Presented by Healthcare Services GroupPresented by Healthcare Services Group

2010 Diagnosis Code Changes 2010 CPT Code Changes CMS Enrollment Forms Preparing for the RACs Office of Inspector General (OIG) Work Plan

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344 New Diagnosis CodesEffective 10/1/09

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◦Neoplasms – 33 New Codes Malignant Poorly Differentiated Neuroendocrine Tumors

Merkel Cell Carcinoma of: Face 209.31 Scalp & Neck 209.32 Upper Limb 209.33 Lower Limb 209.34 Trunk 209.35 Other Sites 209.36

Secondary neuroendocrine tumors (209.70-209.79) Code first associated multiple endocrine neoplasm

syndrome (258.1 – 258.03) Use additional code to identify associated endocrine

syndrome (i.e. carcinoid syndrome 259.2)

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Nervous System & Sense Organs – 6 New

Circulatory System – 25 New Codes◦ Chronic Pulmonary Embolism - 416.2◦ Late effects of Cerebrovascular Disease

438.13-438.14 ◦ Chronic Venous Embolism and Thrombosis

453.50 – 453.79◦ Acute Venous Embolism and Thrombosis

453.81 – 453.89

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Respiratory System - 2 New Codes◦ Influenza Due to Identified Avian Influenza Virus

(488.0)◦ Influenza Due to Identified Novel H1N1

Influenza Virus (488.1)

Digestive System – 3 New Codes◦ Complications of Intestinal Pouch (569.71 & 569.79)◦ Vomiting of Fecal Matter (569.87)

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◦ Genitourinary System – 2 New Codes Benign Endometrial Hyperplasia (621.34) Endometrial Intraepithelial Neoplasia (EIN) (621.35)

◦ Complications of Pregnancy, Childbirth and Puerperium – 16 New Codes Puerperal Endometritis (670.10 – 670.14) Puerperal Sepsis (670.20 – 670.24) Puerperal Septic Thrombophlebitis (670.30 – 670.34) Other Major Puerperal Infection (670.80 – 670.84)

◦ Congenital Anomalies – 2 New Codes

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◦ Perinatal Period – 8 New Codes Hypoxic-Ischemic Encephalopathy (768.70 – 768.73) Newborn Feeding Problems (779.31 – 779.34)

◦ Symptoms, Signs & Ill-Defined Conditions – 15 New Codes Non-specific (Abnormal) Findings on Radiological and Other

Examination of Body Structure; Inconclusive Mammogram (793.82)

Nervousness (799.21) Irritability (799.22) Other Signs and Symptoms Involving Emotional State

(799.29) Apparent Life Threatening Event in Infant (799.82)

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External Causes of Injury & Poisoning – 170 New Codes◦ E Codes

Activities Involving: E000.0 – E000.9 External Cause Status

Civilian Activity Done for Income or Pay Military Activity

E001.0 – E001.1 Walking and Running E002.0 – E002.9 Swimming E003.0 – E003.9 Ice and Snow E004.0 – E004.9 Climbing, Rappelling and Jumping Off

Rock Climbing Bungee Jumping

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E Codes◦ Activities Involving:

E005.0 – E005.9 Dancing and Other Rhythmic Movement

Yoga Cheerleading

E006.0 – E006.9 Sports & Athletics Played Individually

Skateboarding Bike Riding Golf

E007.0 – E007.9 Other Sports & Athletes Played as a Team or Group

Flag or Touch Football Soccer, Football, Basketball, etc Volleyball (beach or court) Physical Games at School Recess or School Camp

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E Codes◦ Activities Involving:

E008.0 – E008.9 Other Specified Sports and Athletics

Boxing Martial Arts Frisbee

E009.0 – E009.9 Exercise Machines Primarily for Cardiorespiratory Conditioning

E010.0 – E010.9 Exercise Machines Primarily for Muscle Strengthening

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E Codes◦ Activities Involving:

E011.0 – E011.9 Computer Technology & Electronical Devices

Hand held interactive electronic device Computer Keyboarding

E012.0 – E012.9 Arts and Handcrafts

E013.0 – E013.9 Personal Hygiene or Household Maintenance

Bathing and Showering Vacuuming

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E Codes◦ Activities Involving:

E014.0 – E014.9 Person Providing Caregiving

E015.0 – E015.9 Food Preparation, Cooking and Grilling

E016.0 – E016.9 Property and Land Maintenance

E017.0 – E017.9 Roller Coasters and Other Types of External Motion

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E Codes◦ Activities Involving:

E018.0 – E018.9 Playing a Musical Instrument

E019.0 – E019.9 Animal Care

E016.0 – E016.9 Property and Land Maintenance

E017.0 – E017.9 Roller Coasters and Other Types of External Motion

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E Codes◦ Activities Involving:

