Monthly Newsletter for the Informed Healthcare Professional
November 2013
Issue 10, Volume 4
The Medical Business Journal Brought to you by the Medical Management Institute mmiclasses.com • 866.892.2765
mmi•updates “Day of Thanks” - SAVE THE DATE!
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MMI News Updates CMS News Updates “Day of Thanks” Student of the Month 2014 CPT® Changes • AMA Announcement • Evaluation & Management • Beyond Evaluation & Management • Overview of GI Changes
To show our gratitude, MMI will be offering the Coder, Biller, and Manager online ICD-10 training & certification at a 30% discount (this is a savings of over $600)! This amazing “Day of Thanks” promotion will take place on November 19th (Tuesday). However, it will ONLY be taking place on this date...so save the date! 2014 Books Are Available Stock up on the 2014 coding books in advance for great savings. The ICD-10-CM Draft Set is $99.95, 3 pack bundle deals (CPT®, ICD-9, HCPCS II) are $279, and 2 pack bundle deals are only $199. Click here for details on pricing and how to order or call 866-892-2765.
Exclusive MBJ Discount
Exclusive MBJ Discount Do you need CEUs? We would like to offer our MBJ readers an exclusive 25% discount on the Fall CEU Bundle! The Fall Bundle is worth 12 AAPC/ MMI CEUs and covers the following topics: ICD-10 Documentation, RAC Audits, Compliant Incident-to Billing, PPACA (Obamacare) Insurance Changes, and Conducting a Baseline Audit.
Billable & Non-Billable Codes
To take advantage of the exclusive discount click here and use promo code MBJFall at the checkout page.
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Spotlight on Modifier 57 2014 Book Deals
Pay for a Nurse Visit? PPACA: Truth or Myth? HIPAA Compliance Courses November Crossword Puzzle
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The MMI Team is grateful for the pleasure of serving you and meeting your coding, auditing & management training and certification needs.
• LinkedIn (Members Only) • Facebook.com/MMIFan • Twitter.com/MMIclasses We look forward to going social with you!
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cms•updates Direct Resource: www.cms.gov M A J O R S AV I N G S F O R M E D I C A R E BENEFICIARIES
October 28, 2013 - The Centers for Medicare & Medicaid Services (CMS) said that health care reform efforts are eliciting significant out-ofpocket savings for Medicare beneficiaries, pointing to zero growth in 2014 Medicare Part B premiums and deductibles, and more than $8 billion in cumulative savings in the prescription drug coverage gap known as the “donut hole.” According to CMS, since the Affordable Care Act provision to close the prescription drug donut hole took effect, more than 7.1 million seniors and people with disabilities who reached the donut hole have saved $8.3 billion on their prescription drugs. In the first nine months of 2013 nearly 2.8 million people nationwide who reached the donut hole this year have saved $2.3 billion, an average of $834 per beneficiary. These figures are higher than at this point last year (2.3 million beneficiaries had saved $1.5 billion for an average of $657 per beneficiary). The health care law gave those who reached the donut hole in 2010 a one-time $250 check, then began phasing in discounts and coverage for brand-name and generic prescription drugs beginning in 2011. The Affordable Care Act will provide additional savings each year until the coverage gap is closed in 2020. MEDICARE OPEN ENROLLMENT BEGAN ON OCTOBER 15TH
October 15, 2013 - The Centers for Medicare & Medicaid Services (CMS) announced the start of the Medicare Open Enrollment, which began on October 15th and ends December 7th. CMS encourages people with Medicare to review their current health and prescription drug coverage
options for 2014. Medicare’s Open Enrollment is not part of the Affordable Care Act’s new Health Insurance Marketplace, and people with Medicare do not need to do anything with Marketplace plans. “Thanks to the Affordable Care Act, Medicare remains strong with more benefits, better choices, and lower costs to beneficiaries,” said CMS Administrator Marilyn Tavenner. “Seniors and people with disabilities have the opportunity to find and compare the best plan for them.” View a brief video on Medicare Open Enrollment. MARKETPLACE OPENS
October 1, 2013 - For the first time ever, all Americans could begin shopping for quality health coverage that is affordable, and not be denied or charged more because they have a preexisting condition. The Health Insurance Marketplace is a new, simpler way for uninsured Americans and their families to purchase health insurance in one place. Coverage begins as early as January 1, 2014 for people enrolling by December 15, 2013. Today also marks the kick-off of outreach and enrollment activities in communities nationwide. Enrollment events will take place in a variety of local settings including public libraries, churches, festivals, sports events, and community meetings. “For years, the financial, physical or mental health of millions of Americans suffered because they couldn’t afford the care they or their family needed,” said U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius. “But thanks to the health care law, all of that is changing. Today’s launch begins a new day when health care coverage will be more accessible and affordable than ever before.”
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“DAY OF THANKS”
NOVEMBER 19TH Dear Valued MMI Members & Alumni, The MMI Team is grateful for the pleasure of serving you and meeting your coding, auditing, & management training and certification needs.
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In this time of gratitude we have put together a “Day of Thanks” this month on Tuesday, November 19th, where we will be offering you our online ICD-10 training at a 30% discount (savings of over $600)! We are bringing back this promotion from last month due to the overwhelming results of our online survey (results shown to the left in the pie chart). Save the date: Tuesday, November 19th.
ICD-10 Billing & Coding Management & Auditing Other
The 30% discount for “Day of Thanks” will be applicable to the Coder, Manager, and/or Biller path for ICD-10. The discount will be valid towards group enrollments as well as the add-on Anatomy & Terminology pre-requisite course. To receive reminders & more information on our promotions click here to join the MMI Email List. Thank you again for your continued support, & save the date!
-The MMI Team
Student of the Month Julie Phipps, RMC & Member Since 2006 MMI will be interviewing a valued member each month for a new feature in the MBJ called ‘Student of the Month’, and our second spotlight is on Julie Phipps!
MMI: Where do you currently work,
and what is your position? JP: SouthEast Alaska Regional Health Consortium (SEARHC) aka Mt. Edgecumbe Hospital. Coding Supervisor since January 2013 in Sitka, Alaska. We have several satellite clinics throughout Southeast Alaska.
