February 2012 Vol. 13, No. 2
2012 CPT update
­understand what changed this year from the previous
Code and guideline
changes spread throughout
surgery s­ ubsections
year,” she adds.
In total, the AMA added 60 new codes throughout
Integumentary system changes
The integumentary system subsection includes nine
new codes, 26 deleted codes, and six revised codes.
Four new codes
the surgery section of the 2012 CPT® Manual, 18 of which
(15271–15274)
appear in the cardiovascular and respiratory system sub-
include a pri-
sections. The AMA also revised 86 codes and deleted 48
mary code and
codes in the surgery section.
an add-on code
In addition, the AMA included significant guideline
for skin substitute
The AMA added a total
of 103 new codes to the
pathology and laboratory
section of the 2012 CPT
Manual. Read more about
these changes on p. 6.
changes in certain subsections of the manual. Coders
grafts applied to
should note these changes as well as the code changes,
the patient’s trunk, arms, and legs. Coders should report
says Peggy S. Blue, MPH, CPC, CCS-P, regulatory spe-
codes 15271 and 15272 for wounds with a total surface
cialist for HCPro, Inc., in Danvers, MA, and an AHIMA-
area of less than 100 square centimeters, says Shelley C.
approved ICD-10 trainer.
Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, of
“Those guidelines are a huge driving force for why
the CCI edits exist,” she says.
The green text in the CPT Manual indicates new
language that the AMA added to the book this year,
Blue notes. “It’s there because it represents a change
of some sort or additional information. Coders need to
Safian Communications Services in Orlando, FL. Safian
is also an AHIMA-approved ICD-10 trainer. For wounds
with a total surface area equal to or greater than 100
square centimeters, report codes 15273 and 15274.
New codes 15275–15278 also represent skin substitute
grafts; however, coders should report these codes for
areas other than the trunk, arms, and legs. Codes 15275
IN THIS ISSUE
p. 6 N
ote major updates to pathology
and laboratory section of
CPT Manual
As part of the 2012 updates to the CPT
Manual, the AMA added 103 new codes
for pathology and lab.
and 15276 denote wounds with a total surface area
of less than 100 square centimeters. Codes 15277 and
15278 denote wounds with a total surface area equal to
or greater than 100 square centimeters.
The only difference between these sets of codes is the
anatomical sites involved, says Safian.
p. 8 Defining ‘integral’ tricky for self-administered drugs
Whether a drug is considered integral to a procedure might depend on
the payer’s definition of integral.
p. 11 This month’s coding Q&A
Our coding experts answer your questions about carving out infusion time
from observation, protocol for complete pulmonary function test, and
reporting hydration with phlebotomy.
In the past, coders would have reported a code for
each type of skin substitute. As of January 1, different
types of grafts are included in a smaller code range. The
eight new codes replace codes 15170–15176, 15300–
15301, 15230–15321, 15330–15331, 15335–15336,
15340–15341, 15360–15361, 15365–15366, 15400–
15401, 15420–15421, and 15430–15431.
Briefings on APCs
Page 2
“They are actually becoming more efficient,” says
February 2012
modifier -51 (multiple procedures). This ­guideline
Safian. “The new codes change the description of the
change appears in green text above code 12001 in the
product to skin substitute graft.”
2012 CPT Manual. “So this is a change not to the code
The old add-on codes represented each additional
itself, but to which modifier should be used,” Safian says.
square centimeter, while the replacement codes denote
The AMA also added guidelines and definitions that
25 square centimeters. “We not only changed the ­general
affect codes in the skin replacement surgery category.
definition to skin substitute graft, we also changed the
The guidelines now define codes 15002–15005 for skin
measurement of what each code is reporting,” Safian says.
replacement surgery as the initial services for preparing a
The AMA also approved a new add-on code (+15777)
clean, viable wound surface for placement of a graft, skin
to report the implantation of biologic implant for soft
­tissue reinforcement.
substitute, flap, or negative pressure wound therapy.
The guidelines also state that the harvest or applica-
The CPT Manual also includes new guidelines for
tion of an autologous skin graft is included in the codes
reporting complex repairs. The new guidelines state that
for autologous/tissue-cultured autografts. However, cod-
if a provider performs more than one repair, each of
ers should report the repair of the donor site separately.
which qualifies for its own repair code, during the same
Coders should not report codes for non-autologous
session, coders should append modifier -59 (distinct
skin grafts, non-human skin substitute grafts, and biolog-
procedural service) to the additional codes, Safian says.
ical products that form a scaffolding for skin growth for
In the 2011 guidelines, coders were instructed to ­append
the application of non-graft wound dressings or injected
skin substitutes.
Editorial Advisory Board Briefings on APCs
Editorial Director: These new guidelines appear in green text above code
15002 in the 2012 CPT Manual.
