676$$76 &2',1* 1(:6/(77(5 Recent Information on CPT and ICD-9 CM Codes for Cardiothoracic Surgeons

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1 N E W S L E T T E R Vol. 13 No. 3 & 4, Fall/Winter , The Society of Thoracic Surgeons, Chicago, IL INSIDE &RGLQJ&KDQJHV1DWLRQDO&RUUH W&RGLQJ,QLWLDWLYH'25 3UR HGXUH&RGLQJ:RUNVKRSV4 $ Clarification on Coding the DOR Procedure Coding Changes. 1 NCCI Bundling Edits. 2 Coding Workshops.. 5 Q & A Coding Hotline 7 The STS/AATS Coding Newsletter is published under the auspices of the STS/AATS Workforce on Nomenclature and Coding Keith Naunheim, M.D., Chair STS/AATS Workforce on Nomenclature and Coding Julie R. Painter, Editor th Street, Suite 1000 Denver, CO Telephone: (720) Fax: (720) juliepainter@physiciancoding.com (NOTE: NEW ADDRESS!) 676$$76 &2',1* 1(:6/(77(5 Recent Information on CPT and ICD-9 CM Codes for Cardiothoracic Surgeons & /$5,),&$7,21 21 & 2',1* )25 7+( ' &('85( In recent discussions with the Centers for Medicare Services (CMS) and the American Medical Association (AMA), it was determined that procedure code Myocardial resection (e.g., ventricular aneurysmetcomy) with the -22 modifier should only be used to report a DOR procedure that includes actual resection of myocardium. This should be reflected in your operative documentation. Otherwise, for DOR/SAVER or other types of ventricular restoration procedures, code Unlisted procedure, cardiac surgery should be reported if no myocardium is resected. CMS has a National Coverage Decision (NCD), 20.26, which considers the Batista procedure as non-covered. The NCD reads as follows: Item/Service Description Partial ventriculectomy, also known as ventricular reduction, ventricular remodeling, or heart volume reduction surgery, was developed by a Brazilian surgeon and has been performed only on a limited basis in the United States. This procedure is performed on patients (Continued on page 5) &2',1* & +$1*(6 M EDICARE C HANGES The final Medicare Rule for the 2005 Physician Fee Schedule brought few changes for cardiothoracic surgery. The main provisions affecting cardiothoracic surgery include the 1.5 percent update of the Conversion Factor resulting in a Conversion Factor of $ effective Jan. 1, The 1.5 percent increase is the result of statutory updates, meaning Congress passed a law to ignore the scheduled Medicare SGR formula cuts, and authorize an increase. For 2006 through 2012, the formula mandates DECREASES of 5 percent per year for seven years. As in previous years when this threat has occurred, this will be a priority and the STS/AATS will solicit members for assistance in preventing these potential cuts. As a result of the MMA, Medicare benefits now include an initial preventive physical examination, including new cardiovascular blood test screening benefits. The final rule also published the announcement regarding the five-year refinement of physician work relative value units. The STS and AATS have anticipated this and will respond with a list of misvalued codes that the societies have identified to be considered in the review. Many of you have already responded with your (Continued on page 6)

2 0 (',&$5( 1 $7,21$/ & 255(&7 & 2',1*, 1,7,$7,9( 1&&, CMS developed the NCCI to promote national correct coding methodologies. The NCCI polices are based on the following: coding conventions defined in CPT, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and review of current coding practice. The NCCI went into effect on January 1, 1996 and is administered by AdminaStar Federal, Inc. The NCCI is updated quarterly. The current version of the NCCI is Version 11.0, which is effective from Jan. 1, 2005 March 31, Unbundling occurs when multiple procedure codes are used to report several procedures that could have been reported under a single more comprehensive code. CMS has developed a set of general correct coding policies which explain the principles under which codes are generally bundled. There are two bundling tables in the NCCI. One table bundles column 1 and column 2 codes. Generally this table will represent the most comprehensive code in column 1 and then the component codes in column 2. The code that will be paid if both codes are reported together is the column 1 code. The second table bundles the mutually exclusive code pairs. The mutually exclusive code pairs generally represent codes that cannot reasonably be done in the same session. This table also represents codes in two columns;however, in this case, if both codes are submitted, only the lowest paid procedure will be paid. The following policies