Welcome
Provider Update Seminar
Austin BioInnovation Institute (ABI)
Wednesday, December 3, 2014
Please be courteous to our speakers and
silence your cell phone and/or pager.
CPT Changes for 2015
An Overview
William C. Fiala, MA, CCS-P, CPC, RMA
Visiting Assistant Professor, University of Akron
Principal, Fiala Analytical Services, Inc.
www.fialaanalytical.org
CPT Changes 2015 Overview:
Objectives
 Understand the range of changes for CPT in 2015;
 Review selected areas of change in detail;
 Provide references for follow-up.
CPT Changes 2015 Overview:
About the Lecturer
 Why should we listen to you?
 You should not, but it is too late to flee, so
here are some rationalizations:
 Diagnosis Coding, Procedure Coding, and Medical Insurance
instructor for the Allied Health Department, University of Akron;
 Certified coder since 1999 (AHIMA CCS-P and later AAPC CPC);
 AHIMA-Approved ICD-10-CM Trainer (initial training 2010, recertified);
 Lecturer to AAPC chapters in Ohio, Summit County Chapter of
Medical Assistants, NE Ohio MGMA chapter;
 Member AAPC, AHIMA, MGMA
CPT Changes 2015 Overview:
General
 AAPC release on October 17, 2014
indicated:
 550 code changes in the 2015 edition of CPT
 “The changes will affect family practice, internal medicine,
cardiovascular, gastrology, pathology/laboratory, and radiology.”
 This discussion is, as its title suggests, merely an overview—we
will not be looking at all 550 changes.
CPT Changes 2015 Overview:
General
 Considerations
 2015 RVUs have been published:
• http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFS-Relative-Value-FilesItems/RVU15A.html?DLPage=1&DLSort=0&DLSortDir=descen
ding
 AMA’s CPT Changes book has been released.
CPT Changes 2015 Overview:
E&M
 Social History elements have been revised;
 Note inclusion of military history as a social history element.
 Surgery Section Guidelines have been revised as to
the E&M services inherent to the surgery:
 “when furnished by the physician or other qualified health care
professional who performs the surgery”
 “Evaluation and Management (E/M) services subsequent to the
decision for surgery on the day before and/or day of surgery
(including history and physical).”
CPT Changes 2015 Overview:
E&M
 Neonate hypothermia services deleted and
replaced:
 99481 and 99482, total and selective neonate hypothermia codes
have been deleted;
 99184—a combination code—replaces these.
 99184 is in the Medicine Section, not the E&M section.
 Recall the “adult” codes, 99185 and 99186 were
deleted in 2010.
CPT Changes 2015 Overview:
E&M
 Neonatal and Pediatric Critical Care guidelines
have been revised to reflect the changes above as
well as come clarification of reporting for services
provided subsequent to the initial services on the
same day or during the same stay.
CPT Changes 2015 Overview:
E&M
 Com plex Chronic Care Coordination Services
section has been re-written.
 Again.
 Now titled Care M anagem ent Services
CPT Changes 2015 Overview:
E&M
 Care M anagem ent Services
 99487 and 99489, Complex Chronic Care Management Services,
are still Status B codes for CMS.
 99490 Chronic Care Management Services, at least 20 minutes . .
. per calendar month, is a new code and it is reimbursed by CMS
in 2015.
• Check definition of chronic conditions (need 2+);
• Requires EMR meeting 2011 or 2014 standards in order to be paid by
CMS;
• December 10, 2014 program by SHN.
CPT Changes 2015 Overview:
E&M
 New Codes for Advance Care Planning
 99497 Advance care planning including the explanation and
discussion of advance directives such as standard forms; first 30
minutes, face-to-face with patient, family member(s), and or
surrogate.
 99498 each additional 30 minutes.
 Status code I for CMS
• “Medicare uses another code . . .”
• AWV includes “end-of-life planning (upon agreement of the
individual).”
