Oklahoma Facts CPT. Definitions. Mohs Micrographic Surgery. What Does That Mean? Billing and Coding for Mohs Surgery

Transcription

1 Billing and Coding for Mohs Surgery Cindy L. Wilson Dermatology Associates of Tulsa Oklahoma Facts Per square mile, Oklahoma has more tornadoes than any other place in the world. The highest wind speed ever recorded on earth was in Moore, Oklahoma on May 3rd during the Oklahoma City F-5 tornado. Wind speed was clocked at 318 mph. Definitions CPT Current Procedural Terminology is a set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers. Each procedure is identified with a five-digit code. The use of CPT codes simplifies the reporting of services. ICD-9 International Classification of Diseases 9 th Revision. Will be replaced by ICD-10 AMA CPT 2009 Professional Edition CPT The purpose of the CPT code is to provide a uniform language that will accurately describe medical, surgical and diagnostic services, and will thereby provide a means for reliable communication among physicians, patients and third parties. What Does That Mean? The CPT codes describe the type of services that Healthcare providers perform (WHAT) and the ICD-9 Codes tell the insurance industry (WHY) the service that is being provided to patients. Mohs Micrographic Surgery Mohs micrographic surgery is a technique for the removal of complex or ill-defined skin cancer with histologic examination of 100% of the surgical margins. It requires a single physician to act in two integrated but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports the services separately, these codes should not be reported -AMA CPT

2 The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces, and each piece is embedded into an individual tissue block for histopathologic examination. Thus a tissue block in Mohs surgery is defined as an individual tissue piece in a mounting medium for sectioning. Mohs Codes were deleted, if you are using these you should not be getting reimbursement!! -AMA CPT 2009 Mohs Codes MMS includes removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of the specimens by the surgeon and the histopathologic preparation including routine stain(s) (eg: hematoxylin and eosin, toluidine blue) of the head, neck, hands, feet, genitalia or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks Each additional stage after the first stage, up to 5 tissue blocks (you can not use this code without being used first!! This is not a stand alone code) Of the trunk, arms, or legs; first stage up to 5 tissue blocks Each additional stage after the first stage, up to 5 tissue blocks (you can not use this code without being used first!! This is not a stand alone code) Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of the specimens by the surgeon, and histopathologic preparation including routine stain(s), each additional block after the first 5 tissue blocks, any stage (you can not use this code without or being used first!! This is not a stand alone code) 2

3 Medicare Guidelines Definition of specimens in a single layer A single layer can be cut into several pieces before processing as frozen sections. Each specimen may have many sections taken from it, however for billing purposes, a specimen refers to the piece or pieces of tissue that together make up a single layer. Medicare Guidelines Special Stains Routine staining of sections using hematoxylin and eosin or toluidine blue cannot be billed separately as it is included in the reimbursement for all codes Special stains such as immunoperoxidase stains may be billed in addition when necessary Use of immunohistochemistry, such as cytokeratin for SCC or S-100 for melanoma, and others, may be billed separately under code Medicare Guidelines The majority of simple skin cancers can be managed by simple excision or destruction techniques. The medical records should clearly show the Mohs surgery was chosen because of the complexity or size or location of the lesion. Mohs micrographic surgery is usually an outpatient procedure done under local anesthesia (with or without sedation). Medicare Guidelines The codes for Mohs micrographic surgery are unique because they code for surgery and pathology services together. Only when a single physician performs duties of both surgeon and pathologist can these codes be used. If one physician excises and maps a skin cancer and another physician examines the tissue margins histologically, the excision and pathology codes must be used instead. Multiple Mohs Procedures Application of Multiple Procedure Reduction for Mohs Micrographic Surgery (CPT Codes & 17313) Under the multiple procedure payment reduction policy, reimbursement for subsequent surgical procedures performed during the same operative session by the same physician is reduced by 50 percent. downloads/cms-1385-fc.pdf Modifiers 57 Modifier decision for surgery E/M services that result in decision to perform surgery are identified by adding the 57 modifier to the E/M service code 3

