Derm Coding Consult
Published by the American Academy of Dermatology Association
[
2012 Medicare Fee Schedule –
Impact on Dermatology
The big news as always is the announcement by the Centers
for Medicare and Medicaid Services in the 2012 Medicare
Physician Fee Schedule: Final Rule of the 2012 Conversion
Factor. The Conversion Factor (CF) is the multiplier used with
the relative value units (RVU) assigned by CMS to each CPT
procedure code to determine the dollar amount that will be
paid for each service by Medicare.
For 2012, the Medicare Conversion Factor is set at
$ 24.6712.
This is a reduction of -27.4% from the 2011 CF of
$ 33.97.64, or
A drop of $ 9.3052 per RVU.
Every year for the past seven years, CMS has been obligated
to announce the Conversion Factor based on the legislative
requirements of the Social Security Act. Historically, Congress
has moved with varying levels of speed each year to “fix”
the conversion factor and avoid any precipitous reduction to
physician payment by Medicare.
Gains in Practice Expense (PE) Relative
Value Units (RVUs)
Dermatology continues to benefit from the four year phase
in of adjustments to the indirect practice expense factors.
Dermatology will see a modest +1% increase to the PE/
RVUs for dermatology procedures. This phased-in increase
is a result of CMS use of updated indirect practice expense
data from the AMA Physician Practice Information (PPI)
Survey conducted in 2008. CMS believes the PPIS is the
most comprehensive source of PE survey information available to date. For 2012, the adjustments are a mix of 75%
PPIS data/25% CMS Practice Expense Supplemental Survey
(PESS) data.
CMS Scrutiny of “Potentially Misvalued
Services” Under the Physician Fee Schedule
The Affordable Care Act (ACA) requires the Secretary of the
Department of Health and Human Services (DHHS) to identify
(using certain criteria) & review “potentially misvalued codes”
and make appropriate adjustments to Medicare payment.
CMS is also charged with developing an independent validation process to validate revised RVU values.
To respond to MedPAC, Congress and other stakeholders,
the AMA Resource Based/Relative Value Scale Update
Committee (AMA RUC) established a Work Group in 2006
to establish criteria for identifying misvalued codes. CMS in
[
Volume 15
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Number 4
Winter 2011
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accordance with SSA Sec. 1848(c) determines the appropriate adjustments to RVUs, taking into consideration AMA RUC
as well as MedPAC recommendations. SSA 1848 authorizes
the use of extrapolation and other techniques to determine
RVU levels while taking into account consultations with organizations representing physicians.
Evaluation and Management Codes
CMS has accepted comments, from many specialty societies
as well as the AMA RUC and has removed the proposal to
re-survey all 91 of the Evaluation and Management codes.
However, of greater concern for dermatology is the CMS
comment that:
“In cases where a service is typically furnished with an E/M
service on the same day, we believe that there may be overlap
between the two services in some of the activities conducted
during the pre- and post-service times of the procedure code.
Accordingly, in cases where the most recently available Medicare PFS claims data show the code is typically billed with an
E/M visit on the same day, and where we believe that the AMA
RUC did not adequately account for overlapping activities in the
recommended value for the code, we systematically adjusted
the physician times for the code to account for the overlap.
— see MEDICARE FEE SCHEDULE on page 2
Contents
2012 Medicare Fee Schedule —
Impact on Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,2,3
Letter from the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
AMA Unveils CPT Code Revisions
and Updates for 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,4,5,6
Dermatology Audit Climate. . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,7
Q&A’s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,8
2012 OIG Work Plan Impact on Derm Practices . . . . . . . . . . . . 8
First Medicare RAC Report Reviewed
by Congress - CMS reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,9
PQRS 2012 Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CMS 5010 Reprieve. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9,10
Advanced Beneficiary Notice of Non-coverage (ABN),
Form CMS-R-131: Revised Effective November 1, 2011. . . . 10
In the Know. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
IMPORTANT Please Route to:
___ Dermatologist ___ Office Mgr
CPT only © 2011 American Medical Association. All Rights Reserved.
|
___ Coding Staff Derm Coding Consult, Winter 2011
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___ Billing Staff
page 1
]
Letter from the Editor
2012 Medicare Fee Schedule –
Dear Derm Coding Consult Reader
Impact on Dermatology
Another year has passed and dermatologists and physicians everywhere are again facing a potential decrease
in Medicare reimbursement for 2012. Keep in mind that
Medicare will not make payment adjustments to claims
submitted with a lower fee schedule should there be a
last minute legislative conversion factor increase. Please
watch your local Medicare carrier website, join your Medicare carrier listserv, and visit the AAD website for updated
information.
— continued from page 1
— continued from page 2
After clinical review, of the pre- and post- service work, we
believe that at least one-third of the physician time in both
the pre-service evaluation and the post-service period is
duplicative of the E/M visit…”
As a result of the above, CMS reduced the AMA RUC recommended pre- and post- service physician time by two thirds
for specific codes reviewed during the recent 4th CMS Five
Year review.
The 2012 AAD Coding & Documentation Manual is available for pre-sale and set to mail in January. Order your new
and expanded copy to ensure that your coding practices
are current and up to date. This year we have included the
dermatology specific ICD-10-CM codes and the new toolkit:
Surviving RAC Audits.
ACA review categories
If you missed the 2012 Coding Update Webinar on November 17, 2011, plan to join us on January 19, 2012 for a
review of 2012 CPT, ICD and Medicare changes as well as
an update on recent legislation. Learn the impact physician reimbursement will have on your practice in 2012.
• 17004 – Destruction of pre-malignant lesions, +15
• 17311 – Mohs, stage 1, H/N/F/G
• 17312 – Mohs, addtl stage, H/N/F/G
The Derm Coding Consult editorial staff: Peggy Eiden,
Faith McNicholas, Mariana Abarca, and Scott Weinberg,
join me in wishing all the peace and joy of this Holiday
Season to you and to your families!