CPT Changes 2015 Overview:
Arthrocentesis
 New codes for ultrasound guidance:
 20604 Arthrocentesis, aspiration and/or injection, small joint
or bursa (eg, fingers, toes); with ultrasound guidance, with
permanent recording and reporting.
 20606 Arthrocentesis, aspiration and/or injection,
intermediate joint or bursa (eg, temporomandibular,
acromioclavicular, wrist, elbow or ankle, olecranon bursa);
with ultrasound guidance, with permanent recording and
reporting
 20611 Arthrocentesis, aspiration and/or injection, major
joint or bursa (eg, shoulder, hip, knee, subacromial bursa);
with ultrasound guidance, with permanent recording and
reporting
 These codes interspersed among 20600, 20605, 20610.
CPT Changes 2015 Overview:
Spine Surgery
 New codes for percutaneous vertebroplasty and
vertebral augmentation:
 22510-22515;
 “The existing codes for vertebroplasty and
kyphoplasty have been deleted for 2015 and new
codes have been created to include all imaging
guidance. Sacroplasty did not yet receive a new
code, but the existing Category III code has been
revised to include all imaging guidance.”
http://www.radadvocate.com/breaking-news-2015-cptchanges/
CPT Changes 2015 Overview:
Spine Surgery
 New codes for percutaneous vertebroplasty and
vertebral augmentation:
 Code changes a function of RVU/RUC reviews:
 Codes 22520-22525 and 72291 were identified as being reported
together 75% of the time or more.
 Recurrent theme of image guidance being
incorporated into the surgery code
CPT Changes 2015 Overview:
Cardiovascular
 Virtually the entire notes section preceding code
33202 has been re-written;
 Changes start with the titling:
 “Pacemaker or Implantable Defibrillator” in 2015 vs.
 “Pacemaker or Pacing Cardioverter-Defibrillator” in 2014.
CPT Changes 2015 Overview:
Cardiovascular
 Virtually the entire notes section preceding code
33202 has been re-written;
 Changes to the devices drive some of the language
changes:
 In 2014, a “pacing cardioverter-defibrillator (ICD)” was
referenced;
 In 2015, two categories of devices have been identified:
• Transvenous implantable pacing cardioverter-defibrillator (ICD)
• Subcutaneous implantable defibrillator (S-ICD)
• The latter treats ventricular tachyarrhythmias , but has no antitachycardia pacing or chronic pacing.
CPT Changes 2015 Overview:
Cardiovascular
 Review new table for coding overview.
 Changes for subcutaneous device specificity.
 New codes:
 33270 Insertion or replacement of permanent subcutaneous
implantable defibrillator system . . .
 33271 Insertion of subcutaneous implantable defibrillator
electrode
 33272 Removal of subcutaneous implantable defibrillator
electrode
 33273 Repositioning of previously implanted . . . electrode
CPT Changes 2015 Overview:
Cardiovascular
 All new codes for prolonged extracorporeal
circulation.
 Codes 33960 and 33961 (cardiac assist codes), as
well as code 36822 (inserting the cannula) have
been deleted.
 New section and codes:
 Extracorporeal Membrane Oxygenation or Extracorporeal Life
Support Services.
 Codes 33946-33989
 READ NEW NOTES
CPT Changes 2015 Overview:
Cardiovascular
 Note RVU changes for cardiology and the
cardiovascular section.
 http://www.cardiosource.org/NewsMedia/Publications/CardiologyMagazine/2014/11/2015-Cardiology-CodingChanges-Preview.aspx
CPT Changes 2015 Overview:
GI Coding
 Recall in 2014 there were extensive changes to the
upper GI endoscopy codes.
 In 2015, those new and revised codes received
quite a bit of note changes, mostly parenthetical
“Do Not Report” notes with some fluoroscopic
guidance notes and re-direction notes.
 Since the upper GI system is tucked in . . .
