes when yu perfrm mycardial strain imaging r mycardial perfusin echcardigraphy. This will allw natinal utilizatin tracking, which is a critical first step twards establishing reimbursement fr these services. Multiple Prcedure Payment Reductin: Technical Cmpnent f Diagnstic Cardivascular Prcedures Physician/Office Payments Under the Medicare Physician Fee Schedule, the Multiple Prcedure Payment Reductin (MPPR) n diagnstic cardivascular prcedures applies when multiple services are furnished t the same patient n the same day. The MPPRs apply t technical cmpnent nly (TC) services, and t the TC f glbal services fr thse prcedures assigned a status indicatr f 6. Echcardigraphy and vascular ultrasund prcedures are designated as status indicatr 6 and are subject t this reductin. Full payment is made fr the TC service with the highest payment under the Medicare Physician Fee Schedule. Payment is made at 75% fr subsequent TC services furnished by the same physician (r by multiple physicians in the same grup practice) t the same patient n the same day. The MPPRs d nt apply t echcardigraphy prfessinal cmpnent (PC) services. This Medicare plicy des nt apply t hspital utpatient services. Nte: Sme insurance cmpanies may adpt a similar plicy fr their nn-medicare health plans. Cding Tips Physicians' Services Mdifiers t Reprt Technical and Prfessinal Cmpnents: These mdifiers are used with diagnstic testing cdes (including cardivascular ultrasund. The acquisitin f the image is the technical cmpnent, and the prfessinal cmpnent is the physician interpretatin f the exam.

7 -TC Technical cmpnent: The technical cmpnent prvided in ambulatry settings such as dctrs ffices and IDTFs is reprted by adding mdifier TC t the CPT cde. The TC mdifier is reprted by the entity that nly prvides the technical service. Institutins such as hspitals d nt append the TC mdifier. The use f this mdifier affects payment. -26 Prfessinal Cmpnent: The physician service nly is reprted separately by adding mdifier -26 t the CPT cde. The use f this mdifier affects payment. N mdifier: When bth cmpnents are furnished by ne prvider, Medicare makes a single glbal payment that is equal t the sum f the payment fr the cmpnents. N mdifier is necessary. Nte that sme cdes such as stress test cdes ( ) and stress echcardigraphy cntrast administratin (93352) are designated as glbal cdes and are never reprted with -26 r TC mdifiers. The fllwing cdes may be reprted with these mdifiers: , 93315, 93317, 93318, 93320, 93321, 93325, 93350, and Increased Prcedural Services: This mdifier is used t identify that the wrk required t prvide a service is substantially greater than typically required. Mdifier -22 is nt a hspital-apprved mdifier. The apprpriate use f this mdifier is subject t payer discretin and typically will trigger individual claim review. Specifically, CMS restricts the use f mdifier -22 t nly surgical prcedures that have a glbal perid f 0, 10, r 90 days. Fr Medicare claims, it is inapprpriate t append mdifier -22 t cardivascular ultrasund prcedures. The fllwing mdifiers may be apprpriate fr cardivascular ultrasund cdes, depending upn the circumstances: -51 Multiple Prcedures: When multiple prcedures, ther than E/M services, Physical Medicine and Rehabilitatin services r prvisin f supplies (e.g. vaccines), are perfrmed at the same sessin by the same individual, the primary prcedure r service may be reprted as listed. The additinal prcedure(s) r service(s) may be identified by appending mdifier -51 t the additinal prcedure r service cde(s). Nte: This mdifier shuld nt be appended t designated "add-n" cdes. -52 Reduced Services This mdifier is used t describe a service r prcedure that is partially reduced r eliminated. It is apprved fr physician and hspital use. As an example, this mdifier can be used t reprt an arterial extremity study ( ) n a patient with an abve the knee amputatin, since the prcedure was nt perfrmed in its entirety. -59 Distinct Prcedural Service: This mdifier is used t reprt prcedures that are nt nrmally reprted tgether but are apprpriate under the circumstances. Mdifier -59 is used t clearly designate nn- rutine instances when distinct and separate multiple services are prvided t a patient n a single date f service. It is apprved fr physician and hspital use. Mdifier -59 shuld nly be used if n ther mdifier mre apprpriately describes the relatinships f the tw r mre prcedure cdes. As an example, if a transthracic ech (93306) is dne fr a particular indicatin, and based n the result, a TEE is als perfrmed; the -59 mdifier wuld be appended t the TEE (93312). -77 Repeat Prcedure by Anther Physician: This mdifier defines a repeat prcedure by anther physician during the same patient encunter. It is apprved fr physician and hspital use. As an example, when a TEE prcedure is repeated by anther physician, the secnd exam wuld require use f the -77 mdifier and assumes that the secnd physician was aware this was a repeat prcedure. Fr example, if a different physician acquires