Best,
CMS has identified dermatology codes within four of the
seven ACA review categories:
Code(s)/code families with fastest growth
CMS has identified the following derm specific codes for
review
Code(s) for new technologies & services
CMS has identified the following derm specific codes for
revalidation of physician work
• 96920-96921-96922 – Laser Treatment of Psoriasis
AAD will be conducting an online survey of the 9692X codes
in November and December for presentation at the Jan
2012 AMA RUC meeting.
Codes that have not been reviewed since RBRVS
implementation (Harvard valued)
CMS has identified the following derm specific codes for
review
• 13100-13152 – Complex Repair Codes
Cynthia A. Bracy, RHIA, CCS-P
Specialist, Practice Management Resources
Other codes determined to be appropriate by the
Secretary.
CMS has also identified the pathology consultations codes
for review
• 88300-88309 – Pathology consultation
— see MEDICARE FEE SCHEDULE on page 3
Editorial Advisory Board
Scott Dinehart, MD, FAAD
Little Rock, AR
Chair, Health Care Finance Committee
Alexander Miller, MD, FAAD
Yorba Linda, CA
AAD Rep. to AMA CPT Advisory Committee
Murad Alam, MD, FAAD
Chicago, IL
ASDS Rep. to AMA/CPT Advisory Committee
Stephen P. Stone, MD, FAAD
Springfield, Il
SID Rep. to AMA/CPT Advisory Committee
Coding & Reimbursement Task Force Members
Scott Dinehart, MD, FAAD, Chair
Kenneth R. Beer, MD, FAAD
Joseph S. Eastern, MD, FAAD
Rebecca Kazin, MD, FAAD
David Kouba, MD, FAAD
Alexander Miller, MD, FAAD
Brent Moody, MD, FAAD
George Murakawa, MD, FAAD
Kathleen Sawada, MS, FAAD
Ben M. Treen, MD, FAAD
James A. Zalla, MD, FAAD
Bryan Gammon, MD, FAAD Resident
Cynthia A. Bracy, RHIA, CCS-P
Editor, Derm Coding Consult
Jeremy Bordeaux, MD, FAAD
ASDS Alternate Rep to AMA CPT Advisory Committee
Norma L. Border, MA
Assistant Editor, Derm Coding Consult
David Pharis, MD, FAAD
ACMS Rep to AMA CPT Advisory Committee
Peggy Eiden, CPC, CCS-P
Assistant Editor, Derm Coding Consult
Faith C. M. McNicholas, CPC, CPC-D
Assistant Editor, Derm Coding Consult
Mariana Abarca, CPC, CPC-D
Assistant Editor
Scott Weinberg
Contributing Writer
[
page 2
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Derm Coding Consult, Winter 2011
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2012 Medicare Fee Schedule –
Impact on Dermatology
Editor’s Notes:
The material presented herein is, to the best of our knowledge accurate and
factual to date. The information and suggestions are provided as guidelines
for coding and reimbursement and should not be construed as organizational
policy. The American Academy of Dermatology/Association disclaims any responsibility for the consequences of actions taken, based on the information presented
in this newsletter.
Mission Statement:
Derm Cod­ing Consult is published quar­ter­ly (March, June, September and
December) to pro­vide up-to-date information on coding and re­im­burse­ment
is­sues per­ti­nent to dermatology practice.
Address Correspondence to:
Scott Dinehart, MD, FACP Editorial Board Derm Coding Consult
American Academy of Dermatology Association
P.O. Box 4014 Schaumburg, IL 60168-4014 CPT only © 2011 American Medical Association. All Rights Reserved.
]
Calculation of Malpractice RVUs
CMS has determined that it is not logistically feasible to
survey and review malpractice insurance premium data
on an annual basis, a comprehensive review of MLI/RVU
data will be set at five year intervals. For new and revised
CPT codes, PLI RVUs will be cross-walked to similar codes
performed by that specialty. Dermatology is consistently
ranked as low risk by malpractice insurers and this valuing
is reflected in the PLI/RVU values for dermatology procedures.
Medicare Telehealth Services For The
Physician Fee Schedule
Under the Medicare Telehealth Services provisions, CMS
has expanded coverage of telehealth service in 2012 to
include smoking cessation counseling (2 codes). CMS has
also expanded the criteria for consideration of Category 2
telehealth services; revised the inpatient telehealth consultation G codes and increased the originating site fee by
0.6%.
Finalizing CY 2011 Interim and Proposed
Values for CY 2012
Medicare Physician Fee Schedule Code
Specific Detail
CMS announced with the publication of the 2012 Medicare
Physician Fee Schedule: Proposed Rule that it would no
longer include the relevant Appendices in the documentation
published in the Federal Register. The display copy of the Final
Rule is downloadable at: http://www.ofr.gov/OFRUpload/
OFRData/2011-28597_PI.pdf
All of the appendices for the Medicare Physician Fee Schedule
are now down loadable from the CMS web site at: http://www.
cms.gov/PhysicianFeeSched/PFSFRN/itemdetail.
asp?filterType=none&filterByDID=-99&sortByDID=4&sortOrder
=descending&itemID=CMS1253669&intNumPerPage=10
AMA Unveils CPT Code
Revisions and Updates
for 2012
At the just ended AMA CPT Symposium in Chicago, Illinois, the
American Medical Association (AMA) unveiled revisions and
updates to certain dermatology codes for CPT 2012. Dermatology practices are encouraged to pay close attention to these
revisions as they may ultimately affect the final code selection
of service performed.
CMS has provided a code by code discussion of the AMA
RUC review, Refinement Panel and CMS decisions on all of
the codes reviewed as part of the CMS 4th Five Year Review.
Comparison of the 2011 and 2012 MFS: Final Rules reveal
that CMS has chosen not to accept the AMA RUC recommendations for a growing number of codes. So far, this has not
negatively impacted specific dermatology codes that were
reviewed and valued.
