Accurate Coding of Nuclear Medicine Procedures Presented by: Denise A. Merlino, MBA, CNMT, CPC Merlino Healthcare Consulting Corp. 1 Unravel Coding Basics October 27, 2009 2 1
Coding Basic Steps diagnosis supply procedure 3 Current Procedural Terminology (CPT) American Medical Association (AMA) Category I, II and III Codes 4 2
CPT Category I Codes Five Digit Numerical System Developed and maintained by the American Medical Association (AMA) to describe Medical Procedures. New Codes released yearly, effective January 1 st Nuclear Medicine Section 78xxx series Diagnostic & 79xxx series Therapeutic Healthcare Common Procedure Coding System (HCPCS) Level I 5 CPT Category II Codes Alpha-Numerical System Four Digits followed by letter F Developed & maintained by the American Medical Association (AMA) to describe Performance/Quality Measures. New Codes released yearly, effective January 1 st Tracking Codes for Performance & Quality Measures 6 3
AMA CPT Category II - Examples Nuclear Medicine Quality Measure CPT Category II 3570F 3572F 3573F Long Descriptor Final report for bone scintigraphy study includes correlation with existing relevant imaging studies (eg, x-ray, MRI, CT) corresponding to the same anatomical region in question (NUC_MED) Measure #147 in PQRI program. Patient considered to be potentially at risk for fracture in a weight-bearing site (NUC_MED) Patient not considered to be potentially at risk for fracture in a weight-bearing site (NUC_MED) Comment This new code could be used to report to a payer the presence or absence (with modifiers) in a nuclear medicine bone scintigraphy procedure report, the discussion of the correlation to other relevant imaging studies. These two new codes could be used to report to a payer the potential risk for fracture and the communications to referring physicians with modifiers. 7 AMA Educational Tools CPT Category II Measure Description, Specification & Worksheet 8 4
CPT Category III Codes Alpha-Numerical System Four Digits followed by letter T Temporary tracking codes, developed and maintained by the American Medical Association (AMA) to describe emerging technology, services and procedures. New Codes released twice yearly, effective January 1 st and July 1 st each year. Temporary Tracking Codes for Emerging Technology 9 CPT Category III: Example CPT Code Revised 2009 0146T 0147T Key Coding Elements Coronary Arteries Only Coronary Arteries & Ca Scoring Long Descriptor Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium Computed tomography, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium (Do not report 0147T in conjunction with 0144T) NOTE: Effective January 1, 2010, CPT deleted these Category III Cardiac CT and Cardiac CTA codes and replaced with new Category I CPT codes, which are in use today. 10 5
AMA CPT Guideline - Introductions Specific guidelines are presented at the beginning of each of the sections. These guidelines define items that are necessary to appropriately interpret and report the procedures and services contained in that section. 11 CPT I Unlisted Procedure Code - 99 Nuclear Medicine has Unlisted CPT codes in each section 78X99. CPT states, Select the name of the procedure of service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code. 12 6
Nuclear Medicine Introduction CPT 78xxx & 79xxx Nuclear Medicine Introduction: 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. Providers use HCPCS LEVEL II supply codes for drugs & radiopharmaceuticals with nuclear medicine procedures 13 CPT Code Symbols CPT Symbol Description New Procedure (red circle) Current code revision has resulted in a substantially altered procedure descriptor (blue triangle) (Green brackets) are used to indicate new and revised text other than the procedure descriptors. (black plus sign) indicates an add-on code. Add-on codes describe additional intra-service work associated with the primary procedure (green circle arrow) refers to the CPT Assistant monthly newsletter or CPT Changes: An Insider's View, an annual book with all of the coding changes for the current year. (red circle arrow) refers to the quarterly newsletter Clinical Examples in Radiology. 14 7
