Medicare 101: Basics of CPT. Part B Provider Outreach and Education February 11, 2015

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1 Medicare 101: Basics of CPT Part B Provider Outreach and Education February 11, 2015

2 Housekeeping Tips When you called in, did you enter your attendee code? Dial-in number: Attendee (participant) Code: The audio portion of the conference may be accessed via the telephone or by using your computer speakers The preferred method of listening is via the toll-free number Ensure the address provided during registration is correct and make sure that your SPAM filter is turned off for items coming from Handout is located under LINKS on top toolbar section of web platform 2

3 DISCLAIMER This resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited. CPT Disclaimer American Medical Association (AMA) Notice and Disclaimer Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA). Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

4 Agenda Medicare Coding System Background ohcpcs Level Code Sets Coding Manuals and Tools Medicare Updates Resources 4

5 Background Healthcare Common Procedure Coding System (HCPCS) o Divided into two principal subsystems o Referred to as Level I and Level II Level I code set known as the HCPCS numeric coding system (comprised of Current Procedural Terminology (CPT-4) Level II code set known as the HCPCS alphanumeric procedure codes Goal = Standardization of Coding Systems 5

6 Current Procedural Terminology (CPT) (Level I HCPCS) Developed in 1966 Maintained by the American Medical Association (AMA) For reporting medical services and procedures o Performed by physicians, non-physician practitioners and suppliers Provides uniform language to describe medical, surgical and diagnostic services 6

7 CPT Manual Providers can find quick reference guides for: o Symbols used in the CPT manual o Illustrated anatomical and procedural review o Commonly billed modifiers (definitions located in Appendix A) o Place of Service Codes and their descriptions Available in the inside cover pages *Based on the CPT-4 Standard Edition 7

8 CPT Manual Section Numbers and their Sequences Divided into 6 main sections *Based on the CPT-4 Standard Edition 8

9 CPT Manual You will also find the: Category II codes set of tracking codes used for performance measurement Codes described with 4 digits followed by the letter F Category III codes contains a set of temporary codes for emerging technology, services and procedures Codes described with 4 digits followed by the letter T *Based on the CPT-4 Standard Edition 9

10 CPT Manual Appendix Listing Appendix A Appendix B Appendix C Appendix D Modifiers Summary of Additions, deletions and revisions Clinical examples of E & M services Summary of CPT add-on codes Appendix E Summary of CPT codes exempt from Modifier 51 Appendix F Summary of CPT codes exempt from Modifier 63 Appendix G Appendix H Summary of CPT codes that include moderate (conscious) sedation Alphabetical clinical topics listing *Based on the CPT-4 Standard Edition 10

11 CPT Manual Appendix Listing Appendix I Appendix J Appendix K Appendix L Appendix M Appendix N Appendix O Genetic testing code modifiers Electrodiagnostic medicine listing Product pending FDA approved Vascular families Deleted CPT codes Summary of resequenced CPT codes Multianalyte assays with algorithmic analyses *Based on the CPT-4 Standard Edition 11

12 Instructions for Use of CPT Select code that most accurately identifies service performed If no procedure code exists, report appropriate unlisted code Medical record documentation must support service billed Must bill using code that is valid for date of service *Based on the CPT-4 Standard Edition 12

13 Add-on Codes Describe additional intra-service work associated with primary procedure Codes must be reported with primary procedure o Never reported as a stand-alone code Add-on codes apply only to services performed by same physician Designated by the symbol Also listed in Appendix D of CPT *Based on the CPT-4 Standard Edition 13

14 Add-On Code Example Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions each additional 10 lesions, or part thereof Hint: Look for the statement List separately in addition to code for primary procedure *Based on the CPT-4 Standard Edition 14

15 Unlisted Procedure Codes Used to report services or procedures not found in CPT manual when: A procedure does not yet have an assigned code The service performed is a variation of a defined procedure code Unlisted codes are found in the guideline sections for E&M, Surgery and Medicine *Based on the CPT-4 Standard Edition 15

16 Unlisted Procedure Codes Service represented by unlisted procedure code must be described on claim Paper claim, in Item 19 of CMS 1500 form Electronic claim, in narrative or free-form field Give explanation or narrative for service