Debridement
Integumentary System - Codes Reviewed
In the continued effort to provide correct and accurate coding
guidelines, AMA has provided a revision to the debridement
code guidelines.
11900-11901 – Injections into skin lesions;
The revised text state, “wound debridements (11042-11047)
are reported by depth of tissue that is removed and by surface
area of the wound. These services may be reported for injuries, infections, wounds and chronic ulcers. When performing
debridement of a single wound, report depth using the deepest
level of tissue removed. In multiple wounds, sum the surface
area of those wounds that are at the same depth, but do not
combine sums from different depths.”
For the following codes, CMS has finalized the RVU values
without change to the interim values for the following codes:
12001-12018 – Simple repairs;
12041- 12051-12054 – Intermediate repairs;
15120, 15121, 15260, 15823 – Skin grafts
CMS has either retained the interim code value or these
codes remain under review in the ACA categories listed
above:
13100-13152 – Complex repairs
15120, 15732 – graft & flaps
CMS has accepted that the AAD 4th Five Year Review survey
data has validated the current values for these codes and
also corrected intra-service times for:
17260 – 17286 – Destruction of malignant lesions
CMS has detailed all of the accepted and/or revised physician
work RVUs resulting from the 4th Five Year Review in Table
15 of the 2012 MFS: FR. CMS has detailed all of the accepted
and/or revised physician pre- intra- and post- service time
minutes resulting from the 4th Five Year Review in Table 16.
[
In 2010, Centers for Medicare and Medicaid Services (CMS)
identified the debridement codes through the site-of-service
anomaly screen and requested that the AMA/RUC review these
codes. As a result, codes 11040 and 11041 were deleted,
97597 and 97598 were revised and a set of new and add-on
codes were created in an effort to correct this problem (11042 11047).
The following example in the debridement guidelines was editorially revised to delete 11045 because this is an add-on code
that is normally reported in conjunction with code 11042 and
would never require the use of a modifier. The revised text now
directs the use of modifier 59 with either code 11042 or 11044
as appropriate.
Example: when bone is debrided from a 4 sq. cm heel ulcer
and from a 10 sq. cm ischial ulcer, report the work with a single
code, 11044. When subcutaneous tissue is debrided from a
16 sq. cm dehisced abdominal wound and a 10 sq. cm thigh
wound, report the work with 11042 for the first 20 sq. cm
CPT only © 2011 American Medical Association. All Rights Reserved.
— see CODE REVISIONS on page 4
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Derm Coding Consult, Winter 2011
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page 3
]
AMA Unveils CPT Code
Revisions and Updates
for 2012
2012 Intermediate Repair Codes Work RVUs
(based
on 2012 MPFS
-27.4%
reduction)
CPT Code
Size
2011
wRVU
2012 wRVU
— continued from page 3
and 11045 for the second 6 sq. cm. If all four wounds were
debrided on the same day, use modifier 59 with 11042, 11045
or 11044 as appropriate.
NOTE: Debridement codes are out of sequence, one is encouraged to check the coding manual for the most accurate code
selection.
2012 Work RVUs
2011
wRVU
2012
wRVU
CPT Code
Descriptor
11042
Debridement,
subcutaneous tissue….
1st 20 sq. cm or less
1.01
Each addle 20 sq. cm,
or part thereof (List
separately…)
0.50
+11045
Nat. Avg.
Reimb.
12031
2.5 cm or less
2.20
2.00
12032
2.6 – 7.5 cm
2.52
2.52
12034
7.6 – 12.5 cm
2.97
2.97
12035
12.6 – 20 cm
3.47
3.50
12036
20 – 30 cm
4.09
4.23
12037
>30 cm
4.71
5.00
12041
2.5 cm or less
2.42
2.10
12042
2.6 – 7.5 cm
2.79
2.79
12044
7.6 – 12.5 cm
3.19
3.19
12045
12.6 – 20 cm
3.68
3.75
12046
20 – 30 cm
4.29
4.20
12047
>30 cm
4.69
4.95
⇒
several new cross-references and instructional notes;
12051
2.5 cm or less
2.52
2.33
12052
2.6 – 5 cm
2.87
2.87
⇒
new add-on code 15777 has been established to report
the implantation o biologic implant (e.g. acellular dermal
matrix) for soft tissue reinforcement e.g. breast, trunk)
in addition to the primary procedure.
12053
5 - 7.5 cm
3.17
3.17
12054
7.6 – 12.5 cm
3.50
3.50
12055
12.6 – 20 cm
4.47
4.50
12056
20 - 30 cm
5.28
5.30
12057
>30 cm
6.00
6.00
Skin Replacement Surgery
(based on 2012 MPFS -27.4% reduction)
Intermediate Repairs (12031 – 12057)
The American Academy of Dermatology (AAD) conducted a
survey among its members and presented the survey results
to the AMA/RUC on CPT codes 12031 – 12057. As a result of
this survey, the smaller size repair codes saw a small decrease
in RVUs while the larger size repair codes had their RVUs
increased. There has also been a revision to section 2 and 4 of
the guidelines in this section to more appropriately describe the
use of modifier 59 instead of 51.
Part of Section 2 states “when more than one classification of
wounds is repaired, list the more complicated as the primary
procedure and the less complicated as the secondary procedure using modifier 51 59”.
The beginning of section 4 states “Involvement of nerves, blood
vessels and tendons: Report under appropriate system
(nervous, cardiovascular, musculoskeletal) for repair of these
structures. The repair of these associated wounds is included
in the primary procedure unless it qualifies as a complex repair,
in which case modifier 51 59 applies.”
Skin replacement surgery consists of surgical preparation and
topical placement of an autograft (including tissue cultured
autograft) or skin substitute graft (i.e. homograft, allograft,
xenograft). The graft is anchored using the provider’s choice
of fixation. When services are performed in the office,
routine dressing supplies are not reported separately.