Lauren McLeod
Associate Editorial Director: Ilene MacDonald, CPC
Senior Managing Editor: Michelle Leppert, CPC-A,
[email protected]
Musculoskeletal system changes
The AMA included seven new codes and 10 revised
codes in the musculoskeletal system subsection of the
Dave Fee, MBA
Product Marketing Manager, Outpatient
Products
3M Health Information Systems
Murray, UT
Frank J. Freeze, LPN, CCS, CPC-H
Principal
The Wellington Group
Valley View, OH
Carole L. Gammarino, RHIT, CPUR
Recruiting Management, HIM Services
Precyse Solutions
King of Prussia, PA
Susan E. Garrison, CHCA, PCS, FCS,
CPC, CPC-H, CCS-P, CHC, CPAR
Executive Vice President of Healthcare
­Consulting Services
Magnus Confidential
Atlanta, GA
Kimberly Anderwood Hoy, JD, CPC
Director of Medicare and Compliance
HCPro, Inc.
Danvers, MA
“There are various new instructional notes and listings
Diane R. Jepsky, RN, MHA, LNC
CEO & President
Jepsky Healthcare Associates
Sammamish, WA
of codes that should also be assigned throughout this
Lolita M. Jones, RHIA, CCS
Lolita M. Jones Consulting Services
Fort Washington, MD
to browse it and make sure you are familiar with the
Jugna Shah, MPH
President
Nimitt Consulting
Washington, DC
Briefings on APCs (ISSN: 1530-6607 [print]; 1937-7649 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite
A-101, Danvers, MA 01923. Subscription rate: $249/year. Copyright © 2012 HCPro, Inc. All rights reserved. Printed in the USA.
Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without
prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. For editorial comments or questions,
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department at the address above. Opinions expressed are not necessarily those of BAPCs. Mention of products and services
does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal,
ethical, or clinical questions. Current Procedural Terminology (CPT) is copyright 2008 American Medical Association. All rights
reserved. CPT is a registered trademark of American Medical Association; no fee schedules, basic units, relative values, or related
listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions
apply to government use.
© 2012 HCPro, Inc.
CPT Manual.
chapter, and it’s important that you take a few minutes
changes,” says Christi Sarasin, CCS, CCDS, CPC-H,
FCS, principal of Sarasin Consulting Group in Friendship,
MD, and an AHIMA-approved ICD-10 trainer.
In particular, the AMA added two new codes for the
treatment of Dupuytren’s contracture (20527 and 26341).
When coders report 20527, which denotes the injection
of an enzyme, they should also report code J0775 for the
Xiaflex™ itself, says Sarasin. Coders should report code
26341 (manipulation of the palmer fascial cord) for subsequent days of manipulation, similar to how they would
report subsequent days of a wound check, she says.
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Briefings on APCs
February 2012
In addition, the AMA added two new codes for reporting arthodesis using a posterior or posterolateral technique (22633 and +22634). The new codes combine the
posterior and posterolateral approaches with posterior
Page 3
➤➤ 29583: Application of multi-layer compression
­system; upper arm and forearm
➤➤ 29584: Application of multi-layer compression
­system; upper arm, forearm, hand, and fingers
interbody technique. They also include the laminectomy
and the discectomy sufficient to prepare the interspace.
“Be very careful about the documentation and wheth-
“We now have codes for the upper arm, forearm,
hand, and fingers that are appearing in the lower
er it’s simply sufficient to prepare that space or if there
extremity subsection of the application of casting
is another clinical reason for doing something more,”
and strapping subsection,” Sarasin says. “There are
Sarasin says.
numerous codes that are out of sequence in the
The AMA developed these codes to combine procedures
providers frequently perform together. The AMA created a
similar combination for 2011 by combining the codes for
CT of the abdomen and CT of the pelvis into one code.
Coders should also pay attention to the exclusions
CPT code book. That is something that is becoming
more prevalent.”
Coders can report codes for the multilayer compression system or the Unna boot, but not both, Sarasin says.
Providers generally apply Unna boots for venous stasis
note under codes 22520, 22521, and +22522. The note
ulcers and chronic edematous ulcers of the leg. Providers
instructs coders not to report these codes in conjunction
generally do not apply these dressings in the same types
with 20225, 22310–22315, 22325, and 22327 when pro-
of settings, she adds.
viders perform these procedures at the same level of the
spine as the ones described in codes 22520–22522.
For example, it is inappropriate to code for a bone
According to parenthetical notes included below codes
29582–29584, coders should not report them with endovenous ablation therapy (36476 and 36479).
biopsy or fracture treatment at the same level as a vertebroplasty, says Sarasin. Likewise, coders should report
22523 and 22525 for kyphoplasty.
