The Two Sides of Gastroenterology

Transcription

1 The Two Sides of Gastroenterology Jill Young, CPC, CEDC, CIMC 1 Disclaimer This material is designed to offer basic information for coding and billing. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This handout is intended as an educational a guide and should not be considered a legal/consulting opinion Compliance Coding compliance requires that the ICD-9 code selected is based on documentation and not solely on reimbursement issues 3 1

2 Official Guidelines The importance of consistent, complete documentation in the medical record cannot be overemphasized 4 Documentation The ICD-9 code (s) used for each claim submission must be documented in the record for that service date Individual service dates stand alone Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. LCD Documentation requirements 5 Medical Necessity CMS has stated that medical necessity drives the level of service not the volume of documentation Medical Necessity defined by a payer is the amount of work necessary to treat the problems presented or found at this visit. 6 2

3 Pre-Procedure E&M Screening services that are specifically authorized by statue, such as colorectal cancer screening tests covered under 1861(s)(2)(R) do not specifically provide for a separate screening E&M visit prior to the procedure. 7 MCM Chapter 12 Sec 40.1.b Definition of Global Surgical Package Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. Modifier?? 8 Pre-Procedure E&M Section 1862(a)(1)(A) of the Social Security Act states that no payment may be made for items or services that are not reasonable and necessarily for the diagnosis and treatment of an illness or injury or to improve the functioning o f malformed body member Section 1862(a)(7) prohibits payment for routine checkups Taken together, these sections prohibit payment for routine screen services, ie; those services furnished in the absence of signs, symptoms, complaints or personal history of disease or injury. 9 3

4 Definition of a Global Surgical Package MCM Ch Continued.. Postoperative Visits Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery; Postsurgical Pain Management By the surgeon; Supplies Except for those identified as exclusions; and Miscellaneous Services Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, 10 Progression 11 Progression 12 4

5 13 14 Colorectal Cancer Screening High Risk Medicare defines high risk of developing colorectal cancer as someone who has one or more of the following risk factors: A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp; A family history of familial adenomatous polyposis; A family history of hereditary nonpolyposis colorectal cancer; A personal history of adenomatous polyps; A personal history of colorectal cancer; or A personal history of inflammatory bowel disease, including Crohn s Disease and ulcerative colitis. 15 5

6 Colorectal Cancer Screening Flexible Sigmoidoscopy G0104 colorectal cancer screening, flexible sigmoidoscopy Coverage without regard to risk Age 50 and over High Risk coverage Every 4 years(47 months) Not High Risk coverage Once every 4 years * or 10 years after a screening colonoscopy. 16 Colorectal Cancer Screening Flexible Sigmoidoscopy (cont d) A physician must order screening Must be performed by Physician (MD;DO) PA NP CNS. 17 Colorectal Cancer Screening Colonoscopy High Risk Coverage G0105-Colorectal cancer screening on an individual at high risk Every 2 years (23 months) Not High Risk Coverage G0121-Colorectal cancer screening on an individual not meeting criteria for high risk Every 10 years (119 months) Not within 4 years of a previous covered screening sigmoidoscopy 18 6

7 Colorectal Cancer Screening Colonoscopy Age 50 and over Must be ordered by a physician Must be performed by a doctor of medicine or osteopathy. 19 Screening that turns Diagnostic 20 Technical Difficulties V

8 Colorectal Cancer Screening Colonoscopy if during the course of a screening colonoscopy a lesion or growth is detected that results in a biopsy or removal of the growth, the appropriate diagnostic procedure should be billed rather than G0121 After January 1, Colorectal Cancer Screening Colonoscopy After January 1, 2011 Append modifier PT to diagnostic code Assures deductable is waived 23 Trailblazers Policy 2939 Diagnostic Colonoscopy ICD-9-CM Codes That Support Medical Necessity The CPT/HCPCS codes included in this LCD will be subjected to procedure to diagnosis editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. 24 8