This subsection of the Integumentary System has been
comprehensively expanded to include new guidelines that
clarify the reporting of wound care management and skin
substitutes. Comprehensive changes were made to the Skin
Replacement code section and its sub-heading.
Other changes include:
⇒
deletion
of twenty-four codes (15300 – 15431), appropriate cross reference has been provided to direct users
to 15271 – 15278 in lieu of 15400 - 15431;
2012 CPT Skin Substitute codes
Deleted
To report: see
15300, 15301
15271-15274
15320, 15321
15275-15278
15330, 15331
15271-15274
15335, 15336
15275-15278
15340, 15341
15271-15278
15360, 15361
15271-15274
15365, 15366
15275-15278
15400, 15401
15271-15274
15420, 15421
15275-15278
15430, 15431
15271-15278
⇒
editorial revision of six codes (15150 – 15157) to remove
the term ‘epidermal’ and replace that with ‘skin’;
⇒
addition of two-tier structure of eight new cods (15271 –
15278) to report the application of skin substitute grafts
which are distinguished according to the anatomic location and surface are rather than by product description:
— see INTERMEDIATE REPAIRS on page 5
[
page 4
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Derm Coding Consult, Winter 2011
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AMA Unveils CPT Code
Revisions and Updates
for 2012
CPT only © 2011 American Medical Association. All Rights Reserved.
]
— continued from page 4
ucodes 15271, +15272, 15275 and +15276
describe the application for total wound surface
area up to 100 sq. cm
ucodes 15273, +15274, 15277, and +15278
describe the application for total wound surface are
greater than or equal to 100 sq. cm;
NOTE: Codes 15271 – 15278 are intended to report topical
application of skin substitutes grafts.
This expansion was effected to achieve greater granularity
and consistency for these services e.g. guidelines now instruct
that skin replacement surgery consists of the surgical preparation and topical placement of an autograft, which includes
tissue cultured autograft, or the skin substitute homograft,
allograft, and xenograft.
Surgical preparation code guidelines (15002 - 15005) for
skin replacement surgery have been revised to describe the
initial services related to preparing a clean and viable wound
surface for placement of an autograft, flap, skin substitute
graft or for negative pressure wound therapy. There have
been no changes to the autograft codes (15040 – 15136).
When selecting the appropriate service codes, avoid reporting
15002 – 15005 for removal of nonviable tissue/debris in a
chronic wound (e.g., venous or diabetic) when wound is left to
heal by secondary intention. See active wound management
codes (97597, 97598) and debridement codes (1104211047) for this service. For necrotizing soft tissue infections
in specific anatomic location, see 11004 – 11008.
prolonged cleansing, when appreciable amounts of devitalized
or contaminated tissue are removed, or when debridement is
carried out separately without immediate primary closure.
The following definition should be applied to those codes that
reference 100 sq. cm or 1% of body area of infants and children” when determining the involvement of body size.
The measurement of 100 sq. cm is applicable to adults and children 10 years of age and older; and percentages of body surface
area apply to infants and children younger than 10 years of age.
The measurements apply to the size of the recipient area. The
measurements apply to the size of the recipient area.
Procedures involving wrist and/or ankle are reported with codes
that include arm or leg in the descriptor. When a primary procedure requires a skin substitute or skin autograft for definitive skin
closure e.g. orbitectomy, radical mastectomy, deep tumor removal,
use 15100 – 15278 in conjunction with primary procedure.”
Skin Substitute Code structure
Location ⇒
Size ⇓
Face, scalp, neck, ears, genitalia, hands, feet, digits
Trunk, arms, legs
1st 25 sq. cm, up to
100 sq. cm
15275
15271
Each addtnl 25 sq. cm,
up to 100 sq. cm
+15276
+15272
1st 100 sq. cm
15277
+15273
Each adding
100 sq. cm
+15278
+15274
Wound =⇒100 sq. cm
For biological implant for soft tissue reinforcement, use
15777 in conjunction with primary procedure. The supply of
skin substitute graft(s) should be reported separately in
conjunction with 15271-15278 (See HCPC codes Q410x to
be reported on your Medicare claims).
2012 Skin Substitute HCPCS Supply Codes
HCPCS Code
Descriptor
Q4100
Skin Substitute, NOS
Q4101
Apligraf, per sq. cm
Q4102
OASIS Wound Matrix, per sq. cm
Q4103
OASIS Burn Matrix, per sq. cm
Q4104
Integra Bilayer Matrix Wound Dressing (BMWD) per sq., cm
Q4105
Integra Dermal Regeneration Template (DRT), per sq. cm
Q4106
Dermagraft, per sq. cm
Q4107
GRAFTJACKET, per sq. cm
Q4108
Integra Matrix, per sq. cm
Q4110
PriMatrix, per sq. cm
Q4111
GammaGraft, per sq. cm
Q4112
Cymetra, injectable, 1cc
Q4113
GRAFTJACKET xpress, injectable, 1cc
Do not sum wounds from different groupings of anatomic sites
(e.g., face and arms), instead use 15002 or 15004 as appropriate for excisions and incisional releases resulting in wounds
up to and including 100 sq. cm of surface area. Use 15003 or
15005 for each additional 100 sq. cm or part thereof.
Q4114
Integra Flowable Wound Matrix, injectable, 1cc
Q4115
Alloskin, per sq. cm
Q4116
Alloderm, per sq. cm
Q4117
Hyalomatrix, per sq. cm
Q4118
Matristem micromatrix, 1 mg
Repair of donor site that requires a skin graft or local flap
is reported separately. However, the removal of the current
graft and/or simple cleansing of the wound is included when
performed (do not report 97602). Debridement is considered
a separate procedure only when gross contamination requires
Q4119
Matristem wound matrix, 1 mg
Q4119
Matristem wound matrix, per sq. cm
Q4120
Matristem burn matrix, per sq. cm
Q4121
Theraskin, per sq. cm
Example: surgical preparation of a 20 sq. cm wound on
the right hand and a 15 sq. cm wound on the left hand
would be reported with a single code, 15004. Surgical
preparation of a 75 sq. cm wound on the right thigh and a
75 sq. cm on the left thigh would be reported with 15002
for the first 100 sq. cm and 15003 for the second 50 sq.
cm. If all four wounds required surgical preparation on
the same day, use modifier 59 with 15002 and 15004.
