Effective January 1, 2011, there will be two new components for precertification:

  1. For all drugs covered under the medical benefit that require precertification, providers will need to report member demographics such as height and weight.
  2. For the following eight drugs, adherence to dosing and frequency guidelines will be reviewed during precertification:
  • Cetuximab (Erbitux)
  • Trastuzumab (Herceptin)
  • OnabotulinmtoxinA (Botox A)
  • Bevacizumab (Avastin)
  • Rituximab (Rituxan)
  • Oxaliplatin (Eloxatin)
  • Intravenous immune globulin (IVIG)
  • Infliximab (Remicade)

To view the dosing policies go to: www.ibx.com/medicalpolicy, select Accept and Go to Medical Policy Online, then click on the Policy notification box.

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Beginning January 1, 2011, IBC will no longer provide payment or reimbursement on any ESWT claims for musculoskeletal conditions. ESWT has been studies in the treatment of conditions including: plantar fasciitis, tennis or golfers elbow, rotator cuff bursitis and other overuse injuries. IBC has determined this treatment for these injuries is investigational.

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IBC capitation changes

On November 5th, 2010, posted in: Industry News by

Upon renewal of plans to existing employer groups, the following changes will take place due to the federal health care reform acts. As required by the act, beginning with renewals from October 1, 2010 there will be no member cost-sharing (i.e. $0 copayment) for certain Preventative Services, which include the list of applicable preventative service codes. The policy will be available on Navinet or www.ibx.com/medpolicy.

As it is expected, per IBC, to take several years for this change to be phased in, you must continually check Navinet and ID cards for member benefit information.

Preventative care $0 capitation rates – your capitation rates will increase to account for this benefits change for members with a new $0 copayment benefits plan for preventative care services. The benefit and rate of capitation payment change is effective October 1, 2010, for certain commercial HMO and POS benefit plans and January 1, 2011 for all Medicare Advantage plans.

The capitation payment rates have been increased to account for the actuarial value of preventative care copayments currently collected under these benefits.

For members with commercial plans and Medicare Advantage plans whose benefits are note changing, the current rates will be continued to be paid.

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The Global Period – clearing up confusion

On November 5th, 2010, posted in: Tips by

Depending on the procedure, the global period assigned to CPT codes can range from 0 to 90 days. The count actually begins the day after the procedure is performed. There are two different views on what is included in the global period.

CPT/AMA rules, which most commercial carriers use, state the global period includes the following:

  • The surgical procedure
  • Local infiltration of topical anesthesia
  • One E/M encounter (including history and physical) that occurs after the decision for surgery has been made
  • Immediate postoperative care
  • Writing orders
  • Evaluating the patient in the post-anesthesia state
  • Typical postoperative care

Note “Typical” in the sense refers to the care that is usually part of the surgical service, such as looking at the healing process, bandage changes when necessary etc.

You should bill and separately report complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring services. This means, any diagnosis that is not the reason you took the patient to surgery.

Medicare differs slightly. From their prospective the global period includes the following services when completed by the physician who performs the surgery:

  • Preoperative visits after the decision is made to operate beginning with the day before surgery for major procedures and the day of surgery for minor procedures. If the decision for major surgery is made the day prior to the procedure, you will be paid for that service.
  • Intraoperative services that are a usual and necessary part of the surgical procedure
  • Follow-up visits
  • Supplies
  • Dressing changes, incision care, removal of sutures, irrigation of catheters, routine peripheral IV lines, nasogastric tubes, etc.

Services NOT included in Medicare’s global fee definition include:

  • The surgeons initial consultation or evaluation of the problem to determine the need for the service
    Services of another physician (except where the surgeon and other practitioner have agreed to split the care/services of the patient)

  • Visits unrelated to the global diagnosis, treatment of underlying conditions, diagnostic test and procedures (including radiological tests)
  • Clearly distinct services
  • Treatment for postoperative complications in the operating room
  • Certain services performed in the physician’s office
  • Immunosuppressive therapy for organ transplants
  • Critical care services (99291-99292)

Modifier ‘24’ – unrelated E/M service by the same physician in a post-operative period is used to report services during the 90 day global. Your choice of diagnosis code (ICD-9) will verify the need for the service.

Understanding the rules and educating ourselves allows us to use the rules for their intended purpose and improve our bottom line.

Source: Medicare www.cms.hhs.gov/manuals/14_car/3b4820.asp#_1_2
CPT/AMA –as quoted in Orthopedic Coding Alert Extra by Alice Marie Reybitz, RN, BA, CPC, CPC-H

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More new codes…..

On November 5th, 2010, posted in: Industry News by

Hip arthroscopy codes:

  • 29914 scope, hip, surgical; femoroplasty
  • 29915 with acetabuloplasty
  • 29916 with labral tear
    • Caution: you will not be able to report 29916 in conjunction with other hip scope codes, 29862-29863.
  • 22551 arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
  • 22552 …..cervical below C2, each additional interspace (list separately in addition to code for separate procedure)
    • In a related change, CPT directs you not to report existing anterior interbody arthrodesis code 22554 in conjunction with discectomy code 63075, even if performed by separate providers. Instead, you are to report the single code, 22551, with both procedures are performed together.
  • Four new peripheral nerve stimulator codes: 64566 , posterior tibial neurostimulator and 64568-64570, cranial nerve neurostimulator placement/revision/removal

Wound Care:

  • Documentation now must state the depth and diameter of the area debrided. Surgical wound debridement codes 11040 and 11041 have been deleted and replaced with 97597 and 97598 for debridement of epidermis r dermis. Codes 11042, 11043 and 11044 have all been revised with the addition of add-on codes between them.

