Rita Shugart, RN, RVT, FSVU Shugart Consulting February 7, 2015

Rita Shugart, RN, RVT, FSVU Shugart Consulting February 7, 2015

No Conflicts Attendees are encouraged to review the specific statutes, regulations, and other interpretive materials referred to in this presentation for a full and accurate statement of their contents, and to check these resources frequently for changes, updates, and revisions. CPT is a registered trademark of the American Medical Association

Process (Coding) Policy (LCD, Orders) Documentation (Report) APPROPRIATE VASCULAR LAB REIMBURSEMENT

LCD s Medicare contractor policies that identify circumstances under which services will be (or will not be) considered covered, correctly coded, and possibly reimbursed The single most important factor in proper coding, billing, & reimbursement

One NIVT LCD Applies to all testing settings hospitals, offices, IDTF s Private insurance often follows same provisions SIGNIFICANT CHANGES PROPOSED!!! WPS NIVT LCD includes: Technical staff/physician qualifications Facility accreditation Type of exams covered Type of exams not covered Frequency of repeat, surveillance exams Documentation requirements Diagnosis codes considered medically necessary

Tech certification or Lab accreditation required (with exceptions) Carotid duplex frequency: 20-39% Annually 40-69% q 6 mo 70-99% as needed Post CEA when clinically necessary Post stent not mentioned Post op ABI s (routine surveillance): 6 weeks q 6 months X 2 years then annually Duplex frequency not mentioned

Local Coverage Determination (LCD): Non-Invasive Vascular Testing (N.I.V.T) (L28586) Coding Information ICD-9 Codes that Support Medical Necessity Group 1 Paragraph: Cerebrovascular Studies 1. Non-invasive Physiologic Studies (93880-93882) a. Visual Disorders Group 1 Codes: 362.30-362.37 opens in new window RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS ENGORGEMENT OF RETINA 362.81 RETINAL HEMORRHAGE 362.84 RETINAL ISCHEMIA 368.10 SUBJECTIVE VISUAL DISTURBANCE UNSPECIFIED 368.11 SUDDEN VISUAL LOSS 368.12 TRANSIENT VISUAL LOSS 368.40 VISUAL FIELD DEFECT UNSPECIFIED 368.41-368.47 opens in new window SCOTOMA INVOLVING CENTRAL AREA - HETERONYMOUS BILATERAL FIELD DEFECTS 377.41 ISCHEMIC OPTIC NEUROPATHY 377.43 OPTIC NERVE HYPOPLASIA Group 2 Paragraph: b. Extracranial Artery Disorders Diagnosis code 785.9 Other symptoms involving cardiovascular system; needs to be used when submitting a claim for the indication pulsatile tinnitus Group 2 Codes: 433.00-436 opens in new window OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL INFARCTION - ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE 437.0-437.9 opens in new window CEREBRAL ATHEROSCLEROSIS - UNSPECIFIED CEREBROVASCULAR DISEASE 438.10-438.19 opens in new window SPEECH AND LANGUAGE DEFICIT UNSPECIFIED - OTHER SPEECH AND LANGUAGE DEFICITS 438.81-438.89 opens in new window APRAXIA CEREBROVASCULAR DISEASE - OTHER LATE EFFECTS OF CEREBROVASCULAR DISEASE 442.81 ANEURYSM OF ARTERY OF NECK 442.82 ANEURYSM OF SUBCLAVIAN ARTERY 443.21 DISSECTION OF CAROTID ARTERY 443.24 DISSECTION OF VERTEBRAL ARTERY 443.29 DISSECTION OF OTHER ARTERY 444.89 EMBOLISM AND THROMBOSIS OF OTHER ARTERY 459.9 UNSPECIFIED CIRCULATORY SYSTEM DISORDER 785.9 OTHER SYMPTOMS INVOLVING CARDIOVASCULAR SYSTEM

Commonly used ICD 9: WPS LCD includes ONLY: 585. Chronic Kidney Disease, unspecified 585.6 End Stage Renal Disease 438.85 Vertigo 386.2 Vertigo of central origin V58.73 Aftercare following surgery of circulatory system V58.49 Other specified aftercare following surgery 441.9 Aortic aneurysm of unspecified site, without rupture 441.4 Abdominal aneurysm without rupture

