CorroHealth Weekly eJournal, June 21, 2023

j our nal e

COVID-19

Screening & Testing

RevisionsTo RequiredForm

Coding Post-Pandemic COVID-19

Screening And Pre-Op Testing

Quest ion:

The FY2023 ICD-10-CM Official Guidelines for Coding and Reporting states:

?During the COVID-19 pandemic, a screening code is generally not appropriate. Do not assign code Z11.52, Encounter for screening for COVID-19. For encounters for COVID-19 testing, including preoperative testing, code as exposure to COVID-19 (guideline I C1 g 1 e)

Coding guidance will be updated as new information concerning any changes in the pandemic status becomes available.?

Are there coding updates now that the Public Health Emergency (PHE) is over?

Answ er:

In their First Quarter 2023 Coding Clinic on March 7, 2023, the AHA announced that beginning with dates of service on or after October 1, 2023, Z11.52 will be considered the appropriate selection for encounter for screening for COVID-19 Until then, providers should continue to report Z20 822 (Contact with and (suspected) exposure to COVID-19)

The AHA?s Frequently Asked Questions Regarding COVID-19 (05-10-2023 Final Version), the following coding scenario is provided for reference:

CODINGPOST-PANDEMICCOVID-19 SCREENING&TESTING

During the PHE, the ICD-10-CM Guidelines instructed providers to first report Z01 812 (Encounter for preprocedural laboratory examination) with the additional diagnosis code Z20 822 for preoperative testing

Per the AMA FAQ, this preoperative coding guideline will remain in place until dates of service on or after October 1, 2023 Then, the coding guidance instructs reporting first Z01 812 with the additional diagnosis codeZ11.52 (Encounter for screening for COVID-19).

Prior Authorization For Facet Joint

Quest ion:

What are the prior authorization requirements on facet joint interventions?And, do these requirements apply to both CAH and OPPS?

Answ er:

As indicated below, critical access hospitals are not required to submit prior authorization requests for facet joint interventions

Please refer to the CorroHealth paper for additional information by clicking on the document here.

The No Surprises Act And Good Faith Estimates

Quest ion:

A patient was given an estimate on 3/20/23 and 4/20/23 for the same upcming service, however the estimates were very different The higher estimate is more accurate in the charges. What is our responsibility in honoring the lower estimate?

Answ er:

The estimate is not a contract, so the patient is still responsible for billed charges. The intent of the estimate is to allow the patient to shop for prices at multiple facilities/providers and have a written document to use should the billed charges exceed that GFE As we discussed, even though the second GFEwas calculated incorrectly and issued in error, it gave the patient the expectation of a lower cost The patient can use that second estimate to initiate a dispute since the billed charges exceeded the second estimate by $400. Fortunately, the error was discovered before they initiated a dispute, so negotiations can occur between the facility and patient outside the formal dispute process

The facility must determine if, and how much, they want to reduce the billed charges to avoid the formal dispute and do service recovery The certified dispute resolution entity fees range in price from $350 - $700. The patient could possibly win the formal dispute costing the facility up to $700 in dispute fees and reimbursing the patient the $25 dispute fee.

More consumer information about the dispute process can be obtained at this link: Dispute a medical bill | CMS

Codes 99406 - 99409

Tobacco Cessation Counseling

Quest ion:

Are there any restrictions when charging codes 99406-99409 during an office visit? Specifically, during pain management or medication assistance therapy when these issues are discussed and documented appropriately.

Answ er:

First, the tobacco cessation counseling There are no CCI edits which prevent billing 99406 or 99407 with an office visit code (99202-99215 ) I have attached our paper on tobacco cessation counseling; the one thing to keep in mind is that Medicare will pay 99406 or 99407 only if a physician or other ?Medicare recognized provider?(ARNP, PA, etc.) provides the counseling.

Our paper offers excerpts and a link and excerpts from Medicare?s National Coverage Determination 210.4, Smoking and Tobacco-Use Cessation Counseling. Here are those codes ? they are reportable by the billing professional and also by the hospital when performed in an outpatient facility setting.