encompass the general issues and coding principles that the CCI edits are based on: Standards of Medical/ Surgical Practice. All services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. EXAMPLE: Performance of a diagnostic bronchoscopy (31622) prior to a thoracic procedure, i.e., lobectomy (32480) are bundled under this definition and should not be separately reported assuming that the diagnostic bronchoscopy has already been performed for diagnosis and biopsy and the surgeon is simply evaluating for anatomic assessment for resection. The diagnostic bronchoscopy is considered as scouting and represents a part of the assessment of the surgical field to establish anatomical landmarks, extent of disease, etc. Medical/ Surgical Package. In general most services have pre-procedure and post-procedure work associated with them; when performed at a single patient encounter, the pre- and postprocedure work does not change proportionately when multiple services are performed and the nature of the work is reasonably consistent across procedures. Pre- and post procedure work that is considered part of a surgical procedure includes some of the following: obtaining and monitoring vascular and/or airway access, such as visualization (i.e., bronchoscopy); anesthesia provided by the performing physician; cardiopulmonary monitoring including cardiac, EKG, oximetry or ventilation management; exploration of the surgical field to determine the anatomic nature of the field and evaluate for anomalies; access through abnormal tissue (i.e. scarred or diseased tissue) to reach the definitive surgical site; surgical approach should be reported using only the most definitive or comprehensive procedure preformed, multiple approaches should not be reported for a single service; endoscopic services to establish the location, confirm presence, establish anatomic landmarks, or define the extent of a lesion; treatment of complications during an operative session before the patient is released from the operating room or procedure suite; or nondiagnostic biopsy obtained and subsequently excision, removal, destruction or other elimination of the biopsied lesion is accomplished. This does not include situations where the decision to perform a more comprehensive procedure is based on the biopsy result. EXAMPLE: While the Medical/Surgical Package is one of the NCCI guidelines that can be used to bundle procedures, there are currently no codes bundled in the NCCI under this definition. Some payers may have edits under this guideline that are not printed in the NCCI. Evaluation and Management Services. It is inappropriate to report an E/M service with an XXX global period procedure unless the physician performs a significant and separately identifiable E/M service on the same day of the service. EXAMPLE: There are currently no edits under this (Continued on page 3)

3 (Continued from page 2) guideline that pertain to cardiothoracic procedures. Anesthesia Service Included in the Surgical Procedure. Anesthesia provided by the physician furnishing the medical or surgical service is not separately reportable. EXAMPLE: Codes (pneumonectomy) and (injection, anesthetic agent; intercostal nerve, single) represent a bundling edit under this guideline. Coding Services Supplemental to a Principal Procedure (Add-on codes). Add-on codes identify services that are performed in certain situations as an additional service or a commonly performed supplemental service complementary to the primary procedure. Incidental services that are necessary to accomplish the primary procedure (i.e. lysis of adhesions) are not separately reported. Using non-supplemental codes that approximate part of a more comprehensive procedure but do not describe a separately identifiable service is not appropriate. EXAMPLE: There are currently no edits under this guideline that pertain to cardiothoracic procedures. HCPCS/CPT Procedure Code Definition. CPT code descriptors may act to bundle codes in two ways. First, many CPT code descriptions are not listed in their entirety. The partial description is indented under the main entry, and constitutes what is always followed by a semicolon in the main entry. The main entry then encompasses the portion of the description preceding the semicolon. The main entry applies to and is a part of all indented entries which follow. The second is that a CPT descriptor may define a NCCI relationship where one code is part of another based on the language examples include: partial and complete, partial and total, unilateral and bilateral, single and