E018.0 – E018.9 Playing a Musical Instrument

E019.0 – E019.9 Animal Care

E029.0 – E029.9 Other Activity

Refereeing a sports activity Spectator at a sports activity Rough housing or horseplay

E 990.0 - E998.9 Military / War Operations

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V Codes – 33 New Codes◦ Personal History:

V10.90 – V15.83 Unspecified Malignant neoplasm Other Personal History Presenting Hazards to Health; Injury;

Traumatic Brain Injury Failed Moderate Sedation Under-immunization Status

V20.31 – V20.32 Health supervision of infant or child

V26.42 – V26.82 Procreative management – fertility preservation procedure

V53.50 – V53.9 Fitting and adjustment of intestinal appliance and device

Lap Band V60.81 – V60.89

Housing, Household and Economic Circumstances; Foster Care (Status) V61.07 – V61.42

Other Family Circumstances; Parent-Child Problems

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V Codes – 33 New Codes◦ Personal History:

V60.81 – V60.89 Housing, Household and Economic Circumstances; Foster Care (Status)

V61.07 – V61.42 Other Family Circumstances; Parent-Child Problems

V72.60 – V72.69 Special Investigations and Examinations

Laboratory V80.01 – V80.09

Special Screening for Neurological, Eye and Ear Diseases V87.32 – V87.46

Other Specified Personal Exposures and History Presenting Hazards to Health Estrogen Therapy Steroid Therapy

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CPT Changes Effective 1/1/10

159 New Codes

66 Deleted Codes

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◦ Integumentary – 2 New Codes◦ Musculoskeletal – 42 New Codes

Excision of Soft Tissue Tumors Radical Resection of Soft Tissue Tumors

Codes 21011 – 28047◦ Respiratory– 14 New Codes

Bronchoscopy – 2 New Codes (31626 & 31627) Instillation(s), via Chest Tube/Catheter, Agent for

Fibrinolysis (32561 & 32562) Replacement of Ventricular Assist Device (33981 –

33983)

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Digestive – 7 New Codes◦ Laparoscopy, Repair of Paraesophageal Hernia (43281 &

43282)◦ Laparoscopy, Surgical, Gastric Restrictive Procedure;

Longitudinal Gastrectomy (43775) Urinary – 3 New Codes

◦ Complex Cystometrogram; with Voiding Pressure Studies (51727 – 51729)

Male Genitourinary – 1 New Code Female Genitourinary – 1 New Code

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Nervous – 10 New Codes◦ Removal of Spinal Neurostimulator Electrode◦ Revision Including Replacement of Spinal Neurostimulator

Electrode CPT Codes 63661 – 63664

◦ Injection(s), Diagnostic or Therapeutic Agent, Paravertebral Facet Joint CPT Codes 64490 - 64495

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Radiology – 14 New Codes◦ CT, Colonography (74261 & 74262)◦ CT, Heart (Previously Category III Codes)

CPT Codes 75565 – 75574◦ Myocardial Perfusion Imaging

CPT Codes 78451 - 78454◦ Pathology & Lab – 15 Codes

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Medicine – 10 New Codes◦ AMA announced on 9/28/09 that they have created a new

code specific to vaccine administration and revised existing code 90663 to include the H1N1 vaccine 90470 – H1N1 Immunization Administration

(intramuscular, intranasal) Including Counseling When Performed

90663 – Influenza Virus Vaccine, Pandemic Formulation, H1N1

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◦ Category III Codes – 20 New Codes Sleep Study – Unattended (0203T – 0204T) Audiometry (0208T – 0212T) Injections, Diagnostic or Therapeutic Agent,

Paravertebral Facet Joint With Ultrasound Guidance (0213T – 0218T)

Placement of Posterior Intrafacet Implant(s) (0219T – 0222T)

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Category II Codes – 21 Codes◦ F Codes (Quality Measures)

Plan for follow-up care for major depressive disorder, documented (0545F)

Seizure type(s) and current seizure frequency, documented (1200F)

Etiology of epilepsy or epilepsy syndrome(s) reviewed and documented (1205F)

Patient interviewed directly by evaluating clinician on or before date of diagnosis of major depressive disorder (2060F)

Body Mass Index (BMI), documented (3008F) Cervical cancer screening results documented and

reviewed (3015F)

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Category II Codes◦ F Codes (Quality Measures)

Pulmonary function test performed within 12 months prior to surgery (3038F)

ABO and Rh blood typing documented as performed (3293F)

Group B Streptococcus screening documented as performed during week 35-37 gestation (3294F)