Turning now to alcohol and other non-tobacco substanceabusescreening and counseling: CPT® codes 99408 and 99409 are not covered by Medicare There are special alternate HCPCSto report when providing an alcohol or other non-tobacco substance abuse assessment or counseling

Attached is a CMSMLN document (SBIRTFact Sheet) which summarizes the different codes that may be reported for alcohol and substance abuse assessments and interventions, which are reported with HCPCSG2011, G0396, or G0397.

In addition, Medicare beneficiaries are eligible for preventive screening and counseling services which cover alcohol abuse alone (without other substances or tobacco ) Qualified providers and facilities can report G0442 (ANNUAL ALCOHOL MISUSESCREENING, 5 TO 15 MINUTES) once annually, and for those who screen positive, G0443 (BRIEFFACE-TO-FACE BEHAVIORAL COUNSELING FORALCOHOL MISUSE, 15 MINUTESup to four times annually.

JUNE30,

Revised Advance Beneficiary Notice Form

Required On June30, 2023

CMSissued an update to the Advance Beneficiary Notice (ABN) Form, CMS-R-131, which will be mandatory beginning June 30, 2023. The expiration date of the new form is 01/31/2026. The updated ABN form, in both PDFand Microsoft Word versions with instructions in English and Spanish and in normal or large print, are available for download:

The CMSsite provides a separate link to download ABN Form Instructions Chapter 30 of the Medicare Claims Processing Manual beginning Section 50.3 also provides information and instructions on the requirements for completing and issuing an Advance Beneficiary Notice

CMS- FFSABN

AMA Releases CPT® Editorial Panel SummaryOf Panel Actions

The American Medical Association (AMA) has made preliminary plans to update certain CPT® codes for 2024 and 2025, as detailed in its Summary of Panel Actions from the May 2023 CPT® Editorial Panel meeting.

The main objective of the CPT® Editorial Panel, also known as the Panel, is to make certain that CPT® codes accurately represent the most up-to-date medical care accessible to patients. Achieving this goal involves maintaining a process that is autonomous, transparent, and open.

The Panel organizes meetings three times a year to actively seek input from various stakeholders, including practicing physicians, medical device manufacturers, developers of advanced diagnostic tests, and advisors from over 100 specialty medical societies that represent physicians and other qualified healthcare professionals

Following each Panel meeting, a comprehensive document summarizing the actions taken by the Panel on each code application is made available on the American Medical Association (AMA) website This document serves as a valuable resource, providing a clear overview of the decisions and updates made by the Panel. It allows healthcare professionals, payers, and other interested parties to stay informed about the latest developments and changes in the CPT® codes.

The Summary advises of anticipated new CPT® codes and other changes that will be published in the CPT® 2024 manual at the end of 2023, and the CPT® 2025 Manual late next year This information is preliminary and is subject to change prior to publication

Anticipated CPT®code updates effective January 1, 2024 include (but are not limited to):

- Deletion of Category III code 0809T and instruction on how to report hybrid SI joint infusion

- Deletion of Category III code 0042T (cerebral perfusion analysis)

- New Category III add-on code for opto-acoustic imaging for breast masses

- New Category III codes for:

- Electrophysiological focused magnetic stimulation of brain

- Quantitative MRI analysis of the brain

- Near infrared spectroscopy (NIRS) for peripheral arterial disease (PAD)

- New Category III codes 0766T, 0767T (and deletion of previous codes 0768T, 0769T) for peripheral nerve transcutaneous magnetic stimulation

- New and revised Category III codes for wireless cardiac stimulation system for left ventricular pacing

- New Category III code for extracorporeal shockwave therapy (EWST) of the corpus cavernosum

- Retention and deletion (sundown) of various Category III codes

- Retention of code 34510 and deletion of 74710

Upcoming expected CPT®code changes for 2025 include:

