3/21/2012. Palmetto GBA NIVT LCD - Parts A and B. Patient population Private insurance applicability Transparency

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1 1. LCD s 2. Ordering and signature requirements 3. CPT and ICD-9 coding 4. Reports 5. Risky practices 6. Case Studies Rita Shugart, RN, RVT, FSVU Shugart Consulting March 21, 2012 LCD s -Medicare payer policies that identify circumstances under which services will be (or will not be) considered covered, correctly coded, and possibly reimbursed Patient population Private insurance applicability Transparency LCD s typically include: Technical Staff Credentialing Facility Accreditation Physician Qualifications Diagnosis codes considered medically necessary Types of exams covered Types of exams not covered Frequency of repeat exams Documentation requirements Palmetto GBA NIVT LCD - Parts A and B ContractorName ContractorNumber Palmetto GBA opens in new window Back to Top LCDInformation DocumentInformation LCDIDNumber L31712 LCDTitle Noninvasive Vascular Testing (NIVT) Contractor'sDeterminationNumber L6607 AMACPT/ADACDTCopyrightStatement CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. ContractorType MAC Part B PrimaryGeographicJurisdiction opensinnewwindow North Carolina OversightRegion Region IV OriginalDeterminationEffectiveDate For services performed on or after 03/19/2011 OriginalDeterminationEndingDate RevisionEffectiveDate For services performed on or after 02/15/2012 RevisionEndingDate Vascular studies must be: 1. performed by or under direct supervision of credentialed persons OR 2. performed in accredited lab Examples of appropriate certification/accreditation: ARDMS RVT ARRT(VS) ICAVL ACR All credentialed laboratories extending their noninvasive vascular testing to include additional CPT codes have 12 months to become accredited for the new CPT codes. It is expected that all labs, after receiving accreditation, maintain credentialed personnel on staff to perform and supervise these procedures. Laboratory accreditation should be specific to the testing being performed. 1

2 1. Evaluation of patients with hemispheric neurologic symptoms, including stroke, transient ischemic attack, and amaurosis fugax. 2. Evaluation of patients with a cervical bruit. 3. Evaluation of pulsatile neck masses. 4. Evaluation of blunt neck trauma. 5. Evaluation of postoperative patients following carotid surgery. 6. Evaluation of suspected subclavian steal syndrome. 7. Preoperative evaluation in patients scheduled for major cardiovascular surgical procedures. 8. Intraoperative monitoring of vascular surgery. For a patient with stenosis of %, surgery is commonly performed If not performed, further surveillance is not usually necessary, unless symptoms are progressive 1. The evaluation of hemodynamic effects of severe stenosis or occlusion of the extracranial arteries greater than or equal to 60% diameter reduction or major basal intracranial artery stenosis greater than or equal to 50% diameter reduction. 2. Detection and serial evaluation of cerebral vasospasm due to subarachnoid hemorrhage h (spontaneous or traumatic). 3. Evaluation of cerebral arteriovenous malformations when surgical intervention is an option. 4. Intraoperative and perioperative monitoring of intracranial hemodynamics during carotid endarterectomy. 5. Evaluation of cerebral embolism. 6. Evaluation of hemodynamics in suspected brain death. Dizziness, not associated with localizing symptoms Headaches Brain tumors Familial and degenerative disease of the central nervous system Psychiatric i disordersd Epilepsy Migraine Intraoperative monitoring during major surgery other than intra or extracranial cerebrovascular surgery Assessment of physiologic and pharmacologic responses of cerebral arteries 1. For a patient with stenosis of 20-49%, annual follow-up may be necessary 2. For a patient with stenosis of 50-80%, repeat studies no more than every 6 months Post Endarterectomy Surveillance: 6 weeks, 6 months and Annually thereafter Annually thereafter Recurrent or new neurological events 3. For a patient with stenosis of %, surgery is commonly performed If not performed, further surveillance is not usually necessary, unless symptoms are progressive 2