CPT Changes 2015 Overview:
GI Coding
 Changes to lower GI coding in 2015!
 Good overview at:
 http://www.gastro.org/practice/coding/preview-changes-tocoding-for-lower-gi-endoscopy-procedures-in-2015
 Changes are specialty society driven:
 “proposed by the AGA, ACG and ASGE, the American College of
Surgeons (ACS), the Society of American Gastrointestinal
Surgeons (SAGES) and the American Society of Colon and
Rectal Surgeons (ASCRS)”
CPT Changes 2015 Overview:
GI Coding
 Changes in part mimic those “above.”
 “The new lower GI endoscopy codes for placement
of endoscopic stents now include pre-dilation,
post-dilation and guide wire passage, when
performed, consistent with the changes made to
stent placement codes for upper GI endoscopy
procedures.” (http://www.gastro.org)
CPT Changes 2015 Overview:
GI Coding
 Changes in part mimic those “above.”
 “Previous code descriptors for control of bleeding
codes included a list of examples such as injection,
bipolar cautery, unipolar cautery, laser, heater
probe, stapler and plasma coagulator. The new
descriptor for control of bleeding replaces all
examples with ‘any method’ throughout all GI
endoscopy families. New language in the section
guidelines clarifies that when bleeding occurs as
the result of an endoscopic procedure, control of
bleeding is not separately reported during the
same operative session. ”
(http://www.gastro.org)
CPT Changes 2015 Overview:
GI Coding
 Additional changes include:
 Ablation;
 Endoscopic mucosal resection (EMR);
 Antegrade transoral small intestine endoscopy (i.e.,
enteroscopy);
 New codes for transendoscopic balloon dilation and
stent placement;
 New section guidelines for pouch endoscopy codes;
 Specific instructions for reporting flexible
sigmoidoscopy;
 Colonoscopy through stoma specificity.
CPT Changes 2015 Overview:
GI Coding
CPT Changes 2015 Overview:
ENT
 Three Eustachian tube codes have been deleted:
 69400, 69401, and 69405;
 To report the work of 69400 or 69405 an unlisted code, 69799, is
recommended;
 For 69401, the appropriate Evaluation and Management
 See discussion at
http://www.entnet.org/content/cpt-changes2015-what-ents-need-know
CPT Changes 2015 Overview:
ENT
 A number of otolaryngology CPT codes have been
re-valued:
 Balance testing codes 92541, 92542, 92543, 92544, and 92545;
 Nose bleed codes 30903 and 30905;
 Nasal/sinus endoscopy balloon codes 31295, 31296, and 31297.
CPT Changes 2015 Overview:
Lab and Pathology
 Drug Testing codes deleted;
 New section Drug Assay, which includes:
 Presumptive Drug Class Screening
• Used to identify use or non-use or drug or drug class
• Class A includes the alcohol and recreational pharmaceuticals such as
amphetamines, cocaine, heroin, TCH, oxycodone, etc.
• Class B includes acetaminophen, nicotine, synthetic cannabinoids,
 Definitive Drug Testing
• Qualitative or quantitative
• Extensive specific drug codes 80320-80377
• See Table: Definitive Drug Classes Listing
 New section Therapeutic Drug Assays
 Known prescribed medication
CPT Changes 2015 Overview:
Lab and Pathology
 New Section: Genom ic Sequencing Procedures and
Other M olecular M ultianalyte Assays
 Advancing technology for DNA sequencing
technology—so-called “next generation
sequencing or massive parallel sequencing.”
 Separate from the M olecular Pathology section,
which was new a number of years back and has
been changing over the past several.
CPT Changes 2015 Overview:
Vaccines
 See http://www.amaassn.org/ama/pub/physician-resources/solutionsmanaging-your-practice/coding-billinginsurance/cpt/about-cpt/category-i-vaccinecodes.page
 This includes November 01, 2014 updates.