[
CPT only © 2011 American Medical Association. All Rights Reserved.
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Derm Coding Consult, Winter 2011
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page 5
]
AMA Unveils CPT Code
Revisions and Updates
for 2012
For more information on 2012 HCPCS codes, visit CMS at
www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp
To obtain a detailed list of all the 2012 revised and updated
codes, please review the 2012 AAD Coding & Documentation
Manual or the AMA 2012 CPT code book.
Dermatology Audit Climate
— continued from page 6
• A modifier -25 is applied only to an E/M CPT service code
(99201-99499).
— continued from page 5
Modifier 92 – Alternative Laboratory
Testing Platform
When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists on a single use,
disposable analytical chamber, the service maybe identified by
adding modifier 92 – alternative laboratory platform testing to
the usual laboratory procedure code. This applies to all tests that
do not require a permanent dedicated space, hence by its design
may be hand carried or transported to the vicinity of the patient
for immediate testing at that site, although location of the testing
is not in itself determinative of the use of the modifier.
88104, 88106 - Smears and Simple Filter Preparation
88107 has been deleted so to report smears and simple filter
preparation, see 88104, 88106.
88312 – 88319 Special Stains including Interpretation and
Report
The special stains codes (88312 – 88319) have been revised
to better define the service and eliminate confusion concerning
special stains where procedures overlap two code definitions.
Additional instructions and cross reference parenthetical notes
have been added to provide a defined hierarchy for codes
88314 – 88319 and define units of service thereof.
CPT Code
Descriptor
88312
Special stain including interpretation and report; Group I for
microorganisms (e.g., Gridley, acid fast, methenamine silver),
incl interpretation and report each.
(Report one unit of 88312 for each special stain, on each surgical
pathology block, cytologic specimen, or hematologic smear)
88313
+88314
[
Special stain including interpretation and report; Group II all other
(e.g., iron, trichrome), except immunocytochemistry and immunoperoxidase stain for microorganisms, stains for enzyme constituents, including interpretation or immunocytochemistry and report
each immunohistochemistry
(Report one unit of 88313 for each special stain, on each surgical
pathology block, cytologic specimen, or hematologic smear)
(For immunocytochemistry and immunohistochemistry, use 88342)
Special stains including interpretation and report; histochemical
staining with on frozen section(s), including interpretation and
report tissue block
(List separately in addition to code for primary procedure)
(Use 88314 in conjunction with 17311-17315, 88302-88309,
88331, 88332)
(Do not report 88314 with 17311-17315 for routine frozen section stain [e.g., hematoxylin and eosin, toluidine blue, performed
during Mohs surgery. When a nonroutine histochemical stain on
frozen tissue during Mohs surgery is utilized, report 88314 with
modifier 59)
(Report one unit of 88314 for each special stain on each frozen
surgical pathology block)
•(For a special stain performed on frozen tissue section material
to identify enzyme constituents, use 88319)
88318
Has been deleted. For determinative histochemistry to identify
chemical components, use 88313
88319
Special stains including interpretation and report; Group III, for
enzyme constituent
(For each stain on each surgical pathology block, cytologic specimen, or hematologic smear, use ne unit of 88319)
For detection of enzyme constituents by immunohistochemical or
immunocytochemical technique, use 88342)
page 6
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Dermatology Audit Climate
Dermatologists are seeing an increase in audits. Recovery
Audit Contractors (RACs) are focusing on Global surgery
reported with an Evaluation and Management (E/M) service
with or without Modifier -25. Since reporting an E/M office
visit with a procedure is common to Dermatology practices, it
is important to understand Modifier -25 use and global package definitions.
CMS and AMA CPT define Modifier 25 as: Significant, separately identifiable evaluation and management (E/M) service
by the same physician on the day of a procedure; and an E/M
and procedure(s) can be reported with one diagnosis.
Medicare Global Package
• Preoperative Visits – Preoperative visits after the decision
is made to operate beginning with the day before the day
of surgery for major procedures and the day of surgery for
minor procedures;
• Intra-operative Services – Intra-operative services that are
normally a usual and necessary part of a surgical procedure;
• Complications Following Surgery – All additional medical
or surgical services required of the surgeon during the
postoperative period of the surgery because of complications which do not require additional trips to the operating
room;
• Postoperative Visits – Follow-up visits during the postoperative period of the surgery that are related to recovery
from the surgery;
• Postsurgical Pain Management – By the surgeon;
• Supplies – Except for those identified as exclusions; and
• Miscellaneous Services – Items such a dressing changes;
local incisional care; etc….”
Each CPT procedure that has a global period includes an
assigned value for related E/M like services but this value
does not include an E/M service that is “separate and identifiable” from the care of the procedure. Medicare makes a
separate payment under certain exceptions.
• To report an E/M with a procedure, use Modifier -25 to
indicate on the day of procedure, the patient’s condition required a significant, separately identifiable E/M
service, above and beyond the usual pre- and postoperative care associated with the procedure or service
performed. To be a separate and identifiable E/M
service, the documentation should support more than
the procedure’s brief History of Present, Illness, Review
of System and Past Family Social History with a limited
physical examination
CPT only © 2011 American Medical Association. All Rights Reserved.
— see AUDIT CLIMATE on page 7
]
NOTE: Be sure to address the reason the patient gave
for the visit in your documentation. This may be difficult for patients presenting for skin screening services
as they generally do not have a chief complaint and
history of present illness.
• The procedure performed must have a global period listed
on Medicare Fee Schedule RVU.
• An E/M service may occur on the same day as a procedure and within the post-operative period of a previous
procedure. Payment is allowed when the documentation
supports the modifier -25 and modifier -24, unrelated E/M
during a post op period.
