Coding And Reimbursement 2007

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1 Coding And Reimbursement 2007 Gary L. Dillehay, MD, FACNP. FACR Professor Radiology Nuclear Medicine Northwestern Memorial Hospital Chicago, IL SNM Coding and Reimbursement Activities Chair SNM Coding and Reimbursement Committee SNM RUC Advisor to AMA Relative Value Update Committee (RUC) ACNP CPT Advisor to AMA CPT Editorial Committee SNM Coding RoadShows Coding Basics Reimbursement CODING Coverage Payment What is CPT? How the CPT system results in reimbursement How is a new CPT code created? New CPT changes for 2007 What is on the horizon? CPT ICD-9 ICD-10 HCPCS CCI MUE Alphabet Soup HOPPS APC RBRVS CF PFS NCD LCD ABN OIG CPT Current Procedural Terminology 1

2 CPT Medical Services and Procedures 5 Digit coding system Modifiers Nuclear Medicine Diagnostic Procedures Therapy Procedures Semicolon Indentation Symbols Add on code + Revised code ^ New code new or revised text > < CPT Structure CPT STRUCTURE CPT Thyroid CA metastases imaging ; CPT CPT CPT limited area (e.g., neck and chest only) with additional studies (e.g., urine recovery) whole body Thyroid CA mets uptake ( list separately in addition to primary procedure (Use with 78018, only ) ICD-9-CM International Classification of Diseases Clinical Modification ICD-9-CM Coding For Diagnostic Tests How Patient Presented Related to Definitive Diagnosis Signs or Symptoms may be used New Guidelines Effective November 15, 2006 ICD-9-CM Coding REASON for the procedure Code to highest level of SPECIFICITY and degree of certainty MATCH ICD-9 code to each CPT code 2

3 ICD-9-CM and Reimbursement Appropriate ICD 9 Codes: -Pain -Injury -Positive Pathology -Disease -Signs & Symptoms ICD-9-CM and Reimbursement Routine examinations and screenings are NOT covered No ICD 9 code for: -routine -rule out (R/O) -probable Coding Guarantee Payment $$$ REIMBURSEMENT what s needed - Physician Report must support what was billed Provide clinical information (ICD9) Describe what was done (CPT) Describe what was found (Report) Provide evidence of medical necessity (prn, audit) Nuclear Medicine Report Indications HX S&S Referring Physician What was Done Radiopharmaceutical and Dose Imaging Procedure Any unusual occurrences Description of Results Interpretation Signature Reimbursement Coding CPT, CCI, MUE HCPCS II Coverage ICD, LCD, NCD Payment RBRVS, CF, HOPPS 3

4 NUCLEAR MEDICINE Coding Issues RADIOPHARMACEUTICALS Coding Issues Patient does not show up for scheduled procedure and you are left with cost of radiopharmaceutical Medicare states that if services are not rendered then you cannot bill. It is the facility choice to decide to bill patient directly, similar to the dentist. Patient shows up, has radiopharmaceutical and for some reason does not return; or patient gets ill, or claustrophobic, etc Bill for procedure with Modifier 52 (reduced service) or Modifier 53 (discontinued service). In some locations payer systems can not accommodate modifier 52 and payer may instruct you to code for radiopharmaceutical plus appropriate administration code. Introduction to Nuclear Medicine Section The services listed do not include the radiopharmaceutical or drug. Diagnostic and therapeutic radiopharmaceuticals and drugs supplied by the physician should be reported separately using the appropriate supply code(s), in addition to the procedure code. RADIOPHARMACEUTICALS Coding Issues How do we get a new CPT code? Every NM Procedure needs at LEAST ONE Are BILLED SEPARATELY from the Procedure Are coded using HCPCS LEVEL II codes must be a distinct, different service, not already done or described by another code currently being performed widely (NOT research) statistics (use of 78x99 codes) literature to support its use is it better (or at least as good) than something already available? How do we get a new CPT code? How do we get a new CPT code? should not be disease or indicator specific should not be specialty specific should not be instrument specific language must describe exactly what is done views, SPECT, W or W/O quantification, contrast single, multiple days

5 GASTROINTESTINAL SYSTEM CPT CARDIOVASCULAR SYSTEM CPT HEPATOBILIARY DUCTAL SYSTEM imaging, Including GALLBLADDER, with or without pharmacological intervention, with or without quantification Myocardial perfusion imaging; (planar) single study, at rest or stress (exercise or pharmacologic), with or without quantification AMA CPT Editorial Panel CARDIOVASCULAR SYSTEM CPT tomographic (SPECT), multiple studies (including attenuation correction when performed), at rest and/or stress (exercise and/or pharmacologic) and redistribution and/or rest injection, with or without quantification ALL specialties represented Some have permanent seats (Radiology) Rotating seats other groups also present Insurance Industry Nursing/Allied Health groups political process long process AMA CPT Editorial Panel CPT specialty society(s) present new code proposal at least 2 members of the panel are assigned new code proposals, but any one on the panel may question presenters the panel votes (secret ballot) whether to accept proposal proposals for code edits, deletions handled the same way political process -2- Category I Procedures Category II Performance Measures Category III Emerging Technology 5