 One new flu vaccine: 90630 quadrivalent I V (I I V4)
CPT Changes 2015 Overview:
Category II Codes
 3 new Category II codes
 Check AMA resource page:
 http://www.ama-assn.org/ama/pub/physicianresources/solutions-managing-your-practice/coding-billinginsurance/cpt/about-cpt/category-ii-codes.page
 Additions and changes revolved around diagnosis
of Barrett’s Esophagus.
 When considering Category II codes, cross
reference HCPCS codes.
CPT Changes 2015 Overview:
Category III Codes
 39 new Category III codes
 Additions include:
 Change and addition to cryopreservation;
 Aqueous drainage devices (ophthalmology);
 Ablation of pulmonary tumors;
 Watch for “Do Not Report” note additions;
 26 deletions—some crossover to Category I codes.
CPT Changes 2015 Overview
 What to do?
Compare Appendix B to a current code usage report;
Read all new and revised notes;
Consider purchasing CPT Changes 2015: An Insider's View;
Watch for CPT Assistant articles;
Follow your specialty society’s guidance—the source for most of
the articles;
 Download 2015 final rule RVUs;
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Do you have any easy questions for the Professor?
Pharmacy
Alynn Purdum, PharmD.
Director, Pharmacy
Topics
 SummaCare Formularies
 Medicare Part D Prior Authorization Request Process
 Centers for Medicare & Medicaid Services (CMS) Requirements
 Importance of supplying complete information
 Vaccines
 Part B and Part D
SummaCare Formularies
 Access from http://www.summacare.com/
 3 formularies:
Medicare Part D
Commercial
HIX/QHP
 HIX/QHP Formulary follows Commercial Formulary
Medicare Part D Prior
Authorization Request
 Strict timeframes exist for processing Prior
Authorization requests
 Standard = 72 hours
 Expedited = 24 hours
 Per CMS, requests should be ‘Expected’ if prescriber believes
waiting for a decision under the standard timeframe may place the
patient’s life, health, or ability to regain maximum function in serious
jeopardy
 Time begins when initial contact is made from
prescriber
 SummaCare delegates prior authorization process to its
Pharmacy Benefit Manager (PBM)
 Contact may be a telephone call or fax a Medication Request
Form
Medicare Part D Prior
Authorizations, Cont’d.
 A recent CMS Audit identified prior authorization
requests that were denied because additional
information was needed from the prescriber, but was
not received in time
 This information was needed to make a proper decision
 Prompt responses to requests for additional
information area needed in order to prevent delays in
patients’ prescription therapy
 If prior authorization request is denied due to lack of information,
the Appeals process ensues
 More time consuming for prescribers and office staff
Vaccines
 Most preventative vaccines are covered under
Medicare Part D
 Part D Covered Vaccines:
 Varicella-Zoster Vaccine (Zostavax)
 Part B Covered Vaccines
 Influenza Vaccine
 Pneumococcal
 Hepatitis B
Vaccine Billing
 SummaCare recommends that patients receive their
preventive vaccines at participating pharmacies
 If patients are administered Part D vaccines in
provider’s offices, the patient should submit their bill
to MedImpact (SummaCare’s Part D Carrier)
 MedImpact will process the Part D vaccine claim under the
patient’s Part D benefit.
 When the patient receives reimbursement, he/she should then
forward that payment to your office
SummaCare Medicare
Advantage Plans 2015
Phyllis Cain
Sales Director
Individual Products
Different Year
 Currently we are closed for new enrollments due to
recent marketing and enrollment sanctions by the
Centers for Medicare & Medicaid Services (CMS),
effective August 11, 2014. We are working actively to
correct the deficiencies that resulted in the sanctions.
 Current Members Plans are not affected and can stay
on their current plan without disruption to their care.
