CTSINUSAND CTFACIAL BONES

Quest ion: Our Radiology Manager is asking for a review of w hat should be charged w hen a physician orders bot h a CT of t he Facial Bones along w it h a CT of Sinus Can you give your t hought s on t he appropriat e charging and coding?

Answ er: According to CPT® Assistant, March 2002, ?If two separate studies with separate interpretations and written reports, signed by the interpreting physician were performed, then code 70486 should be reported twice, once for each study.? If a CTof the paranasal sinuses and a CT of the maxillofacial bones are both performed and interpreted separately, some payers will allow reporting of both with an appropriate modifier (e g , XS, XU)

However, there is a CMSMedically Unlikely Edit (MUE) limit of 1 unit per DOSfor CPT® 70486 in the OPPSsetting. Only one unit can be billed per date of service for Medicare patients under OPPSmethodology, even if both studies are performed and interpreted separately. For additional information, please see the March 2002 edition of the AMA publication CPT® Assistant, which is available to specially selected users on the PARA Dat a Edit or.

Observation Pro Fees99222 And 99238

Quest ion: An edit is prevent ing us from report ing professional codes for init ial observat ion professional code w it h t he discharge code How should t his be report ed?

Answ er: As noted, CCI Edits prevent reporting Pro Fee Codes 92222 (Initial Hospital Inpatient or Observation Care, per day) with the 99238 (Hospital Inpatient or Observation Discharge Day Management).

In their presentation Advancing Landmark Revisions Across More Settings of Care, the AMA instructs providers to select an evaluation and management code from the following CPT® code set to report when a patient was admitted and discharged on the same date of service and the practitioner had two or more separate encounters (an initial and a discharge):

If there was only one practitioner encounter for the admission and the discharge and the patient?s stay was less than 8 hours, one of the following codes should be reported:

If there was only one practitioner encounter for the admission and the discharge and the patient?s stay was 8 or more hours (even if it spanned two dates), one of the following codes should be reported:

Quest ion 1: Our underst anding is t hat regardless of 76376/ 77, 3D post -processing is inherent t o CTAs (e g , 72191/ 71275) Would t he sam e concurrent physician supervision be required?

Answ er: The physician ?work?component of the RBRVSfor CPT®s 76376/76377 is much less than that of 72191/71275. These codes are reported in conjunction with base imaging procedures which reimburse for the additional work required of the physician; the documentation of the physician supervision and the distinction between ?separate workstation?factor into the work portion of the reimbursement Therefore, CPT® has been very specific about the nature of the physician's work.

For CTAs, the physician's work is inherent in the procedure. A CTA could not be interpreted without the physician's work; therefore, CPT® has not specified the extent of physician supervision or the ?separate workstation?for CTAs.

Quest ion 2: How is ?independent w orkst at ion? defined? In ot her w ords, if t he im age goes from t he CT scanner t o a 3rd part y 3D soft w are, t hen t o PACS, is t hat considered t he independent w orkst at ion?

Answ er: Reformatting of the 2D CTimages is done either on the acquisition scanner software or at a separate, independent workstation. The term ?PACS?(picture archiving and communication system) can be loosely used to denote a wide variety of systems used for processing, storing and viewing images and image-related information. The scenario described indicates the 3D software is not integrated into the image acquisition scanner. Therefore it meets the ?separate workstation?requirement. CPT® Assistant, April 2016 defines an independent workstation as ?a separate computer or workstation used for the purpose of three-dimensional (3D) reconstruction.?

Quest ion 3: Would prot ocols suffice for concurrent supervision if developed under t he Radiologist ?s direct ion?

Answ er: No. Concurrent supervision as described in CPT®s 76376 and 76377 requires the radiologist?s personal involvement.

Quest ion 4: What t erm s (ot her t han 3D) offer support ing docum ent at ion of 3D im aging?

Answ er: Clinical Examplesin Radiology(Fall 2013) states terms such as maximum intensity projection (MIPS), shaded surface rendering, and volumetric rendering support coding of 76376/76377, when applicable Multi-planar reconstructions (MPR) and 2D reconstructions should not be reported using codes 76376/76377.

Quest ion 5: Are t here any ot her ?best pract ice? art icles t o assist in bet t er underst anding t his phenom enon?

Answ er: The American College of Radiology offers several articles that relate to this question The first one below is of particular interest: http://www acr org/Advocacy/Economics-Health-Policy/Billing-Coding/Coding-Source-List/ 2009/MayJun-2009/QA https://www

Quest ion: Our ult rasound depart m ent has been perform ing bilat eral upper and low er venous duplex scans on t he sam e dat e of service and charging t w o lines of CPT® 93970 In t hese inst ances, is t he use of m odifier -76 appropriat e?