3 1. Clinical instability of patients with intracranial hemorrhage or intracranial vascular surgery 2. Inconclusive study for brain death Part B, Outpatients Part A, Inpatients All states except: 30 states +jurisdictions: AR, CO, CT, DE, FL, IL, IN, AZ, AK, MT, ND, OR, SD, UT, WA, WY (Noridian) IA, KS, KY, LA, MD, MI, MS, MO, MN, NC, NE, NJ, NM, NV, NY, OH, OK, PA, SC, TX, VA, WV, WI; DC, PR, VI MA, ME, NH, RI, VT (NHIC) Plus some providers in all states except NY where WPS is the FI asp?from2=index_lmrp_bystate_criteria.asp& Before you start, determine your MAC, Carrier, FI Select state name Select Part A (inpatient) or Part B (outpatient) Accept License Agreement Look in alphabetical list of Active Policies for vascular testing (may be under several different letters) Also check Draft and Future Effective Policies Check frequently for updates, changes Local not used in every state Not applied to all providers within some states Frequent changes due to Medicare contractor reform Small specialties have little representation on CAC s Poorly written incomplete, contradictory, inaccurate, non-sensical, exhibit poor understanding of real practice Constant vigilance required Carotid Duplex TCD 3

4 Diagnostic tests must have orders from Treating Physician/Practitioner ALL orders should include type of exam and diagnosis/indication/reason for test Referring physician must document intent to order and reason for exam in his/her office notes Maintain copies of orders in case of audit Follow regulations for additional/un-ordered tests A physician /practitioner as defined under the SS Act AND Who treats for a specific medical problem OR Who furnishes a consultation AND Who uses the results of the diagnostic test in the management of the specific medical problem Provide space for some, but not all, demographics Have clearly defined space for type of test, indication Have space for referring extra info, notes, instructions If ICD-9 codes are listed, avoid steering to only those codes that meet medical necessity Distribute to referring MD s offices as referral and marketing tool Medicare Benefit Policy Manual, Chapter 15, 80.6 Provider clearly identified Legible first and last names, credentials recommended Can be handwritten or Electronic Digitized Electronic Digital Not acceptable: Signature stamps Signed but not read Signature on File 4

5 Effective January 1, 2011 Clarification, more specific wording of definitions iti of CPT codes 93922, 93923, and Instructions can be found in the Introduction to Noninvasive Vascular Diagnostic Studies in the CPT Code Book CPT definition : LOWER Extremities ONLY TREADMILL stress testing ONLY MOTORIZED treadmill Bilateral Must include: At rest, immediately after, and at timed intervals after standardized protocol Time of onset of sx, max walking time, time to recovery One deletion: cerebrovascular physiologic studies (OPG, periorbital, spectral analysis) One addition Unlisted noninvasive vascular diagnostic study Read the CPT book Be sure that: The coder understands how to code vascular exams The exam performed fulfills the requirements of the billed CPT code Remember you may know more about the patient, vascular testing. and vascular diagnoses than the official coder The use of a simple handheld or other Doppler device that does not produce hard copy output, or that produces a record that does not permit analysis of bidirectional vascular flow, is considered to be part of the physical examination of the vascular system and is not separately reported. Noninvasive physiologic studies are performed using equipment separate and distinct from the duplex scanner. Photoplethysmography is NOT a covered service CPT 2012, AMA 5

6 A complete transcranial Doppler (TCD) study (93886) includes ultrasound evaluation of the right and left anterior circulation territories and the posterior circulation territory (to include vertebral arteries and basilar artery). In a limited it TCD study (93888) there is ultrasound evaluation of two or fewer of these territories. To report common carotid intima-media thickness (IMT) study for the evaluation of atherosclerotic burden or coronary heart disease risk factor assessment, use Category III code 0126T. CPT 2012, AMA Know the definition of the CPT Code; all components of the procedure as defined by the CPT Code must be included in the exam If the exam does not meet the definition of the CPT Code, another CPT Code or a modifier must be used The documentation (Report) must fully support the CPT Code on the claim Example 1: Billing CPT Code (Exercise Exam) for TOS exam or LE Exercise exam with toe-ups or walking in hallway Example 2: Billing CPT Code (Duplex Access) for evaluation of access site only Example 1: Billing CPT Code (LE Arterial Physiologic Ltd) for someone with an AKA. If only one extremity is examined, include Modifier -52 to indicate Reduced Service or less than service Example 2: Billing CPT Code (EC Car Dup, limited) for IMT. IMT is billed as Code G0126 Example 1: Billing CPT Code (UE Arterial Duplex complete) and report reads antegrade flow in vertebral arteries Example 2: Billing CPT Code (TCD complete) and report reads no evidence of intracranial ICA dissection 6