Nuclear Medicine CPT Category I CPT Code Range Organized by 9 Systems Primarily Organ Based 78000-78099 Endocrine 78102-78199 Hematopoietic, Reticuloendothelial & Lymphatic 78201-78299 Gastrointestinal 78300-78399 Musculoskeletal 78414-78499 Cardiovascular 78580-78599 Respiratory 78600-78699 Nervous 78700-78799 Genitourinary 78800-78999 Other Procedures (Including PET) 79005-79999 Therapeutic Healthcare Common Procedure Coding System (HCPCS) Level I 15 Nomenclature Terminology: a system of words used to name things in a particular discipline The selection of a word or phrase in CPT is carefully considered by the CPT Editorial Panel: For example: when or if performed, means that the wording preceding this phrase is part of the procedure, however, if not performed would NOT preclude you from selecting that CPT code. If there is NO mention, the procedure must be performed to select that particular CPT code. 16 8
CPT Structure Semicolon ; Some procedures in the CPT are not printed in their entirety but refer back to a common portion of the procedure. This is evident when an entry is followed by one or more indentations. This is done in an effort to conserve space. CPT Code Description 78300 Bone and/or joint imaging; limited area CPT Assistant Mar 97:11, Dec 05:7 Clinical Examples in Radiology Winter 09:5 78305 multiple areas 78306 whole body 78315 3 phase study 78320 tomographic (SPECT) 17 Basics of Add-On CPT Codes Add-ons are never reported alone; they must be reported with one of the primary codes listed in their CPT entry. The service described in the add-on must be performed in the same session as the primary procedure and billed on the same claim. Never use the 51 modifier on add-ons; Medicare won't take a 'multiple procedure' reduction off the fee because the cut is built into the add-on code. Remember that all add-ons follow these rules, and they are marked with a plus sign in the CPT book. Add-On Codes located in CPT & Summary in Appendix D 18 9
Nuclear Medicine Add-On CPT Codes CPT Code Description 78020 78496 78730 Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure 78018) Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List separately in addition to code for primary procedure 78472) Urinary bladder residual study (List separately in addition to code for primary procedure 78740) 19 Multiple Studies Cardiac Imaging Two or More Studies are performed Stress Study Rest Study Redistribution Study Note: Prone Imaging is not considered a separate study. Prone imaging can be obtained as part of any one of the three studies mentioned above. 20 10
CPT Myocardial Perfusion Imaging CPT 78451-78454 Description 78451 Myocardial Perfusion SPECT Single study 78452 Myocardial Perfusion SPECT Multiple studies 78453 Myocardial Perfusion Planar Single study 78454 Myocardial Perfusion Planar Multiple studies Key Word (s) Important for Code Choice Planar vs SPECT vs PET Single Study vs Multiple Study Protocols; Rest/Stress, Stress/Rest, Dual Isotope, prone, Redistribution--- Multiple Day s (general rule 7-10 days) Wall Motion and/or Ejection Fraction, First Pass Technique NOT part for Code Choice 21 AMA CPT 2010 Example: Addition CPT 2010 CPT Category I Long Descriptor Comments 78452 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Crosswalk 78465 MPI plus 78478 wall motion & 78480 ejection fraction 22 11
AMA CPT 2010 Example Revision: CPT 2010 Parenthetical Comment (78460 78465 have been deleted. To Parenthetical to direct provider to new codes report, see 78451 78454) as 2009 codes have been deleted. (Do not report 78472, 78473 in conjunction with 78451-78454, 78481, 78483, 78494) (Do not report 78481-78483 in conjunction with 78451 78454) Code combination restriction clarification: Regarding technique of how you obtain the ejection fraction, it can be by first pass technique or gating, either would be acceptable methods included as part of the new MPI packaged CPT codes. An important note, providers can no longer bill separately using CPT 78481 or 78483 for first pass technique on a separate camera with any of the new packaged codes. This is because the first pass study for ejection fraction, if performed, are considered part of the entire MPI packaged code description. 23 Tips & Terminology for Nuclear Medicine Procedures performed over multiple days are typical in nuclear medicine and should NOT be coded for each individual day, read the code descriptions carefully. SPOT or Delayed (on same or next day) imaging are part of the CPT procedure codes, additional coding is not appropriate. 24 12