Answ er: A complete bilateral venous duplex of the lower extremity veins (93970) includes examination of the common femoral, [superficial] femoral, proximal deep femoral, great saphenous, and popliteal veins A complete bilateral upper extremity venous duplex study (also 93970) includes evaluation of the subclavian, jugular, axillary, brachial, basilic, and cephalic veins. When less than a full exam containing these elements is performed, code 93971 should be assigned Both color and spectral doppler must be utilized and documented in order to report these codes.

From a general coding perspective, it is appropriate to report 2 units of code 93970 when complete bilateral venous duplex studies of both the upper and lower extremities are medically necessary, performed and documented (Clinical Examples in Radiology, Winter 2008) Modifier -59 or -XSwould be most appropriate here. However, under Medicare, code 93970 has a Medically Unlikely Edit (MUE) adjudication indicator of 3 with a reporting limit of 1 unit per date of service Therefore, only 1 unit may be reported per DOSfor Medicare patients, and the only way to receive payment for the second study would be to successfully appeal the denial.

Quest ion: We need som e clarificat ion. The surgical package booklet says t hat visit s perform ed aft er t he decision t o have surgery are part of t he global surgical package Does it m at t er if t he visit is not perform ed by t he surgeon, but by a physician em ployed by our hospit al? The scenario is: t he pat ient is deem ed t o have surgery and our surgeon sends t he pat ient t o our out pat ient clinic t o have a pre-op H&P (hist ory and physical) done. Can w e charge for t hat visit , or no? The out pat ient clinic is different from t he clinic in w hich t he surgeon w orks, if t hat m akes a difference

Answ er: In general, an H&Pperformed by another provider after the decision for surgery, but days before the surgical service is performed, is billable/reimbursable, provided that the surgery is not a screening colonoscopy. The H&Pclaim must indicate a medically necessary ICD-10 diagnosis to be a covered service For example, a screening colonoscopy patient is, by definition, asymptomatic ? so an H&Pfor that kind of procedure won? t meet medical necessity criteria. The following is an excerpt from the American Gastroenterological Society website on this point: https://gastro org/practice-resources/reimbursement/coding/coding-evaluationmanagement-faq/

In addition, the American Academy of Professional Coders has provided a Q&A on this topic at: https://www aapc com/blog/27288-separate-em-with-screening-colonoscopy-plus-pre-op-screenings/

There are several contributing factors which influence whether a pre-operative H&Pvisit should be separately reported and/or reimbursed:

- Whether the E/M is performed by the same physician/same group practice who will perform the surgical procedure, and,

- Whether the decision for surgery has already been made at the time of the H&P, and,

- Whether the E/M is performed on the same day or the day prior to the surgical procedure, and,

- Whether the global period for the surgical procedure is 10 days or less, and,

- Whether the service was medically necessary; in other words, were there conditions that required assessment before the patient could safely have surgery

Surgeons may bill for a visit prior to surgery, as they need to evaluate the problem and determine the best surgical approach ? but:

- If the global surgical period is greater than 10 days -- A pre-operative examination by the same physician that will perform the surgery to clear the patient for surgery on the same day, or the day prior to surgery, is part of the global surgical package, and should not be reported separately

- If the procedure has a global period of 10 days or less, and the surgeon makes the decision to perform surgery during a visit which occurs within a day before the surgery, the surgeon may bill for an E/M with modifier 57 (decision for surgery), in addition to the surgery

Another physician (not the surgeon) can bill for an H&Pafter the surgeon makes the decision to perform surgery, and refers the patient to a second physician (often a primary care physician) for a pre-operative H&P. This service is reportable, but if the visit is not deemed to be medically necessary, a payer may deny payment. Medical necessity will be determined by the documentation and diagnosis coding provided in addition to the ICD10 Z01 81x:

We offer the following matrix in an attempt to simplify the various scenarios:

Below are the references used to develop this information:

The CPT® manual says that the H&Pis included in the global surgical package only if the same surgeon performs it, and not within one day of the date of surgery:

CPT® Surgical Package Definit ion

By their very nature, the services to any patient are variable The CPT® codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. In defining the specific services ?included?in each CPT® surgical code, the following services related to the surgery when furnished by the physician or other qualified health care professional who performs the surgery are included in addition to the operation per se:

- Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical

- Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia

- Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals

- Writing orders

- Evaluating the patient in the post anesthesia recovery area

- Typical postoperative follow-up care

In February 2009, CPT® Assistant published the following Q&A:

Surgery Guidelines

Quest ion: Are pre-operative visits billable?If so, what code should be used and what is the time frame before surgery to submit this code?

Answ er: Only the pre-operative E/M service related to the procedure performed on the day immediately before the date of the procedure (including the history and physical) is stated as inclusive of the CPT® surgical package definition.

CPT® Assistant also provides the following information, as well as helpful coding scenarios, in its March 2015 edition:

?The concept of a ?surgical package?refers to a combination of services provided by the physician once the decision for surgery is reached The elements of the surgical package vary widely but are considered inherent in a readily identifiable CPT® procedure code. Therefore, it is important to understand which components of a procedure may or may not be reported individually The reporting exception(s) include additional services performed at the time of or subsequent to the definitive surgical procedure(s) due to complications, exacerbations, recurrence, or the presence of other disease(s) or injury(ies) ?