7 International Classification of Diseases Published by WHO MD s required to use for MCR reimbursement since Purposes: Describe medical necessity of a procedure Facilitate payment of health services Evaluate utilization patterns Permit study of appropriateness of health care costs Serve as basis for epidemiological studies Serve as basis for research into health care quality Code the diagnosis, symptoms, conditions or reasons responsible for the service being provided Code a confirmed or definitive diagnoses documented by the diagnostic test Do not use the initial referral indication if it is inaccurate Choose the ICD-9 code that provides the highest degree of accuracy and completeness Can not use rule out, suspected, probable, or questionable on outpatients Know the definition of the ICD-9 Code The patient s clinical condition, history, or the test results must meet the definition of the ICD-9 Code (Diagnosis Code) on the claim The exam documentation (Report) must fully support the ICD-9 Code on the claim Rest Pain Atherosclerosis with Rest pain Atherosclerosis of BPG of extremities, unspecified graft Atherosclerosis of autologous vein bypass graft Atherosclerosis of synthetic graft Example 1: Pt has Family history, but no personal history, of AAA Billing with ICD-9 Code 441.4, Aneurysm Abdominal Aorta, not ruptured and report reads no evidence of AAA Example 1: Billing with ICD-9 Code atherosclerosis with intermittent claudication, and report describes burning, stinging in toes and feet Example 2: Billing with ICD-9 Code 435.9, TIA and report shows indication as headache 7

8 It Depends Which exams Reasons for exams (indications) Documentation How claim is filed NCCI MUE s Use of modifier Which exams Must not be bundled codes Reasons for exams Both exams must be medically necessary Documentation Both exams must meet LCD requirements Both exams must meet definition of billed CPT codes Separate ICD-9 codes not required, but good to use, if appropriate Report each exam separately to reflect the separate amount of work associated with each exam REPORTS Modifier Not Allowed (cannot be billed together): Review your Report Forms! Be sure that: Final Reports are complete, easy to understand CMS Ordering and Signature requirements are fulfilled Records are maintained as required by LCD, state law, other policies Report should stand alone (all necessary documentation included) Report should include space for required components of CPT code (i.e include space for all relevant intracranial arteries) Don t use Lab-specific names for Reports Don t combine documentation for two or more CPT codes on one Report form (i.e. Extracranial Carotid Duplex + TCD + IMT combined on one Comprehensive Cerebrovascular Evaluation Report) 8

9 Medical Necessity is established through Indications & Impression sections of the Report Indications: Use narrative/words, not only numerical ICD-9 code Be specific to that patient for that exam on that day Include relevant associated medical history Impression: Distinguish between ultrasound findings and Impressions/Conclusions (example: velocities and plaque morphology vs. % stenosis) Be as specific as possible, especially if results may change the ICD-9 coding on the claim (to make the ICD-9 more specific) Include important negative conclusions as well as positive conclusions 9

10 CerebrovascularDuplexScan Patient: Account#: DOB: StudyQuality: StudyDate: Room:Room3 ReferringPhysician: OrderingPhysician: CC: Indications:Followupof60 79%rightICAstenosiswithmaximumvelocitiesof273PSV/67EDVon lastexamofx/xx/11.thelefticahasknownocclusion.norecentrelatedsymptoms. Results Right Left PSV EDV Stenosis Plaque PSV EDV Stenosis Plaque (cm/s) (cm/s) (cm/s) (cm/s) ProxCCA DistCCA % ProxICA Occluded % MidICA Occluded % DistICA Occluded ECA Vertebral PatentEndarterectomy Antegrade VertebralFlow Retrograde Findings Right:ModeratefocalincreaseinICAvelocities. Left:SignificantplaqueandnoaudibleflowintheICA. Conclusions 1. ModeraterightICAstenosis,60 79%. 2. ICAocclusionontheleft. 3. Comparedtopreviousexam,theseresultsremainessentiallyunchanged. Sonographer: ReadingPhysician: ElectronicallysignedonX/XX/201210:47:33AM. 10