All tests must have a signed order Order should include type of test and a diagnosis/indication/reason for test Ordering MD should document intent to order and the reason for the test in office or progress notes The Order may conditionally request an additional diagnostic test if the result of the initial test yields to a certain value May not perform an un-ordered test until a new order has been received (but some exceptions) Standing orders/internal protocols not permitted Maintain copies of orders in case of audit Medicare Benefit Policy Manual, Chapter 15

Category III Code 0126T IMT > Category I Code: 93895 Quantitative Carotid Intima Media Thickness and Carotid Atheroma Evaluation, Bilateral 93985 Non-Covered by Medicare and most (maybe all?) payers

Know the definition of the selected CPT Code All components of the CPT Code must be included in the exam If the exam does not meet the definition of the CPT Code, select another CPT code (or attach a modifier) The CPT Code on the claim must be fully supported by the Report

Incorrect: Billing CPT Code 93924 (Exercise Exam) for TOS exam or LE Exercise exam with toe-ups or walking in hallway 93924 is an LE exam only and must include exercise on a motorized treadmill

Incorrect: Billing CPT Code 93990 for duplex scan of a hemodialysis access site only 93990 Duplex scan of hemodialysis access must include evaluation of arterial inflow, body of access, and venous outflow

Incorrect: A Vein Mapping of the bilateral cephalic veins is performed, and the CPT Code 93970 Venous Duplex, Complete bilateral study is billed Correct: Although bilateral, this is not a complete exam; should be billed as 93971, Venous Duplex, unilateral or limited

Incorrect: Report reads only no evidence of intracranial ICA dissection and CPT Code 93886 TCD complete is billed Correct: CPT Code 93886 requires evidence that the bilateral anterior and posterior circulation were evaluated

93922 (ABI s w/waveforms) performed incorrectly: Done with duplex imager Done with PPG No waveforms documented 93924 (LE Exercise)- done w/o treadmill TOS billed as Exercise study Superficial Vein Mapping billed as UE or LE Venous Duplex Complete (93970), when only limited exam performed Dialysis Access (93990) study does not include inflow, outflow

-59: Distinct procedures/services not normally reported together, but appropriately billable under the circumstances 4 new, more specific Modifiers will eventually replace -59 XS - Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure XE - Separate Encounter XP - Separate Practitioner XU - Unusual Non-Overlapping Service CMS will initially accept either a -59 modifier or the more selective -X modifiers as correct coding MAC s may begin requiring use of -X modifiers as desired For more info: http://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf

Code the diagnosis, symptoms, conditions or reasons for ordering the test Use LCD Cheat Sheets to assist in diagnosis code selection Do not use the initial referral indication if it is known to be inaccurate There are no codes in LCD that include rule out, suspected, probable, or questionable - try to get symptoms or signs on Orders May code a confirmed or definitive diagnosis documented by the diagnostic test Choose the diagnosis code that provides the highest degree of accuracy and completeness

Test: Duplex abdominal aorta 93978 Indication: Family history of AAA Report: no evidence of AAA Incorrect ICD-9 Code Billed on claim: 441.4 Aneurysm Abdominal Aorta, not ruptured

Test: Cerebrovascular Duplex Complete 93880 Indication: Headache Report: no evidence of ICA stenosis bilaterally Incorrect ICD-9 Code Billed on claim: 435.9 TIA

ICD 10 MUST be used for studies performed starting 10-1-2015 EVERY diagnosis code will change From 17,000 diagnosis codes to 150,000 Pressure ulcers 1 >>> 125 Angioplasty 1 >>>> 854 Fractures 747 >>> 17,099 Diabetes 69 >>> 239 ESRD 11 >>> 5 No effect on CPT CODING

New Concepts: Stratification mild mild intermittent mild persistent moderate persistent severe Laterality Right side = character 1 Left side = character 2 Bilateral = character 3 Unspecified side = character 0 or 9 Co-Morbidities history of tobacco use (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17.-) tobacco use (Z72.0)

