2014 OB/GYN Surgery Medicare Reimbursement Coding Guide

Transcription

1 2014 OB/GYN Surgery Medicare Reimbursement Coding Guide Effective January 1, 2014 Medicare National Average Rates and Allowables (Not Adjusted For Geography) CPT * HCPCS Code Procedure ABDOMINAL HYSTERECTOMY Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall- Marchetti-Krantz, Burch) Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s) Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s) Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof LAPAROSCOPIC HYSTERECTOMY, surgical, supracervical hysterectomy, for uterus 250 g or less;, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s), surgical, supracervical hysterectomy, for uterus greater than 250 g; PHYSICIAN * MPFS (CF=$ ) Facility Classification HOSPITAL OUPATIENT Descriptor ** Rate AMBULATORY SURGICAL CENTER *** ASC $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $ $1, $1, I I I $5, $2, $5, $2, $5,365.42

2 CPT * HCPCS Code Procedure, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/ or ovary(s), surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed, surgical, with vaginal hysterectomy, for uterus 250 g or less;, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s), surgical, with vaginal hysterectomy, for uterus greater than 250 g;, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/ or ovary(s), surgical, with total hysterectomy, for uterus 250 g or less;, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s), surgical, with total hysterectomy, for uterus greater than 250 g;, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Wedge resection or bisection of ovary, unilateral or bilateral PHYSICIAN * MPFS (CF=$ ) Facility Classification $1, HOSPITAL OUPATIENT Descriptor I ** Rate $5, AMBULATORY SURGICAL CENTER *** ASC $1, Inpatient, not reimbursed in outpatient or $ $1, $1, $1, $ $1, $1, $1, $ I $5, $2, $2, $2, $2, Oophorectomy, partial or total, unilateral or bilateral; $ Inpatient, not reimbursed in outpatient or Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy(s), with or without omentectomy Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited paraaortic lymphadenectomy Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy VAGINAL HYSTERECTOMY Vaginal hysterectomy, for uterus 250 g or less; $ Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele Vaginal hysterectomy, for uterus 250 g or less; with colpourethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control $1, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $ $1, $1, Inpatient, not reimbursed in outpatient or

3 PHYSICIAN HOSPITAL OUPATIENT AMBULATORY SURGICAL CENTER CPT * HCPCS Code Procedure Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele * MPFS (CF=$ ) Facility Classification $ Descriptor ** Rate *** ASC Vaginal hysterectomy, with total or partial vaginectomy; $1, Inpatient, not reimbursed in outpatient or Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele $1, Inpatient, not reimbursed in outpatient or Vaginal hysterectomy, radical (Schauta type operation) $1, Inpatient, not reimbursed in outpatient or Vaginal hysterectomy, for uterus greater than 250 g; $1, Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele $1, $1, $1, Inpatient, not reimbursed in outpatient or $1, NOTES: Multiple Procedure Discounting Multiple surgical procedures furnished during the same operative session are discounted. 50% is paid for any other surgical procedure(s) performed at the same time. The above National Average and ASC (Freestanding) Rates represent the reimbursement amounts paid directly to the facility for the technical portion of the procedure. The Physician (surgeon) would separately receive the professional fee (MPFS Allowable) for the procedure performed. TABLE REFERENCES: * PFS Relative Value File, RVU14A ( ), effective January 1, 2014 ** January 2014 HOPPS Addenda A and B ( ), effective January 1, 2014 *** January 2014 ASC Addendum AA, BB, DD1, DD2, and EE (1-2-14), effective January 1, 2014 ICD-9-CM Volume 3 Hospital Procedure Codes Procedure Code* HYSTERECTOMY Laparoscopic supracervical hysterectomy [LSH] Other and unspecified subtotal abdominal hysterectomy Laparoscopic total abdominal hysterectomy Other and unspecified total abdominal hysterectomy Laparoscopically assisted vaginal hysterectomy (LAVH) Other and unspecified vaginal hysterectomy Laparoscopic radical abdominal hysterectomy Other and unspecified radical abdominal hysterectomy Laparoscopic radical vaginal hysterectomy [LRVH] Other and unspecified radical vaginal hysterectomy 68.9 Other and unspecified hysterectomy Laparoscopic unilateral oophorectomy Other unilateral oophorectomy Laparoscopic unilateral salpingo-oophorectomy Other unilateral salpingo-oophorectomy Other removal of both ovaries at same operative episode Other removal of remaining ovary