A patient may report a new complaint and/or the provider
may make an unexpected new discovery. If the problem or
abnormality requires a workup that is separate and identifiable from the procedure, a separate problem-oriented
evaluation and management service note should be documented into the medical record. You should then append a
modifier -25 to the E/M code.
AAD staff having the opportunity to review members’ E/M
documentation with a procedure, found in many cases a
vague, conflicting or missing chief complaint. Each medical record should clearly reflect the chief complaint or
the main reason for the visit. This notation is needed for
all levels of history documentation. It is typical for chief
complaint to be copied from the appointment schedule
or staff. The element of the history is a valued piece of
information as it sets the tone and/or contact between
the patient and physician. If chief complaint hints of a
procedure, auditors will dismiss the E/M documentation
as included in the procedure.
The chief complaint is a concise statement describing the
symptoms, problem, condition, diagnosis or other factor
that is the reason for the encounter, usually stated in the
patient’s words. When eliciting the reason for the patient’s
visit, ask open-ended questions. Clarify the response
given by the patient, if necessary. CMS/AMA documentation guidelines indicate that a chief complaint is needed
for every visit. For fee-for-service visits, the chief complaint
also helps determine if the visit is medically necessary for
the treatment of illness or injury.
E/M services, by their nature, are a diverse set of cognitive procedures. AMA CPT E/M code set describes the
various physician work and expense scenarios encompassed within the procedures. Medicare is required by
federal law to pay only for services that are medically
reasonable and necessary.
CMS’ definition of medical necessity requires that paid
services meet but not exceed the patient’s medical needs
and be provided in accordance with accepted standards of
medical practice. The patient’s condition (severity, acuity,
[
number of medical problems, etc.) is the key determinant for
the frequency and intensity of E/M services for which Medicare pays. Coding E/M services first on the basis of medical
necessity followed by verification of documentation of
required key work components for the selected code allows
providers to avoid several common pitfalls of E/M documentation and coding.
Q&A’s
Questions below on coding answered by Alex Miller,
MD FAAD
Q: ICD-9 says “spindle cell neoplasm consistent with
malignant fibroxanthoma” – code 238.1. Our
dermpath says it should be “spindle cell neoplasm
consistent w/ malignant fibrohistiocytoma” – code
171.X
A: Malignant fibrous histiocytoma: 238.2 vs. 171.X. The
answer is 171.X, as malignant fibrous histiocytomas
are characteristically tumors of subcutaneous and
fascial tissue, rather than primary in skin. Unusual
question, anyway, as these are rare tumors in the
first place, and are particularly exceedingly rare for
dermatologists to deal with. Maybe the question really
concerns “atypical fibroxanthoma” (AFX), which is a
malignant tumor of primary cutaneous origin. In that
case, neither 238.2 nor 171.X would be appropriate for
AFX. One would then have to follow the coding conventions by cutaneous tumor location: 173.XX, with the
particular code determined by the tumor location and
the “other specified malignant neoplasm” characteristic (starting 10/01/2011).
Q: ICD-9 says “atypical squamous proliferation” –
code 238.2 – Our dermpaths say it should be 173.X
(malignant)
A: “Atypical squamous proliferation” is just that: “atypical”. It does not specify benign versus malignant
because one cannot foretell the future behavior of
the lesion. This kind of diagnosis specifies “uncertain
behavior”. So, the appropriate code is 238.2. 173.XX
is not justified, as the diagnosis is not one of cancer.
Q: ICD-9 says “Bowenoid Papulosis” – code 216.x – Our
dermpaths say it should be 232.5
A: Bowenoid papulosis: this is a bit challenging to code,
as the lesions of the condition both clinically and
histologically can closely resemble condyloma acuminatum. So, in some cases one may even be justified
in using the condyloma acuminatum code, 078.11.
However, the more “classic” bowenoid papulosis has
scattered to plentiful atypical squamous cells, and may
even appear virtually indistinguishable from Bowen’s
disease histologically. Consequently, it could accept
more than one code. It could be coded as neoplasm of
uncertain behavior (238.2, 235.5, 236.3, and 236.6)
or it could be coded as carcinoma in situ, 232.5 or 233.
XX. Any of the aforementioned codes could be correct.
CPT only © 2011 American Medical Association. All Rights Reserved.
— see Q&A’s on page 8
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Derm Coding Consult, Winter 2011
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page 7
]
Q&A’s
— continued from page 7
216.X is not correct, however, because the tumor is
either considered viral (condyloma) or of uncertain
behavior or carcinoma in situ. It is not appropriate to
code for benign neoplasm.
Q: ICD-9 says “Bowenoid Papulosis” – code 216.x – Our
dermpaths say it should be 232.5
A: Large cell acanthoma -- this lesion can be considered
benign or actinic keratosis, depending upon the individual histology of the particular large cell acanthoma
in question. Consequently, either the benign or the
actinic keratosis codes can be appropriate, depending upon the specific acanthoma histology, and I would
leave it up to the pathologist to let the coder know
which is his/her preference.
Q: If a patient had Moh’s surgery, a complex repair was
performed, and the patient came back two days later
complaining of extreme swelling and redness of the
surgical site, can I bill for an office visit?
A: According to the CPT guidelines, the complex repair
has a 10 day global period; therefore, it may not be
billed for an additional office visit, unless unrelated
to the surgical site. Also, RUC database states that
complex closure has two office visits included postoperative.
Q: I am seeing a new patient for Mohs surgery. I
want to read the tissue slide the patient’s previous
physician performed, I was not asked for consultation by the previous physician. May I bill for
reading the slide?
A: You may not bill for reading the slide since the consultation was not requested by the performing physician.
