How To Comply With The American Medical Association'S Lcd

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1 Contractor Information Contractor Name Palmetto GBA Contract Number Contract Type MAC - Part B LCD Information Document Information LCD ID L31712 Jurisdiction North Carolina LCD Title Noninvasive Vascular Testing (NIVT) Original Effective Date For services performed on or AMA CPT/ADA CDT Copyright Statement after 03/19/2011 CPT only copyright American Medical Association. All Rights Reserved. CPT is a Revision Effective Date registered trademark of the American Medical For services performed on or Association. Applicable FARS/DFARS Apply to after 03/21/2013 Government Use. Fee schedules, relative value units, conversion factors and/or related Revision Ending Date components are not assigned by the AMA, are not N/A part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly Retirement Date practice medicine or dispense medical services. N/A The AMA assumes no liability for data contained or not contained herein. The Code on Dental Notice Period Start Date Procedures and Nomenclature (Code) is published 10/23/2011 in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. Notice Period End Date CDT and CDT are trademarks of the N/A American Dental Association. 1. LCD s 2. Orders 3. Coding 4. Reports 5. Risky practices 6. Reimbursement 2013 Rita Shugart, RN, RVT, FSVU Patient population Private insurance applicability Transparency Nothing is more important to maximizing legitimate vascular lab reimbursement than knowing, understanding, and complying with LCD provisions! Local Coverage Determination (LCD): Noninvasive Vascular Testing (NIVT) (L31712) Local Coverage Determination (LCD): Noninvasive Vascular Testing (NIVT) (L31712) Contractor Information Contractor Name Palmetto GBA Contract Number Contract Type MAC -- Part B LCD s -Medicare payer policies that identify circumstances under which services will be (or will not be) considered covered, correctly coded, and possibly reimbursed 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 LCD Information Document Information LCD ID L31712 LCD Title Noninvasive Vascular Testing (NIVT) AMA CPT/ADA CDT Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS 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. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT are trademarks of the American Dental Association. Jurisdiction North Carolina Original Effective Date For services performed on or after 03/19/2011 Revision Effective Date For services performed on or after 03/21/2013 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 10/23/2011 Notice Period End Date N/A 1

2 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. 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. 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 Local not used in every state Applied to more lab settings than ever before Hospital labs are especially unaware Certification/Accreditation requirements may have significant impact on who can take call Frequent changes due to MCR contractor reform Small specialties have little representation on CAC s (Contractor Advisory Committees) Poorly written incomplete, contradictory, inaccurate, non-sensical, exhibit poor understanding of real practice Constant vigilance required Carotid Duplex Part B, Outpatients Part A, Inpatients TCD All states except: 30 states +jurisdictions: AZ, AK, MT, ND, OR, SD, UT, WA, WY (Noridian) MA, ME, NH, RI, VT (NHIC) AR, CO, CT, DE, FL, IL, IN, 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 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 Check the box for ALL policies, and review Active, Draft, and Future LCD s Check frequently for updates, changes 3