Current: 433.10 Occlusion and stenosis of carotid artery without cerebral infarction ICD 10: 165.21 Occlusion and stenosis of right carotid artery 165.22 Occlusion and stenosis of left carotid artery 165.23 Occlusion and stenosis of bilateral carotid arteries 165.29 Occlusion and stenosis of unspecified carotid artery

Current: 440.21 Atherosclerosis of native arteries of the extremities with intermittent claudication ICD 10: 170.211 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg 170.212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg 170.213 Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs 170.218 Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity 170.219 Atherosclerosis of native arteries of extremities with intermittent claudication, unspecified extremity

THERE S A CODE FOR THAT! Z89.412 Acquired Absence of Left Great Toe

Who does the diagnosis coding now? Who is training them for ICD 10? What plans is your EMR vendor making? in will they be ready before 10-1-15? will you be able to practice with ICD 10 before 10-1-15? will they install ICD 10 codes included in NIVT LCD s? will you get an alert if an ICD 10 code is entered that is not LCD? Who will help physicians, nurses, clerical staff who enter Vasc Lab orders? Are paper or electronic cheat sheets needed? Who will prepare? Who will be available to help staff on 10-1-15? Does schedule need to be adjusted for 10-1-15?

Labs may will need to get expanded information in Orders Coders may will need expanded History/Indications in Vascular Lab Reports LCD s with ICD 10 codes are available now Review the ICD 10 LCD and make new Cheat Sheets! Expect disruptions in workflow, productivity, reimbursement

Aorta Limited Patient: XXX Account #: YYY DOB: 00/00/0000 Study Quality: Study Date: 00/00/0000 10:26:40 AM Room: Room 0 Referring Physician: Indications: Follow up of infrarenal AAA with maximum diameter of 5.0 cm, right CIA 1.3 cm, left CIA 1.9 cm, on last exam of 00/00/2013. Vel (cm/s) Diam (A-P) (cm) Diameter (Lateral) (cm) Proximal Aorta 96.7 2.76 2.3 Mid Aorta 150.5 5.0 4.8 Distal Aorta 37.6 1.7 1.8 R Common iliac 125.9 2.2 L Common iliac 77.6 2.1 Not just for results anymore May determine reimbursement

Indications narrative, not only ICD-9, ICD-10 code Include major components required by CPT code (i.e. 93990 include space for inflow, access, and outflow) Don t use Lab-specific names for Reports ( Post ELVS vs. LE Venous Duplex report with post laser ablation as Indication) One test (CPT code) per Report is best (i.e. LE Art Duplex ltd + LE physio ltd combined on one Graft Scan Report) Impression should berelated to Lab s Diagnostic Criteria, not restatement of ultrasound findings

States of MI, IN, IA, KS, MO, NE 4 New Draft LCD s (ICD-9): Non-Invasive Cerebrovascular Studies (DL35735) Non-Invasive Peripheral Arterial Vascular Studies (DL35741) Non-Invasive Peripheral Venous Vascular Studies including Hemodialysis Access (DL35745) Non-Invasive Abdominal/Visceral Vascular Studies (DL35749) Same 4 Draft LCD s published for ICD-10: Non-Invasive Cerebrovascular Studies (DL35753) Non-Invasive Peripheral Arterial Vascular Studies (DL35761) Non-Invasive Peripheral Venous Vascular Studies including Hemodialysis Access (DL35751) Non-Invasive Abdominal/Visceral Vascular Studies (DL35755)

1. Deletion of diagnoses previously considered medically necessary TCD testing- sickle cell Abdominal/visceral testing pulsatile mass 2. Poorly written Credentialing/Accreditation section 1. Arterial testing 93922 is non-covered CPT Code

Current Cerebrovascular LCD for TCD testing includes among Indications: Evaluating children with various vasculopathies such as sickle cell disease and Moyamoya And lists ICD-9 Codes 282.60 282.69 and 437.5 among codes that may meet medical necessity Draft Cerebrovascular LCDs for TCD testing state: The following are considered investigational and not medically necessary: Evaluation of children with various vasculopathies, such as moyamoya disease and neurofibromatosis. And deletes relevant ICD-9 Codes

