The
beginning of a new year in the ambulatory surgery center industry is rapidly
approaching. Along with a new year, comes a series of changes impacting ASC
workflow and reimbursement. Three industry experts outline five of the biggest
coding and billing changes to anticipate for 2015.
1. ICD-10. When signed into law in April, the Protecting Access to Medicare Act of 2014 effectively delayed ICD-10 implementation until Oct. 1, 2015. Though the switch to the new code set will take place 10 months into the year, the ramifications make it one of the biggest changes to anticipate — the shift from approximately 14,000 ICD-9-CM codes to 68,000 ICD-10-CM codes is no small step to take. "It could take [ASCs] six months to a year to get up to speed".
In addition to preparing all software and staff internally, ASCs will need to form closer ties with physician office coding staff. "We will see an increasing collaboration between provider facilities and physician offices". "Submitting a claim with different codes from the physician's office and the ASC may delay payment."
"The overall impact of ICD-10 on revenue is still not known, other than there will be the usual sort of factors that cause cash to decrease in the short term, i.e., errors in implementing systems, learning curve for coders, payers' internal systems not working as expected, etc.,"
1. ICD-10. When signed into law in April, the Protecting Access to Medicare Act of 2014 effectively delayed ICD-10 implementation until Oct. 1, 2015. Though the switch to the new code set will take place 10 months into the year, the ramifications make it one of the biggest changes to anticipate — the shift from approximately 14,000 ICD-9-CM codes to 68,000 ICD-10-CM codes is no small step to take. "It could take [ASCs] six months to a year to get up to speed".
In addition to preparing all software and staff internally, ASCs will need to form closer ties with physician office coding staff. "We will see an increasing collaboration between provider facilities and physician offices". "Submitting a claim with different codes from the physician's office and the ASC may delay payment."
"The overall impact of ICD-10 on revenue is still not known, other than there will be the usual sort of factors that cause cash to decrease in the short term, i.e., errors in implementing systems, learning curve for coders, payers' internal systems not working as expected, etc.,"
2. CPT code updates. The American Medical Association is
set to release 2015 updates for its Current Procedural Terminology code set on
Nov. 1. Last year, upper GI/endoscopy codes were reviewed and nearly 25 percent
of the CPT code changes affected the field of gastroenterology. This year,
lower GI codes, including those for colonoscopy, are up for review. Radiology
and pain management will also be affected by the CPT code changes.
3. Modifier -59 change. CMS is creating four new HCPCS modifiers to define subsets of modifier
-59, which denotes a "distinct procedural service." The four new
HCPCS included:
• XE Separate Encounter:
• XS Separate Structure
• XP Separate Practitioner
• XU Unusual Non-Overlapping Service
"We can still use modifier -59, but CMS has the right to insist there is a more specific modifier needed," "Column 1 and column 2 CPT codes will the most impacted."
• XE Separate Encounter:
• XS Separate Structure
• XP Separate Practitioner
• XU Unusual Non-Overlapping Service
"We can still use modifier -59, but CMS has the right to insist there is a more specific modifier needed," "Column 1 and column 2 CPT codes will the most impacted."
4. Bundled codes. ASC leaders can expect to see the
bundling of multi-level pain procedures in 2015. CMS is no longer allowing more than one level
of pain procedure. They are not paying on more than one code. We can expect to
see other major payers follow this lead. The bundling of codes will lead to a
decrease in reimbursement for a number of pain procedures performed in ASCs.
Radiology is also being impacted by bundled codes. We are seeing ever increasing bundling with radiology and ultrasound codes. Three new joint arthrocentesis codes for 2015 will include ultrasonic guidance, which will impact reimbursement."
5. Increase in MNRPs.
Radiology is also being impacted by bundled codes. We are seeing ever increasing bundling with radiology and ultrasound codes. Three new joint arthrocentesis codes for 2015 will include ultrasonic guidance, which will impact reimbursement."
5. Increase in MNRPs.
More
payers will begin to increasingly offer Maximum Non-Network Reimbursement
Plans, or Medicare-based plans, which have lower rates of reimbursement.
"With the increasing volume of MNRPs, payers are opting to reimburse at
the lower Medicare rate than historic reimbursement rates, i.e., PPO or
commercial-based plans," says Mr. Silva. "An analysis should be done
comparing the CYTD and PYTD payer and case mixes and based on the results of
that analysis, the ASC directors need to be educated on how the cash flow will
be impacted."
6. Payer demand for specificity. Payers will not only expect providers to adhere to the increased specificity of ICD-10, but many are also calling for complete medical records prior to claim adjudication. Failure to supply complete medical records for these payers can lead to claim denial and loss of appeal rights. Perform an analysis of payer mix to determine which payers are calling for information. "The revenue cycle management office could then be proactive by dropping the claims to paper for those particular payers/procedures and including the complete medical records on the first submission". "The ASC's RCM office needs to respond to the issue quickly and efficiently."