Reading the slide is considered a part of the medical
decision making portion of the E&M service
2012 OIG Work Plan Impact
on Derm Practices
The U.S. Department of Health & Human Services (HHS) Office
of Inspector General’s (OIG) 2012 Work Plan was released
on October 5. Their fiscal year is from October 1st though
September 31st of each year for Medicare issues. The OIG’s
compliance plan is still voluntary for physicians. This work plan
is a good tool to monitor and identify billing issues within a
dermatology practice.
The OIG will continue their investigations of last year’s work
plan: place-of-service errors; E/M utilization errors; physician’s
compliance with assignment rules; E/M services during the
[
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Derm Coding Consult, Winter 2011
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global surgery period; and electronic health records (EHRs)
cloned documentation. Because many of the same issues
remain a part of the OIG Work Plan year after year, indicates
these are perennial problems.
The newest concerns for physician services in 2012 include
the following reviews of:
• High cumulative Part B payments to determine if they are
reasonable and necessary, adequately documented, and
provided consistent with federal regulations.
• Whether incident-to billing has a higher error rate than
that for non incident-to services.
• Appropriateness of the use of certain modifiers (-24 &
-79) during the global surgery period.
As health care expenses continue to rise and consume
a greater portion of federal dollars, the OIG has become
more aggressive in pursuit of noncompliance, fraud,
and abuse. In 2010, $3.8 billion in expected investigative receivables were court ordered or paid through civil
settlements that resulted from cases developed by OIG
investigators; and HHS program managers pursued $1.1
billion in audit receivables as a result of OIG audit disallowance recommendations.
All practices and facilities should read the OIG Work Plan in
its entirety, and take steps to identify and rectify any potential
issues they may have, before the OIG does.
• OIG’s 2012 Work Plan: http://oig.hhs.gov/reports-andpublications/workplan/index.asp
First Medicare RAC Report
Reviewed by Congress –
CMS reports
Congress has reviewed the first report from the Recovery Audit Program. 2010 was the first year in which the
Recovery Auditors began actively identifying and correcting improper payments. They have since identified and
corrected $92.3 million in combined overpayments and
underpayments. 82% of all Recovery Audit program corrections were identified as overpayments, and 18% were
identified underpayments that were refunded to providers,
according to CMS.
Dermatology practices are encouraged to ensure coding
guidelines and convention compliance, improve medical
record documentation to illustrate detailed patient encounter and medical necessity justification for services provided.
These simple checks and balances will help keep unnecessary audits at bay.
CPT only © 2011 American Medical Association. All Rights Reserved.
— see RAC Report on page 9
]
First Medicare RAC Report
Reviewed by Congress –
CMS reports
— continued from page 7
FY 2010 by each Recovery Auditor
Amount Corrected
($ Millions)
Region
Recovery Auditors
Region A
Diversified Collection Services (DCS)
5.9
Region B
CGI, Inc.
15.5
Region C
Connolly, Inc.
27.5
Region D
HealthData Insights (HDI)
For more information about the changes to PQRS, visit
www.aad.org/qrs.
43.4
Total:
92.3
More information on the report can be found at: http://
www.cms.gov/Recovery-Audit-Program/Downloads/
FY2010ReportCongress.pdf
PQRS 2012 Update
There will be several changes to the Physician Quality Reporting System (PQRS) in 2012. Dermatologists who report
quality measures to PQRS, formerly known as PQRI, will make
themselves eligible for a bonus payment of 0.5 percent of
their total Medicare Part B allowed charges as opposed to
1% in 2011. In addition, dermatologists will have four dermatology-appropriate measures in 2012 to report in order to
make themselves eligible for a bonus incentive. Three of
the measures, 137, 138, and 224, will largely continue as
measures from the 2011 program. Measure 224, overutilization of imaging studies in melanoma, however, has changed
to include all melanoma patients, regardless of the melanoma stage.
New Dermatology Measure!
Measure 265, biopsy follow-up, has been added to the
program. Measure 265 measures the percentage of
patients whose biopsy results have been reviewed and
communicated to the primary care/referring physician and
to the patient by the performing physician. To satisfy this
measure, the biopsying physician must: review the biopsy
results with the patient, communicate those results to the
primary care/referring physician, track communication in
a log, and document the tracking process in the patient’s
medical record. This measure applies to all patients undergoing a biopsy, regardless of diagnosis.
A dermatologist wishing to participate in PQRS must report
at least three measures. Therefore, he or she only has to
report three of the four dermatology-appropriate measures
to qualify. All of the quality measures must have at least
one eligible instance for a dermatologist to qualify for the
incentive. For example, “new melanoma” is the only applicable diagnosis for measure 138, so to successfully report
measure 138; the dermatologist must have at least one
[
Medicare patient with a new diagnosis of melanoma. If not,
then the dermatologist can choose to report measure 265
to meet the three measure threshold. Additionally, a greater
than zero percent performance rate for all three measures is
necessary to qualify for the incentive payment. This means
that you must perform the measure on at least one patient
per measure to qualify for the incentive payment. Each of the
four dermatology measures must be reported via electronic
registry, for only a full year reporting period (January 1-Decemeber 31, 2012). In past years, one could report for only a
six-month period.
CMS 5010 Reprieve
On January 1, 2012, the 5010 version of the electronic transaction standards will replace the current 4010 version widely
used by practices, clearinghouses and payers to transmit and
process claims. Recently, however, the Centers for Medicare
and Medicaid Services (CMS) issued a reprieve advising that
it would not enforce the January 1st compliance deadline
until March 31, 2012. At the same time, CMS encouraged all
covered entities (hospitals, medical practices, practice management/billing software vendors, claims clearinghouses, and
public/private payers) to make a good faith effort to comply with
the original deadline. In issuing this enforcement notice, CMS
noted that it will roll out further instructions to its contractors on
how to process claims after January 1st, and issue additional
guidance for all covered entities.
What does this mean?