2015 Individual Plans
 Ruby HMO (Core)
 Sapphire HMO/POS (Silver)
 Emerald HMO/POS (Gold)
2015 Individual Plans, Cont’d.
 Three Medicare Advantage (MAPD) Plans
 Premiums $0 to $182/month
• Continue to pay Part B premium
 $4000 on the Ruby and Emerald Plan and $5000 on the Sapphire
Plan, in-network medical OOP Max
 All Plans include Part D Coverage (Pharmacy)
• $0 Generic Copay (Preferred – Tier I)
 $0 PCP Copayment
 Silver Sneakers Included
New for 2015
 Lower Inpatient Hospital per day amounts on all
plans!
 Ruby plan
 Lower specialist copay to $35.00
 Ambulance copay lowered to $100.00
 All plans have a lower amount for:
 Diagnostic Procedures and Tests
• $0 - $125.00
Secure Employer Group Plans
 Similar coverage to individual plans – Medical and
Pharmacy
 Typically lower copays and coinsurances
 Most offer coverage through the Part D coverage gap (not all)
 Can reside In and Out of Service Area
For more information about Medicare
plans available through SummaCare,
contact us:
 Providers: 330-996-8401
 Members: 330-996-8440
ICD10 Update
Dana Robinson, MBA-HCM, PAHM
Provider Relations Representative
ICD10 Update
 SummaCare will reject claims submitted with ICD9
codes for dates of service on or after 10/1/2015
 We have completed initial testing with 3 provider
partners and are looking at end to end testing to start
the end of the first quarter.
 If any providers would like to test with SummaCare,
please send your provider information and
clearinghouse information to Debbie Crockett at
[email protected]
ICD-10 Readiness
 ICD10 survey is in your packet to gauge where your
office is in the process.

 Please complete the survey here or visit the Provider
News and Updates section of SummaCare.com and
complete the survey monkey online.
 CMS has frequent webinars and testing accessibility
if you are not aware. You can locate information at
CMS MLN Connects Calls
<[email protected]>
 We appreciate your participation!
Risk Adjustment Update
Chris Tabellion, RN
Supervisor, Data Management
The Facts
• The Balanced Budget Act of 1997 mandated that
Medicare Advantage organizations be paid based on
the risk score (hierarchical condition categories) of
the member.
• It was phased in and has been the 100% payment
model since 2007.
• The Affordable Care Act mandated risk adjustment
payment beginning in 2015 for all health plans
participating in the Market Place model.
Why Risk Adjust?
 Transfer funds from plans that enroll lower risk
individuals to plans enrolling higher risk individuals.
 Goal is to eliminate premium differences in plans
based solely on member selection.
 CMS risk adjustment relies on complete and accurate
data.
 Medicare and Market place products use the same
risk adjustment model.
Diagnosis Coding Abstraction
 In accordance with industry standards
 Using ICD-9 or ICD-10 guidelines
 Validates the HCC
 Hierarchical Condition Category
 Category of conditions that map to corresponding group of ICD-9
codes and soon, ICD-10
 2913 Diagnosis codes map to 70 HCC
 250.40 Diabetes with renal manifestations maps to HCC 15
Diabetes with complications
Types of Encounters
 Included are:
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Hospital Inpatient
Hospital Outpatient
Face-to-face visits with qualified
Physicians, PAs and NPs
 Not included are:
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Radiology
DME
Pathology
Labs
Validation Audits
 Health Plans are audited annually by CMS to validate
the ICD-9 codes submitted to CMS that result in risk
adjustment for the Medicare population.
 Health plans must pay for independent approved
auditors to validate the Market Place records between
06/01/2015 - 12/31/2015.
Provider Impact
 Health Plans are mandated to submit all claims to
CMS for risk adjustment scoring.
 ICD-9 codes (soon to be ICD-10 for DOS Oct 1, 2015)
are used for risk adjustment.
 CPT coding does not risk adjust.
 Accurate ICD coding and supporting clinical
documentation is imperative for accurate risk
adjustment!
Provider Impact, Cont’d.
 We will continue requesting records for review.