9 Trailblazers Policy 2939 Diagnostic Colonoscopy Medicare is establishing the following limited coverage for CPT/HCPCS codes 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44397, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387, and 45392: 25 Trailblazers Policy 2939 Diagnostic Colonoscopy Covered for: Amebiasis unspecified Intestinal infection due to enterohemorrhagic e. Coli Intestinal infection due to campylobacter Intestinal infection due to clostridium difficile Ill-defined intestinal infections Tuberculous peritonitis Tuberculosis of intestines, peritoneum, and mesenteric glands other Streptococcus Group B Streptococcus Group D [enterococcus] Malignant neoplasm of colon Malignant neoplasm of rectosigmoid junction Malignant neoplasm of other sites of rectum rectosigmoid junction and anus Malignant neoplasm of pelvis 26 WPS Policy L30304 Diagnostic Colonoscopy WPS Policy L Chronic intestinal amebiasis without abscess Amebic nondysenteric colitis Amebiasis unspecified Interstinal infection due to Enterohemorrhagic E.Coli Intestinal infection due to campylobacter Intestinal infection due to clostridium defficile infectious colitis enteritis & gastroenteritis-diarrhea of presumed infectious origin Trailblazers Policy Amebiasis unspecified Intestinal infection due to enterohemorrhagic e. Coli Intestinal infection due to campylobacter Intestinal infection due to clostridium difficile Ill-defined intestinal infections Tuberculous peritonitis Tuberculosis of intestines, peritoneum, and mesenteric glands other 27 9

10 Colon Anatomy Complete Colonoscopy Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without collection colon decompression (separate procedure). Because this code is diagnostic and a separate procedure, it should never be reported with any other colonoscopy code. Per the CPT manual, when a diagnostic endoscopy is followed by a surgical endoscopy, the diagnostic endoscopy is considered part of the surgical endoscopy and is not to be separately reported. Only when the provider performs a diagnostic colonoscopy with brushings, washings and/or decompression and nothing else (no biopsies, excisions, etc.) should this code be reported

11 Colonoscopy Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique. Snaring involves lassoing a polyp or lesion with a wire loop and shaving it off the bowel wall. The snare may or may not be heated. Any snare technique including cold snare, hot snare, and bipolar snare would be reported with this code. The snare technique is the most often used technique and is best when removing both sessile polyps (those attached by a large base) and pedunculated polyps (those attached by a stalk). 31 Colonoscopy with Biopsy Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple 32 Colonoscopy with Biopsy Colonoscopy, flexible, proximal to splenic flexure; This code can only be reported once regardless of the number of biopsies. According to CPT Assistant, July 2004, this code is also used to describe polypectomy with cold biopsy forceps. A cold biopsy with forceps is not the same as hot biopsy forceps and it is not a snare technique, therefore codes and would not be appropriate. If the physician does remove a polyp or other lesion with a different technique and then takes a biopsy on a separate lesion, this code may be reported in addition with modifier

12 Colonoscopy Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injections(s), any substance The physician injects a substance into the submucosa, directed at specific areas through the scope while viewing the colon. (E.g. saline, India Ink). This code is not to be used for injections used to control bleeding may be reported in addition to other procedures with modifier -51 or Colonoscopy Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g. injections, laser, stapling, plasma coagulator) This code is used when a physician controls bleeding in the colon due to a condition such as diverticulosis. This code is not used to report control of bleeding caused by a procedure performed during the same encounter. For example, there may be small amount of bleeding after a polyp is excised. This would not be reported because control of bleeding is integral to therapeutic or surgical procedures. However, if the physician treated a bleeding condition and then removed a polyp at a different location, the services may be reported together with modifier Colonoscopy Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amendable to removal by hot biopsy forceps, bipolar cautery or snare technique This code is used when a physician ablates tumors, polyps or other lesions by laser or other method (e.g. fulguration) 36 12

13 Hot Biopsy Forceps Colonscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesions(s) by hot biopsy forceps or bipolar cautery Do not use when the procedure is described using a forceps instrument 37 Saline Injection of Polyp Snare polypectomy performed after submucosal injection of normal saline & Reported together or separately? Injection performed to lift prior to removal Injection performed to tattoo area for later identification during subsequent procedure or during surgery 38 Saline Injection of Polyp Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injections(s), any substance 39 13

14 Polypectomy with Bleeding Injection for Hemostasis Bleeding as result of intervention Intervention: Snare removal, biopsy, etc Considered part of initial therapeutic procedure and not reported separately Esophagoscopy, Upper GI Endoscopy, and Enteroscopy Esophagoscopy Limited study of the esophagus Esophagogastroduodenoscopy (EGD) Including study of the esophagus, stomach, and either the duodenum and/or jejunum 42 14