MMI: What made you choose the Registered
Medical Coder (RMC) certification through the Medical Management Institute and how has it played a part in your career/education? JP: Sitka is an island in Southeast Alaska, so it is expensive to travel to a location for other certifications that you have to take a test at a test site. ARHCP [MMI] offers the test online, which was a lifesaver for me.
MMI: In your opinion, what makes the RMC stand
out among other coding credentials? JP: Like in real life, you are able to use any references you need (books, internet) where as with other credentials the tests are limited to certain books. We are also able to take tests online, which is unique. Even taking the test online with any references, I found the tests challenging.
MMI: As you know, the ICD-10 implementation date
is slowly creeping up...how do you feel about this major transition, and do you feel prepared? JP: I/We are definitely not prepared. We have had some webinars, and are ready to jump into formal training soon.
pulling charts and filing paperwork when a position came open for a medical transcriptionist. I had never done anything like this, but the supervisor gave me a shot, and that is what I did for 12 years. I moved to the lower 48 (what us Alaskans call the mainland) and it was much more difficult to find a job. I worked for a remote transcription company for a few years, then moved back to Sitka. I felt that working at home was too isolated so I took a job at SEARHC again as an intermittent transcriptionist. A data entry tech position opened up, and I decided to try that, which was data entering ICD-9 and CPT codes (after it had been coded) to our health record database. I thought data entry was not challenging enough for me, but it was a stepping stone into coding. An opening for a coding position became available, and once again I was given the chance to advance, and now I am the coding supervisor of 4 in-house coders plus an additional 17 remote coders.
MMI: What advice do you have for those trying to break into the medical coding industry? JP: Learn as many specialties as you can, the more you can code, the better. Keep your skills honed. A good coder is definitely worth their weight in gold.
MMI: Do you have anything else to add? JP: If anyone is thinking of becoming a coder, I would highly recommend it. It is always interesting and challenging, and the possibilities are endless as far as specialties go.
MMI: When you aren’t working, what do you like to do in your free time? JP: Beading, reading, Hello Kitty, and I am addicted to the MMORPG World of Warcraft.
MMI: Something we hear a lot as student service
representatives is, “I have the education and certification, but I can’t seem to land a coding job.” How did you first begin your career in the medical field; specifically medical coding? JP: Sitka is a small community, so that made it easier. I started in the medical records department
Would you like to be considered for a Student of the Month feature? Let us know! Email Carleigh Benscoter at c.benscoter@mmiclasses.com, or call 866-892-2765 x 240.
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AMA Announces CPT® Changes for 2014 2014 CPT® Changes | Kathy Dyson
There are 335 CPT code changes in the 2014 CPT code set. These updates were made to reflect the latest technological advances in medical, surgical and diagnostic services. The codes are available for use on or after January 1, 2014. Understanding the new codes is crucial to obtaining the proper reimbursement for your services and will be the basis for the MMI Annual Update exam. This edition of the newsletter addresses several of the important changes. Changes include 175 new codes, 107 revised codes and 53 deleted codes. There are also changes in the guidelines. In the CPT 2014 manual, Appendix B contains a summary of all Additions, Deletions, and Revisions.
for lower gastrointestinal services can be expected for CPT 2015.
Most of the 335 changes will be found in these subsections: Digestive system, molecular pathology, cardiovascular system and Evaluation and Management.
In the article “CPT®2014 Overview of GI Changes”, (page 15 of this issue) you will find the AMA’s grid of new codes, released earlier this year, to assist in transitioning to the new codes. In diagnostics, the scope of the molecular pathology services codes have also been substantially broadened with the addition of 316 molecular tests for detection of genes, somatic disorders and germlines to the nine molecular pathology resource based Tier II codes.
Nearly one-quarter of this year’s CPT code changes resulted from an ongoing two-year effort to revise gastroenterology codes to capture significant advances in endoscopic technology, devices and techniques. In recent years, miniaturization, powerful optical magnification and new imaging technologies have led to a wide variety of new applications for minimally invasive upper gastrointestinal endoscopic surgical procedures and improved diagnostic capabilities. Coding changes
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“The newest edition of the CPT code set better captures the work involved with sophisticated endoscopic procedures now available to examine the upper gastrointestinal tract and advance the early detection of cancer and digestive disorders,” said Dr. Hoven. “Broad input from practicing physicians, medical specialty societies and the greater health care community produced the practical enhancements that CPT needs to reflect the coding demands of the modern health care system.”
Additional CPT enhancements for 2014 due to advancements in technology include new and revised codes for breast biopsies and imaging, multi-system image guided catheter drainage; cardiology and vascular embolization procedures.
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Evaluation & Management 2014 CPTÂŽ Changes | Kathy Dyson
Interprofessional Consultations Consultation codes, while not paid by Medicare and many other payers these days, are still in the E&M section of the CPT 2014 manual. The E&M changes for 2014 include new codes for physicians contacted by other physicians or health care professionals for an expert opinion on the management or treatment of a patient who is under the requesting individual's personal care but not currently receiving direct care from the consulting physician. The term being used for these types of communication is interprofessional consultations. These consultations do not involve face-to-face or telephone time with patients Codes 99446–99449 are interprofessional telephone/Internet assessment and management services provided by a consultative physician. A consultative physician is not the attending or treating physician for the patient. The session must be documented in the patient record and a written report to the patient’s treating or attending physician must be submitted. The codes are reported based on the consultant's time spent providing the interprofessional consultation. At least 50% of the time must be spent in direct communication with the physician and the remainder of the time spent on the review of labs, etc. and the written report and documentation. For consults less than 5 minutes, no code is billable. This
code may only be billed one time during a 7 day interval for the patient, regardless of the number of calls or contacts with the requesting physician.
These codes are useful for consultation through a local physician when circumstances such as distance from the consultant or nature of a problem may make a timely face-to-face patient encounter with the consultant impracticable. Patients may be new or established to the consulting physician. Any face-to-face contact within 14 days of the consult (before or after the date) means that you cannot bill the interprofessional consultation. When billing for the interprofessional consultation, the consulting physician uses the Place of Service that the requesting physician is using for their faceto-face service. Do not use these interprofessional telephone/ Internet codes if a transfer of care is the purpose of the consultation or if the consultation results in a transfer of care or a face-to-face appointment within
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14 days or at the consultant's next available appointment. Until the Physician Fee Schedule is released, we will not know if these codes are reimbursed by Medicare or other payers. Early speculation is that Medicare will not pay for them, as they are ‘consultation’ codes and they quit paying the other consultation codes in 2010.