Is the stress test included as part of the MPI or Cardiac NM CPT code(s)? Answer: NO CPT Introduction Cardiovascular System (78414-78499) Myocardial perfusion and cardiac blood pool imaging studies may be performed at rest and/or during stress. When performed during exercise and/or pharmacologic stress, the appropriate stress testing ti code from the 93015-9301893018 series should be reported in addition to code(s) 78451-78454, 78472, 78473, 78481, 78483, 78491, and 78492. 25 Stress Test Codes CPT 93015-93018 CPT 93015 93016 93017 93018 Description Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only Not subject to TC or 26 modifier 26 13
Tips & Terminology for Nuclear Medicine Limited Multiple Whole Body Limited is one area Multiple can be two or more Areas Imaged or Two or More DAYS Be Careful Whole body is head to toe (almost) for bone scan imaging (CPT 78306) and in CPT; for PET (CPT 78812, 78815) is the base of skull to mid thigh, h for PET (CPT 78813, 78816) is top of skull to substantially below the knees usually extending to the feet, for thyroid cancer (CPT 78018) head to below pelvis 27 Bone Imaging CPT 78300-78320 CPT Description 78300 Bone Imaging Limited Area 78305 Bone Imaging Multiple Area 78306 Bone Imaging Whole Body 78315 Bone Imaging Three Phase 78320 Bone Imaging Tomographic SPECT Key Word (s) Planar vs SPECT vs Three Phase vs SPECT Whole Body vs Limited vs Multiple Protocols; Spot Planar views are included in all types of Bone Imagine--- SPECT and Whole Body is acceptable code pair together Important for Code Choice NOT part for Code Choice 28 14
Tips and Terminology for Nuclear Medicine Coding Acceptable code pairs are Whole body and SPECT for Bone or Tumor codes Not acceptable pairs are multiple spot (ie limited planar) and SPECT or with Whole body Considered Unbundling Spot or Delay Imaging is part of the base code for nuclear medicine and is not coded separately Triple Phase (flow, BP, Delay) and other codes (ie SPECT) sites should choose to bill only one, the triple phase, or SPECT. 29 Multiple Studies Other Two or More Studies are performed Lung Ventilation Lung Perfusion Kidney with Drug Kidney without Drug Requires two doses No difference in coding for Single day protocol versus Two day protocols 30 15
AMA CPT 2012 Additions Lung Imaging Family CPT Category I Descriptor Comments Pulmonary ventilation imaging i (eg, Crosswalk(s) 78586, 78587, 78579 78591, 78593 or 78594 aerosol or gas) (Collapsed into one simplified code.) Pulmonary perfusion imaging (eg, Crosswalk 78580 78580 particulate) 78582 Pulmonary ventilation (eg, aerosol Crosswalk(s) 78584, 78585 or 78588 or gas) and perfusion imaging (Collapsed into one simplified code.) Quantitative differential pulmonary Crosswalk New 78597 perfusion, including imaging when performed 78598 Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed Crosswalk 78596 CPT is a registered trademark of the American Medical Association 31 Renal CPT Codes CPT Code Description 78700 Kidney imaging morphology; limited area 78701 with vascular flow 78707 with vascular flow and function, single study without pharmacological intervention 78708 with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) 78709 with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) 78710 tomographic (SPECT) 78725 Kidney function study, non-imaging radioisotopic study 32 16
AMA CPT 2012 Additions Hepatobiliary Family CPT Category I Descriptor Comments 78226 78227 Hepatobiliary system imaging, including gallbladder when present; Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, ti including quantitative measurement(s) when performed Crosswalk 78220 or 78223 Crosswalk 78223 CPT is a registered trademark of the American Medical Association 33 AMA CPT 2012 Revision Lymphatic Family CPT Category I Descriptor Comments 38900 New in 2011 38792 Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure) (For injection of radioactive tracer for identification of sentinel node, use 38792) (Use in conjunction with 19302,19307,38500,38510, 19307 38500 38510 38520,38525,38530,38542,38740,38745) Injection procedure; radioactive tracer for identification of sentinel node This is for the injection and probe with blue dye. If imaging is performed, bill 78195 CPT is a registered trademark of the American Medical Association 34 17
Radiopharmaceutical Coding - Every NM Procedure needs at LEAST ONE - Are BILLED SEPARATELY from the Procedure - Are coded using HCPCS LEVEL II codes 35 Healthcare Common Procedure Coding System (HCPCS) Centers for Medicare & Medicaid Services (CMS) Level II Codes 36 18