The AMA determined that providers have billed code
Respiratory system changes
The respiratory subsection of the CPT Manual includes
important new guidelines for reporting lung and pleu-
+29826 (arthroscopy, shoulder, surgical; decompression
ral biopsies. The respiratory subsection of codes has not
of subacromial space with partial acromioplasty, with or
been updated since the 1990s, and coders should review
without coracoacromial release) with another shoulder
the changes carefully, says Sarasin. “The parethetical
procedure more than 95% of the time, Sarasin says. As a
notes are going to be critical for the application of correct
result, the AMA returned the code to addon status.
codes,” she says.
Codes 29880 and 29881 for surgical knee arthroscopy
The new guidelines define various procedures includ-
with meniscetomy are typically performed in conjunc-
ed in this subsection and provide instruction regarding
tion with 29877 (arthoscopy with condroplasty). For this
how to select the appropriate codes. The AMA defines
reason, the AMA bundled code 29877 into codes 29880
the following:
and 29881, says Sarasin.
➤➤ Different approaches that physicians may use for
The AMA also added three new codes to the extremity category of codes to denote the application of a multilayer compression system. The new codes are:
➤➤ 29582: Application of multi-layer compression
­system; thigh and leg, including ankle and foot,
when performed
© 2012 HCPro, Inc.
lung procedures
➤➤ Amount and type of tissue that physicians
may remove
➤➤ Whether a procedure is diagnostic or therapeutic
➤➤ Ways physicians may perform various removal
procedures
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Briefings on APCs
Page 4
The guidelines also more distinctly identify wedge
resections as follows:
A therapeutic wedge resection requires attention
February 2012
➤➤ Removal of lung or lung segments (32669–32671).
➤➤ Resection-plication of emphysematous lung (32672).
➤➤ Resection of thymus (32673). Coders should ­report
to margins and complete resection even when the
this code for patients with myasthenia gravis—not
wedge resection is ultimately followed by a more
for a tumor taken by way of VATS or an excision per-
extensive ­resection.
formed through an external slit, says Sarasin.
➤➤ Mediastinal and regional lymphadenectomy
When a physician uses intraoperative pathology
(+32674). Lymph nodes that are listed with single
consultation to determine that he or she must perform
digits are mediastinal, while those listed with double
a more extensive resection at the same anatomical site,
digits are regional, says Sarasin.
coders should report the wedge resection as a diagnostic wedge resection (32507 and 32668). If no additional
The AMA revised code 32601 (diagnostic thoracos-
extensive resection is necessary, coders should report
copy) to include “pericardial sac” and “mediastinal”
the procedure as a therapeutic wedge resection (32505
because this service includes these areas as part of the
and 32666).
diagnostic procedure, says Sarasin.
The AMA added three new codes for thoracotomy
with diagnostic biopsies of lung infiltrates (CPT code
32096), lung nodules or masses (CPT code 32097), and
pleura (CPT code 320980).
Coders will also find new codes for the use of video-
Cardiovascular system changes
The AMA included extensive instruction under the
pacemaker or pacing cardioverter-defibrillator category
of codes in the cardiovascular subsection of the CPT
assisted thoracic surgery, specifically thoracoscopy. These
Manual. The new guidelines define what is included in
new diagnostic codes include:
a cardioverter-defibrillator as well as what is involved in
➤➤ 32607–32608 for diagnostic biopsies
the various procedures.
➤➤ 32609 for biopsy of the pleura
Coders will also find a table that clarifies the codes they
should report for pacemakers as well as the ones they
The new surgery codes also include the following
should report for implantable cardioverter-defibrillators.
surgical thoracoscopy codes:
“It’s important to note with that table that the introductory
➤➤ 32666–32667 for therapeutic wedge resection
language and the code descriptions are going to supersede
➤➤ +32668 for diagnostic wedge resection followed by
the information in that table in the event of any inconsis-
lung resection
tencies,” says Sarasin.
Nine of the new codes in this section involve cardiovas-
The codes for these surgical procedures differentiate
between the tissue location, the type, and nature of
the wedge resection (diagnostic or therapeutic),
➤➤ 33221: Insertion of pacemaker pulse generator only;
with existing multiple leads
➤➤ 33227–33229: Removal of permanent pacemaker
says Sarasin.
Also note that code 32667, which is an add-on code,
denotes a metastatic tumor of a different type, Sarasin
says. Ideally, the surgeon would remove all nodules with
a 1- to 2-centimeter margin.