Example from AAP Coding Newsletter A patient is seen in the office of his primary care pediatrician (PCP) for reading of a tuberculosis (TB) skin test after exposure to a classmate confirmed to have TB. The nursing staff read the test as positive and consult the PCP. The PCP examines the patient, confirms that the skin test is positive, and reviews the child's history of adoption from China and immunization record indicating bacille CalmetteGuérin vaccine after birth. The PCP calls the local hospital pediatric infectious disease specialist for advice on whether or not additional testing is indicated to confirm diagnosis of latent TB and what treatment regimen should be used. The PCP relates the current problem. The specialist asks for additional history, including prior TB test results, the measurement of induration from the current test, and general health history. The specialist recommends obtaining a chest x-ray and provides a treatment plan if the chest x-ray is positive and an alternative plan if it is negative. The specialist's total time spent in discussing the case and providing a recommendation is 10 As with all consultations, the request for advice or opinion should be documented in the patient record. Verbal and written opinion reports from the consultant must be documented. The physician requesting the interprofessional consultation may report prolonged services for the time spent communicating with the consultant if the total time of the encounter exceeds 30 minutes beyond the typical time of the associated E/M service. Prolonged service codes 99354–99357 may be reported when the patient is present and accessible to the requesting physician during the time of service. Prolonged services without the patient present are reported with codes 99358– 99359.
Total Body Systemic or Selective Head Hypothermia The previously reported Category III CPT® codes 0260T and 0261T, for total body or selective head hypothermia, have been deleted and replaced with Category I CPT codes. The new codes are: 99481 – Total body systemic hypothermia in a critically ill neonate per day 99482 – Selective head hypothermia in a critically ill neonate per day
Both of these codes are add-on codes, reported only when performed in conjunction with a primary service. Primary services for these codes include hourly critical care, 99291–99292, and neonatal critical care, 99468–99469. Codes 99481– 99482 are reported only once per day for all hypothermia services provided on that date. When reporting hourly critical care services, it will be necessary to distinguish the time spent in critical care services from that spent initiating and managing hypothermia. During either cooling approach, monitoring includes radiographic confirmation of core temperature probe, assessment of continuous amplitude electroencephalogram monitoring, and laboratory evaluations required to monitor for cooling-specific complications, including metabolic and coagulation alterations.
Clarification: Pediatric Critical Care Transport To clarify the reporting of time by the control physician for supervision of inter-facility transport care, the following instruction has been added to the prefatory text for pediatric critical care patient transport codes: Code 99485 is used to report the first 30 minutes of non-face-to-face supervision of an interfacility transport of a critically ill or critically injured pediatric patient and should be reported only once per date of service. Only the communication time spent by the supervising physician with the specialty transport team members during an interfacility transport should be reported. Code 99486 is used to report each additional 30 minutes beyond the initial 30 minutes. Non-face-to-face interfacility transport of 15 minutes or less is not reported. As indicated in the errata for CPT 2013, the critical care transport prefatory language has also been revised to reinsert the list of services included when performed during pediatric critical care transport. The following services are included when performed during the pediatric patient transport by the physician providing critical care and may not be reported separately: routine monitoring evaluations (eg, heart rate, respiratory rate, blood pressure, and pulse oximetry), the interpretation of cardiac output measurements (93562), chest X-rays (71010, 71015, 71020), pulse oximetry (94760, 94761, 94762), blood gases and information data stored in computers (eg, ECGs, blood pressures, hematologic data) (99090), gastric intubation (43752, 43753), temporary transcutaneous pacing (92953), ventilatory management (94002, 94003, 94660, 94662) and vascular access procedures (36000, 36400, 36405, 36406, 36415, 36591, 36600). Any services performed which are not listed above should be reported separately. Services provided by
the specialized transport team are not reported by the control physician.
Revisions: Complex Chronic Care Coordination Codes 99487–99489 were added to CPT in 2013 for reporting complex chronic care coordination. The guidelines provided in the prefatory language for these codes are revised for 2014. Significant revisions include expanded description of the typical service, patient selection methods, typical patient descriptions, definition of a care plan, and required abilities of practices that report complex chronic care coordination. For the full text of the revisions, please see the CPT®2014 manual. These services typically involve clinical staff developing, substantially revising, and implementing a care plan under directioned by of the physician or other qualified health care professional. Substantial revision to a care plan typically occurs when the patient's clinical condition changes sufficiently (eg, identification of a new problem requiring additional interventions, introduction of new interventions because existing interventions are deemed ineffective, exacerbation of an existing problem requiring new interventions) to require more intensive staff monitoring, changes in the treatment regimen, and additional time to educate the patient and/or caregiver about the patient's condition and/or change in treatment plan and prognosis. Providers may not report care coordination services if the care plan is unchanged or requires minimal change (eg, only a medication is changed or an adjustment in a treatment modality is ordered). Patients who require complex chronic care coordination services may be identified by practicespecific or other published algorithms that recognize multiple illnesses, multiple medication use, inability to perform activities of daily living, requirement for a caregiver and/or utilize reported conditions and services (eg, predictive modeling risk score or repeat admissions or emergency department use) or by clinical judgment. visits. Typical pediatric patients receive three or more therapeutic interventions (eg, medications, nutritional support, respiratory therapy) and have two or more chronic continuous or episodic health conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/ decompensation or functional decline. A care plan is based on a physical, mental, cognitive, social, functional, and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health problems. It typically includes, but is not
limited to, the following elements: problem list, expected outcome and prognosis, measurable treatment goals, symptom management, planned interventions, medication management, community/social services ordered, how the services of agencies and specialists unconnected to the practice will be directed/coordinated, identify the individuals responsible for each intervention, requirements for periodic review and, when applicable, revision of the care plan. The care coordination office/practice must have the following capabilities: • Provide 24/7 access to care providers or clinical staff; use a standardized methodology to identify patients who require chronic complex care coordination services; have an internal care coordination process/function whereby a patient identified as meeting the requirements for these services starts receiving them in a timely manner; use a form and format in the medical record that is standardized within the practice; • Be able to engage and educate patients and caregivers as well as coordinate care among all service providers, as appropriate for each patient.
