Post on 19-Jul-2018
transcript
8/16/2010
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Policies
Presented by: Shelly Cronin, CPC, CPMA, CGSC, CANPC, CGIC
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Agenda
• Understand the roles of Policies and your
practice
• Overview of NCD, LCDs and Carrier
Policies
• Impact on coding and payment
• How to stay current on policy changes
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Policy Roles
Insurance Companies
Policies
Policy
Holders
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What is a Policy?
• An insurance policy is a contract between the
insurer and the insured, known as a
policyholder, which determines the claims
which the insurer is legally required to pay.
• Medical Policies serve as one of the sets of
guidelines for coverage decisions. Benefit
plans vary in coverage and some plans may
not provide coverage for certain services
discussed in the medical policies.
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Coverage Decisions
• Coverage decisions are subject to all
terms and conditions of the applicable
benefit plan, including specific exclusions
and limitations, and to applicable state
and/or federal law. Medical policy does not
constitute plan authorization, nor is it an
explanation of benefits.
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Policy Development
• Policy development
– External professional organizations
– Medical societies
• State
• Specialty
– Independent physician advisory board
• Important issues to physicians
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How to Read a Policy
• May include subsections
– Description
• Explanation of the policy topic
– Diabetes Tests, Programs and Supplies
– Coverage Determination
• Outlines what is covered under the plan based on
the policy description
– Different tests, procedures, and equipment relevant to
disease
• Guide for specific information
– Benefit coverage and limitations
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How to Read a Policy cont.
• Background
– Contains information
• Clinical Medical information regarding conditions
treated by a specific
– Device
– Medication
– Procedures
– Medical Alternatives
• Possible alternatives to the device or procedure
– Provider Claim Codes
• Contains
– CPT®, HCPCS, & ICD-9-CM codes
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How to Read a Policy cont.
• Medical Terms
– Definitions of terminology
• Dysphagia is a swallowing disorder that may be
due to various neurological, structural, and
cognitive deficits
• References
– Details
• Titles
• Authors
• Publication dates
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How does this help you?
• Better understanding
– What to look for
– What is covered
– What constitutes medically necessary
reasons for treatment
• Determined by each individual payer
– When the treatment or service will not be
covered and why
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Policy Example• Clinical Policy Bulletin: HIV Testing
– Number: 0542
Policy - Aetna considers human immunodeficiency virus (HIV) testing medically
necessary for screening persons for HIV infection, according to the
recommendations of the U.S. Preventive Services Task Force and the Centers
for Disease Control and Prevention.
• Aetna considers the Orasure oral HIV test kit (OraSure Technologies,
Bethlehem, PA) medically necessary for the same indications as standard
HIV testing.
• Aetna considers the OraQuick Rapid HIV-1 Antibody point-of-care test kit
(OraSure Technologies, Bethlehem, PA) an adequate alternative to
laboratory HIV blood tests for medically necessary indications for HIV
testing. Note: Aetna does not cover home HIV test kits that do not require a
physician's prescription under any plans. These include:
– Home Access At Home HIV Test
– Confide Home HIV Test (Johnson & Johnson).* Withdrawn due to lack of interest
CPT® Codes / HCPCS Codes / ICD-9 Codes
CPT® codes covered if selection criteria are met:
86689 Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot)
86701 Antibody; HIV-1
86702 Antibody; HIV-2
86703 Antibody; HIV-1 and HIV-2, single assay
87390 Infectious agent antigen detection by enzyme immunoassay technique, qualitative
or semiquantitative, multiple-step method; HIV-1
87391 Infectious agent antigen detection by enzyme immunoassay technique, qualitative
or semiquantitative, multiple-step method; HIV-2
HCPCS codes covered if selection criteria are met:
S3645 HIV-1 antibody testing of oral mucosal transudate
ICD-9 codes covered if selection criteria are met:
042 Human immunodeficiency virus [HIV] disease
V01.79 Contact with or exposure to other viral diseases
V08 Asymptomatic human immunodeficiency virus [HIV] infection status
V73.89 Special screening examination for other specified viral diseases
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National Correct Coding
Initiative• Developed by CMS to reduce Medicare
program expenditures
• NCCI – used to prevent improper payment
when incorrect code combinations are
reported (unbundling)
• Contains
– Over 140,000 code pairs or edit pairs that
cannot be reported on the same claim on the
same date of service
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National Correct Coding
Initiative• Coding policies are based on:
– Analysis of standard medical and surgical
practices
– Coding conventions included in CPT®
– Coding guidelines developed by medical
specialty societies
– Local and national coverage determinations
– Review of current coding practices
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National Correct Coding
Initiative• NCCI contains two tables of edits
– Column One/Column Two Correct Coding
Edits table
– Mutually Exclusive Edits table
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NCCI Terms and Definitions
• CCI edits – applied to services billed by
the same provider for the same beneficiary
on the same date of service
– Pairs of CPT® and/or HCPCS codes not
separately reportable except under certain
circumstances
• Example - If a laparoscopic procedure becomes
open, you should only report the open CPT® code
and not both open and laparoscopic
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NCCI Terms and Definitions
• Column 1 code – represents the major
procedure or service than to the other
code
– Higher payments are associated due to the
codes greater work, effort, and time
• Example – A patient has a deep and superficial
biopsy of the same site report only the deep
biopsy, reporting both with result in a denial
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NCCI Terms and Definitions
• Column 2 code – represents the lesser
procedure when reported with another
code
– Can be considered a component code, lower
payments are associated with these services
• Example - A patient has a deep and superficial
biopsy of the same site, but the surgeon
determines that it is medically necessary and has
supporting documentation, a modifier should be
added to either of the code pairs.