 Providers who can allow us remote electronic access
will have less intensive work.
 We are working with record retrieval companies to
obtain charts for us, which makes your job easier.
 Thank you for your on-going support and
cooperation!
Important Billing Information
Amy Rastetter
Provider Support Services Coordinator
Corrected Claims
 When you submit a corrected claim, please submit
your claim electronically with the appropriate HIPAA
837 indicator to expedite processing.
 Please note that corrected claims can also be submitted via Plan
Central.
 If you are unable to submit electronic claims, please
mark paper claims as CORRECTED in Box 19.
 Claims submitted without the appropriate indicator will be denied
as a duplicate or as a provider billing error.
 Corrected claims from facility charges must be submitted
electronically with the appropriate bill type to avoid a
duplicate or billing error denials.
Facility Late Charges
 When facilities submit late charges, a delay in
payment occurs as claims processors must manually
review all submissions.
 Please consider holding the initial claim for a few
days in order to submit a complete claim and
streamline the claim processing time.
 The appropriate bill type must be submitted. If the
appropriate bill type is not submitted, the claim will be
denied as a duplicate or as a provider billing error.
Multiple Surgery Claims
 To streamline claim processing and improve
efficiencies, physicians must bill bilateral surgery
claims with the procedure on one service line with
modifier 50/51 and a single unit.
 In the near future, multiple surgery claims billed with
multiple units and modifier 50/51 will be rejected up
front and will not enter our claims processing system
for consideration. Additional details will be provided
at a later date.
Electronic COB
 All COB claims can be submitted via EDI
 We prefer that you submit your claims and COB via EDI versus
paper.
 The paper remit DOES NOT need to be mailed
 COB information must be submitted at the service
line level for non-institutional providers
Medical Records
 Please do not send medical records unless specifically
requested by the health plan.
 If the explanation code on the EOP does not state to
send medical records please do not automatically
forward medical records and a claim adjustment request
form. SummaCare will not provide reimbursement for
records that were not requested by the health plan.
 Many claim denials are not eligible for medical review,
therefore medical records are not necessary.
 If the claim is not eligible for medical review, we will review to
determine how to assist you without submitting medical records.
Medical Records, Cont’d.
 If you are unsure how to handle the review of a denial,
please contact Provider Services, Provider Relations or
login to Plan Central to view the claim detail.
 iCES is available via Plan Central and contains the disclosure
behind most of our code edits. The disclosure statement will
explain why the claim denied if it is an iCES denial. iCES is the
tool our representatives use when you call us for assistance.
 Code edit denials are generally not appealable. If you disagree
with how a claim was processed as a result of a code edit denial,
please review the disclosure statement (as mentioned above).
Plan Directed Care
 When referring a SummaCare Medicare member to
another provider for care, please ensure the member is
referred to a SummaCare Medicare contracted provider.
 You can search for SummaCare Medicare providers on
our website at www.summacare.com.
 As a reminder, members enrolled in the SummaCare
Medicare Ruby (HMO) plan do not have out-of-network
coverage – except for emergencies, urgent care
services and renal dialysis.
Plan Directed Care, Cont’d.
 Network providers are considered agents of the plan
and are acting on the plan’s behalf.
 While we recognize members do not always have
their SummaCare ID card with them, Plan Central can
be used to verify the member’s plan coverage and is
available 24 hours a day.
 When members are referred to an out-of-network
provider by a network provider, CMS considers this
plan directed care and SummaCare must process the
claim as if the provider was in-network.
Questions & Answers
 Please write any questions you may have on the
index card in your packet
 We realize you may have questions surrounding the
CMS audit and Organization Determination process.
We are only able to discuss this topic high level at
this time.
 We will be scheduling a discussion in a conference call type forum
in the near future. Please indicate your wish to participate on your
index card along with your name and phone number.
 Please pass index cards to the end of your table to be
collected
 Please complete your evaluations
Thank you for your time and attendance!