Current Abdominal/Visceral LCD lists ICD-9 Codes 789.30 789-39 Abdominal or Pelvic Mass or Lump among those that may meet medical necessity for CPT Codes: AND 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study 93976 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study 93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study Draft Abdominal/Visceral LCD s lists ICD-9 Codes 789.30 789-39 Abdominal or Pelvic Mass or Lump among those that may meet medical necessity ONLY for CPT Codes: 93975, 93976

Not a new section, but needs revision/rewriting: Vague, inaccurate language Recommendations in some sections, but contradictory musts in other sections While trying to promote certified technologists and facility accreditation, so many loopholes are available that policy is unenforceable Questionable authority of MAC for some requirements

Language Errors: ASN Neurosonology credential ARRT Vascular credential Facility accreditation incorrectly called certification Omission: CCI s RPhS credential

1.a. All non-invasive vascular diagnostic studies must be performed meeting at least one of the following: performed by a physician who is competent in diagnostic vascular studies or under the general supervision of physicians who have demonstrated minimum entry level competency by being credentialed in vascular technology, Means that anyone, even with no credential, training, or experience can perform vascular tests as long as the supervising physician is credentialed- high school student, secretarial staff, convicted sex offender, etc.

If a certified technologist supervises technologists who are not certified, the certified RVT must: provide direct supervision and sign the record of the test along with attesting in writing to the quality of the examination. No requirement in LCD that non-certified techs MUST be supervised but, after talking with WPS, it is clear that was their intent For compliance, Part A allows co-signature of supervising tech; Part B requires an attestation sentence on the bottom of each report, plus co-signature CMS identifies concepts of "general, direct, and personal supervision", but they apply only to physicians, not even to PA's and NP's. Does a MAC have the authority to require direct supervision by a technologist? Vascular technology credentials certify only one's competence in testing, not in supervision of testing Will EMR s permit co-signature? Potential liability issues when certified tech attests to quality of study he/she has not witnessed

Appropriate personnel certification include, but are not limited to, Negates the effect of requiring the recognized, traditional vascular ultrasound credentials Permits testing by those with credentials developed specifically to circumvent LCD certification/accreditation requirements

93922- Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries No explanation by WPS for non-coverage decision Non-coverage decisions typically made by CMS Does WPS have the authority to declare a CPT Code non-covered when CMS has decided it IS a covered test? If WPS does have that authority, can they make a noncoverage decision without explanation?

93922- Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries Many reasons that 93922 is medically necessary Physiologic information provided by 93922 often cannot be obtained from imaging (duplex) exam 93922 is often the only test necessary, thus reducing costs to Medicare program Important in evaluating status of access sites in UE, preserving life and saving money on higher-cost studies (higher level physiologic studies, fistulagrams, angiograms) Eliminating payment for 93922 may reduce access to appropriate care for Medicare beneficiaries

Comment Period begins 2/5/15, ends 3/21/15 Comments should come from Physician (include NPI) Talking Points savings to Medicare program, Standards of Care, legal authority, access to care, medical necessity Include references that support your position Articles, Professional society guidelines, Consensus Statements, Accreditation documents, Appropriate Use Criteria Cite a brief typical example of a problem, unintended consequences, misinterpretation caused by implementation of LCD as proposed Do NOT refer to 93922 as ABI s

Comment Letter may be signed by multiple providers in your group Identify and send Comment Letters to members of the CAC (Carrier Advisory Committee) Comment period will likely be last opportunity to effect change for a LONG time ICD 10 implementation, difficult to change a Final LCD Send comments to Dr. Ella Noel at policycomments@wpsic.com Email only, no postal mail

http://www.cms.hhs.gov/mcd/index_lmrp_bystate_crite ria.asp?from2=index_lmrp_bystate_criteria.asp& 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 Draft and Future LCD s are at the bottom of each page of the Active LCD s Review the ENTIRE list of LCD s -NIVT LCD s may be named differently by different MAC s Check frequently for updates, changes

336-339-4323 rita@shugart-consulting.com