multiple, or with and without. EXAMPLE: (repair of hypoplastic or interrupted aortic arch; without cardiopulmonary bypass) and (repair of hypoplastic or interrupted aortic arch; with cardiopulmonary bypass) represent this guideline. HCPCS/ CPT Coding Manual Instructions/ Guidelines. CPT Manual instructions in each of the six major sections of the book and several of subsections of the book include guidelines that may define items or provide explanations that are necessary to appropriately interpret and report procedures or services and define terms that apply to that particular section. In addition parenthetical notes may also define usage of the code. EXAMPLE: Codes (mitral valve replacement) and (exploratory cardiotomy, with cardiopulmonary bypass) are bundled under this guideline. Separate Procedure. Some CPT codes include the parenthetical statement (Separate Procedure) in the definition. The inclusion of this statement indicates that the procedure, while possible to perform separately, is generally included in a more comprehensive procedure and the service should not be billed when a related, more comprehensive service is performed. When a related procedure from the same section, subsection, category, or subcategory is preformed, a code with the designation of separate procedure is not be billed with the primary procedure. EXAMPLE: 32141(excisionplication of bullae) and (total pulmonary decortication) are bundled under this guideline. Family of Codes. In a family of codes, there are two or more component codes that are not billed separately because they are included in a more comprehensive code. The component codes, as members of the comprehensive code family, represent parts of the procedure that should not be listed separately when the complete procedure is done. However, the component codes are considered individually if performed independently of the complete procedure and if not all the services listed in the comprehensive codes were rendered to make up the total service. EXAMPLE: There are currently no edits under this guideline that pertain to cardiothoracic procedures. More Extensive Procedure. When procedures that are basically the same or are performed on the same site are qualified by an increased level of complexity, only the more extensive procedure should be reported. Examples include simple and complex, limited and complete, simple and complicated, superficial and deep, intermediate and comprehensive, incomplete (Continued on page 4)

4 (Continued from page 3) and complete, and external and internal. EXAMPLE: (four vein CABG) and (single vein CABG) are bundled under this definition. Sequential Procedures. If an initial approach to a procedure is followed at the same encounter by a second, usually more invasive approach and there are separate CPT codes describing each service, the second procedure is usually performed because the initial approach was unsuccessful in accomplishing the medically necessary service. Only the CPT code for the more invasive procedure should be billed. EXAMPLE: (Excision of mediastinal cyst) and (find needle aspiration; without imaging guidance) are bundled under this concept. Laboratory Panel. Components of a specific organ or disease-oriented laboratory panel should not be separated out of the more comprehensive panel code. Example: This edit is generally specific to pathology services. Misuse of Column 2 Code with Column 1 Code. CPT codes describing services or procedures that would not typically be performed with other services or procedures but may be construed to represent other services have been identified and paired with the column 1 CPT codes. Additionally, pairs of codes have been identified which would not be reported together because another code more accurately describes the services performed. EXAMPLE: (ascending aorta repair) and (transthoracic mediastinotomy with exploration) are bundled under this concept. Mutually Exclusive Procedures. Mutually exclusive codes are those that cannot reasonably be done in the same session. For example, repair of an organ can be performed by two different methods. Only one repair method should be billed. Mutually exclusive codes are based on CPT definition such as initial and subsequent or the medical impossibility/ improbability that the procedures could be preformed at that same session. EXAMPLE: Codes (prosthetic aortic valve replacement) and (stentless aortic valve replacement) are considered mutually exclusive codes. Excluded Service. Services identified as excluded from coverage under the Medicare program are not