The federal government has mandated that all covered entities
must transition to the new 5010 version of the electronic transaction standards to comply with the Health Insurance Portability
and Accountability Act (HIPAA). While the deadline remains
January 1, 2012, CMS has noted that it will not start enforcing compliance until 90 days after—on March 31, 2012. The
sooner you comply, the better off your practice will be financially
since it will mean there is less risk of incurring claims processing delays and cash flow disruption. Note that a dermatology
practice is considered a covered entity if it submits electronic
claims to payers, even if the claims are submitted through a
clearinghouse or billing company.
What steps should I take to make sure my
practice is fully compliant?
Don’t delay, act now to avoid problems. Despite the 90-day
grace period, dermatology practices are encouraged to confirm
with their practice management/billing system software vendor
that their system has been upgraded to use the new 5010
standard (which comes with new formatting and functionality
requirements) by the deadline. If your vendor cannot meet the
deadline, then make sure you work with them to achieve full
compliance shortly after January 1st. After the upgrade, you
will need to test and verify that your claims can be transmitted successfully to your clearinghouse and payers without any
technical difficulties and delays.
CPT only © 2011 American Medical Association. All Rights Reserved.
— see CMS 5010 Reprieve on page 10
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Derm Coding Consult, Winter 2011
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]
CMS 5010 Reprieve
— continued from page 9
For practices looking to purchase billing software, it is ideal to
have billing software that is “dual compatible.” Dual compatible billing software will allow you to send claims in the new
5010 version as well as in the older 4010 standard in case
your payers are still working on compliance. Your software
vendor and clearinghouse can help with this flexible approach.
Steps for dermatology practices to take
Other factors to consider
Before January 1, 2012, find out from your
practice management/billing software
vendors about when to expect your 5010
software upgrade. The sooner the better.
Depending on the situation
of the practice, avoid major
capital purchases for the first
part of 2012 so that you are
not cash-strapped and can
continue to operate.
Once system has been upgraded, make
sure to test by sending “test claim” transmissions to your clearinghouse and payers.
Once tested successfully, you will be able
to assess what payers are compliant and
which ones will likely be problematic.
Monitor this closely to be sure you know
what to expect in terms of payment delays.
Budget carefully to reflect
potential business emergencies. A sound contingency
budget can help with surviving
temporary economic situations.
The latest version of the ABN (with the release date of March
2011 (3/11) printed in the lower left hand corner) is now
available for immediate use. In order for providers and
suppliers to have time to transition to using the newly posted
notice, mandatory use of this version began on November
1, 2011. The mandatory ‘use’ date has been changed from
September to November to accommodate those providers
and suppliers with pre-printed stockpiles of ABNs so that
they have more time to exhaust any supplies of the outgoing ABN.
All ABNs with the release date of March 2008 that are used
on or after November 1, 2011 will be considered invalid.
The newest version of the ABN and instructions is in the AAD
2011 Coding & Documentation Manual on page 468 and
can be downloaded at this CMS website: https://www.cms.
gov/BNI/02_ABN.asp.
Remember to make sure your billing software system can handle both 5010 and
4010 transactions in case some private
payers are not ready.
Don’t delay. If you can, file all your 2011
claims before or by December 31, 2011
to avoid claims disruption and reimbursement threats. Being proactive here will
mean one less thing to worry about that
could have been prevented.
Advanced Beneficiary Notice
of Non-coverage (ABN),
Form CMS-R-131: Revised
Effective November 1, 2011
If needed, consider a business
loan or line of credit from your
bank or other lender.
Remember that with the new 5010 version, you will not be able to use a P.O. Box
or lock box address as your billing provider
data field. Instead, you will be required
to use only a street address or physician
location under the billing provider section.
Continuing to use P.O. boxes in the billing
provider will result in your claims being
rejected.
Amgen and Pfizer are
proud sponsors of the
American Academy of
Dermatology Coding
Consult Newsletter.
Additional resources:
The Academy has resources to help members with the
transition to 5010 version at www.aad.org/membertools-and-benefits/practice-management-resources/
coding-and-reimbursement/icd-10/icd-10-updates .
To view the CMS notification, please visit: www.cms.gov/
ICD10/Downloads/CMSStatement5010EnforcementDiscretion111711.pdf
CMS also published a list of frequently asked questions that
can be found at: https://questions.cms.hhs.gov/app/
answers/list/kw/enforcement/search/1
© 2011 Amgen Inc., Thousand Oaks, CA 91320 and Pfizer Inc. All rights reserved. MC41309-I-1 1-11
[
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CPT only © 2011 American Medical Association. All Rights Reserved.
]
In The Know…..
Centers for Medicare & Medicaid Services (CMS) recently
announced that is transferring the responsibility of issuing demand letters to providers from its Recovery Audit
Contractor Auditors (RACs) to its claims processing
contractors as of January 3, 2012. CMS states that they Medicare Administrative Contactor’s (MACs) - will take
on the responsibility of performing the adjustments based
on the RAC’s review and issue an automated demand
letter. MACs will then be responsible for fielding any
administrative concerns providers may have such as timeframes for payment, recovery and the appeals process.
MACs will include the name of the initiating RAC and
contact person information in the related demand letter.
CMS states that this change was initiated to avoid any
delays in demand letter issuance. As a result, when a
Recovery Auditor finds that improper payments have been
made to you, they will submit claim adjustments to your
Medicare (claims processing) contractor. Your Medicare
contractor will then establish receivables and issue automated demand letters for any Recovery Auditor identified
overpayment. The Medicare Contractor will follow the
same process as is currently in place to recover any other
overpayment from healthcare providers.
American Academy of Dermatology
PO Box 4014
Schaumburg, Illinois 60168-4014
RAC Demand Letter issuance now
responsibility of CMS
More information on the CMS Directive can be found at:
http://www.cms.gov/Recovery-Audit-Program/
Downloads/MLNMattersArticle.pdf
Now you are in the know!
Derm Coding Consult
Published by the American Academy of Dermatology Association
Distribution of Derm Coding Consult is made
possible through support provided by Amgen Pfizer.
[
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CPT only © 2011 American Medical Association. All Rights Reserved.
]