11 False statement or misrepresentation made or caused to be made that is material to entitlement or payment Incorrect reporting of diagnoses or procedures to maximize payments Billing for services not furnished Altering claim forms, electronic claim records, medical documentation, etc., to obtain a higher payment amount. Misrepresentations of dates and descriptions of services furnished or the identity of the beneficiary or the individual who furnished the services. Billing non-covered or non-chargeable services as covered items. Poor documentation of medical necessity through vague, inadequate, or incorrect Indications Ambiguous or lab-specific exam name unclear if it matches the billed CPT code Exam performed differs from order Documentation doesn t support billed CPT code Documentation doesn t support billed ICD-9 code Multiple tests on same date of service Continuing to bill for services or combinations of services that are usually denied Routine use of modifiers to bypass CCI and MUE edits Always billing complete exams Billing structural and vascular codes from the same body parts together Claims review something that stands out statistical outlier random sampling Pattern recognition Claim differences Part A versus Part B Diagnosis Coding Qui Tam suits RAC Target Signed Order from referring MD Referring MD s documentation of intent to order and reason for exam Exam performed by qualified technologist Final Report signed by qualified interpreting physician Final Report that documents all components of billed CPT code Final Report that supports all billed ICD 9 codes 11

12 Scenario: Cardiology office lab Surveillance of CEA pts: Exam performed w/no MD appt; If all is OK, RVT writes down time for next appt on bottom of encounter form; US appt made, still w/no MD appt Discovered during consultation Potential Issues: No order No documentation that MD is fulfilling resp as treating physician ( uses the results of the diagnostic test in the management of the specific medical problem ) Potential charge of medical negligence ( If a doctor fails to give a patient the proper tests, performs unneeded procedures, or fails to check progress after a procedure, he is committing medical negligence MedicalMalpracticeHelp.com) Outcome: Next appointment no longer made at Check Out MD completes Order Form as he/she reads each exam MD sends fu letter to patient regarding results of exam and time of next follow up appt Patients scheduled for appt with MD or PA at least every two years Scenario: IDTF located in state identified by OIG as having excessive us utilization Order by neurologists for Carotid dup + TCD Indications: dizziness, vertebral insufficiency Billed as 5 complete exams: Car dup, TCD, Car physiologic, UE Art Dup, UE art physiologic Potential Issues: Multiple studies (5) on same patient, same DOS Performing unordered exams No medical necessity for unordered exams Following internal protocols All requirements of billed CPT codes not met Located in high-utilization state Found by Medicare contractor audit to be statistical outlier with > 800% higher billing than comparable provider 12

13 Outcome: One audit becomes multiple audits Multiple personal and telephone meetings with MAC Repayment of $$$,$$$ Placed on Pre-Payment Audit Lab income decreased by 90%, consultant called Outcome: Testing Protocols, billing practices changed Off Pre-Payment Audit after 1 year Lab survived Scenario: Office-based vascular lab, owned by large hospital Orders for Bilateral UE Vein mapping prior to dialysis access placement Coded as CPT 93970, Venous Duplex Complete (x 2 years) Audit performed by Coding Consultant hired as result of complaint from vascular lab staff member Potential Issues: Exams were of bilateral cephalic veins only All requirements of billed CPT code were not met (bilateral exam, but limited (not complete) exam was performed) Outcome: Termination of Technical Director Voluntary re-payment of $$,$$$ to Medicare Threatened shut-down of facility by owner Complete audit of all lab coding/billing/exam protocols Some testing Protocols, billing practices changed Continuing compliance scrutiny of practice by hospital corporate owner No subsequent scrutiny by MAC (? Yet) Scenario: Order reads Carotid duplex exam for rule out CVA Billed as Carotid duplex exam - CPT 93880/dx CVA + TCD Complete - CPT 93886/dx CVA + Carotid Duplex Limited CPT 93882/dx CVA included only intracranial carotid arteries was actually for an IMT exam Discovered incidental to consultation for separate matter Potential Issues: Performing unordered exams No medical necessity for unordered exams Following internal protocol All requirements of billed CPT code not met Billing IMT exam (Cat III Code) as reimbursable code Billing rule out diagnoses as true diagnoses on clam 13

14 Outcome: Testing Protocols, billing practices changed 14