addressed in the CCI bundling edits. Unlisted Service or Procedure. The unlisted service or procedure codes are not included in the CCI bundling edits because of the multiple procedures that can be assigned to these codes. The NCCI policies discussed above provide general information as to why codes may be bundled in the NCCI. There are always situations that arise that may be considered an exception to the rule. For situations where column1/colum 2 or mutually exclusive codes are appropriately furnished, modifiers have been developed to allow for the coding pairs to be unbundled. Each code pair is assigned an indicator. A 0 indicator with a code pair means that the NCCI unbundling modifiers cannot be used and the codes can never be reported together. A 1 indicator means that in certain situations it may be appropriate to unbundled a code pair and one of the NCCI unbundling modifiers can be used. If one of the NCCI modifiers are used to unbundle one of the NCCI coding pairs, the modifier should be appended to the column 2 code or to the lowest paid procedure for the mutually exclusive code pairs (or the one in jeopardy of being denied). The physician must provide documentation in the patient s medical record supporting the use of the modifiers. The unbundled codes will still be subjected to the multiple surgery reduction (modifier -51) all that the NCCI modifiers accomplish is to allow payment on the second code when it would otherwise be denied. The NCCI modifiers that will most commonly be used by cardiothoracic surgeons include the following: -58 Staged or related procedure or service by the same physician during the postoperative period. The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive then the original procedure; or c) for therapy following a diagnostic surgical procedure. (CPT 2004) EXAMPLE: If (limited thoracotomy for lung or pleural biopsy) is performed and then based on the results of that biopsy, the physician makes the final determination as to if the patient needs a more definitive procedure such as a wedge resection (32500) or a lobectomy (32480), or if the physician uses the results of the biopsy to determine the type of resection required such as a bilobectomy (Continued on page 5)

5 (Continued from page 4) (32482) vs. a lobectomy (32480), the physician should clearly document this in his/her records and append the -58 modifier to code (biopsy) to pull it out of the bundling edits. -59 Distinct Procedural Service. Under certain circumstances the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. It is used to identify procedures/ services that are not normally reported together, but are appropriate under the circumstance. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. (CPT 2004) EXAMPLE: If an atrial thrombus is removed (33315) at the same time as a single arterial CABG (33533), a separate incision into the heart to remove the thrombus is required and represents distinct work. Modifier -59 should be appended to code to indicate that it was a distinct procedure and to pull it out of the bundle. Code will still be subject to the multiple procedure (modifier 51) reduction. -78 Return to the Operating Room for a Related Procedure During the Postoperative Period. The physician may need to indicate that anther procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room. (CPT 2004) EXAMPLE: If a patient is returned to the OR on the same day for bleeding (35820) after a mitral valve replacement (33430), modifier -78 should be appended to code to pull it out of the bundle. -79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period. The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. (CPT 2004) EXAMPLE: If a patient had a transthoracic mediastinotomy (39010) for exploration of a mediastinal mass and then later that day developed cardiac problems requiring a single venous CABG (33510), modifier -79 would be appended to to pull the procedure out of the bundle. It is important to consider both the NCCI bundling edits and the CMS Global Package discussed in the STS/AATS Coding Newsletter, Vol. 13, No. 2 (Summer 2004) when submitting claims. Not all of the services that are considered part of the global surgical package are captured in the NCCI bundling edits. However, you are still responsible for recognizing these services and reporting them separately only ccc when appropriate. (Continued from page 1) Clarification on Coding for the DOR Procedure with enlarged hearts due to endstage congestive heart failure. Partial ventriculectomy involves reducing the size of an enlarged heart by