6. Payer demand for specificity. Payers will not only expect providers to adhere to the increased specificity of ICD-10, but many are also calling for complete medical records prior to claim adjudication. Failure to supply complete medical records for these payers can lead to claim denial and loss of appeal rights. Perform an analysis of payer mix to determine which payers are calling for information. "The revenue cycle management office could then be proactive by dropping the claims to paper for those particular payers/procedures and including the complete medical records on the first submission". "The ASC's RCM office needs to respond to the issue quickly and efficiently."
A Look Ahead: Pathology CPT Changes for
2015
In
2015, Pathology will see many CPT changes.
Some of the bigger changes will include changes to immunohistochemistry
codes (88342, 88360 and 88361) as well as the ISH series of codes (88365, 88367
and 88368). As we have seen in previous
years there will be revisions, deletions and additions to these code sets.
First,
there will be revisions clarifying the “per block,” “per slide” and “per
specimen” issue. The code descriptor for
IHC and ISH will now include “per specimen” for each primary code. Second, each primary code will read, “initial
single antibody procedure” for IHC and “initial single probe stain procedure”
for ISH which leads to the addition of a new IHC add-on code for “each
additional antibody stain procedure” and three new ISH add-on codes for “each
additional single probe procedure,” one for qualitative results and two for
quantitative/semi-quantitative; manual or computer-assisted. Third, CPT has added four new codes for IHC
and ISH to report for multiplex procedures.
The descriptor for these new codes will also include “per
specimen.” These new codes will not be
add-on codes and, per CPT there will be an either/or choice. You will assign either the initial single
procedure or you would assign the multiplex stain procedure (see pages to
follow for CPT codes and descriptions).
Last, code 88343 has been deleted for 2015 and replaced with 88341.
Two
things that had not changed for both IHC and ISH will be whether the study is a
qualitative versus quantitative/semi-quantitative result and whether the
procedure is manual or computer-assisted. Overall the CPT changes for 2015
should clarify and simplify coding of these services.
CPT
2015 definitions of global surgical clarification
New
codes for vertebroplasty and kyphoplasty, with more bundling
New
rebundling arthroplasty and kyphoplastyriet, with more bundling issues
Some
changes regarding Sacroiliac joint arthrodesis
New
codes for total disc arthroplasty, along with myelogram coding changes (correct
coding will depend on what physician is doing which portion)
Much
more that will affect 2015 coding and reimbursement for orthopedic practices
BREAST IMAGING
As anticipated, new codes have been
introduced this year for breast tomosynthesis. Also, the existing code
for breast ultrasound was deleted and two new codes have been introduced for
limited and complete ultrasound. ADVOCATE is seeking guidance as to what
defines “limited” and “complete” for these exams.
76641 Ultrasound, breast, unilateral, real time with image
documentation, including axilla when performed; complete
76642 Ultrasound, breast, unilateral, real time with image
documentation, including axilla when performed; limited
77061 Digital breast tomosynthesis; unilateral
77062 Digital breast tomosynthesis; bilateral
77063
Screening digital breast tomosynthesis, bilateral (List separately in addition
to code for primary procedure)
Orthopedic Billing
The
expected coding changes coming with the ICD-10 implementation of next year are
having a big impact on all physician billing practices. In the meantime there
are changes to the Current Procedural Terminology (CPT) codes effective as of
January 1 that orthopedic practices should be aware of. If you are just
catching up on all this now, here are a handful of key areas in which the most
important changes have occurred.
Key
Areas of Orthopedic Billing Affected by CPT Coding Changes for 2015
- Evaluation and Management
An
entirely new set of evaluation and management codes has been issued this year.
They cover consultations done over the telephone and the Internet. While the
entire presentation of the codes is lengthy, it boils down to a handful of key
issues.
For
example, codes 99446-99449 are distinguished by time intervals over which
medical consultations occur, with 99446 covering consultations of 10 minutes or
less and 99449 covering those of more than 30m minutes.
- Soft-Tissue Tumors
In
the 20000 (Musculoskeletal) section of the CPT, there have been revisions to
the codes in each body area that describe the radical resection of soft tissue
tumors. The example given previously was malignant neoplasm, which has
been removed, and replaced by sarcoma.
- Shoulder, Humerus and Elbow
The
new set of codes does not simply add to the total number of codes. Some have
been deleted as repetitive among in the new arrangement. For example, codes
23331 and 23332 were deleted and replaced by 23333-23335. The first two were
vague codes regarding the removal of foreign bodies in the shoulder area while
the three newest are more specific about parts and procedures.
Other
codes were revised, such as 24160 and 24165, which described the removal of
prostheses. There are now also specific mandates about which codes may or may
not be used together and how they may be reported simultaneously.
- Sacroiliac Joint
The
AMA created a new Category III code in January 2013. Code 0034T regards
sacroiliac joint stabilization and it now appears in the 2014 CPT guide. Please
note consequent changes to parenthetical notes for 27216, 27218 and 27280.
- Chemodenervation
Pediatric
orthopedic billing for spasticity should become more effective with the latest
chemodenervation codes. The new manual deletes code 64614 and adds six
additional codes to provide specificity with regard to this type of procedure.
It
is not too late to get started adapting your office to the new codes. However,
to improve communication, it is necessary for everyone to be updated about the
new codes and those that have been eliminated.
For more information , please call 305-227-2383 or 1-877-938-9311
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