Clinical tumor, node and metastases staging documented and reviewed prior to surgery (Lung/Esop Cx) (3323F)

MRI or CT scan ordered, reviewed or requested (3324F) Performance status documented and reviewed within 2

weeks prior to surgery (Lung/Esop Cx) (3328F)

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Category II Codes◦ F Codes (Quality Measures)

EEG ordered, reviewed or requested (3650F) Patient screened for tobacco use AND received tobacco

cessation counseling, if identified as a tobacco user (4004F)

Antidepressant pharmacotherapy considered and not prescribed (4063F)

Duration of general or neuraxial anesthesia 60 minutes or longer, as documented in the anesthesia record (4255F)

Duration of general or neuraxial anesthesia less than 60 minutes, as documented in the anesthesia record (4256F)

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Category II Codes◦ F Codes (Quality Measures)

Counseling about epilepsy specific safety issues provided to patient or caregiver (4330F)

Counseling for women of childbearing potential with epilepsy (4340F)

Consideration of referral for a neurological evaluation of appropriateness for surgical therapy for intractable epilepsy within the past 3 years (5200F)

Patient queried and counseled about anti-epileptic drug side effects (6070F)

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◦ Effective 11/30/09 Must use new CMS-855I (for physicians and non-

physicians) and CMS-855B (for medical groups and clinics) Identify the new forms by looking for the revision date of

(02/08) (EF 07/09) in the bottom-left corner Older versions of the forms with (02/08) only in the

bottom-left corner will be denied after 11/30/09

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RAC Audits◦ RACs do not do random reviews◦ Audit targets are based on:

Data mining Aberrant billing patterns Experience of RAC auditors

Many are former Medicare contractor auditors

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Identify Risk Areas◦ Review many risk areas and billing errors such as:

Physical Therapy PT re-evaluations conducted 30 days after initial evaluation and every 30

days after Cannot be billed as a matter of routine Must have documented medical necessity

More than one modality Each modality reported in units (based on time) Number of minutes in chart must correspond to the units on the claim

Incorrectly Applying Modifier 59 to Override CCI Edit Pharmacy and Drug Administration

i.e. Neulasta – drug that reduces the risk of infection in cancer patients Commonly reported with a chemotherapy drug administration code rather

than a therapeutic administration code which creates an overpayment Drugs are high volume and high dollar

Documentation Documentation must be carefully maintained in the medical records

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Physician OIG Work Plan for 2010 E-Prescribing Incentive Programs

◦ Review of e-prescribing payments will help the OIG prepare for reviews of the even larger incentive programs that will be handed out in the future for implementing electronic medical records (EMR)

Medicare Practice Expenses Incurred by Selected Physician Specialties◦ Medical & Surgical Procedures◦ Office Visits & Consultations

Determine whether Medicare payments for physician services performed by selected specialties are comparable to the actual expenses incurred by the physicians in providing services and operating their practices

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Physicians’ Medicare Services Performed by Non-Physicians◦ Overutilization of “Incident-to”

Examine the qualifications of non-physician staff that perform “incident-to” services and assess whether these qualifications are consistent with professionally recognized standards of care

Referrals from Excluded Providers◦ CMS allowed physicians to use their own NPI on

claims in place of an ordering or referring physician who didn’t have an NPI or was unable to obtain it OIG to look for claims that were ordered or referred by a

provider excluded from Medicare

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Place of Service (POS) Errors◦ Medicare pays a a physician a higher amount when

the service is performed in a non-facility setting OIG to determine whether physicians properly coded the

POS on claims for services provided in ASC’s and hospital outpatient departments

Pain Management◦ Transforaminal Epidural Injections

Payments increased by 130% between 2003 & 2007 OIG reviewing for medical necessity

Mismatches Between Date of Service and Date of Death◦ To review claims and make recommendations to CMS

on how they can improve their review process

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Hospital OIG Work Plan for 2010

Hospital Ownership of Physician Practices◦ To determine whether hospitals have met the Federal

requirements to obtain the provider-based designation

◦ To assess the impact of the increased cost to Medicare Reimbursement under OPPS for physician services in

provider-based practices◦ To determine the extent to which hospital-owned

physician practices without provider-based designation improperly received reimbursement under OPPS

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Payments for Diagnostic X-Rays in Hospital Emergency Departments (ED)◦ Potential overuse of diagnostic imaging services

Continuing to Review:◦ Coding & Documentation Changes Under the

Medicare Severity Diagnosis Related Group System (MS-DRG) Determine if specific MS-DRG’s are being upcoded

◦ Serious Medical Errors (“Never Events”) Review key issues, policies and practices regarding

never events in hospitals

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“The material contained in this presentation is for general information and should not be acted upon without prior professional

consultation.”