8 additinal images, interprets, and prepares a reprt in additin t the preperative TEE, then (image acquisitin, interp/reprt) r (cngenital image acquisitin, interp/reprt) can be reprted with mdifier -77. This indicates that the additinal image acquisitin and interpretatin was prvided by a different physician. The medical recrd shuld reflect the medical necessity fr repeating these prcedures. Hspital Outpatient Services Even thugh add-n cdes are nt separately paid under the OPPS, make sure that these cdes are reprted when perfrmed, and a separate charge is included n the claim. Please nte that special C cdes (rather than CPT cdes) apply t cntrast-enhanced echcardigraphy prcedures. In additin, the cntrast agent shuld be reprted, alng with a separate cntrast agent charge, using the apprpriate Q cde. *** This newsletter is fr infrmatin purpses nly. N guarantee f payment is stated r implied. It is the respnsibility f the health care prvider t prperly cde and t seek reimbursement fr rendered medically apprpriate and necessary services. CPT Cpyright 2016 American Medical Assciatin. All rights reserved. CPT is a registered trademark f the American Medical Assciatin. Applicable FARS/DFARS Restrictins Apply t Gvernment Use. Fee schedules, relative value units, cnversin factrs and/r related cmpnents are nt assigned by the AMA, are nt part f CPT, and the AMA is nt recmmending their use. The AMA des nt directly r indirectly practice medicine r dispense medical services. The AMA assumes n liability fr data cntained r nt cntained herein Physician Fee Schedule and HOPPS Rates fr Ech CPT1/ Md Descriptin 2016 PFS rate 2017 PFS Diff $ Diff % 2016 APC 2017 APC Diff $ Diff % HCPCS rate Ech transthracic $ $ $ (0.88) 0% TC Ech transthracic $ $ $ (1.03) -1% $ $ ($248.97) -36% Ech transthracic $ $ $ % Ech transthracic $ $ $ % TC Ech transthracic $ $ $ (0.08) 0% $ $ $ % Ech transthracic $ $ $ % TTE w/dppler cmplete $ $ $ % TC TTE w/dppler cmplete $ $ $ % $ $ $ % TTE w/dppler cmplete $ $ $ % TTE w/ dppler cmplete $ $ $ (0.05) 0%

9 93307 TC TTE w/ dppler cmplete $ $ $ (0.16) 0% $ $ $ % TTE w/ dppler cmplete $ $ $ % TTE f-up r lmtd $ $ $ % TC TTE f-up r lmtd $ $ $ % $ $ $ % TTE f-up r lmtd $ $ $ % Ech transesphageal $ $ $(59.58) -19% TC Ech transesphageal $ $ $(48.02) -26% $ $ ($ ) -36% Ech transesphageal $ $ $(11.56) -9% Ech transesphageal $ $ $(11.07) -48% $ $ ($ ) -36% Ech transesphageal $ $ $(63.18) -21% TC Ech transesphageal $ $ $(50.86) -26% n/a n/a Ech transesphageal $ $ $(12.32) -12% Ech transesphageal $ - $ - $ TC Ech transesphageal $ - $ - $ - $ $ ($ ) -36% Ech transesphageal $ $ $(12.23) -8% Ech transesphageal $ $ $(11.39) -29% Ech transesphageal $ - $ - $ TC Ech transesphageal $ - $ - $ Ech transesphageal $ $ $(12.31) -11% Ech transesphageal intrap $ - $ - $ TC Ech transesphageal intrap $ - $ - $ - $ $ ($ ) -36% Ech transesphageal intrap $ $ $(11.21) -9% Dppler ech exam heart $ $ $ % TC Dppler ech exam heart $ $ $ % n/a n/a n/a Dppler ech exam heart $ $ $ % Dppler ech exam heart $ $ $ % TC Dppler ech exam heart $ $ $ % n/a n/a n/a Dppler ech exam heart $ 7.52 $ 7.54 $ % Dppler clr flw add-n $ $ $ % TC Dppler clr flw add-n $ $ $ % n/a n/a n/a

10 Dppler clr flw add-n $ 3.22 $ 3.23 $ % Stress TTE nly $ $ $ % TC Stress TTE nly $ $ $ % $ $ $ % Stress TTE nly $ $ $ % Stress TTE cmplete $ $ $ % TC Stress TTE cmplete $ $ $ % $ $ $ % Stress TTE cmplete $ $ $ % Admin ECG cntrast agent $ $ $ % Ech transesphageal (TEE) $ $ $ % n/a n/a n/a Cntrast Ech APC rates, HCPCS Cde Shrt Descriptr APC Payment Rate 2016 APC Payment Rate 2017 Diff $ % Diff C8921 TTE w r w/ fl w/cnt, cm $ $ $ % C8922 TTE w r w/ fl w/cnt, f/u $ $ $ % C8923 2D TTE w r w/ fl w/cn,c $ $ $ % C8924 2D TTE w r w/ fl w/cn,fu $ $ $ % C8925 2D TEE w r w/ fl w/cn,in $ $ $ % C8926 TEE w r w/ fl w/cnt,cng $ $ $ % C8927 TEE w r w/ fl w/cnt, mn* $ $ $ % C8928 TTE w r w/ fl w/cn,stres $ $ $ % C8929 TTE w r w fl wcn,dppler $ $ $ % C8930 TTE w r w/ cntr, cnt ECG $ $ $ %

11 CPT 1 / HCPCS Md Descriptin 2016 PFS $ 2017 PFS $ Diff $ % Diff Duplex Studies HOPPS Rate 2016 HOPPS Rate 2017 $ Diff % Diff Extracranial bilat study $ $ $ % TC Extracranial bilat study $ $ $ % $ $ $ % Extracranial bilat study $ $ $ % Extracranial uni/ltd study Extracranial uni/ltd TC study Extracranial uni/ltd 26 study $ $ $ (0.41) 0% $ $ $ (0.47) 0% $ $ $ % $ $ $ %