6 RUC Process RUC Process when the CPT code approved now must have relative work value assigned specialty societies survey their members anchor code (another CPT code with assigned RVU) intensity of work stress issues time spent Practice Expense Review Committee (PERC) Practice Expense issues non-physician work supplies equipment -2- Practice Expense Methodology CMS Goals To ensure that the PE payments reflect, to the greatest extent possible, the actual relative resources required for each of the services on the PFS. This could only be accomplished by using the best available data to calculate the PE RVUs. To develop a payment system for PE that is understandable and at least somewhat intuitive, so that specialties could generally predict the impacts of changes in the PE data. To stabilize the PE payments so that there are not large fluctuations in the payment for given procedures from year-to-year. RBRVS Basic Definitions Resource Based Relative Value Scale Calculation of payment based on RBRVS: Work RVU* + PE RVU* + PLI RVU* = RVU PC = RVU pw + RVU MD/pe + RVU MD/mp TC = RVU office/pe + RVU office/mp Global = PC + TC Note: Formula above is National information. Each RVU is multiplied by a regional Geographic Practice Cost Index (GPCI) not noted above. There are separate GPCIs for each component, Work, Practice Expense and Malpractice. Total RVU x $ conversion factor = payment CF = Dollar Multiplier (Per Tax Relief and Health Care Act of 2006 frozen for 2007 at $37.90 avoiding -5% cut in CMS MPFS Final Rule eff. Jan 1, 2007 ) * All adjusted for geographic differences Physician Fee Schedule Nuclear Medicine - Cardiac MPFS Professional National Rates Medicare uses a fee schedule to determine payment for outpatient Nuclear Medicine services in the non-hospital setting. They are unique to each area (locality) and updated yearly. The AMA with medical specialties and the RUC (Relative Value Update Committee) play a key role in this payment system HCPCS CPT Description Status A MPI; multiple studies, (planar) at rest and/or stress (exercise and/or pharmacologic), and redistribution and/or rest injection, with or without quantification A MPI; tomographic (SPECT), multiple studies (including attenuation correction when performed), at rest and/or stress (exercise and/or pharmacologic), and redistribution and/or rest injection, with or without quantification A MPI, with wall motion, qualitative or quantitative study (Use in conjunction with 78460, 78461, 78464, 78465) A MPI, with ejection fraction (Use in conjunction with 78460, 78461, 78464, 78465) 2006 $64.80 $76.93 $32.97 $ $59.88 $73.14 $26.53 $18.57 RBRVS rates will vary geographically. Figures used are not actual payment rates. 6

7 The 2007 Medicare Formula Results of FYR For 2007, CMS is also using the revised work RVUs resulting from the 5-year review of work that has led to a large increase in the total number of work RVUs. Section 1848(c)(2)(B)(ii) of the Act requires that increases in RVUs may not cause the amount of expenditures to increase by more than $20 million from what the expenditures would have been had the changes not been made, Therefore, CMS is establishing a work budget neutrality (BN) adjustor of that will reduce all work RVUs accordingly. Five Year Review For Nuclear Medicine and Nuclear Cardiology The work RVU changes from the FYR were to a total of 400 services and are projected to increase the cost to the Medicare Program by $4 billion dollars. Because Law requires any changes must be budget neutral, a 10.1 percent budget neutrality reduction in ALL work values will be required. Large contributors to this $4 Billion increase are primarily due to the substantial increases in the value changes for some evaluation and management code RVUs and the 2005 volumes, specifically, CPTs 99204, 99213, 99214, 99222, The Perfect Storm PLUS! Realized If the CF (Conversion Factor) is unchanged Why did my reimbursement go down? DRA Tc Payment Caps at HOPPS Technical Look for CMS HOPPS CAP RVUs Intentional CMS Decision to keep DRA separate from Calculated MPFS, hence provider confusion regarding the 2007 Rates. Effects of Five Year Review & PE Methodology Calculations MUE Decreased Reimbursement for Imaging in 2007 In Office and IDTF Setting P4P -5% FYR all codes 10.1% work BN FYR MPI add on codes reduced work RVUs PE methodology RVU changes some Multiple Procedure Reduction At 25% for 2007 Conversion Factor, SGR % CF avoided for 2007, GPSI Rural Fix Potential 1.5% bonus for Quality Measures Tax Relief and HC Act 06 The 2007 Medicare Formula What s New in Non-Facility Pricing Amount = [((Work RVU * Budget Neutrality Adjustor (0.8994)) (round product to two decimal places) * Work GPCI) + (Transitioned Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor 2007 Facility Pricing Amount = [((Work RVU * Budget Neutrality Adjustor (0.8994)) (round product to two decimal places) * Work GPCI) + (Transitioned Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor revised renal codes deleted some, redefined others now an add-on code ONLY! deleted testicular imaging without flow (Note: When applying the work adjustor to the work RVU you must round the product to two decimal places.) 7

8 What s on the horizon? revision of CPT codes SPECT/CT codes? fusion codes QUESTIONS? 8

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