Additionally, new surgical thoracoscopy codes include
thoracoscopy for:
© 2012 HCPro, Inc.
cular pacemakers or cardioverter-defibrillators, including:
pulse generator with replacement of pacemaker pulse
generator
➤➤ 33230–33231: Insertion of pacing cardioverter-­
defibrillator pulse generator only
➤➤ 33262–33264: Removal of cardioverter-defibrillator
pulse generator
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Briefings on APCs
February 2012
Note that all of these codes are out of numerical
Page 5
These codes include the catheterization and renal
order, and the symbol indicating new or revised text is
angiography of the main renal artery as well as all of the
missing, says Sarasin.
accessory renal arteries on the same side, road mapping,
The AMA also included additional guidelines for the
pressure gradient measurements, radiological supervi-
cardiac arrest category of codes. In addition, the AMA
sion and interpretation, moderate sedation, and use of a
clarified the use of codes for endovascular repair of an
closure device, says Sarasin.
iliac aneurysm to include a more appropriate code range
They do not include endovascular intervention by
(i.e., 36200, 36245–36248) for the introduction of guide
way of an embolization, insertion of a stent, angiogra-
wires and catheters.
phy, or ultrasonic guidance. Coders should report these
Under the Intra-arterial—Intra-aortic subsections,
coders will find new guidelines for diagnostic studies of
procedures separately, says Sarasin.
The AMA also added three new codes for intravascu-
arteriovenous shunts for dialysis to clarify reporting for
lar vena cava filters, depending on whether the physi-
codes 36147 and 36215.
cian performed insertion (37191), repositioning (37192),
New guidelines related to the endovascular revas-
or retrieval (37193). Physicians place intravascular vena
cularization category of codes clarify the specific type
cava filters for patients who have deep vein thrombosis
of closures included for lower-extremity endovascular
and cannot be placed on anticoagulants, says Sarasin.
procedures. Additional guidelines specify that procedures
include pressure application of an arterial closure device
or standard closure of a puncture site by suture. The
Digestive system changes
The AMA added three new codes in the digestive
guidelines also specify services that coders should report
system subsection, including two for abdominal para-
separately, such as extensive repair or replacement of
centesis (diagnostic or therapeutic):
an artery (35226 or 35286).
➤➤ 49082: Without imaging guidance
Coders now have four new catheter placement
➤➤ 49083: With imaging guidance
codes from which to choose, depending on the type
of catheter placement and whether the physician
Coders should report the third new code, 49084, to
­performs the procedure unilaterally or bilaterally. The
denote peritoneal lavage, including imaging guidance,
new codes are:
when performed. This is an open procedure that physi-
➤➤ 36251: Selective catheter placement (first-order),
cians typically perform on acute unstable patients. Physi-
main renal artery and any accessory renal artery(s)
cians use it to assess a patient’s blood for enteric contents
for renal angiography; unilateral
and for additional laboratory analysis, Sarasin says.
➤➤ 36252: Selective catheter placement (first-order),
main renal artery and any accessory renal artery(s)
for renal angiography; bilateral
➤➤ 36253: Superselective catheter placement (one or
Nervous system changes
Changes to the codes for the nervous system include
four new codes for destruction by neurolytic agent, para-
more second order or higher renal artery ­branches)
vertebral facet joint nerve(s) with imaging guidance (fluo-
renal artery and any accessory renal artery(s) for
roscopy or CT). The codes are divided into two sections:
­renal angiography; unilateral
➤➤ Cervical or thoracic (64633, +64634)
➤➤ 36254: Superselective catheter placement (one or
➤➤ Lumbar or sacral (64635, +64636)
more second order or higher renal artery ­branches)
renal artery and any accessory renal artery(s) for
­renal angiography; bilateral
© 2012 HCPro, Inc.
Each pair of codes features one code for the first level
and an add-on code for the additional levels.
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Briefings on APCs
Page 6
Coders will find new codes for electronic analysis of
February 2012
Coders should not report 62369 and 62370 in con-
programmable, implanted pump; with programming
junction with 95990 and 95991. The latter two codes
and refill (62369) and with programming and refill (i.e.,
are for refilling of an implantable pump without
requiring a physician’s skill) (62370).
­reprogramming. n
2012 CPT update
Note major updates to pathology and laboratory section
Coders can find the largest number of new codes in
the pathology and laboratory section of the 2012 CPT
®
Manual. The AMA added a total of 103 new codes,
factor II) (e.g., hereditary hypercoagulability) gene analysis, 20210G>A variant.
The molecular pathology guidelines note that coders
101 of which denote Tier 1 and Tier 2 molecular path-
should separately report any procedures performed prior
ology procedures.
to cell lysis, such as microdissection.
In addition, the AMA deleted two codes and revised
five additional codes.
Some tests require a physician or other qualified
healthcare professional to interpret results. When
­providers only perform the interpretation, coders should
Molecular pathology guidelines
Molecular pathology procedures are lab procedures
that analyze nucleic acid to detect variations in genes
append modifier -26 (professional component) to the
specific pathology code.
The CPT Manual also includes an extensive list of defi-
that may indicate constitutional disorders or somatic
nitions for molecular pathology that can assist coders.
(e.g., neoplasm) conditions. These tests may also be
Coders will find additional instructional parenthetical
used to test for histocompatibility antigens.
notes and cross-references throughout the section.