excising a portion of the left ventricular wall followed by repair of the defect. It is asserted that this procedure makes the failing heart pump better by improving the efficiency of the remaining left ventricle. Indications and Limitations of Coverage Since the mortality rate is high and there are no published scientific articles or clinical studies regarding partial ventriculectomy, this procedure cannot be considered reasonable and necessary within the meaning of 1862(a)(1) of the Social Security Act. Therefore, partial ventriculectomy is not covered by Medicare. In reporting the DOR/SAVER or other surgical ventricular reconstruction procedures, the CT surgeon must determine if the procedure he/she performs falls under the non-covered procedure, or if it is one of the newer, more effective techniques. The surgeon should document the procedure clearly. The primary difference in the Batista procedure and the newer techniques is the diagnosis and how the procedures are performed. The newer techniques are very precise as to where and how tissue is removed from the heart. ccc &2',1* : The 2005 Coding Workshop will be held Oct. 7-8 in St. Louis, Mo.There is only one Coding Workshop in Plan to attend. Please visit later this year for details. ccc

6 (Continued from page 1) 2005 Coding Changes willingness to participate in the survey process required to support potential changes in the work RVUs. If you would like to volunteer to participate in filling out surveys, please contact Julie Painter at or The Workforce on Nomenclature and Coding will hold a breakfast session at the STS Annual Meeting in Tampa, Fla. from 6:30-7:30 a.m. on Mon., Jan. 24. Please look for information on this meeting and plan to attend if you are concerned about current payments for cardiothoracic surgery procedures. This session will be used to further educate interested parties on the five-year review process as well as to collect some initial data needed to support this process. The fiveyear review is the only venue that will allow changes to physician payments. Our success in this process relies heavily on member participation CPT Changes New CPT codes for 2005 that may be used by cardiothoracic surgeons include the following: Bronchoscopy, rigid or flexible, with our without fluoroscopic guidance; with placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus Total Medicare RVU Global period Bronchoscopy, rigid or flexible, with our without fluoroscopic guidance; each additional major bronchus stented (List in separately in addition to code for primary procedure) (Use in conjunction with 31636) Total Medicare RVU Global period ZZZ Bronchoscopy, rigid or flexible, with our without fluoroscopic guidance; with revision of tracheal or bronchial stent inserted at previous session (includes tracheal/bronchial dilation as required) Total Medicare RVU Global period Insertion of indwelling tunneled pleural catheter with cuff (If imaging guidance is performed, use 75989) Total Medicare RVU - Facility Non-Facility Global period 000 Descriptor change to code Donor pneumonectomy (including cold preservation), from cadaver donor Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral Total Medicare RVU carrier priced, Part A payment Global period XXX Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral Total Medicare RVU 0.00 carrier priced, Part A payment Global period XXX Descriptor change to code Donor cardiectomypneumonectomy (including cold preservation) Backbench standard preparation of cadaver donor hear/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation Total Medicare RVU 0.00 carrier priced, Part A payment Global period XXX Descriptor change to code Donor cardiectomy (including cold preservation) Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for implantation Total Medicare RVU 0.00 carrier priced, Part A payment Global period XXX Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis (two docking limbs) Total Medicare RVU Global period 090 CPT has also added a new symbol to the book for The symbol looks like this Q and indicates that a CPT code includes conscious sedation. This means that conscious sedation provided by the surgeon should not be reported with the procedure code if conscious sedation is used. Cardiothoracic codes that have this symbol include the following: , 31635, , 32019, 32020, 32201, 33010, 33206, 33207, 33208, 33210, 33211, 33212, 33213, 33214, 33216, 33218, 33220, 33222, 33223, 33233, 33234, 33235, 33240, 33241, 33244, and A full explanation and list of codes can be found in Appendix G of the CPT book.