4 Diagnostic tests must have orders from Treating Physician/Practitioner What test? Why? Ordering physician must document intent to order and reason for exam 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 Demographics Clearly defined space for type of test, indication Space for extra info, notes, instructions Avoid steering to only those diagnoses/codes that meet medical necessity Use 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 Refinement of 5 physiologic codes Clarification, more specific wording of definitions of CPT codes 93922, 93923, and Instructions can be found in the Introduction to Noninvasive Vascular Diagnostic Studies in the CPT Code Book One deletion: cerebrovascular physiologic studies (OPG, periorbital, spectral analysis) One addition: Unlisted noninvasive vascular diagnostic study One addition 0311T - Non-invasive calculation and analysis of central arterial pressure waveforms with interpretation and report Category III Code temporary code Created for emerging technology, services, and procedures No reimbursement, but used for gathering data, establishing usage patterns, etc May some day be Category 1 Code (ABI s)- w/duplex imager, PPG (LE Exercise)- w/o treadmill TOS billed as Exercise study Superficial Vein Mapping billed as UE or LE Venous Duplex Complete, when really a limited exam Dialysis Access study does not include all required components Carotid IMT billed as carotid duplex (should be Cat III Code 0126T) Read the CPT book Be sure that the coder understands how to code vascular exams Remember you may know more about the patient, vascular testing. and vascular diagnoses than the official coder Don t completely trust your EMR vendor for coding advice 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 2013, 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 2013, AMA 1. Know the definition of the CPT Code; all components of the procedure as defined by the CPT Code must be included in the exam 2. If the exam does not meet the definition of the CPT Code, another CPT Code or a modifier must be used 3. 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 1. Know the definition of the ICD-9 Code 2. The patient s clinical condition, history, or the test results must meet the definition of the ICD-9 Code (Diagnosis Code) on the claim 3. 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 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/documented through Indications Impressions Sample Reports Indications Use narrative/words, not only numerical ICD-9 code Be specific to that patient for that exam on that day (no cloning ) Include relevant associated medical history Impressions Be as specific as possible, because Impressions may change the ICD-9 coding on the claim Include important negative conclusions as well as positive conclusions 9

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11 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. Risky CPT or Diagnosis (ICD 9) Coding practices Risky documentation practices Claims review something that stands out statistical outlier random sampling Pattern recognition Claim differences Part A versus Part B Qui Tam suits RAC Target Incorrect reporting of diagnoses or procedures to maximize payments 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 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 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 Fraud Prevention System Health Care Fraud Prevention and Enforcement Action Team (HEAT) Senior Medicare Patrol Secret Shoppers PI s hired to conduct enrollment site visits, IDTF Audits Fighting Fraud Can Pay You may get a reward of up to $1,000 if You report suspected Medicare fraud and The reported fraud creates a new investigation CMS and law enforcement confirms fraud has occurred Action is taken to recover lost monies At lease $100 of Medicare money is recovered due to CMS/law enforcement action You are not an excluded individual Call MEDICARE for information January 2, % cut in MCR reimbursement related to SGR formula was averted (through ). No permanent fix Same legislation reduced payments to MD offices for advanced imaging by $800 million (in addition to $1 Billion cuts for imaging, radiation therapy in 2012) Sequestration effective April 1, 2013, 2% reduction in reimbursement for MCR Fee for Service claims 12

13 Applies to Outpatient Labs Medicare will not pay the Part B technical component of diagnostic services provided in an entity wholly owned or wholly operated by a hospital with DOS in the 3 days prior to inpatient admission TC is considered operating costs of inpatient hospital services and included in hospital s payment Physician practices add modifier PD to the physician fee schedule code to identify such services as subject to the 3-day payment window Hospital must include the technical component of all out outpatient diagnostic services during 3-day window on the hospital s claim for inpatient stay Part B professional component (PC) paid as usual Applies to Outpatient Labs When patient has more than one test: Medicare will provide full payment for the Technical Component of the test t with the highest payment amount, then 75% payment of TC for the second and subsequent tests provided on the same date of service by the same MD or by multiple MD s in the same group practice Already applied to advanced imaging Jan 1, 2013 applied to vascular, echo, and ophthalmology codes Only applies to the TC, not to the PC For services subject to both MPPR and OPPS cap on imaging, MAC applies MPPR, compares that amount to OPPS cap, and pays the lower of the 2 amounts For some VL studies, OPPS cap is lower, so MPPR will not apply Claim Adjustment Reason Code 59 Processed based on multiple or concurrent procedure rules. March 25, 2013 Diagnostic Imaging Services Access Protection Act introduced in Senate to undo Multiple Procedure Payment Reduction Rationale: MPPR does not reduce # of scans ordered Radiologists penalized, but they do not order scans Each image dataset requires separate interpretation Interpreter spends the same time and effort reading each image regardless of the date of service Efficiencies gained by performing more than one scan on a patient in a session are variable and much less than policymakers assert 13