Healthcare Common Procedure Coding System (HCPCS) Level II Single Alpha Four Digit Numerical Coding System Developed and maintained by the Centers for Medicare and Medicaid Services (CMS) to describe medical Drugs, Radiopharmaceuticals, Contrast Agents, Supplies and Procedures 37 Radiopharmaceutical (RP) HCPCS Level II Description Format Element 1 2 3 4 All RPs are RP and/or Diagnostic Billing unit, If description, per radioelement with or or per study study dose an up AXXXX Codes without compound Therapeutic dose, per to amount is listed and with form if necessary i.e capsule(s)/ solution/aerosol treatment dose, per millicurie (mci), per microcurie (uci) for most RPs Example: A9503 Technetium Tc-99m medronate diagnostic (dx) per study dose up to 30 millicuries 38 19
Myocardial Perfusion Imaging (MPI) Radiopharmaceuticals HCPCS Trade Description Level II Name A9500 Cardiolite & Generic Technetium Tc-99m sestamibi, diagnostic, per study dose A9502 Myoview Technetium Tc-99m tetrofosmin, diagnostic, per study dose A9505 Generic Thallium Tl-201 thallous chloride, diagnostic, per millicurie Caution w/ units, thallium round up to highest full mci administered. Single study one (1) per study dose, multiple studies two (2) doses of Tc labeled or PET MPI Agents. 39 Pharmacological Stress Agents Document waste, round up. Look for local MAC policies requiring use of JW modifier for waste HCPCS Level II J0152 J1245 J1250 J2785 JW Description Inj, Adenosine per 30 mg (do not use J0150 adenosine per 6 mg for ED use) ( 90 mg vial and 60 mg vial) Inj, Dipyridamole per 10 mg Inj, Dobutamine HCL/250 mg Inj, Regadenoson per 0.1 mg Drug amount discarded/not administered to any patient Watch Billing Units e.g J2785 (4) units 40 20
Other Drugs HCPCS Level II J0280 J0460 J1160 J1265 J1800 Description Inj, Aminophyllin up to 250 mg Inj, Atropine sulfate, up to 0.3 mc Inj, Digoxin, up to 0.5 mg Inj, dopamine HCL, 40 mg Inj, Propranolol HCL, up to 1 mg Document waste, round up. 41 Drugs Administered for Nuclear Medicine Procedures are Coded Separately With or without Pharmacological Intervention Stress Agents for Cardiac Stress Tests Adenosine, Dipyridamole, Dobutamine Hepatobiliary Imaging Morphine, Kinevac, CCK, Sincalide Kidney or Brain Imaging ACE Inhibitors, Digoxin, Lanoxin, Diamox 42 21
Medicare Non-Covered PET Procedures HCPCS Level II G0219 G0235 G0252 Description PET imaging whole body; melanoma for non-covered indications Initial staging regional lymph nodes PET imaging, any site, not otherwise specified PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g. initial staging of axillary lymph nodes) For PET codes that do not currently correspond to any Medicare covered conditions, providers may choose to obtain a signed ABN from the patient. 43 May 2011 HCPCS Preliminary January 1, 2012 Level II Codes HCPCS Level II Code Axxxx Long Descriptor Iodine I-123 Ioflupane, diagnostic, per study dose, up to 5 millicuries Trade Name: DaTscan is a radiopharmaceutical indicated d for striatal dopamine transporter visualization i using single photon emission computed tomography (SPECT) brain imaging to assist in the evaluation of adult patients with suspected Parkinsonian syndromes (PS). 44 22
Modifiers Two Digit Letter or Number A modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities. Modifiers may be used to indicate to the recipient of a report that: A service or procedure had both a professional and technical component. A service or procedure was performed by more than one physician and/or in more than one location. A service or procedure was increased or reduced. Only part of a service was performed. An adjunctive service was performed. A service or procedure was provided more than once. Unusual events occurred. 45 HCPCS Level I & II Modifiers COMMON - 26 Professional - TC Technical - 59 Separate procedure OTHERS - 51 Multiple procedures - 22 Increased service - 52 Reduced service - 77 Repeat Procedure by another physician - JW Discarded Drugs (See CR 5520 Transmittal 1248 Implemented July 2, 2007 ) Located on inside cover of the CPT Code book & Appendix A 46 23