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New Observation Codes

On November 5th, 2010, posted in: Industry News by

2011 brings additional observation codes for ‘subsequent’ care while a patient is in observation status in the hospital.

Historically, patients admitted to observation in the hospital were either discharged or admitted as an inpatient within 24 hours. Consequently, the old codes defined exactly that – codes 99234-99236 when the service took place, admit and discharge within the same calendar day and 99218-99220 for the admission and 99217 for the discharge when the service spanned midnight.

In recent years, physicians have been keeping patients in observation status for multiple days (not just initial care and discharge) which has lead to CPT adding codes for the ‘in-between’ dates of service.

99224 subsequent care, problem focused, patient is stable, recovering or improving – provider usually spends 15 minutes in total at the bedside and on the floor/unit

99225 subsequent care, expanded problem, moderate complexity, patient is responding inadequately to therapy or has developed a minor complication – provider time spent 25 minutes in total at the bedside and on the unit/floor

99226 subsequent care, high complexity, patient is unstable or has developed a significant complication or new significant problem. Provider will spend 35 minutes typically in total at the bedside and on the floor/unit.

Patient still in observation status Wednesday – 99224-99226
Patient discharged from observation Thursday – 99217

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Drug Waste documentation

On November 4th, 2010, posted in: Industry News, Tips by

CMS requires that you document clearly in the medical record any drug waste. The policy states: “It is expected that the medical record will contain the name of the drug, dosage, and route of administration, time and date given. When a portion of the drug is discarded, the medical record must clearly document the amount administered and the amount wasted.”

Please insure your documentation is clear and appropriate when you are administering drugs.

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OIG targeting epidural injections

On November 4th, 2010, posted in: Industry News by

Medicare Administrative Contractors are getting ready to review transforaminal epidural injections (64479, 64480, 64483 and 64484) so get prepared for documentation requests, pre and post payment.

The reason? The OIG has reviewed these services that were performed in 2007 and was not pleased with the findings. They state that 34% of the services reported should not have been paid resulting in overpayments to physicians in the amount of $45 million and $23 million for facilities.

Highmark Medicare LCD (local policy) for transforaminal epidural, paravertebral facet and SI injections states that “due to the inherent risk with transforaminal epidural injections (specifically with the cervical procedures and risk of inadvertent arterial injection and L1 and L2 procedures and the risk of inadvertent injections into the artery of Adamkiewicz), physicians performing this procedure should have substantial and specific experience with transforaminal epidural injections and a clear understanding of the patient risks involved.”

The biggest errors found were documentation errors. In many instances the records didn’t have a description of the service or the service performed was not documented at all. Medical necessity accounted for another $19 million in overpayments.

As a result of these findings, the OIG wants CMS to instruct MACs to take the following steps:

  1. Issue provider education on transforaminals
  2. Review claims data for transforaminals performed in the office setting
  3. Develop LCDs for transforaminals
  4. Crete additional edits to enforce existing LCD requirements
  5. Identify improper payments through medical review
  6. Recoup the improper payments identified by the OIG

CMS has agreed to all recommendations, except number 3. The individual MAC determines whether or not it will develop a local policy. Bottom line, expect audits.

The OIG target list for 2011 includes (but probably not limited to):

  • Part B payment for imaging services
  • Clinical social work
  • Partial hospitalization program services
  • Polysomnography payments
  • Outpatient physical therapy provided by independent physical therapists
  • Diagnostic payment testing
  • Hemoglobin A1C test payments
  • Trends in laboratory use
  • GY modifier
  • ESRD payments
  • Sleep Testing and
  • Place of service errors for service provided in ASCs

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Scribe Use Reminder

On November 4th, 2010, posted in: Tips by

The scenario: You have nurse shadowing you during rounds and recording patient vitals, labs and possibly your exam in the progress notes, who signs the note?

Medicare states that “the situation should be clearly indicated so the reviewer can identify the provider who performed the service and both parties, the scribe and the physician, should sign the record, clearly indicating which signature belongs to whom.”

Remember that earlier this year Medicare issued stricter guidelines for signatures, please use them, including the attestation statement when necessary.

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CVA diagnosis guidelines – updated

On November 4th, 2010, posted in: Tips by

The phrases ‘stroke’ and ‘CVA’ are often used interchangeably to refer to a cerebral infarction. Each description falls under the diagnosis 434.91 (cerebral artery occlusion, unspecified, with cerebral infarction).

The guidelines that were updated on October 1, 2010, add “additional code(s) should be assigned for neurological deficits with the acute CVA, regardless of whether or not the neurological defect resolves prior to discharge.” (www.cdc.gov/nchs/data/icd9/ocdguide10.pdf)

Example: Some of the defects you might document in addition to the CVA include, but certainly are not limited to:

784.59 other speech disturbances
331.83 mild cognitive impairment, so stated
799.53 visuospatial deficit
342.01 flaccid hemiplegia and hemiparesis, affecting dominant side

Don’t mix late effects with neurological defects. The 438 series of diagnosis codes deal with the late effects of the cardiovascular disease. According to the most recent guidelines you should use codes in the 438 category only for late effects of cerebral vascular disease not for neurological deficits associated with an acute CVA. An example:

If a patient has a facial droop as a late effect of a CVA two years ago, you would report 438.83 (other late effects of cerebral vascular disease, facial weakness). According to HIPAA mandated guidelines, your code choice would change if the patient is in the acute phase of the stroke. In this case, you would report 781.94, facial weakness. Clear documentation is the key.

Final note, always report the most specific diagnosis and the current status of the patient because each diagnosis assigned may have a potential impact on future treatments, insurance coverage, etc for the patient.

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