Clarification: Transitional Care Management Services Revised prefatory text for transitional care management (TCM) services includes the following instructions: Codes 99495 and 99496 are used to report transitional care management (TCM) services. These services are for an a new or established patient. . . TCM requires a face-to-face visit, initial patient contact, and medication reconciliation within specified time frames. The first face-to-face visit is part of the TCM service and not reported separately. Additional E/M services provided on subsequent dates after the first face-to-face visit may be reported separately. The same individual may report hospital or observation discharge services and TCM. However, the discharge service may not constitute the required face-to-face visit. The same individual should not report TCM services provided in the postoperative period of a service that the individual reported. These changes align CPT instructions to the guidance issued for reporting TCM services to Medicare patients. By including new patients, an opportunity is presented for patients without a medical home to be appropriately referred by the discharging physician to a community physician to establish a continuing relationship through TCM services.
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Beyond Evaluation & Management 2014 CPT® Changes | Kathy Dyson Other changes to the Current Procedural Terminology (CPT®) effective January 1, 2014, were also made. This article will highlight and briefly describe some of these changes, such as revision of the code for removal of impacted cerumen and a new code for percutaneous transcatheter closure of patent ductus arteriosus. Please see the CPT 2014 manual for complete information on changes to the surgical and medicine sections. More information on changes will be included in the December, 2013 edition of the MBJ.
comprehensive visual evoked potential testing. It is used to report testing with an automated screening device that includes an algorithm with a pass/fail result. It was effective on July 1, 2013.Continue to use 95930 to report a more comprehensive visual evoked potential testing of the central nervous system with physician interpretation.
Integumentary System Change for Draining by Catheter
This CPT Category III code (new or emerging technology) was added for reporting unilateral or bilateral quantitative pupillometry. This service involves use of a handheld pupillometer to measure the reactivity of the pupils with physician or other qualified health care professional interpretation and report.
10030 – Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous This is a new CPT code when draining fluid using catheterization. Report this code for each individual collection drained with a separate catheter.
Digestive System Change for Draining by Catheter 49405 - Image-guided fluid collection drainage by catheter [e.g., abscess, hematoma, seroma, lymphocele, cyst]; visceral [e.g., kidney, liver, spleen, lung/mediastinum], percutaneous) 49406 - … peritoneal or retroperitoneal, percutaneous 49407 - … peritoneal or retroperitoneal, transvaginal or transrectal These new CPT codes when draining fluid from the visceral, but includes using image-guidance.
Automated Visual Evoked Potential 0333T - Visual evoked potential, screening of visual acuity, automated
This is a new Category III code (new or emerging technology) to differentiate between limited and
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Pupillometry 0341T - Quantitative pupillometry with interpretation and report, unilateral or bilateral
Removal of Impacted Cerumen 69210 – Removal impacted cerumen (separate procedure) requiring instrumentation, 1 or both earsunilateral
A revision to code 69210 makes this code specific to a unilateral procedure with instructions to append modifier 50 when performed bilaterally. The code descriptor no longer includes "one or both ears" and specifies that the code is reported for removal of impacted cerumen using instrumentation. A parenthetic instruction advises to report removal of cerumen that is not impacted or does not require instrumentation with an appropriate evaluation and management (E/M) code.
Examples of Reporting Services Provided in 2014 A physician uses an otoscope and wax curettes to remove impacted cerumen from a patient's left ear: Code 69210 is reported. A physician uses an otoscope and wax curettes to remove impacted cerumen from both ears: Modifier 50 (bilateral procedure) is appended to cerumen removal code (69210 50).
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A medical assistant uses lavage to remove impacted cerumen: If provided on the same date as a physician's E/M service, only the appropriate-level E/M service is reported. If provided on a date when no physician service is provided, an E/M service not requiring the presence of a physician or other qualified health care professional (99211) may be reported (subject to payer rules for incidental services such as provision in continuation of the physician's plan of care and under direct physician supervision).
Quadrivalent Influenza Vaccine 90685 – Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use 90688 – Influenza virus vaccine, quadrivalent, split virus, when administered to 3 years of age and older, for intramuscular use These codes were posted to the American Medical Association (AMA) CPT Category I vaccine codes Web site in the summer of 2013, without a qualifier of pending FDA approval, as they were approved.
Fetal Evaluation Codes for OB/GYN This CPT code will primarily be used by Ob-Gyns when they test the plasma of pregnant women to screen for fetal aneuploidy. This is a noninvasive prenatal testing that uses cell free fetal DNA. 81507 - (Fetal aneuploidy [trisomy 21, 18, and 13] DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy).
Evaluation of Speech, Language, and Hearing Code 92506 - Evaluation of speech, language, voice, communication, and/or auditory processing has been deleted for 2014. New codes 92521–92524 delineate services for evaluation of speech production, receptive language, and expressive language abilities through observation and assessment of performance. These codes are not reported in conjunction with evaluation of central auditory function (92620–92621).
Percutaneous Transcatheter Closure of Patent Ductus Arteriosus 93582 – Percutaneous transcatheter closure of paten ductus arteriosus. This is a new code used to report only percutaneous transcatheter closure of patent ductus arteriosus. The code includes congenital right and left heart catheterization for congenital cardiac anomalies, catheter placement in the aorta, and aortic arch angiography are also included when performed. This new code includes moderate sedation. Repairs of patent ductus arteriosus by ligation or division are still reported with codes 33820, 33822, or 33824. Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (93462) is separately reportable, as are injection procedures reported with codes 93563–93566 and 93568. For intracardiac echocardiographic services performed at the time of transcatheter patent ductus arteriosus closure, report code 93662.
Anogenital Examination 99170 – Anogenital examining, , with colposcopic magnificationmagnified, in childhood for suspected trauma, including image recording when performed
Code 99170 is revised for 2014 to more appropriately describe the procedure as well as including the capture of digital imaging for legal recording/documentation. Use 99143-99150 to report sedation, if used, as it is not included in this code.
Diagnostic Radiology 72040 - Radiologic examination, spine, cervical; 2 or 3 views
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This code for cervical spine x-rays has been revised this year, further clarifying CPT code assignment based on the number of views only.
Radiation Therapy 77295 - 3-dimensional radiotherapy plan, including dose-volume histograms The existing code for 3D radiation therapy simulation has been revised to include the dosimetry.