7 ccc 4 8(67,216 $ 16:(56 Q: How do you report a bilateral, bidirectional Glenn procedure? A: The bidirectional Glenn code (33767) is not recognized by most payers as a bilateral code; therefore, it would be inappropriate to report the procedure using a -50 modifier. The STS andaats are currently in the process of obtaining a new add-on code for this situation; however, that will not be available until In the meantime, you will need to work with your payers regarding the best method of reporting this procedure. Options include appending the -22 modifier to the procedure code, using the unlisted code 33999, or reporting the procedure with a 2 in the units' box and applying the multiple procedure reduction (modifier -51). Payers may or may not recognize the additional work of a bilateral, bidirectional Glenn procedure. Q: How do I report multiple VSD repairs? A: The STS/AATS is considering requesting a new add-on code for this situation. The STS/AATS recognize that there is extra work involved in the closure of additional VSD's, which includes extra time on bypass, difficulty in locating, assessing, and securely closing the additional VSD's, especially those on the trabeculated portion of the ventricular septum. In addition, a separate incision into the right or left ventricle may also be required. However, at this time, there is no code to account for the extra work. As with the previous question, there are several ways in which you could account for the extra work for closure of multiple VSD's. One option would be to append the -22 modifier to the VSD code;you could also use the unlisted procedure code to report the service, or you could indicate the appropriate number or repairs in the units' box. Again, payers may or may not recognize payment for this procedure. Q: How do I report pericardial reconstruction with Goretex? A: Pericardial reconstruction using Goretex should be reported by appending the -22 modifier to the main procedure code or by using the unlisted cardiac code, As a reminder, if you use the -22 modifier, you will need to submit a cover letter explaining the use of the modifier (most payers look for 20%-30% more work then described by the procedure) and the operative report. If you use the unlisted code, you will also need to send in a cover letter and the operative report. In the cover letter, you will want to establish a value for the procedure and the best way to do this is for the surgeon to select an existing CPT code that has similar time, effort, and risks involved, and use the total RVU for that code to establish value for the unlisted procedure. Q: How do I report atrial appendage ligation or plication? A: Atrial appendage ligation or plication is considered to be part of a mitral valve repair ( ) or replacement (33430) procedure and a Maze (33253) procedure and should not be reported separately when performed in the same session as these procedures. If an atrial appendage ligation or plication is performed with a CABG or other cardiac procedure, then it may be reported using one of the following methods: 1) If the atrial appendage ligation is performed to remove thrombus, then code 33310/33315 (cardiotomy) should be reported appending the -59 and the -51 modifiers. 2) If the ligation or plication is performed for other then thrombus removal, you may append the -22 modifier to the main procedure or use the unlisted code, to report the atrial appendage ligation or plication procedure. ccc The material presented herein is, to the best of our knowledge, accurate and factual to date. The information and suggestions are provided as guidelines for coding and reimbursement and should not be construed as organizational policy. The STS/AATS disclaim any responsibility for the consequences of actions taken, based on the information presented in this newsletter. CODING HOTLINE ASSISTANCE AVAILABLE FOR STS MEMBERS The STS Coding Hotline is available to assist STS/AATS members and their staff with coding questions. You may ask questions via phone at , Fax at , or e- mail them to: jpainter@physiciancoding.com, or via mail. Please limit operative notes to one per month per physician. All requests must include the physician s name, STS or AATS membership number, and a phone number. All answers will be provided via a return phone call. ccc STS/AATS Coding Newsletter Please send subscription-related questions to: The Society of Thoracic Surgeons Coding Department 633 N. Saint Clair St., Suite 2320 Chicago, IL Phone: (312) FAX: (312)

8 5(48(67 )25 3$57,&,3$7,21 $7 7+( 83&20,1* 676 $118$/ 0((7,1* )25 $66,67$1&( :,7+ 7+( <($5 5(9,(: 352&(66 The Workforce on Nomenclature and Coding, which oversees the RUC Process, will host a breakfast session on Mon., Jan. 24 from 6:30 7:30 a.m. at the STS Annual meeting in Tampa, Fla. in rooms 18 and 19 of the Tampa Convention Center. We ask that members who are concerned about reimbursement attend this free breakfast session to learn more about the five-year review process and the assistance we will need from STS/AATS members to help make the process a successful one for STS/AATS members. As many of you know, the CMS five-year review process is currently the only opportunity to revalue the physician work relative value units, one of the three components that determine physician payment. The process requires the input of individual physicians, and we encourage you to participate in this process. Many of you have already responded to our request for assistance. This breakfast session at the STS Annual Meeting is critical for gathering information for the review. Please plan to attend. Each individual physician s participation is critical to this process; we look forward to seeing you there! The Society of Thoracic Surgeons 633 N. Saint Clair Street Suite 2320 Chicago, IL PRESORTED STANDARD U.S. POSTAGE PAID BERWYN, IL PERMIT NO. 73