Nuclear Medicine 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. - CMS Instructions for Charges for Missed Appointments See Transmittal 1279 CR5613 Patient shows up, has radiopharmaceutical and for some reason does not return; or patient becomes ill, or claustrophobic, etc - Bill for procedure completed, such as limited or can bill 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. 47 Nuclear Medicine Coding Issues What about using injection and other administration codes? Resources INCLUDED in most NM procedures Exceptions: CSF,sentinel node (lymphoscintgraphy w/o scintigraphy) peritoneal shunts, intra-arterial therapy 48 24
International Classification of Diseases - Clinical Modification (ICD- 9 & 10 CM) Centers for Medicare & Medicaid Services (CMS) Revision 9 & 10 49 (International Classification of Diseases) ICD Codes Universal diagnosis codes used by all medical specialties used to describe current problem as well as past history Organized by disease state Used by gov t to track trends 50 25
(International Classification of Diseases) ICD-9 Codes REASON for the procedure Code to highest level of SPECIFICITY and degree of certainty MATCH ICD-9 9codetoeachCPTcode each 51 (International Classification of Diseases) ICD-9 Codes How Patient Presented Related to Definitive Diagnosis Signs or Symptoms may be used Guidelines Effective October 1, 2007 http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf 52 26
ICD - Structure ICD- 9-CM 3-5 characters First character is numeric or alpha (E or V) Characters 2-5 are numeric Always at least 3 characters Use of decimal after 3 characters Alpha characters are not case-sensitive ICD- 10-CM 3-7 characters Character 1 is alpha Character 2 is numeric Characters 3-7 are alpha or numeric All letters except U Always at least 3 characters Use of decimal after 3 characters Alpha characters are not case-sensitive 53 ICD-9-CM 54 27
ICD-10-CM October 1, 2013 55 Hospital Revenue Codes American Hospital Association (AHA) National Uniform Billing Committee (NUBC) Hospital Tracking Codes for Accounting Purposes 56 28
Four Digit Numeric Revenue Codes (RC) 0254 Drugs Incident to Other Diagnostic Tests 0255 Drugs Incident to Radiology 0340 Nuclear Medicine - General 0341 Nuclear Medicine - Diagnostic procedure 0342 Nuclear Medicine - Therapeutic procedure Nuclear Medicine - Diagnostic Radiopharm Established Oct 1, 2004 Nuclear Medicine - Therapeutic Radiopharm Established Oct 1, 2004 0349 Nuclear Medicine - Other 0350 CT Scan - General 0352 CT Body Scan 0404 Other Imaging Services - (PET) 0480 General Cardiology 0482 Stress Test 0636 Drugs requiring detailed coding Charges for drugs and biologicals (with the exception of radiopharmaceuticals, which are reported under Revenue Codes 0343 and 0344) requiring specific identification as required by the payer. Intermediary Manual, Part 3, Claims Processing, Transmittal 1875 Feb 7, 2003 Note: Choice of specific revenue code is up to the hospital. For revenue codes, coding to the highest level of specificity is NOT required. 57 AHA Hospital RC 034X Nuclear Medicine Charges for procedures, tests and RPs provided by a department handling radioactive materials as required for diagnosis and treatment. 0341 Diagnostic Procedures 0342 Therapeutic Procedures 0343 Diagnostic Radiopharmaceuticals 0344 Therapeutic Radiopharmaceuticals 0636 Drugs requiring detailed coding Charges for drugs and biologicals (other than RPs) requiring specific identification as required by the payer. Note: Choice of specific revenue code is up to the hospital. For revenue codes, coding to the highest level of specificity is NOT required. 58 29
Basics of a Charge Master 59 Charge Description Master Basics What is a Chargemaster (CDM)? Department # Item # Description Price CPT/HCPCS Code Revenue Code (RC) Dept # Item # Limited Description CPT/HCPC RC Price Active Code Deactivation/ Date 302 18490 MPI wall motion 78478-TC 0341 $300.00 N 1/1/2010 302 18491 MPI ejection fraction 78480-TC 0341 $200.00 N 1/1/2010 302 55501 MPI, SPECT, Multiple 78465-TC 0341 $1,500.00 N 1/ 1/2010 302 55523 MPI SPECT Multiple WM&EF 78452-TC 0343 $2,000.00 Y New 302 40325 99mTc MIBI, PSD A9500 0343 $120.00 Y 302 40330 201Thallium, Per mci A9505 0343 30.00 Y 302 60235 Inj, regadenoson, per 0.1 mg J2785 0636 $80.00 Y PSD = per study dose 60 30
When to Update the CDM Minimum Annual Update with Coding Changes, (October thru December). Changes in Payer Guidelines or Instructions Changes in Technology Department Provides New Services or New Product Lines CMS Quarterly Updates (HCPCS & APC) Updates (January, April, July, October) 61 Authoritative Documents & Implementation Dates 62 31