Vascular Interventional Radiology CPT 2014 is following the ongoing trend in interventional radiology with the creation of comprehensive codes that include all radiologic supervision & interpretation.
Transcatheter Embolization Embolization codes have undergone significant changes in 2014. Four new codes replace existing embolization codes of 37210 (uterine fibroid embolization) and the non-CNS, non-head embolization code, 37204. It is important to note that the existing embolization codes for CNS (61624) and intracranial (61626) embolization are still active. Because the new codes do not make a distinction based on CNS or intracranial, this may lead to some confusion in the proper code selection. Advocate will be at the forefront of these discussions.
Transcatheter Stent Placement The existing stent placement codes 37205-37208 and 75960 have been replaced by 4 new codes. These comprehensive codes include all radiologic supervision and interpretation, any associated angioplasty, and no longer have a designation based on open or percutaneous approach. These codes are not to be used in areas of the body where other more specific codes currently exist (lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary). 37236 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery 37237 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure) 37238 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein 37239 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure)
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The major distinction in the new codes is the reason for embolization (e.g., AVMs, varices, hemorrhage, tumor, ischemia, infarct, etc.). These codes also are defined by arterial or venous and once again include all radiological supervision and interpretation required to perform the procedure. 37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) 37242 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) 37243 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction
37244 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation
Non-Vascular Interventional Radiology Breast Procedures Percutaneous breast procedures will see many changes in 2014. Nine new comprehensive codes have replaced the existing biopsy (19102/19103), clip (19295), and localization (19290/19291) procedure codes. Procedure codes will now include any procedures commonly performed at the time of biopsy (clip placement, specimen radiograph, etc.) Codes are based on the type of radiologic guidance, which is now included in the code, and also based on the number of lesions treated. Other percutaneous breast procedures such as preoperative needle/wire localization, clip placement, and radiotherapy can be coded when done as a stand-alone procedure and not in conjunction with a biopsy. 19081 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance 19082 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) 19083 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance 19084 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure) 19085 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when
performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance 19086 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure) 19281 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance 19282 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including mammographic guidance (List separately in addition to code for primary procedure) 19283 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance 19284 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) 19285 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance 19286 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure) 19287 Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including magnetic resonance guidance 19288 Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)
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Abscess Drainage Four new abscess drainage codes have been created in CPT 2014 which replace all existing site specific abscess drainage codes. The new codes include radiologic guidance. Three codes are percutaneous and are based on body site-soft tissue, visceral, and peritoneal/retroperitoneal; the other code is for peritoneal/retroperitoneal abscess drainage via a transvaginal or transrectal approach. 10030 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, soft tissue (eg, extremity, abdominal wall, neck), percutaneous 49405Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous 49406 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous 49407 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal
Vascular Surgery Eight new codes were granted for endovascular repair of visceral abdominal aorta. These procedures were previously assigned Category III* codes 0078T-0081T. 34841 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) 34842 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 34843 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target
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zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 34844 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 34845 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) 34846 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 34847 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 34848 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]).
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CPT® Overview of GI Changes Excerpt fromOverview the American Medical Association CPT® 2014 of GI Changes The following table is a listing of the new, revised, and deleted codes in the Esophagus/Endoscopy section effective January 1, 2014. The table lists the CPT® code, a brief description of the included services for each code and other notable changes. Detailed information regarding these codes such as full descriptors, guidelines, parenthetical notes, rationales and clinical examples can be found in CPT Changes 2014: An Insider’s View. This important resource provides a complete review of all 2014 CPT code additions, deletions and revisions that impact various clinical areas including the Cardiovascular System, Molecular Pathology, Complex Chronic Care Coordination Services, Transitional Care Management Services and Appendix C. You may learn more by visiting amastore.com.
Key to symbols used: Revised Code
●
New Code
Add On Code
Moderate Sedation
#
Out of Numerical Sequence Code
Change Type New
CPT Code
●43191
Procedure(s) • • •
New
New
New
New
●43192
●43193
●43194
●43195
rigid transoral esophagoscopy diagnostic brushing washing
Change Detail For flexible, use 43200 For transnasal, use 43197
•
rigid transoral esophagoscopy
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submucosal injection(s)
•
rigid transoral esophagoscopy
For flexible, use 43202
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biopsy
For transnasal, use 43198
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rigid transoral esophagoscopy
For flexible, use 43215
•
foreign body removal
•
rigid transoral esophagoscopy
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balloon dilation
For flexible, use 43201
For flexible, use 43220
Click here to download the entire overview from the AMA.
Copyright 2013, American Medical Association, All rights reserved. CPT is a registered trademark of the American Medical Association
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SPOTLIGHT ON MODIFIER 57 Modifier of the Month | Monthly Feature
Each month in the MBJ, we will feature a modifier and discuss the appropriate use. So far we have reviewed Modifiers 24, 25, & 26, so this month we will take a look at Modifier 57. First let’s look at the definition and use.
Modifier 57 Decision for Surgery is only used on the Evaluation & Management [E&M] procedure codes (CPT). It is used when the E&M is done on the previous or same day as a major surgery. Normal pre and post-operative services on the day before surgery, the day after surgery and during the global period are typically included in the surgical CPT code. Major surgeries are typically defined as surgeries having a 90 day global period. Remember that the global period and definition of major surgeries can vary by insurance payer, so know your insurance policies. E&M codes include 99212-99499 and 92002-92014, E&M Ophthalmology Services.
Use of Modifier 57 The modifier 57 should not be used if the visit is for a preoperative evaluation. The
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documentation must clearly indicate that an E&M service was performed and the INITIAL decision for surgery was made as a result of the exam and medical decision making. E&M’s on the day before or day of surgery will typically be paid if the modifier 57 is appended to the E&M code on the claim. This does not apply to facility charges.
Billing The decision to perform any type of surgery does not automatically qualify billing an E&M service. Medicare is clear that it must be medically necessary to do an E&M service and documented by the physician or QHCP as such in the medical record. For example, the initial consultation or evaluation of the problem by the surgeon to determine the need for surgery can justify the E&M for major surgery. When an E&M service resulting in the initial decision to perform major surgery is furnished during the post-operative period of another
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SPOTLIGHT ON MODIFIER 57
services do not have to be billed on the same claim. The E&M would be coded with the modifier 57 appended.