The Medicare Claims Processing Manual offers the following guidance: https://www cms gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12 pdf

30 6 6 - Paym ent for Evaluat ion and Managem ent Services

Provided During Global Period of Surgery

(Rev. 954, Issued: 05-19-06, Effective: 06-01-06, Implementation: 08-20-06)

A. CPT® Modifier ?-24?- Unrelated Evaluation and Management

ServicebySamePhysician DuringPostoperativePeriod

A/B MACs (B) pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT® codes 99221-99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT® modifier ?-24,?and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure

They do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery

All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment

B. CPT® Modifier ?-25?- Significant Evaluation and Management Service by Same Physician on Date of Global Procedure Medicare requires that CPT® modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified non-physician practitioner) to the same patient on the same day as another procedure or other service. A/B MACs (B) pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure.

Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service Modifier -25 is added to the E/M code on the claim Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner in the patient?s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim

If the physician bills the service with the CPT® modifier ?-25,?A/B MACs (B) pay for the service in addition to the global fee without any other requirement for documentation unless one of the following conditions is met:

- When inpatient dialysis services are billed (CPT® codes 90935, 90945, 90947, and 93937), the physician must document that the service was unrelated to the dialysis and could not be performed during the dialysis procedure;

- When pre-operative critical care codes are being billed on the date of the procedure, the diagnosis must support that the service is unrelated to the performance of the procedure; or

- When an A/B MAC(B) has conducted a specific medical review process and determined, after reviewing the data, that an individual or a group has high use of modifier ?-25? compared to other physicians, has done a case-by-case review of the records to verify that the use of modifier was inappropriate, and has educated the individual or group, the A/B MAC(B) may impose prepayment screens or documentation requirements for that provider or group When a A/B MAC(B) has completed a review and determined that a high usage rate of modifier ?-57,?the A/B MAC(B) must complete a case-by-case review of the records. Based upon this review, the A/B MAC(B) will educate providers regarding the appropriate use of modifier ?-57.?If high usage rates continue, the A/B MAC(B) may impose prepayment screens or documentation requirements for that provider or group A/B MACs (B) may not permit the use of CPT® modifier ?-25?to generate payment for multiple evaluation and management services on the same day by the same physician, notwithstanding the CPT® definition of the modifier.

C. CPT® Modifier ?-57?- Decision for SurgeryMadeWithin Global Surgical Period

A/B MACs (B) pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT® modifier ?-57?to indicate that the service resulted in the decision to perform the procedure

A/ B MACs (B) m ay not pay for an evaluat ion and m anagem ent service billed w it h t he CPT® m odifier ?-57? if it w as provided on t he day of or t he day before a procedure w it h a 0 or 10-day global surgical period

Many hospitals struggle with understanding what Durable Medical Equipment (DME) can be billed to Medicare without enrollment as a Medicare DME Supplier. This paper informs clients how to use the PARA Data Editor to assist in identifying DMEitems which may be reported on a facility fee claim and reimbursed by Medicare, even though the hospital is not otherwise enrolled as a DMEsupplier In addition, it informs users how to use Medicare?s helpful product HCPCScoding lookup tools provided on the internet by Medicare Pricing, Data Analysis, and Coding contractor (PDAC), Palmetto GBA.

To identify DMEthat hospitals may bill without enrollment as a DMEsupplier, PARA Dat a Edit or users should navigate to the ?Filters?tab and run the DMEOPPSExempt Audit The PDFreport generated will identify all billable DMEitems by HCPCSand description, and will indicate whether there is an established line item within the hospital chargemaster coded with each of the billable HCPCS.

To run the audit report, go to the ?filters?tab of the PARA Data Editor and use the dropdown under ?Audit?; select the audit named ?DMEOPPSExempt?, and then click ?Create PDF?:

The report generated will list hundreds of billable DMEHCPCScodes, including wrist and knee braces, air splints, and cervical collars. Since the report is typically over 40 pages long, users may wish to use the ?find?function to locate the code descriptions which may contain a keyword, such as ?knee.?

Here?s an example of a report ? note that for HCPCScodes which have an established chargemaster line item, the procedure item detail, utilization statistics, and pricing is provided below the HCPCSdescription under the broken line:

Verify the Correct HCPCSAssignment: Medicare?s DMEPricing, Data, and Coding contractor, Palmetto, offers a product lookup feature to assist providers in correctly coding prefabricated DMEitems Users may search by either HCPCS, manufacturer, product model number, or by DMEclassification.

The ?Product Classification List?feature allows the user to enter a value in one or more of the data points available ? for example, we entered ?Medline?as the manufacturer and ?Wrist Splint? in the Product Name fields: https://www4 palmettogba com/pdac dmecs/