“The codes are based on the analyte or the gene-togene variant and not on the technology or the methodology that was used to determine the result,” says
Molecular pathology codes
The molecular pathology procedure codes are divided
Christi Sarasin, CCS, CCDS, CPC-H, FCS, principal
into two subsections: Tier 1 and Tier 2 codes. Tier 1
of Sarasin Consulting Group in Friendship, MD.
(codes 81200–81383) includes 92 codes that repre-
The CPT Manual uses the Human Genome Organiza-
sent gene-specific and genomic procedures. “The code
tion–approved gene names. The code descriptors also
instructions clarify that these codes are stand-alone and
include proteins or diseases associated with the genes—
should not be used with what is otherwise referred to as
for example, code 81228, Cytogenomic constitutional
stacking codes,” says Sarasin.
(genome-wide) microarray analysis; interrogation
Tier 2 includes nine codes (81400–81408) that describe
of genomic regions for copy number variants (e.g.
molecular pathology procedures not listed in Tier 1. These
Bacterial Artificial Chromosome [BAC] or oligo-
codes are categorized according to the level of technical
based comparative genomic hybridization [CGH]
resources and interpretive professional work required.
microarray analysis).
When an abbreviation represents a gene name,
The tests associated with these codes are usually
performed less frequently than Tier 1 procedures. Coders
the abbreviation appears first in the code description,
should report the appropriate Tier 2 code that includes
followed by the complete gene name in parentheses.
the specific gene being analyzed, Sarasin says. Each Tier
One example is code 81240, F2 (prothrombin, coagulation
2 code lists between one and 20 analytes.
© 2012 HCPro, Inc.
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Briefings on APCs
February 2012
Page 7
“Tier 2 codes represent different ways to test for
HIV-1 antigen(s) with HIV-1 and HIV-2 antibodies, single
the same variants, but they have an escalation in the
result. “This test uniquely detects HIV antibodies approx-
work and the practice expense to capture the analyses,”
imately one to three weeks earlier than current antibody
­Sarasin says.
tests,” Sarasin says.
Currently, Tier 2 codes represent 80 analytes. “As the
The AMA updated the existing cross-reference follow-
section matures, it is anticipated that these nine Tier 2
ing code 86703 to include code 87389 and deleted the
codes will have over 1,000 analytes incorporated in
reference to the term “antibody.”
them,” says Sarasin, who attended the AMA’s annual
CPT symposium.
The AMA also revised codes 88312, 88313, 88314,
and 88319 to accomplish the following:
During the symposium, representatives from the
➤➤ Create better definitions for the special stain codes
AMA stated that the codes for the molecular pathology
➤➤ Eliminate confusion regarding special stains where
chapter will include even more analytes, she notes. It
will also include more information in the introduction
procedures overlap two code definitions
➤➤ Revise existing instructional notes and add new
as well as additional definitions. The AMA also plans to
­instructional and cross-reference parenthetical
include language that is specific to coders versus provid-
notes to create a defined hierarchy for codes 88314
ers, she says.
and 88319
If the analyte tested is not represented by a Tier 1 code
➤➤ Define units of service
or listed under a Tier 2 code, coders should report the
appropriate methodology code (codes 83890–83914 and
88384–88368).
These codes represent a newly defined hierarchy for
surgical pathology special stains, says Sarasin. With the
exception of code 88314, the codes are divided into these
Other laboratory and pathology changes
Coders will find two other new codes in the laboratory and pathology section:
➤➤ 86386, Nuclear Matrix Protein 22 (NMP22), qualita-
three groups:
➤➤ Group 1 (88312), which is used to identify
microorganisms
➤➤ Group 2 (88313), which is used to identify other
tive. The AMA established this code in the immunol-
(e.g., iron, trichromes), which are not microorgan-
ogy subsection to report qualitative nuclear matrix
isms or enzymes
testing. This testing was previously reported using
code 86294. NMP is found in all patients; however, it
➤➤ Group 3 (88319), which is used to identify
enzyme constituents
is high in patients with bladder cancer, Sarasin says.
➤➤ 87389, Infectious agent antigen detection by enzyme
The stains in group 1 and 2 are always paraffin em-
immunoassay technique, qualitative or semiquanti-
bedded. The stains for group 3 can be frozen block or
tative, multiple-step method; HIV-1 antigen(s), with
paraffin embedded.
HIV-1 and HIV-2 antibodies, single result. This code is
included in the microbiology subsection.
Code 88314 does not belong to any group. It represents a frozen block to preserve certain elements, such as
a muscle biopsy, Sarasin says.
The AMA also revised five codes in the laboratory and
pathology section of the 2012 CPT Manual.