Why can’t I use modifier 25 on the E&M? Some payer’s may prefer the use of modifier 25 to indicate a separate and distinct E&M service was delivered on the same day as a procedure. Medicare specifies that if it is a minor surgery[less than 90 days post operative period] performed the same day, that modifier 25 is the appropriate code. Modifier 57 should only be used on major surgery cases. The E&M service must be provided by the same physician, either the day before or the day of a major surgery (modifier 57) and on the day of a minor procedure(modifier 25). unrelated procedure, then the E&M service must be billed with both the 24 and 57 modifiers.
Do not use Modifier 57 on: • A surgical procedure code; • An E&M procedure code performed the same day as a minor surgery. When the decision to perform a minor procedure is done immediately before the service, it is considered a routine preoperative service and not billable in addition to the procedure; • The day of surgery for a preplanned or prescheduled surgery; or • The day of surgery if the surgical procedure indicates performance in multiple sessions or stages.
Example The patient's attending physician refers them for complaints of abdominal pain. After an examination, the physician decides the patient needs an appendectomy later that day. These two
Example This example, from Dirk Elston, in the article “When do I use the 57 modifier instead of the 25 modifier?” presents an excellent case for using modifier 57 and has an interesting twist: You see an established Medicare patient for a new lesion on the nasal tip. You perform an appropriate history and physical examination and upon discussion with the patient explaining the procedure, the decision is made to perform Mohs micrographic surgery with closure by means of an adjacent tissue transfer. Mohs has a zero-day global period, but the flap closure has a 90 day global period. The E/M services provided, including the decision to perform surgery, would be reported with modifier 57. When an E/M service resulting in the initial decision to perform major surgery is furnished during the post-operative period of another, unrelated procedure, the E/M service must be billed with both the 24 and 57 modifiers. - Kathy Dyson, MMI Learning Director
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Billable & Non-Billable Codes Cigna no longer accepts non-billable or invalid ICD-10 codes Billable A billable (or valid) ICD-9 or ICD-10 code is defined as a code that has been coded to its highest level of specificity. The general rule for billable codes is that if a five-digit diagnosis code exists, it must be used because it is the most specific. For example, 290.10 is a billable code, but 290.1 is not.
Non-Billable A non-billable ICD-9 or ICD-10 code is defined as a code that has not been coded to its highest level of specificity. An invalid ICD code is defined as one that is not coded to the highest level of specificity, even though it may have once been a "billable" code (e.g., G32.8 is now G32.81). The five-character code is "valid" or "billable," while the four-character code is "invalid" or "non-billable."
CMS 1500 format change • CMS 1500 (HCFA) forms are changing for ICD-10 • Indicates format of ICD-9 or ICD-10 • Increases number of Diagnosis from 4 to 12 • Qualifiers to identify ordering/referring/supervising roles
Timeline is anticipated by CMS as: • January 6, 2014 – begin receiving and processing using version 02/12 • January 6 – March 31, 2014 – processing BOTH • April 1, 2014 – Only use new version 02/12
Cigna Cigna will continue to accept CMS (08/05) 1500 claim forms and all claim formats until further notice. However, the older claim formats do not support the submission of ICD-10 codes on paper forms. With ICD-10 implementation, health care professionals must use the revised (02/12) 1500 claim form when submitting paper claims to ensure accurate and prompt claim payment
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November’s
MMI Check-Up for ICD-10 ICD-10 Exercises & Scenarios | Monthly Feature MMI will provide coding exercises and scenarios each month in the MBJ so that you can verify your progress in understanding and coding ICD-10. You will need an ICD-10 manual to complete the exercise, so if you have not already signed up for our ICD-10 curriculum. MMI’s ICD-10 Check-Ups are posted on the MMI Blog as well! Scenario 1 A 9 year old male presents with parent today. Cut right hand on car sign per mom 10 days ago. Went to ED, 10 sutures placed, mom keeping clean daily, here to be sure not infected, doing well otherwise, no fevers no recent illness noted. Physical exam notes healing laceration to lateral side of right hand, has 10 sutures dry and intact, no s/s of infection noted, no tenderness noted.
Scenario 2 While playing outside with his sons, Ralph had chest pain, shortness of breath, and light-headedness. His sons rushed him to the hospital, as they suspected he was having a heart attack. Ralph was having a heart attack and was diagnosed with an acute non-ST anterior wall myocardial infarction.
Coding Practice Code the following diagnoses in ICD-10: 1. 2. 3. 4. 5. 6. 7.
Stuttering - adult Compulsive gambling Premature graying of hair Dysuria Nausea with Vomiting Gestational Diabetes controlled with insulin Scoliosis of the lumbar region, secondary to cerebral palsy 8. Acute Rheumatic fever 9. BTHS (Barth syndrome) 10. Benign neoplasm of tonsil
Code the External Cause Activity Codes in ICD-10: 11. 12. 13. 14. 15. 16.
Injured while texting Injured while performing pilates Injured while playing the clarinet Injured while putting clothes in dryer Injured while trying out for cheerleading Stung by jellyfish while SCUBA diving
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Answers: Scenario 1: S61.411A - laceration without foreign body of right hand, initial encounter Scenario 2: R07.9 – Chest pain R06.02 – Shortness of breath, R42 – Dizziness and giddiness, I21.4 – Non-ST elevation (NSTEMI) myocardial infarction Coding Practice 1. F98.5 Adult onset fluency disorder 2. F63.0 Pathological gambling 3. L67.1 Variations in hair color 4. R30.9 Painful Urination 5. R11.2 Nausea with vomiting, unspecified 6. O24.419 Gestational Diabetes mellitus while pregnant, controlled with insulin 7. M41.46 Neuromuscular scoliosis, lumbar region 8. I01.9 Acute rheumatic heart disease, unspecified 9. E78.71 Barth syndrome 10. D10.4 Benign neoplasm of tonsil Code the External Cause Activity Codes 11. Y93.C2 Activity involving computer technology and electronic devices, hand held interactive electronic device 12. Y93.B4 Activity involving other muscle strengthening exercises, pilates 13. Y93.J4 Activity involving computer technology and electronic devices, hand held interactive electronic device 14. Y93.E2 Activity involving computer technology and electronic devices, hand held interactive electronic device 15. Y93.45 Activity involving dancing and other rhythmic movement, cheerleading 16. Y93.15 Activity involving water, underwater diving and snorkeling
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Pay for A Nurse Visit? Why do I have to pay a co-pay? | Kathy Dyson, MMI Learning Director I was recently asked if we had a policy explaining to patients their charge for a minimal office visit or nurse visit. Often, patients come in to ask for a urinary analysis to see if they have a UTI. They get lab work done and need a prescription adjusted. They need follow-up from a previous visit to be sure a condition has resolved appropriately… you know the list. Some patients do not feel they should be charged for these services; they certainly do not want to pay the co-pay for the visit. It is the 99211 and 99212 that patients seem to feel ‘entitled’ to receiving from their physicians. So, some practices try to show the patient examples from the CPT code book to justify their position. Other’s ask for a policy that they can add to the stack of policies and paperwork collected during the initial patient visit or as an annual update.