- Development of Category I codes for Chimeric Antigen Receptor (CAR-T) services (and deletion of existing Category III codes)

- Addition of codes for excision or destruction of intra-abdominal peritoneal, mesenteric, and/or retroperitoneal primary or secondary tumors or cysts; deletion of codes 49203-49205

- Deletion of code 58957 (resection/debulking of intra-abdominal/retroperitoneal tumors) and revision of code 58958

- New codes for MRI-monitored transurethral USablation of the prostate

- Code addition and revisions relating to hand repair (suspension with interposition) (25447)

- Several new, revised and deleted codes for transcranial Dopper studies

- Updates to time recommendations for telemedicine E&M service codes

ULTRASOUND DOCUMENTATION REQUIREMENTS

Ultrasound Documentation Requirements: CompletevsLimited

Int roduct ion

Many facilities bill diagnostic ultrasound services from the referring physician?s order as an automated process, without any review by a coding professional This practice is discouraged because when charging for complete diagnostic ultrasounds, the CPT® Manual outlines very specific documentation requirements for these examinations.

The radiology report serves as the documentation for both the professional and technical portions of the examination The documentation within the medical record must support the exam that was performed--both for the professional fee (the radiologist?s interpretation) and the technical fee (the technologist?s work of performing the exam).

It is the reading radiologist?s responsibility to ensure the components of each diagnostic ultrasound exam performed are documented appropriately in the radiology report. The CPT® guidelines for diagnostic ultrasound state that all diagnostic ultrasound studies require the following:

- Permanently recorded images with measurements (when such measurements are clinically indicated)

- A final, written report to be issued for inclusion in the patient?s medical record

Per CPT® , ?Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.?

Com plet e vs Lim it ed Ult rasound

CPT® instructions pertaining to coding a complete vs. a limited ultrasound are as follows: ?For those anatomic regions that have ?complete?and ?limited?ultrasound codes, note the elements that comprise a ?complete?exam The report should contain a description of these elements or the reason that an element could not be visualized (eg, obscured by bowel gas, surgically absent).

If less than the required elements for a ?complete?exam are reported (eg, limited number of organs or limited portion of region evaluated), the ?limited?code for that anatomic region should be used once per patient exam session A ?limited?exam of an anatomic region should not be reported for the same exam session as a ?complete?exam of that same region ?

ULTRASOUND DOCUMENTATION REQUIREMENTS

Breast Ult rasound -- 76641 And 76642

Complete diagnostic ultrasound of the unilateral breast requires evaluation and documentation of the following:

- All four quadrants of the breast

- Retroareolar region

- Axilla, if performed

If a focused assessment of one or more, but not all, of these elements are evaluated and documented, the limited code 76642 should be reported

Abdom inal Ult rasound ? 76700 and 76705

Complete diagnostic ultrasound of the abdomen requires real-time evaluation and documentation of the following:

- Liver

- Gallbladder

- Common bile duct

- Pancreas

- Spleen

- Kidneys

- Upper abdominal aorta

- Inferior vena cava

If less t han t he required elem ent s for a com plet e exam are perform ed and docum ent ed, code 76705 should be report ed.

Ret roperit oneal Ult rasound -- 76770 And 76775

Complete diagnostic ultrasound of the retroperitoneum requires real-time evaluation and documentation of the following:

- Kidneys

- Abdominal aorta

- Common iliac artery origins

- Inferior vena cava

OR If clinical history suggests urinary tract pathology, complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound.

ULTRASOUND DOCUMENTATION REQUIREMENTS

If less than the required elements for a complete exam as described in the previous page are documented, the exam should be reported using limited code 76775.

Obst et rical Ult rasound ? First Trim est er ? 76801 and 76802

Complete first trimester (<14 weeks 0 days gestation) OB ultrasound evaluation requires real-time evaluation and documentation of the following:

- Determination of number of gestational sacs and fetuses

- Gestational sac/fetal measurements appropriate for gestational age

- Survey of fetal visible fetal and placental anatomic structure

- Qualitative assessment of amniotic fluid volume and gestational sac shape

- Examination of the maternal uterus and adnexa

If less than the required elements for a complete exam are performed and documented, code 76815 should be reported.