Code 86703 now includes the word “result” instead
Finally, the AMA deleted two codes for 2012: 88107
(cytopathology, fluids, washings or brushings, except
cervical or vaginal; smears and filter preparation with
of “assay.” A cross-reference following code 86703 has
interpretation) and 88318 (determinative histochemistry
been added to direct coders to report code 87389 for
to identify chemical components [e.g., copper, zinc]). n
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Briefings on APCs
Page 8
February 2012
Defining ‘integral’ tricky for self-administered drugs
Self-administered drugs present a significant issue
considered integral to the procedure. Transmittal A-02-129
for coders, especially when considering how they
states, “certain drugs are so integral to a treatment or
may or may not be covered by Medicare Part B. In
procedure that the treatment or procedure could not be
many instances, payers may consider a drug to be self-
performed without them.” The transmittal cited the fol-
administered in some circumstances but not in others.
lowing examples of drugs that are integral to being able
As a result, coders must pay special attention to how
to perform the procedure:
these drugs are used within their setting.
➤➤ Sedatives administered to patients in the operative
“Although it sounds like these drugs should be
categorized by the FDA, it’s actually your local FI/MAC
prep area
➤➤ Mydriatic drops instilled into the eye to dilate the
that makes the determination as to whether a drug is or
­pupils, anti-inflammatory drops, antibiotic ointments,
is not self-administered,” said Kimberly Anderwood
and ocular hypotensives that are administered to a
Hoy, JD, CPC, director of Medicare and compliance for
patient immediately before, during, or immediately
at HCPro, Inc., in Danvers, MA. “They post not only the
following an ophthalmic procedure
process used to make the determination, but also a list of
drugs that are to be considered self-administered.”
According to Hoy, who spoke during HCPro’s October
11 audio conference, “Self-Administered Drugs: Master
➤➤ Barium or low-osmolar contrast media used for diagnostic imaging procedures
➤➤ Topical solutions for photodynamic therapy, local
­anesthetics, and antibiotic ointments
Billing Complexities and Avoid Compliance Pitfalls,”
Medicare pays for drugs and biologicals under Part B for
In 2011, CMS indicated that the coverage policy for
hospital outpatients if the drugs are:
self-administered drugs is very limited and does not
➤➤ Incident to a physician’s service and not usually
cover the majority of self-administered drugs. This
self-administered
➤➤ Required in the performance of diagnostic services,
even if self-administered
seems to indicate that regardless of an individual patient’s needs, the procedure dictates whether a drug is
considered self-administered, Hoy said. Check with your
➤➤ Self-administered, but covered by statute
local FI/MAC for further clarification if you commonly
➤➤ Self-administered, but are so integral to a procedure
encounter situations similar to the examples provided.
or treatment it could not be performed without them
Coders and billers should also review the Federal
Register for further guidance on how to define integral.
What is considered integral
The last point relating to the idea of integral to a pro-
According to 67 FR 66767:
A drug would be treated as a packaged supply in
cedure creates the greatest number of problems for cod-
cases where … it is directly related and integral to a proce-
ers. Whether a drug is considered integral to a procedure
dure or treatment and is required to be provided to a patient
might depend on your definition of integral, said Hoy.
in order for a hospital to perform the procedure or treatment
Does integral mean for this particular patient or integral
during a hospital outpatient encounter.
for every patient? CMS, MACs, FIs, and commercial payers have conflicting guidelines. As a result, integral can
be defined in conflicting ways.
In 2002, CMS provided some specific guidelines
for understanding which self-administered drugs are
© 2012 HCPro, Inc.
This guidance seems to indicate the individual patient’s needs define integral, rather than the procedure.
In Medicare’s brochure “How Medicare Covers SelfAdministered Drugs Given in Hospital Outpatient
For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
Briefings on APCs
February 2012
Setting,” CMS tells beneficiaries, “Part B generally
to be looking at the individual patient, rather than
doesn’t pay for self-administered drugs unless they
the procedure.
are required for the hospital outpatient services you’re
Page 9
This contrasts with how intermediaries determine
getting.” This language seems to indicate that self-
whether a drug is self-administered. These payers take
administered drug coverage is patient-specific, not
into account every patient rather than individual pa-
procedure-specific.
tients’ circumstances. The FI or MAC determines whether
Additionally, AHA’s Coding Clinic provides additional
50% of the beneficiary population can self-administer
coding guidance in this area. Coding Clinic, Fourth Quar-
a given drug. If so, the FI or MAC considers the drug to
ter 2007, states that drug administration services “spe-
be self-administered even if a particular patient cannot
cific to the patient,” although not part of the “regular
self-administer it. This may not be the best comparison
routine” for a procedure, are integral and not reported if
because it only takes into account the drug itself and not
due to the procedure. This would seem to indicate that
procedures, Hoy said.
the particular patient in question dictates whether the
With all the confusion surrounding what defines
drugs are billable, rather than the procedure itself, said
integral, Hoy emphasizes the importance of hospital
Hoy. However, as coverage should be established before
guidelines. “You have to decide, based on the informa-
applying coding guidance, it’s unclear whether this ratio-
tion that’s out there, what you do find most convincing
nale can justify billing Medicare.
and develop a policy with applicable guidelines that you
found to be convincing,” said Hoy. “This may include
What is not considered integral
While CMS has not published guidance specifying
seeking guidance from your FI/MAC as they may be able
to provide you with additional guidance.”
what does count as integral to a procedure, Hoy noted
clear definitions exist dictating what does not constitute
integral to a procedure. According to 67 FR 66767 and
Transmittal A-02-129, drugs that are not directly related
and integral or packaged supplies are:
➤➤ Drugs given to a patient for his or her continued use
at home. One example of this would be starting a patient on an oral antibiotic in the ED, then providing a
prescription for continuing doses.