?
So, should you charge for the services like this? How do you communicate the reason for the charges? Someone who chose to remain anonymous, had this to say:
Their CPA has a qualified person who inputs their data which then gets crunched by a computer program to produce a simple tax return. If it's not a complicated return the CPA doesn't charge as much as for a complex client. Do they think the CPA shouldn't charge them at all? Their attorney creates a will using a fill in the blank program. Their will may not be as complex as someone who has multiple assets and trusts that need to be set up. Do they think the attorney should not be compensated just because it's easier? When they go to the grocery store they pay for what they get. Sometimes it's a buggy full of groceries and sometimes it's a gallon of milk. Either way they go past the cash register. Would they say "I shouldn't have to pay because I'm not doing my regular shopping." If they went to the hospital lab to have their coumadin checked or to have a UTI investigated do they honestly think they would get it done for free? I think the same way about this as about FMLA paperwork or disability papers. You pay for the expertise of the provider. It is he who has the medical background to interpret a UTI or make the
adjustments to a coumadin level. Doesn't matter if the nurse or lab tech is looking at the results. They are operating under orders issued by a physician. Every time the provider's name goes on a prescription or a test result he is putting his license up on the line saying, "In my medical opinion, this is medically correct". Should you have to pay for that expertise? Boy howdy. My personal favorite came from a physician’s wife that manages their practice. She said, “When they go to the gas station and get gas does someone say the first $25 is free?” Do they get to say, “I need the gas today but will pay you next week”? All of this reminds me of the old cartoon show Popeye. Remember J. Wellington Wimpy saying, “I will gladly pay you Tuesday for a hamburger today?” So, yes, use the Appendix C Clinical Examples to be sure you are charging correctly for these activities. Know that you are within the guidelines on these charges. Include the appropriate documentation in the Medical Records, and don’t apologize for your physician’s need to earn money to pay your salary, pay malpractice insurance, pay all of the occupancy costs and other expenses of providing medical care to a sometimes cranky population of ‘entitled’ patients. But it is also important to have compassion and empathy. Assume that the patient is not aware of what is involved. Educate them on the different levels of office visits. And remember that if you are starting the practice of charging for these visits, where you have not before, let patients know. And while we are on soap boxes, signage in the office is okay but don’t have so many signs up that none are taken seriously! I think a well worded paragraph in the financial policy that you hand out for signature and scan into the patient’s file should do the trick. Introducing any new or changed policy will take patience. And remember that not collecting co-pays is a violation of your contract with the Insurance Company. You must show good faith efforts in collections and have a policy that supports your actions. Even the criteria for when you write off a portion of the services for financial hardship should be documented and consistently applied.
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Truth or Myth? Patient Protection & Affordable Care Act | Janet Salyer is two times the individual amount, or $12,700. After the maximum out-of-pocket amounts are met, then the in-network costs are covered 100% by the insurance company for the calendar year.
If I pay the penalty, I don’t have to buy insurance or pay for my health care. MYTH. The penalty is now called the Shared Responsibility Payment. The penalty is just a penalty. You will be responsible for all your health care costs.
The penalty in 2014 is only $95. The Patient Protection and Affordable Care Act will change the culture of health care in the United States. The news is full of information and commentary about the Affordable Care Act, better known as “Obamacare”. Is everything you hear true? What do you think will change in 2014? As an insurance broker, I talk to people from many different backgrounds, and they all have questions. Here are some of the most common truths and myths I’ve answered this year. Information will help people to make the best decisions for their health insurance coverage in 2014. Please note: The Affordable Care Act (“Obamacare”), is still being debated and reviewed in Congress. The latest difficulties with the marketplace website have caused even more debate and hearings. The answers given here are true today, but they may not be true when Congress finishes their investigations.
All health care will be free in 2014. MYTH. The costs of health care continue to increase each year, and all of us will have to pay for care as we receive it. If you have health insurance, then the cost of the wellness care will be covered by the health insurance plan and you will have no out of pocket costs for the wellness care. Patients will have to pay for all other health care either by a co-pay or as the deductible or coinsurance until the maximum out of pocket costs are met. The ACA sets the maximum in-network outof-pocket costs for an individual the same as the out of pocket costs for a Qualified Health Savings Account Plan – or $6,350 for 2014. The maximum for a family
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TRUE & MYTH. The shared responsibility payment for an adult is the greater of $95 per person or 1% of the annual income. A child penalty is half that of an adult. A household can have a maximum penalty for two adults and two children. A single adult making $40,000 would have a fine of 1% or $400. Some uninsured people are exceptions to the shared responsibility penalty including extremely low income and recognized religious sects—they won’t have to make any shared responsibility payment even if they don’t have insurance.
Individuals & families will only be able to purchase insurance on the Marketplace (formerly called the Exchange). MYTH. Individuals and families can purchase insurance in many ways: (1) the marketplace, (2) through an insurance company, (3) they may use an agent or broker for either the marketplace or the insurance company, or (4) through a private exchange. Applications can be made online, by phone, or by completing a paper application. Many individuals and families will have more options outside the marketplace (exchange) than they will on the marketplace. But plans sold on and off the marketplace must cost the same. Plans sold by an agent or broker on or off the marketplace must also cost the same as those sold without a broker or agent. Households making 400% or less of the Federal Poverty Level (FPL) should check the plans on the marketplace to see if they qualify for premium tax credits.
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Health Savings Accounts will be available next year.