17 Alpha-Numeric HCPCS Codes (Level II HCPCS) Developed in 1983 Maintained by the Centers for Medicare and Medicaid Services (CMS) asecodesets/alpha-numeric-hcpcs.html Billing of services/procedures not in CPT Primarily supplies, materials and injections Ambulance services *Based on the HCPCS Level II Professional 17

18 Alpha-Numeric HCPCS Codes Instructions Identify the services or procedures Look up the appropriate term Assign the appropriate code *Based on the HCPCS Level II Professional 18

19 Alpha-Numeric HCPCS Manual Introduction o Commonly used symbols and definitions o Index organized by description and alpha-numeric codes o Categories of procedures, services and supplies 19

20 Alpha-Numeric HCPCS Manual Category Transportation Services Medical & Surgical Services Procedures & Professional Services (temporary) Drugs (other than oral) Chemotherapy drugs Medical Services Pathology & Laboratory services Q codes Alpha-Numeric Listing A0000 A0999 A4000 A8999 G0008 G9147 J0000 J8999 J9000 J9999 M0064 M0301 P2028 P9615 Q0035 Q9968 HCPCS Sequence *Based on the HCPCS Level II Professional 20

21 Alpha-Numeric HCPCS Manual Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix Table of drugs Modifiers (alpha-numeric) Abbreviations/Acronyms Publication 100 References (CMS Internet Only Manual) New, Changed, Deleted & Reinstated Place of Service *Based on the HCPCS Level II Professional 21

22 Procedural Coding Tools Medicare Physician Fee Schedule Database (MPFSDB) File National Correct Coding Initiative (NCCI) Edits Durable Medical Equipment (DME) Jurisdictional Chart Preventive Services Quick Reference Chart 22

23 The MPFSDB is the acronym for the Medicare Physician Fee Schedule Database. It is also known as the Relative File. Affects payment profile MPFS Database File Changes are made quarterly CMS controls the edit process File has over 10,000 physician services which contain the associated relative value units (RVUs), fee schedule status indicators, and various payment policy indicators (i.e., payment of assistant at surgery, bilateral surgery) 23

24 Common MPFSDB Denials Status Indicators Status indicators is a category listed on the MPFSDB file The indicator description will provide details when (not an allinclusive list) A code is deemed active Bundled for payment Carrier-priced procedure Procedure codes are most commonly denied when they have a status indicator of B = Bundled code D = Deleted codes I = Code is not valid for Medicare purposes N = Non-covered services 24

25 Where to Locate the MPFS File Cahaba GBA Website Visit the Cahaba GBA website at From the Home Page go to Part B Quick Links Click on the Schedules and select the appropriate year Print and copy the MPFSDB Indicator File Descriptors; and, Download the National MPFS Relative Value File 25

26 Where to Locate the MPFS File CMS Website 26

27 National Correct Coding Initiative (NCCI) Edits within the claim processing systems for dates of service on or after January 1, 1996 Implemented to prevent improper payment when incorrect code combinations are reported Based on coding conventions defined in the American Medical Association s CPT manual, national and local policies, coding guidelines developed by national societies, etc. NCCI updates are made quarterly 27

28 NCCI Edit Files The NCCI file consist of the Column One/Column Two coding edits Part B providers use the Physician CCI Edits searchable database CMS has created a manual titled How to Use the Medicare NCCI Tools Dedicated NCCI website located at nited/index.html 28

29 NCCI Add-On Codes CMS has divided the add-on codes into three groups Type I: Limited number of identifiable primary procedure codes Type II: Does not have a specific list of primary codes Type III: Some specific primary procedure codes identified in the CPT manual CMS updates the list annually on January 1 Quarterly updates are posted as necessary on April 1, July 1 and October 1 each year 29

30 NCCI Add-On Codes NCCI Add-On Codes 30

31 2015 Durable Medical Equipment HCPCS Jurisdiction List A chart which lists HCPCS codes to determine the responsible contractor to bill DME related services It will include the HCPCS, description and jurisdiction 2015 DMEPOS Jurisdiction List is located at HCPCS Description Jurisdiction A A0999 Ambulance Services Local Carrier A A4209 Medical, Surgical, and Self- Administered Injection Supplies Local Carrier if incident to a physician's service (not separately payable). If other, DME MAC. A4210 Needle Free Injection Device DME MAC This is not an all-inclusive list 31

