2015 Coding & Payment Policy Update

Transcription

1 The Society for Cardiovascular Angiography and Interventions presents 2015 Coding & Payment Policy Update Faculty Peter Duffy, MD, MMM, F, Secretary, , Advocacy and Government Relations Committee Chair Cliff Kavinsky, MD, PhD, F, RUC Representative, Structural Heart Disease Committee Chair December 15,

2 Disclaimer is committed to making every reasonable effort to provide accurate information regarding the use of CPT, and the rules and regulations set forth by CMS for the Medicare program. However, this information is subject to change by CMS and does not dictate coverage and reimbursement policy as determined by local Medicare contractors or any other payor. assumes no liability, legal, financial, or otherwise, for physicians or other entities who utilize this information in a manner inconsistent with the policies of any payorsor Medicare carriers with which the physician or other entity has a contractual obligation. CPT codes and their descriptors are copyright 2014 by the American Medical Association. Coding Update Cliff Kavinsky, MD, PhD December 15,

3 Category I vs. Category III Category I Used for established procedures Procedure or service approved by the Food and Drug Administration (FDA) Procedure or service commonly performed by health care professionals nationwide Procedure or service's clinical efficacy is proven and documented Nationally valued Released annually Category III Used for emerging technologies Can be better than an unlisted code in regards to claims processing Not nationally valued Biannual electronic release Many Local Coverage Determinations that declare experimental and investigational when provided outside of a clinical trial Category III TMVR Codes Effective for Dates of Service Prior to 1/1/ T Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; initial prosthesis 0344T Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; additional prosthesis(es) during same session (list separately in addition to code for primary procedure) (Use 0343T in conjunction with 0344T) December 15,

4 New Category I TMVR Codes Effective for Dates of Service 1/1/ Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (list separately in addition to code for primary procedure) NO OFFICIAL CMS DIRECTIVE FOR TMVR CODING CMS issued clear instruction for coding for TAVR No official instructions issued yet for TMVR General instructions available for Coverage with Evidence Development (CED) claims December 15,

5 Special Coding Requirements for Coverage with Evidence Development (CED) Claims Based on the general CED claims instructions, our recommendation for coding TMVR claims, is as follows: TMVR registry number - CT Q0 modifier -signifying CED participation in a qualified registry or clinical study ICD-9 secondary diagnosis code V signifying CED participation in a qualified registry RVU Values for TMVR initial clip placement Physician work value of and a total facility RVU rate of second and subsequent clip placement same session Physician work value of 7.93 and a total facility RVUs of December 15,

6 Medicare Payment for a Procedure Physician Work RVUs + Practice Expense RVUs + Liability Insurance RVUs Sum x Conversion Factor* = Medicare Payment Conversion factor through March 31, $ It s All Relative The new transcathetermitral valve repair (TMVR) codes reflect the valuation recommendations of and the RUC. initial clip placement (33418) national average Medicare reimbursement rate $ second and subsequent clips placed (33419) national average Medicare reimbursement rate $ To put the values of the new TMVR codes in perspective, the percutaneous femoral TAVR code (33361) has a payment rate of $ However, the TAVR code requires co-surgeon status for its performance translating to each operating receiving payment $ December 15,

7 NCD for TMVR The National Coverage Determination (NCD) for TMVR specifically states, TMVR must be performed by an interventional cardiologist or a cardiothoracic surgeon. Interventional cardiologist(s) and cardiothoracic surgeon(s) may jointly participate in the intra-operative technical aspects of TMVR as appropriate. (Source: Co-surgeon Status for TMVR? Assistant-at-Surgery for TMVR? CMS, We ll look into this. December 15,

8 Definition of Co-Surgeon CMS definition - Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient s condition. In these cases, the additional physicians are not acting as assistants-at-surgery. Definition of Assistant-at-Surgery CMS definition - An assistant at surgery is a physician who actively assists the physician in charge of a case in performing a surgical procedure. (Note that a nurse practitioner, physician assistant or clinical nurse specialist who is authorized to provide such services under State law can also serve as an assistant at surgery). The conditions for coverage of such services in teaching hospitals are more restrictive than those in other settings because of the availability of residents who are qualified to perform this type of service. December 15,

9 Co-Surgeon Impact on Payment Reimbursement is at 62.5% of the global surgery fee schedule amount for co-surgeons Assistant-at-Surgery Reimbursement equals 16% of the amount otherwise applicable for the global surgery. But.. CMS assigned status indicators of 0 for both assistant-at-surgery and co-surgeon modifier use for the new Transcatheter Mitral Valve Repair (TMVR) codes, and December 15,

10 Co-surgeons 0-Indicator Status 0=Co-surgeons not permitted for this procedure. Assistant-at-Surgery 0=Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. s Request As the NCD for TMVR specifically supports coverage for co-operator and assistant-atsurgery scenarios for these procedures, we believe the co-surgeon and assistant-at-surgery status indicators need to be corrected to a status indicator of 2 through the issuance of a technical correction for the 2015 MPFS RVU file prior to the January 1, 2015 effective date for the new TMVR codes. December 15,

11 Co-Surgeon Status Indicator 2 2=Co-surgeons permitted and no documentation required if the two-specialty requirement is met. Assistant-at-Surgery 2=Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid. Co-Surgeon Modifier Modifier -62 Both surgeons need to report the same surgery code with the modifier 62. If one surgeon bills with a modifier "62, and one surgeon bills with no modifier, the claim with the modifier will suspend for review. December 15,