4 Example of 57 Modifier Patient comes into the practice with a biopsy proven SCC of the left nasal ala referred by primary care physician, decision is made to perform Mohs that same day. Surgery was 1 stage of Mohs (17311) and repaired with a complex closure measuring 1.2cm (13151) Your HCFA would billed as: or Modifiers 58 Staged / Related procedure or service, same physician during the post-op period Attach this modifier to a staged or related procedure or service performed during the post-op period of a major surgery (major surgery = 90 day post-op period) Example You return to the operating room to excise additional tissue on a large congenital nevus which is being removed in stages to minimize the resultant scar Modifiers 59 Distinct procedural service Distinct or independent service performed on the same day Designates different or separate site, incision, excision, lesion, or injury performed on the same day Multiple surgery reimbursement reductions apply Example You perform Mohs on an ear and Mohs on a nose the same day Example of 59 Modifer Patient comes into the office for Mohs with two separate lesions, BCC of R neck and BCC of L ear. The R neck required 2 stages of MMS with a complex repair measuring 2.7cm. The L ear required 1 stage of MMS and was repaired with complex repair measuring 1.5cm. Your HCFA would be billed as: (173.4 R Neck) (173.4) (173.4) (173.2 L Ear) (173.2) Modifers 78 Return to OR for related procedure during post-op period Used to indicate another procedure performed during post-op period related to the first procedure Example You return to the OR to revise a necrotic flap 60 days after it was placed. Modifers 79 Unrelated procedure during post-op period Used to indicate another procedure performed during the post-op period unrelated to the original procedure Example: You perform MMS on the scalp and repair the defect with a FTSG 3 weeks later you excise a cyst on the left buttock 4

5 Consults The request must be in writing. May be verbal if documented in both charts Both Providers must document the request The consulting provider may initiate treatment and diagnostic services. The consulting provider must send a written report to the requesting provider If there is an additional request for advice for the same or a new problem, for the same patient, by the same or other provider, a consultation may be charged again Mohs Consults The requesting provider must be seeking opinion or advice, not transferring care of the condition. Transfer of care means that the requesting provider wants the Mohs surgeon to take over the complete care for the condition and does not expect to continue treating or caring for the patient for that condition. Medicare Internet Only Manual ( for Consults) Top 10 links Click on manuals Upper left corner, click on Internet Only Manuals Click on Click on Chapter 12 Go to section Click on Consultation Services (Codes ) What You Need to Know: Impact to You The implementation of HIPAA 5010 has significant changes in the content of the data that is submitted in your claims as well as the data available to you in response to your electronic inquiries. The implementation will require changes in software, systems, and perhaps procedures that you use for billing Medicare and other payors. * The Future HIPAA 5010 and ICD10 is the future of reporting patients diagnosis and treatment to insurance companies, physicians and the government. E-prescribing and EMR- this is an integral part of HIPAA 5010 Insurance companies will have the capability of viewing all patient s medical records. 5

6 Version 5010 (Health Care Transactions) Version 5010 of the HIPAA standards includes improvements in structural, front matter, technical, and data content (such as improved eligibility responses and better search options). * Compliance Dates The compliance date for implementing Version 5010 is January 1, 2012 * The exception is for small health plans, who must be compliant on January 1, 2013 * * Palmetto GBA- Railroad Medicare- An Introductory Overview of the HIPAA 5010 ICD 10 WHO WHY WHAT WHEN - HOW The who is the World Health Organization, used for reporting disease, morbidity, and mortality The why is compatibility among all countries in reporting morbidity and mortality. -ICD 9 lacks the desired flexibility directed by HIPAA and is limited to 10,000 codes, most of which are in use The why is ICD 10 will provide laterality (left and right) and will give a more precise clinical picture with greater specificity at the 6 th and 7 th digit levels ICD 9 has insufficient structure for reporting new technology The what is a totally new coding system with 13 chapters and new chapters for the eyes and ears There will be up to seven places allowing codes to be more descriptive The when is scheduled for October 1, 2013 The how is a redesign of paper or electronic superbills because there will be many more codes -This means most vendors will need to change their systems to comply with the new changes to be in compliance-don t panic there will be numerous opportunities to become informed to the changes of ICD10 You Just Never Know When You May Need Your Insurance 6

7 7