➤➤ Drugs related to the procedure or treatment. An
example of this would be supplying a patient with
­aspirin for a headache while the patient receives
chemotherapy treatment.
➤➤ Drugs the patient normally takes at home—for example, a daily supply of insulin or ­hypertension medication for a patient undergoing outpatient surgery.
In this case, it appears that integral relates to a par-
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ticular patient, Hoy said. In the chemotherapy example,
the patient needs aspirin for a headache and not because
of the chemotherapy treatment. Therefore, CMS appears
© 2012 HCPro, Inc.
For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
Briefings on APCs
Page 10
Because of the level of confusion surrounding this
issue, Hoy advised staying tuned on a national level for
further clarification.
February 2012
to choose the other revenue codes for reporting the
drugs,” she said.
Coders should be sure to report the most specific
HCPCS code possible, Rinkle added. If no specific HCPCS
Create custom notices for patients
code is available, report the generic HCPCS code. These
Hoy recommended facilities develop custom notices to
charges will appear in the covered column of the UB-04.
patients explaining their self-administered drug policy so
If a facility determines that a specific self-administered
patients are aware that they may be responsible for any
drug is not covered, it should bill the drug with revenue
noncovered drugs.
code 0637. Rinkle said that the HCPCS code specific to
“What I like about doing your own notice is that you
can tailor it to make it similar to an ABN or very dif-
the drug may be used if one exists.
“If not, you would use A9270 to identify this as a non-
ferent from an ABN. But you have more control about
covered item or service. If you bill without a HCPCS code
putting specific information about the drug benefit issues
notice, then the OCE bypasses the edits requiring a code,
rather than having it be very generic,” said Hoy. This in-
but your MAC might not treat it the same way,” said
cludes listing the names of specific drugs the patient will
Rinkle. As a result, coders and billers need to ­understand
have to pay for out of pocket.
the specific MAC requirements. This charge would be
Individual facilities may voluntarily provide the patient an ABN, but Hoy recommended ensuring that the
reflected in the noncovered column of the UB-04.
Additionally, coders and billers should append modi-
billing department is familiar with the use of voluntary
fier -GY (item or service statutorily excluded or does not
ABNs. The billing office needs to know it can still bill the
meet the definition of Medicare benefits) when billing
patient. “Not providing the voluntary ABN does not af-
for noncovered drugs.
fect the patient’s liability for the drug,” said Hoy.
One of the most important reasons to include
modifier -GY is that it triggers an explanation of benefits
Coding for self-administered drugs
Valerie Rinkle, MPA, revenue cycle director for
to be sent to the beneficiary. This explains to them
that they will be liable for the drugs, said Rinkle. If
­Asante Health System in Medford, OR, and Hoy’s co-
modifier -GY is left off the claim, this explanation of
speaker, outlined several ways in which coders can code
benefits will not be sent to the beneficiary.
for self-administered drugs based on how their facility
interprets integral in the above guidelines.
“Once you make a determination that the drug is
Understanding self-administered drugs and how
they may be billed represents a significant issue in the
revenue cycle department. Hoy and Rinkle agreed that
integral to the procedure and you choose to bill it as a
further guidance on a national level would be helpful in
covered drug, you want to choose one of the appropri-
clarifying the guidelines.
ate revenue codes [0250, 0343, 0636],” said Rinkle. “You
As it stands, when individual MACs and hospitals
have the option if you bill 0636 or 0343 to include the
develop their own policies and guidelines, it leads to
specific HCPCS code.”
inconsistent billing practices across regions. As a result,
If facilities choose to report the HCPCS code with
beneficiaries in one region are paying more than ben-
revenue code 0250, they must remember that many
eficiaries in another. Uniform guidelines on a national
carriers do not read the HCPCS code if billed with 0250,
level could help eliminate these discrepancies. For the
said Rinkle. “If you really want them to see the HCPCS
time being, however, Hoy and Rinkle stressed that each
code—and there are a lot in the OPPS system where
hospital should review its own policies and update them
you want them to read the code—you might want
as necessary based on the available guidelines. n
© 2012 HCPro, Inc.