Obst et rical Ult rasound ? Aft er First Trim est er ? 76805 and 76810

Complete OB ultrasound evaluation after the first trimester (> or = 14 weeks 0 days gestation) requires real-time evaluation and documentation of the following:

- Determination of number of fetuses and amniotic/chorionic sacs

- Measurements appropriate for fetal age

- Survey of intracranial, spinal, and abdominal anatomy

- 4-chambered heart

- Umbilical cord insertion site

- Placenta location

- Amniotic fluid assessment

- Examination of the maternal adnexa

If less t han t he required elem ent s for a com plet e exam are perform ed and docum ent ed, code 76815 should be report ed.

ULTRASOUND DOCUMENTATION REQUIREMENTS

Obst et rical Ult rasound ? Det ailed Fet al Anat om ic Eval -- 76811 And 76812

Complete OB ultrasound with detailed fetal anatomic evaluation requires real-time evaluation and documentation of the following:

- All the elements required for code 76805/76810, plus

- Fetal brain/ventricles

- Face

- Heart/outflow tracts and chest anatomy

- Abdominal organ specific anatomy

- Number, length, and architecture of limbs

- Detailed evaluation of umbilical cord and placenta

- Other fetal anatomy as clinically indicated

The imaging report should document the results of the evaluation of each element described above or the reason for non-visualization

If less t han t he required elem ent s for a com plet e exam are perform ed and docum ent ed, code 76815 should be report ed

Obst et rical Ult rasound -- Transvaginal -- 76817

Code 76817 describes obstetrical ultrasound evaluation via a transvaginal approach. Per CPT® Assistant, November 2011, this code includes evaluation of:

- Embryo(s) and gestational sac(s)

- Maternal uterus, adnexa, and/or cervix

76817 may be reported in addition to a follow-up transabdominal approach OB US(76816) when necessary to adequately view the structures.

Fem ale Pelvic Ult rasound -- 76856 And 76857

Complete non-obstetric ultrasound of the female pelvic anatomy requires real-time evaluation and documentation of the following:

- Description and measurements of the uterus and adnexal structures (i e , fallopian tubes and ovaries)

- Measurement of the endometrium

- Measurement of the bladder (when applicable)

- Description of any pelvic pathology (e g , ovarian cysts, uterine leiomyomata, free pelvic fluid)

76857 should be reported

ULTRASOUND DOCUMENTATION REQUIREMENTS

If less t han t he required elem ent s for a com plet e exam are perform ed and docum ent ed, code 76857 should be report ed.

Fem ale Pelvic Ult rasound -- Transvaginal -- 76830

According to the American College of Radiology (ACR) Ultrasound Coding User?s Guide, a complete non-OB transvaginal ultrasound includes evaluation of:

- Uterus

- Endometrium

- Ovaries

- Adnexa (e g , ovaries, fallopian tubes, and uterine ligaments)

Clinical Examplesin Radiology(Winter 2016) indicates that while the adnexa must be evaluated and documented, the fallopian tubes do not need to specifically be mentioned. If evaluation of the uterus is not performed or documented, modifier 52 should be applied to code 76830 to indicate reduced services

It is appropriate to report 76856 or 76857 with 76830 when both are performed together However, the practice of performing and reporting both studies for every patient is discouraged Per Clinical Examplesin Radiology(Spring 2020), when transabdominal and transvaginal pelvic ultrasound are performed together, the transvaginal ultrasound is considered a specialized, problem-focused exam and should be performed only when medically necessary

Male Pelvic Ult rasound -- 76856 And 76857

Complete ultrasound of the male pelvic anatomy requires real-time evaluation and documentation of the following:

- Evaluation and measurement (when applicable) of the urinary bladder

- Prostate and seminal vesicles (to the extent visualized transabdominally)

- Any pelvic pathology (e.g., bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess)

If less t han t he required elem ent s for a com plet e exam are perform ed and docum ent ed, code 76857 should be report ed.