12 Assistant-at-Surgery Modifiers Modifier -80 Modifier -82 Modifier -AS Modifier -80 Modifier -80 The assistant at surgery service was provided by a medical doctor (MD) -For non-teaching hospital December 15,

13 Modifier -82 Modifier -82 is used when the assistant at surgery service was provided by an MD and there was not a qualified resident available. Documentation must include information relating to the unavailability of a qualified resident in this situation. Attestation for Modifier -82 I understand that 1842(b)(7)(D) of the Act generally prohibits Medicare physician fee schedule payment for the services of assistants at surgery in teaching hospitals when qualified residents are available to furnish such services. I certify that the services for which payment is claimed were medically necessary and that no qualified resident was available to perform the services. I further understand that these services are subject to post-payment review by the Medicare carrier. December 15,

14 Modifier -AS Use the modifier "AS" for assistant at surgery services provided by a Physician Assistant (PA) or Nurse Practitioner (NP). The provider must accept assignment. Medicare allows 85% of the 16% for the assistant at surgery services provided by a PA or NP. A MD/DO should not submit the "AS" modifier. This modifier is only valid for use by non-physician practitioners (NPP) when billing under their own provider number. Recommendation Hold co-surgeon claims until correction to the MPFS RVU file is made. Assistant-at-surgery claims may be submitted but, pre-payment documentation will be required to support medical necessity. Read your E-Newsletters to keep abreast of the situation. We fully anticipate CMS will fix this problem!! December 15,

15 Modifier -59 Phase Out **CMS is phasing out modifier-59 and replacing it with new modifiers needed to override National Correct Coding Initiative (NCCI) edits in place for ad-hoc PCI procedures.** When is this happening and what are the new modifiers? Modifiers XE, XS, XP, XU are effective January 1, CMS will initially accept either a -59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged. However, these modifiers are valid modifiers even before national edits are in place, so contractors are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs. December 15,

16 Recommendation Might as well start using modifiers XE, XS, XP, XU effective January 1, Modifier XE XE -Separate Encounter-A Service That Is Distinct Because It Occurred During A Separate Encounter December 15,

17 Modifier XS XS-Separate Structure-A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure Modifier XP XP-Separate Practitioner-A Service That Is Distinct Because It Was Performed By A Different Practitioner December 15,

18 Modifier XU XU-UnusualNon-Overlapping Service -The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service Policy Update Peter Duffy, MD, F December 15,

19 Conversion Factor Frozen Through March 31, 2015 With legislation already in place, freezing the Medicare conversion factor through March 31, 2014, the annual SGR fix cliff hanger has been delayed for a few extra months this year. No doubt we will be seeking member support in rallying for a SGR fix in the first quarter of 2015 to avert the anticipated 21.2 percent cut that will take place on April 1, 2015 absent legislative intercession. Elimination of 10-and 90-Day Global Periods Interventional Cardiology has a small number of procedures with 90-day global periods that will be impacted: percutaneous valvuloplasty, AAA and TAA endovascular repair, carotid stenting, and now the new initial placement TMVR code. December 15,

20 Enhanced Transparency in Rate-setting Under the new model providers will no longer have to wait for the Final Rule each year in order to learn what CMS decided about valuations for new and revised codes. Instead, going forward, if CMS received RUC recommended values by Feb. 15 of the preceding year, CMS will present their proposed values for these new/revised codes in the proposed rule typically issued in early July of each year. New CPT-RUC Schedule December 15,

21 New Transparency in Rate Setting New Category I Transcatheter Pulmonic Valve Implant (TPVI) Code has in the pipeline will benefit from the new transparency in rate setting CMS Will Track Claims fromoff-campus Provider-Based Departments Expect physician claims to require use of a new offcampus provider-based department place of service (POS) code CMS is working on getting the new POS code issued sometime in 2015 Expect hospital off-campus provider-based department claims to require modifier use will be monitoring these developments closely, so we can provide accurate and timely guidance to our members as CMS issues new billing requirements throughout December 15,

22 Specialty Designation C3 Interventional Cardiology More Accurate Physician Profiles and Fair Comparison Quality of care performance scores are linked to your physician profile. The specialty designation will help assure that these scores are like-for-like comparisons with other interventionalists. Using another specialty code may adversely result in comparison of your performance data with less intensive specialists such as internal medicine or general cardiology resulting in the perception of poorer quality of care. Public perception and choice in selecting providers may be influenced by these scores. Quality of care performance scores may be used by private payers in their quality programs, trial lawyers in litigation, hospital administrators in determining new hires, patients choosing a physician, and the media. December 15,

23 Reduction In Denied Claims The new specialty code will allow for the reporting of the involvement of two or more physicians providing distinct services to an individual patient. Medicare contractors use specialty code data to develop claims processing edits to help identify potentially duplicative care provided by members of the same specialty. The specialty code designation will afford billing for new patient evaluations by two physicians on the same day of care. More Accurate Utilization Data The Society, and the public, will be able to obtain better estimates of the total number of interventionalistssubmitting claims to Medicare. This data will have direct application in advocacy efforts with policy makers with the goal to create a better regulatory environment for this specialty. The data, showing the total number of interventionalists, may also demonstrate that this specialty, as an aggregate, has better performance scores as a field of medicine relative to others. December 15,

24 Q & A Resources Available Dawn Gray Dgray@.org Coding Mailbox Coding@.org December 15,