4 Procedure Code* Laparoscopic removal of both ovaries at same operative episode Other removal of both ovaries and tubes at same operative episode Other removal of remaining ovary and tube Laparoscopic removal of both ovaries and tubes at same operative episode Laparoscopic removal of remaining ovary and tube NOTES: The ICD-9-CM Hospital Procedure Codes listed above may be used in the MS-DRG Classifications (See Inpatient DRG Payment Rates Table) The appropriate MS-DRG classification is also dependent on the diagnosis code, demographics, sex and possible co-conditions. TABLE REFERENCES: *2014 Hospital ICD-9-CM Volume 3, 9th Revision, Clinical Modification, Sixth Edition Inpatient DRG Payment Rates MS-DRG* MS-DRG Title Arithmetic Mean Length of Stay (Days) National Average Payment** HYSTERECTOMY 734 Pelvic Evisceration, Rad Hysterectomy and Rad Vulvectomy w CC/MCC 6.7 $14, Pelvic Evisceration, Rad Hysterectomy and Rad Vulvectomy w/o CC/MCC 2.3 $6, Uterine and Adnexa Proc for Ovarian or Adnexal Malignancy w MCC 12.4 $24, Uterine and Adnexa Proc for Ovarian or Adnexal Malignancy w CC 6.2 $11, Uterine and Adnexa Proc for Ovarian or Adnexal Malignancy w/o CC/MCC 3.3 $7, Uterine, Adnexa Proc for Non-Ovarian/Adnexal Malig w MCC 8.7 $18, Uterine, Adnexa Proc for Non-Ovarian/Adnexal Malig w CC 4.1 $9, Uterine, Adnexa Proc for Non-Ovarian/Adnexal Malig w/o CC/MCC 2.1 $6, Uterine and Adnexa Proc for Non-Malignancy w CC/MCC 4.0 $8, Uterine and Adnexa Proc for Non-Malignancy w/o CC/MCC 1.9 $5, Uterine and Adnexa Proc for Ovarian or Adnexal Malignancy w MCC 12.4 $24, Uterine and Adnexa Proc for Ovarian or Adnexal Malignancy w CC 6.2 $11, Uterine and Adnexa Proc for Ovarian or Adnexal Malignancy w/o CC/MCC 3.3 $7, Uterine, Adnexa Proc for Non-Ovarian/Adnexal Malig w MCC 8.7 $18, Uterine, Adnexa Proc for Non-Ovarian/Adnexal Malig w CC 4.1 $9, Uterine, Adnexa Proc for Non-Ovarian/Adnexal Malig w/o CC/MCC 2.1 $6, Uterine and Adnexa Proc for Non-Malignancy w CC/MCC 4.0 $8, Uterine and Adnexa Proc for Non-Malignancy w/o CC/MCC 1.9 $5, NOTE: *One DRG per patient is assigned to each inpatient stay. TABLE REFERENCES: ** FY 2014 Final Rule, Federal Register, Vol. 78, No. 160, Monday, August 19, 2013, Table 1A-1E. National Average Payment Rate is based upon the National Average Operating Standardized Amount ($5,370.28) plus the Capital Standard Federal Payment Rate ($429.31). ICD-9-CM Diagnosis Codes Dx Code** HYSTERECTOMY Malignant neoplasm of corpus uteri, except isthmus Malignant neoplasm of isthmus Malignant neoplasm of other specified sites of body of uterus 218.x* Uterine leiomyoma Uterine prolapse without mention of vaginal wall prolapse Uterovaginal prolapse, incomplete Uterovaginal prolapse, complete Uterovaginal prolapse, unspecified Unspecified genital prolapse Polyp of corpus uteri

5 Dx Code** Endometrial intraepithelial neoplasia [EIN] Hematometra Intrauterine synechiae Other specified disorders of uterus, not elsewhere classified Unspecified disorder of uterus Unspecified symptom associated with female genital organs Excessive or frequent menstruation Metrorrhagia Other disorders of menstruation and other abnormal bleeding from female genital tract Unspecified disorders of menstruation and other abnormal bleeding from female genital tract Premenopausal menorrhagia Postmenopausal bleeding Malignant neoplasm of corpus uteri, except isthmus Malignant neoplasm of isthmus Malignant neoplasm of other specified sites of body of uterus Malignant neoplasm of ovary Malignant neoplasm of fallopian tube Malignant neoplasm of broad ligament of uterus Malignant neoplasm of parametrium Malignant neoplasm of round ligament of uterus Malignant neoplasm of other specified sites of uterine adnexa Malignant neoplasm of uterine adnexa, unspecified site 220 Benign neoplasm of ovary Follicular cyst of ovary Corpus luteum cyst or hematoma Other and unspecified ovarian cyst Prolapse or hernia of ovary and fallopian tube NOTES: *Check 4th or 5th digit. REFERENCE: **2014 Hospital ICD-9-CM Volume 1 and 2, 9th Revision, Clinical Modification, Sixth Edition

6 Disclaimer: The information contained in this guide is provided to help you understand the reimbursement process. It is not intended to increase or maximize reimbursement by any payer. We strongly recommend that providers consult their payer organization with regard to local reimbursement policies. The information contained in this guide is provided for information purposes only and represents no statement, promise or guarantee by Covidien concerning levels of reimbursement, payment or charge. Similarly, all CPT HCPCS and ICD-9-CM codes are supplied for information purposes only and represent no statement, promise or guarantee by Covidien that these codes will be appropriate or that reimbursement will be made. ICD-9-CM is based on the official version of the World Health Organization s Ninth Revision, International Classification of Diseases. CPT codes and descriptions only are copyright 2013 American Medical Association. All rights reserved. CPT does not include fee schedules, relative values or related listings. The source for this information is the Centers for Medicare and Medicaid Services (CMS). Reimbursement rates reflected in this guide are Medicare National Average rates as published by CMS at the time of printing, and do not reflect provider payment adjustment factors such geographic adjustment, participation as a Disproportionate Share or Teaching Hospital, participation in the CMS Shared Service (ACO) program, or Value Base Purchasing adjustments. The content provided by CMS is updated frequently. It is the responsibility of the health services provider to confirm the appropriate coding required by their local Medicare Administrative Contractors (MACs), carriers, fiscal intermediaries and commercial payers. All Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, numeric modifiers, instructions, guidelines and other material are copyright 2013 American Medical Association. All rights reserved. Code associations and values have been reviewed and validated by NMD Healthcare, Inc. COVIDIEN, COVIDIEN with logo, Covidien logo and positive results for life are U.S. and internationally registered trademarks of Covidien AG. * Trademark of its respective owner Covidien US Longbow Drive Boulder, CO [t] [us]