32 Medicare Preventive Services Aortic Aneurysm Screening Adult Immunizations Annual Wellness Visit; Including Personalized Prevention Plan Services Bone Mass Measurements Cancer Screenings Cardiovascular Screening Diabetes Screening Diabetes Self-Management Training Diabetes Supplies Glaucoma Screening HIV Screening Initial Preventive Physical Exam ("Welcome to Medicare" Physical Exam) Intensive Behavioral Therapy for Cardiovascular Disease Intensive Behavioral Therapy for Obesity Medical Nutrition Therapy (for Medicare beneficiaries with diabetes or renal disease) Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse Screening for Depression in Adults Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling to Prevent STIs Tobacco-Use Cessation Counseling Services Network-MLN/MLNProducts/PreventiveServices.html 32

33 Quick Reference Preventive Services 33

34 CMS Internet Only Manuals Medicare Claims Processing Manual Ch. 12, Physicians/Nonphysician Practitioners (NPP) Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Medicare Claims Processing Manual Ch. 18, Preventive and Screening Services Guidance/Guidance/Manuals/downloads/clm104c18.pdf 34

35 Claim Submission Errors Procedure Codes Providers should be mindful to avoid the following: Procedure codes that are deleted or invalid for Medicare purposes Submitting claims with a transposed codes Appending the incorrect modifier Procedure codes billed with the wrong place of service Codes submitted to Medicare Part B in error 35

36 Claim Submission Error Example Incorrect Correct

37 Claim Submission Error Example Incorrect Correct

38 Claims Issue Log Current status of issues affecting Part B Medicare claims 38

39 HCPCS Release Information National Technical Information System (NTIS) Call NTIS at or visit to order the following: 2015 Alpha-Numeric HCPCS on CD-ROM (including paper documentation) Stock number: PB CPT-4 Code Information Contact the American Medical Association: Telephone number Visit the AMA store via their website at HCPCS manuals can be found at your local bookstore 39

40 Medicare Resources HCPCS Release & Code Sets found on the CMS website at /index.html Stay up to date with the latest Remittance Advice Reason and Remark codes from the Washington Publishing Company Search the Cahaba GBA website for General Medicare Billing references at https://www.cahabagba.com/partb/education/general-billing-information-2/ 40

41 CMS Internet Only Manual CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 23, Fee Schedule Administration and Coding Requirements CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 23, Section 20, Healthcare Common Procedure Coding System (HCPCS) CMS Manual System, Pub 100-9, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 6, Section , Responding to Coding Questions 41

42 Acronyms Participants can view a list of acronyms used during today s webinar by accessing the glossary section on the Cahaba GBA website,

43 CMS and Cahaba GBA 2015 Medicare Updates 43

44 Chronic Care Management CPT code non face-to-face care management/coordination services Available for Medicare beneficiaries having multiple (two or more) chronic conditions CMS is encouraging providers to refer to the 2014 PFS final rule (CMS-1600-FC) and 2015 PFS final rule (CMS-1612-FC) 44

45 Chronic Care Management CMS will be hosting a National Provider Call Payment of Chronic Care Management Services Register at 45

46 CMS will be sponsoring the classes Available for online and inperson Road to ICD-10 They will offer more than 50 classes March, April and May Classes include specialty references 46

47 Transitioning to Jurisdiction J CMS awarded Jurisdiction J (JJ) A/B Medicare Administrative Contractor on September 17, 2014 Administration of Medicare Part A and Part B Alabama, Georgia and Tennessee Part B workload will assume full responsibility on July 1, 2015 Watch the Cahaba GBA website for communication throughout the implementation and transition 47

48 InSite Recertification Cahaba GBA will be conducting mandatory recertification for InSite Local Security Officers and users Recertification period is scheduled for February 15 through April 15, 2015 All MACs are required by the Centers for Medicare and Medicaid Services 48

49 Questions? Provider Contact Center:

50 We would like to encourage everyone to complete the Post- Test assessment. Test Your Knowledge The link was sent to you in an notification. Feel free to share it with members of your staff that attended today s event with you. You will need to complete the online test at 50

51 Evaluate Today s Webinar Event We value your opinion and appreciate your feedback and comments regarding today s event Take a moment to complete the Online Evaluation upon conclusion of the webinar We appreciate your feedback and thank you for your participation! 51

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