For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
Briefings on APCs
February 2012
Carve out time for infusions
Q
We’re struggling with nursing documentation of
Page 11
Other clinical departments could assist with information
regarding most common diagnostic procedures.
stop times for IV infusions (e.g., piggybacks and
hydration). The nurses also inconsistently document
Protocol for complete pulmonary function test
know that CMS now allows us to use average times for
Q
common services, and we’re interested in considering
PFT [pulmonary function test].” Is there a standard defi-
this approach at my organization. Can you share addi-
nition for a complete PFT? If no such definition exists,
tional specifics?
may we develop a protocol for the tests that physicians
a patient’s return to the unit from diagnostics. We
a patient receives a therapeutic service that reA Ifquires
active monitoring, coders must carve that
Some physicians send patients to our hospital outpatient department with an order for “complete
order most frequently? Would notifying the physicians of
such a protocol be sufficient?
services require active monitoring, such as colonoscopies
is a comprehensive term that describes a group
A PFT
of studies used to assess lung function. The exact
and administration of certain drugs. Carving out time for
type of tests required to assess an individual situation
drug administration services can be particularly confus-
varies according to a patient’s symptoms.
time out of the total observation time. A wide range of
ing because coders need to look at each separate service
No single CPT code provides a standard definition for
to determine whether it requires active monitoring. Drug
a complete PFT. Development of an internal hospital-
infusion titrations require a nurse to stand by and moni-
defined protocol can address the lack of consistency;
tor the infusion. However, other services that fall under
the same HCPCS code for drug administration do not require active monitoring.
CMS requires hospitals to follow CPT guidelines for
Contributors
We would like to thank the following contributors for
answering the questions that appear on pp. 11–12:
reporting drug administration and other services. Hospitals may only use average times for non-time-based
Andrea Clark, RHIA, CCS, CPC-H
services. Therefore, because CPT already specifies an
President
average time of infusion (i.e., coders should report one
Health Revenue Assurance Associates, Inc.
hour of infusion when services last 31 minutes to 1 hour
Plantation, FL
and 29 minutes), hospitals may not use average times
when reporting this particular service.
However, CPT does not specify how much time is
included in an IV push. Therefore, hospitals have some
latitude when establishing an average length of time.
To establish an average, consider performing an actual
time study or obtaining an approximate length of time
required to push the most frequently administered drugs
via this route. Nursing and/or pharmacy staff can pro-
Kimberly Anderwood Hoy, JD, CPC
Director of Medicare and Compliance
HCPro, Inc.
Danvers, MA
Denise Williams, RN, CPC-H
Director of Revenue Integrity Services
Health Revenue Assurance Associates, Inc.
Plantation, FL
vide information related to drug administration services.
© 2012 HCPro, Inc.
For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
Briefings on APCs
Page 12
February 2012
ordering physician, who may not want these particular
use therapeutic phlebotomy to reduce a
A Providers
patient’s total blood volume, decrease the number
tests performed.
of red cells, or reduce high amounts of iron in the blood.
however, it won’t necessarily reflect the intent of the
CMS considers the expressed intent of physicians
The purpose of hydration is to replace some of the fluid
who order test(s), and a hospital-defined protocol does
volume that is removed as the procedure is performed.
not meet this requirement. Ordering physicians should
Therefore, the service is integral to the therapeutic phle-
specify the tests to be performed. This will satisfy CMS’
botomy procedure.
requirement for individualized orders/care and mitigate
the risk of revenue reversal.
The National Correct Coding Initiatives Policy Manual, Chapter 11 (available at www.cms.gov/­nationalcorrectcodinited),
If your facility currently uses a preprinted order form,
states, “Services integral to performing the phlebotomy
add the components defined in the protocol to the form.
(e.g., CPT codes 36000, 36410, 96360–96376) are not
This demonstrates that the ordering physician knows
separately reportable.”
what he or she is ordering. It also allows the ordering
physician to add or remove tests for a specific patient.
It’s best practice to list individual tests on preprinted
Based on this portion of the policy manual as well
as the presence of an NCCI edit that requires coders
to append modifier -59 (distinct procedural service) to
order forms and allow physicians to select those that are
96360 when reported with 99195, do not report hydra-
appropriate for each patient.
tion service when it is provided as part of a therapeutic
phlebotomy procedure. n
Reporting hydration with phlebotomy
Q
We provide IV fluids to our patients who undergo
therapeutic phlebotomy procedures to replace
Questions? Comments? Ideas?
fluid volume lost during those procedures. Should we
Contact Senior Managing Editor
Michelle Leppert, CPC-A
report CPT code 96360 (intravenous infusion, hydration;
initial, 31 minutes to 1 hour) or 96361 (intravenous
Telephone: 781/639-1872, Ext. 3737
infusion, hydration, each additional hour) for the hydra-
E-mail: [email protected]
tion with CPT code 99195 (phlebotomy, therapeutic
[separate procedure])?
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