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ExampleColumn 1 Column 2 Modifier 0= not
allowed, 1=allowed,
9=N/A
40490 51703 1
40490 62310 0
40490 64550 9
0 = not allowed - means that there is no modifier that you can apply
to this code to make it billable and override the edit
1 = Allowed - means that you can use a 59, 24 or 25 modifier to
override this edit
9 = N/A - means that the edit is not applicable, or that there is no
conflict requiring a modifier to override
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Misuse of Column 2
• CMS manuals and instructions often
describe groups of HCPCS/CPT® codes
that should not be reported together for
the Medicare program
– Edits based on these instructions are often
included as misuse of column two code with
column one code
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Example• CMS limits separate payment for use of the operating
microscope for microsurgical techniques (CPT® code
69990) to a group of procedures listed in the online
Claims Processing Manual (Chapter 12, Section 20.4.5
(Allowable Adjustments)).
– The NCCI has edits with column one codes of surgical
procedures not listed in this section of the manual and column
two CPT® code of 69990. Some of these edits allow use of
NCCI-associated modifiers because the two services listed in the
edit may be performed at the same patient encounter as a third
procedure for which CPT® code 69990 is separately reportable.
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Example• There may be limited circumstances when the column
two code is separately reportable with the column one
code.
– For example, the NCCI has an edit with column one CPT® code
of 80061 (lipid profile) and column two CPT® code of 83721
(LDL cholesterol by direct measurement). If the triglyceride level
is less than 400 mg/dl, the LDL is a calculated value utilizing the
results from the lipid profile for the calculation, and CPT® code
83721 is not separately reportable. However, if the triglyceride
level is greater than 400 mg/dl, the LDL may be measured
directly and may be separately reportable with CPT® code
83721 utilizing an NCCI-associated modifier to bypass the edit.
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Modifiers and NCCI
• Modifiers may be appended to
HCPCS/CPT® codes only if the clinical
circumstances justify the use of the
modifier
• A modifier should not be appended to a
HCPCS/CPT® code solely to bypass an
NCCI edit if the clinical circumstances do
not justify its use
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Modifiers and NCCI
• Modifiers that may be used under
appropriate clinical circumstances to
bypass an NCCI edit include
– Anatomic modifiers: E1-E4, FA, F1-F9, TA,
T1-T9, LT, RT, LC, LD, RC
– Global surgery modifiers: 25, 58, 78, 79
– Other modifiers: 27, 59, 91
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Modifier 59 and NCCI
• Modifier 59 is an important NCCI-
associated modifier that is often used
incorrectly
• For NCCI its primary purpose is to indicate
that two or more procedures are
performed at different anatomic sites or
different patient encounters
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Modifier 59 and NCCI
• Only used if no other modifier more
appropriately describes the relationships
of the two or more procedure codes
• Modifier 59 and other NCCI-associated
modifiers should NOT be used to bypass
an NCCI edit unless the proper criteria for
use of the modifier is met
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Modifier 59• Most common misuse of modifier 59
– Letting the definition of modifier 59 confuse you
in appropriate assignment
• code descriptors of the two codes of a code pair edit usually
represent different procedures or surgeries
– Attaching a 59 modifier to report two codes being
different procedures/surgeries
• If two procedures/surgeries are performed at separate
anatomic sites or at separate patient encounters on the same
date of service, modifier 59 may be appended to indicate that
they are different procedures/surgeries on that date of
service
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59 Modifier Example• Example: Column 1 Code/Column 2 Code 93529/76000
– CPT Code 93529 – Combined right heart catheterization and left
heart catheterization through existing septal opening (with or
without retrograde left heart catheterization)
– CPT Code 76000 – Fluoroscopy (separate procedure), up to one
hour physician time, other than 71023 or 71034 (eg, cardiac
fluoroscopy)
• Policy: Standards of medical/surgical practice
• Modifier -59 is: 1) Only appropriate if the fluoroscopy
service 76000 is performed for a procedure done
unrelated to the cardiac catheterization procedure.