15 43 44 Endoscopic Biopsy Upper gastrointestinal endoscopy, simple primary examination (eg, with small diameter flexible endoscope) (separate procedure) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 45 15

16 Gastrointestinal Endoscopy Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance with endoscopic ultrasound examination limited to the esophagus 46 Gastrointestinal Endoscopy Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasoundguided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus) 47 Gastrointestinal Endoscopy Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; Upper Gastrointestinal endoscopy including Esophagus, stomach and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple 48 16

17 Gastrointestinal Endoscopy Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 49 Gastrointestinal Endoscopy Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 50 Endoscopy Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) For radiological supervision and interpretation, see 74328, 74329, 74330) Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation 51 17

18 52 ENDOSCOPY FACILITY GLOB MULT BILAT ASST CO- TEAM ENDO TOTAL DAYS PROC SURG SURG SURG SURG BASE HCPCS MOD DESCRIPTION Uppr gi endoscopy, diagnosis Uppr gi scope w/submuc inj Endoscopic us exam, esoph Uppr gi endoscopy w/us fn bx Upper GI endoscopy, biopsy Esoph endoscope w/drain cyst Upper GI endoscopy with tube Uppr gi endoscopy w/us fn bx Upper gi endoscopy & inject Upper GI endoscopy/ligation Uppr gi scope dilate strictr Place gastrostomy tube Operative upper GI endoscopy Uppr gi endoscopy/guide wire Esoph endoscopy, dilation Upper GI endoscopy/tumor Operative upper GI endoscopy Operative upper GI endoscopy Uppr gi endoscopy w/stent Uppr gi scope w/thrml txmnt Operative upper GI endoscopy Endoscopic ultrasound exam COLONOSCOPY FACILITYGLOB MULT BILAT ASST CO- TEAM ENDO HCPCS MO DESCRIPTION TOTAL DAYS PROC SURG SURG SURG SURG BASE Diagnostic colonoscopy Diagnostic colonoscopy Colonoscopy w/fb removal Colonoscopy and biopsy Colonoscopy, submucous 7.35 inj Colonoscopy/control bleeding Lesion removal colonoscopy Lesion remove colonoscopy Lesion removal colonoscopy Colonoscopy dilate stricture Colonoscopy w/stent Colonoscopy w/endoscope 8.81us Colonoscopy w/endoscopic 11.34fnb

19 Multiple Procedure Column Key 2=Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50% and by report). Base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage. 3=Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in the Endobase field of this file. Apply the multiple endoscopy rules to a family before ranking the family with the other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure. Payment for the base procedure is included in the payment for the other endoscopy. 55 Multiple Procedures Same procedure technique on multiple lesions Bill code only once Multiple techniques during single colonoscopy on multiple lesions Biopsy of lesion in transverse colon Snare polypectomy is descending colon Coding guidelines Both methods reported Highest RVU valued procedure assigned first Modifier 59 on subsequent procedures 56 Multiple Procedures National Correct Coding Manual the NCCI edit with column one CPT code and column two CPT code is often bypassed by utilizing modifier -59. Use of modifier -59 with the column two CPT code of of this NCCI edit is only appropriate if the two separate procedures are performed on separate lesions or at separate encounters 57 19

20 Multiple Procedures CPT Assistant From a CPT coding perspective, if the same lesion is biopsied, and subsequently removed during the same operative session, then you should only report the code for the removal of the lesion. However, if one lesion is biopsied and a separate lesion is removed during the same operative session then it would be appropriate to report a code for the biopsy of one lesion and an additional code for the removal of the separate lesion. 58 PAYMENT METHODOLOGY Highest value procedure? How do we know? What work is inherent to all codes in this family? What additional work is being done? 59 MCM CHAPTER 12 Section C.13 EXAMPLE In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes and The value of codes and have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 percent for the highest valued procedure (45385) and 50 percent for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378). Carriers assume the following fee schedule amounts for these codes: $ $ $ Pay the full value of ($374.56), plus the difference between and ($30.58), for a total of $

21 COMPUTATION Polyp removal (highest RVU code) $ % Lesion Biopsy (next highest RVU code) Diagnostic (subtract base endo code fee) $ $ $ (difference) Add difference to 1 st code fee for a total of $ MULTIPLE ENDOSCOPY RULES Base Code? Family?? Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) Diagnostic colonoscopy 62 PROCEDURE REPORT TIPS Pre-Op and Post-Operative Diagnosis How was procedure performed Use common language and, as appropriate, language of the code Makes your job easier and audit proof Where Location, location, location Remember report only one code when different techniques are used on the same lesion 63 21