I can buy insurance any time I like, so I’ll just wait until I need it.
TRUE. Insurance companies will still sell qualified health savings account plans in 2014. Because the plans must meet “metal levels”, the 2014 ACA qualified health plans may have higher deductibles than the plans sold in 2013.
TRUE & MYTH. The ACA eliminates underwriting and pre-existing conditions. So you can purchase insurance even if you are sick, and the insurance will cover your sickness – when you are able to buy it! The ACA also sets an open enrollment period. The initial enrollment period is October 1, 2013 to December 15, 2013 for January 1, 2014 effective date. This first enrollment period is extended through March 31, 2014, but the effective dates change. If you apply between December 16, 2013 and January 15, 2014, your effective date is February 1, 2014. If you apply between the 1st and the 15th of the month, your coverage is effective the first of the following month. If you apply between the 16th and the 31st of the month, your coverage will not be effective until the first of the second month. The effective date will always be at least 15 days after you apply, and may be as long as 45 days after you apply. After March 31, 2014, you will not be allowed to purchase or change individual/family insurance until the next open enrollment period. The ACA sets the annual open enrollment period from October 15 to December 7 for an effective date of January 1 of the next year. So, after our initial open enrollment period, individuals/families will only be able to purchase or change their insurance one time a year. The exception to open enrollment is special enrollment periods for loss of a job or marriage, birth, divorce, or death (employer groups will be able to purchase insurance during the year, but not individuals.)
I will be able to keep my doctor. MAYBE. There are several different reasons why it’s impossible to really answer this question. Doctors and other providers have the option to contract with insurance companies or not. If your favorite doctor decides to not accept insurance, then you will either have to pay all the costs out of pocket or go to a different doctor. The ACA encourages the use of “care coordinators” which are primary care doctors who coordinate the care of the patient with specialists the patient sees. These “care coordinators” are part of HMO plans. Traditionally, doctors have not participated as much in the HMO plans as they have in the POS and PPO plans. Doctors and other providers may choose to only contract with the insurance company’s POS and PPO networks and not the HMO networks. It’s important to know the name of the network of the plan as well as the insurance company you choose so you can verify the providers and hospitals and even pharmacies that participate in that network.
Open enrollment started October 1, so I can purchase this new insurance today. TRUE. Everyone can now purchase an individual or family plan, either on the marketplace or off the marketplace. BUT, the effective date of the coverage is January 1, 2014. You can buy the coverage all day long, but you can’t use it until January 1, 2014.
I don’t want Obamacare, so I’ll just buy my coverage off the marketplace. TRUE & MYTH. You can purchase your insurance off the marketplace, but all insurance plans sold for a January 1, 2014 effective date or after OR renewing on January 1, 2014 or after will have to update to the new “Obamacare” which is really ACA qualified “metal plans”. The only exception is the “grandfathered” plans. These grandfathered plans had to be in place on March 23, 2010, with no major changes made to the plan.
I have health insurance at work, so will I have to pay a penalty. MYTH. The individual mandate says you must have health insurance. So, group health insurance at work covers you so you don’t have to pay a penalty.
All health plans update to the “Obamacare” on January 1, 2014. MYTH. The existing health insurance plans will update as they renew in 2014. Only “grandfathered” plans will not update to the ACA guidelines for deductibles, coinsurance, copays and essential health benefits. Have a question about the new healthcare law? Send your questions to MMI and we will try to have the answers in an upcoming newsletter article.
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NOVEMBER CROSSWORD We hope you enjoyed this issue‌ now test your knowledge!
Across
Down
2. The promo code that you can use to receive 25% off the Fall CEU Bundle
1. Secretary of US Department of Health and Human Services (HHS)
4. Student of the Month (November) 7. Not collecting co-pay is an example of this
3. What the Marketplace used to be referred as 5. MMI will be offering online ICD-10 training at a 30% discount on "Day of Thanks", which will be ______ __, 2013 6. A _______ code is defined as a code that has been coded to its highest level of specificity 8. What the Affordable Care Act is better known as (nickname)
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THE MEDICAL BUSINESS JOURNAL BROUGHT TO YOU BY THE MEDICAL MANAGEMENT INSTITUTE The Medical Business Journal is a monthly source of up-to-date information on all issues affecting the healthcare industry. Its content ranges from medical coding and billing to healthcare reform legislature and beyond. The MBJ is not affiliated in any way with the Department of Health and Human Services, Medicare, or the Centers for Medicare and Medicaid Services. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting or other professional services, and is not a substitute for individualized expert assistance. The CPT® codes, descriptors, and modifiers are copyrighted by the American Medical Association. For more information, please call MMI at 866-892-2765.
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October, Issue 10, Vol 4
Editor in Chief Carleigh Benscoter
Contributors Kathy Dyson Janet Salyer Carleigh Benscoter
Layout & Design Carleigh Benscoter
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Link List [Issue 10, Vol 4] CMS News Updates: www.cms.gov, www.youtube.com/watch?v=uIufZm8spBc, MMI News: http://www.linkedin.com/ groups?gid=5174936&goback=%2Ebzo_*1_*1_*1_*1_*1_*1_*1_2609576&trk=rr_grp_name, www.facebook.com/mmifan, www.twitter.com/mmiclasses, CPT 2014 Changes: https://www.google.com/url? sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCsQFjAA&url=http://www.ama-assn.org/resources/doc/cpt/ cpt-2014-overview-of-gichanges.pdf&ei=dxSBUrrHDcjqkAeJ5IGADQ&usg=AFQjCNHRqGlFeI2iX2AQK1ZpbPTB-9hA7A&bvm=bv. 56146854,d.eW0, ICD-10 Check-Up: http://www.mmi-classes.com/collections/2014-medical-coding-books/products/ 2014-icd-10-draft, http://www.mmi-classes.com/pages/icd-10-online-certification-training, http://www.mmiclasses.com/blogs/mmi-check-up-for-icd-10, HIPAA Compliant: http://www.mmi-classes.com/collections/hipaa-training 2014 Book Deals: http://www.mmi-classes.com/collections/2014-book-bundle-deals Fall CEU Bundle: www.mmi-classes.com/fallCEU Day of Thanks: http://www.mmi-classes.com/blogs/mmi/9948897-day-of-thanks-on-november-19th-save-the-date