ULTRASOUND DOCUMENTATION REQUIREMENTS

Ext rem ely Ult rasound -- 76881 And 76882

Complete ultrasound of a specific joint within an extremity requires real-time evaluation and documentation of the following:

- Joint space (e.g., effusion)

- Peri-articular soft tissue structures surrounding the joint (muscles, tendons, other soft-tissue structures)

- Any identifiable abnormality

The imaging report should document the results of the evaluation of each element described above or the reason for non-visualization

If less t han t he required elem ent s for a com plet e exam are perform ed and docum ent ed, code 76882 should be report ed

Ult rasound Guidance

Accurate and complete documentation is essential when reporting ultrasound guidance. The documentation should clearly indicate the type of procedure, the specific anatomical location of the images, the specific anatomic structures visualized, and a documented description of the localization process. This information is critical to ensure that the service is accurately reported.

The CPT® Manual states the following:

?Ultrasound guidance procedures also require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized. Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable ?

For additional information regarding accurate documentation and reporting of ultrasound guidance, please see the link to the PARA paper located in the PARA Dat a Edit or:

Ultrasound Guidance in the Hospital Setting

ULTRASOUND DOCUMENTATION REQUIREMENTS

Addit ional Resources

The American College of Radiology (ACR) offers specific parameters for the performance and interpretation of various types of imaging exams, including ultrasound:

https://www.acr.org/Clinical-Resources/Practice-Parameters-and-TechnicalStandards

ULTRASOUND DOCUMENTATION REQUIREMENTS

Test Your Know ledge

Below is an example of a radiology report for a complete abdominal ultrasound Does this documentation meet the criteria for reporting a complete exam of the abdomen?

Answ er: No, this report does not meet the documentation criteria for reporting a complete abdominal ultrasound. There is no documentation of evaluation of the inferior vena cava (IVC), which is a component of a complete abdominal US. If the IVCwas evaluated, the radiologist should include this documentation in the report to support a complete study In this instance, an amended or corrected report could be issued to support charging a complete study

Conclusion

Code selection for diagnostic ultrasound is based on a variety of very specific documentation requirements. Clear documentation is extremely important to ensure proper coding and reimbursement Code descriptions and documentation should be reviewed carefully, and when unclear, the provider should be queried

CorroHealt h invit es you t o check out t he m lnconnect s page available from t he Cent ers For Medicare and Medicaid (CMS). It 's chock full of new s and inform at ion, t raining opport unit ies, event s and m ore! Each w eek PARA w ill bring you t he lat est new s and links t o available resources. Click each link for t he PDF!

Thursday, June 15, 2023

New s

- Inflation Reduction Act Continues to Lower Out-of-Pocket Prescription Drug Costs for Drugs with Price Increases Above Inflation

- CMSAnnounces Multi-State Initiative to Strengthen Primary Care

- Critical Access Hospitals: Annual Average Patient Length of Stay Requirement

- Skilled Nursing Facility Probe and Educate Review

- Billing Medicare Part B for Insulin with New Limits on Patient Monthly

Coinsurance

- ESRD Prospective Payment System: July Update

- Medicare Learning Network Web Refresh

- Men?s Health: Encourage Your Patients to Prioritize Their Health

Claim s, Pricers, & Codes

- ICD-10-PCSProcedure Codes: FY2024

MLN Mat t ers®Art icles

- DMEPOSFee Schedule: July 2023 Quarterly Update

- Hospital Outpatient Prospective Payment System: July 2023 Update

- New JZ Claims Modifier for Certain Medicare Part B Drugs

t r ans mit t al s

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2 m edl ear ns

Therew ereTWOnew or revised MedLearnsreleased thisw eek.

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