22 PROCEDURE REPORT TIPS Notes in operative report removed in it s entirety or removed piecemeal are not techniques to be considered in code selection. 64 PROCEDURE REPORT TIPS Are these notes acceptable? This procedure was repeated in several areas Several polyps were removed using differing techniques Multiple lesions removed using listed techniques 65 CHALLENGES IN BILLING ALL PROCEDURES PERFORMED RVU differential A/R Work Carrier issues 66 22

23 WHAT DO YOUR CARRIERS DO? Blue Cross/Blue Shield Aetna Cigna Priority Health United Health 67 MODIFIERS What is a Modifier? Shows that a procedure has been modified but not changed in its identification or intention 68 Modifier 22 Increased Procedural Service (2007 unusual procedural service ) When the work required to provide a service is substantially greater than typically required, it may be identified by addicting modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie increased intensity, time, technical difficulty of procedure, severity of patient s condition, and mental effort required.) NOTES this modifier should not be appended to an E/M service When the service (s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the unusual procedure number. A report may also be appropriate (CPT 2007) Article on Modifier 22 and documentation recommended by AMA Presenter on Modifiers from June 2000 Bulletin American College of Surgeons

24 Defining Increased Services Claim should be submitted with Statement/letter describing how the service differs from the usual Additional diagnoses (ie BMI, Tortuous colon) Procedure/Operative report reflecting the additional work, time, effort Select fee based on similar services Increase fee based on percentage of additional work Identifies the service as being greater than that usually required. Used on procedural codes, not E&M codes. 70 Tell A Story In the details listed in the procedure report In the diagnosis billing WHY was there significant work? 71 Incomplete Colonoscopy Colonoscopy, flexible, proximal to splenic flexure Modifier 53 Discontinued Procedure Discontinued procedure due to extenuating circumstances or those that threaten the well being of the patient. Only valid for CMS when attached to a surgical code or medical diagnostic code when the procedure was started but had to be discontinued. Not valid for use for elective cancellation of a procedure before anesthesia induction and/or surgical preparation in the OR suite. Documentation should clearly state how far the scope was inserted and the reason for the discontinuation. Additional documentation available on request 72 24

25 73 74 MODIFIER 52 Reduced Service Service or procedure partially reduced or eliminated at the physicians discretion. Basic service still intact Service was started NOT used if anesthesia and/or surgical prep in the OR May not affect payment (carrier discretion) Carrier may not recognize Do not use if billing for outpatient hospital or ASC CMS Does not recognize with E&M services Document note and letter (statement) must be attached 75 25

26 Modifier 25 Significant Separately Identifiable E&M Service Provided by the Same Physician on the Same Day as the Procedure or Other Service It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significantly, separately identifiable E/M service is defined or substantiated by the documentation that satisfied the relevant criteria for the respective E/M service to be reported Modifier 25 For significant, separately identifiable non- E/M services, use modifier 59 Does not require different diagnosis may be prompted by the symptom or condition for which the procedure and/or service was provided Documentation must support separate additional work E&M Services Guidelines used in determining level of E/M Monitored for high utilization Modifier 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. Modifier 59 is used used to identify procedures and services that are not normally reported together, but are appropriate under the circumstances

27 Modifier 59 Distinct Procedural Service This may represent the following: A different session A different procedure or surgery A different site or organ system A separate incision or excision A separate lesion A separate injury However, when another already established modifier is appropriate. It should be used rather than modifier MODIFIER 57 Decision for Surgery An E&M service that resulted in the initial decision to perform the surgery Attach to the E&M code Documentation must demonstrate No increase in payment allowance Usually not used when surgery is scheduled in the future (weeks) CMS Must be for decision for major surgery Initial evaluation is always included for minor surgeries Major surgery has a global of 90 days Minor surgery per CMS 0-10 days endoscopies Other carriers may follow either policy. 80 Modifier 59 Distinct Procedural Service Indicates that the two procedures were independent of one on another when two distinct and separately identifiable procedures are performed on the same day May represent a different session or patient encounter, different procedure or surgery, different site or organ system, or separate injuries Place modifier 59 on the component codes

28 QUESTIONS? 82 28