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Medically Unlikely Edits (MUEs)
• Developed by CMS – January 1, 2007
• Used to reduce claim payment errors for
Part B claims
• MUEs
– Maximum units allowable by the same
provider for the same beneficiary for the same
date of service• http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage
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Medically Unlikely Edits Example
• Eve Smith underwent a cataract extraction
in her right eye.
– Claim was submitted with a 4 units in block 24
• Result: Claim Denied
– Rational: The claim was denied due to medically unlikely
edit because the units indicate that the patient had a
cataract removed from 4 right eyes. The patient had only
one right eye.
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Medicare Coverage Database
• Medicare Coverage Database (MCD) – used to
determine whether a procedure or service is
reasonable or necessary for the diagnosis or
treatment of an illness or injury.
• Contains:
– National Coverage Determinations (NCDs)
– Local Coverage Determinations (LCDs)
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National Coverage
Determinations (NCDs)
• Updated “real-time” by CMS to create edits for
rules, called local coverage determinations
(LCDs)
• Link ICD-9-CM diagnosis codes with procedures
or services considered medically necessary
• Use this to determine if an ABN is needed
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National Coverage
Determinations (NCDs)• Additional uses for NCDs
– Prevents payment of surgical errors
• Wrong surgical or other invasive procedures
performed on a patient
• Wrong body part
• Wrong patient
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• Example – NCD for Bariatric Surgery– B. Nationally Covered Indications
• Effective for services performed on and after February 21, 2006, Open
and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and
laparoscopic Biliopancreatic Diversion with Duodenal Switch
(BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are
covered for Medicare beneficiaries who have a body-mass index > 35,
have at least one co-morbidity related to obesity, and have been
previously unsuccessful with medical treatment for obesity. These
procedures are only covered when performed at facilities that are: (1)
certified by the American College of Surgeons as a Level 1 Bariatric Surgery
Center (program standards and requirements in effect on February 15,
2006); or (2) certified by the American Society for Bariatric Surgery as a
Bariatric Surgery Center of Excellence (program standards and
requirements in effect on February 15, 2006).
• Effective for services performed on or after February 12, 2009, the Centers
for Medicare & Medicaid Services (CMS) determines that Type 2 diabetes
mellitus is a co-morbidity for purposes of this NCD.
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Local Coverage Determination
(LCDs)• LCDs - a decision by a fiscal intermediary (FI) or
carrier whether to cover a particular service on
an intermediary-wide or carrier-wide basis in
accordance with Section 1862(a)(1)(A) of the
Social Security Act (e.g., a determination as to
whether the service or item is reasonable and
necessary).
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Local Coverage Determination
(LCDs)• Important:
– Only employed for a specified geographical
area based on contractor
– Provides guidance not guidelines
– NCDs take precedence over LCDs
– Carefully read the LCDs to ensure that you
are looking at active policies
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LCD example• Several National Coverage Determinations (NCDs) relevant to the
Local Coverage Determination (LCD) are available at the "coverage"
website at CMS. Based on National Coverage Decisions, Medicare
does not cover: • Gastric balloon surgery,
• Intestinal Bypass;
• Open adjustable gastric banding;
• Open and laparoscopic sleeve gastroectomy;
• Open and laparoscopic vertical banded gastroplasty or
• Bariatric surgery to treat obesity alone.
• Medicare does cover bariatric surgery with these limitations:
(1) Body Mass Index (BMI) must be equal to or greater than 35, (2)
and at least one co-morbidity related to obesity such as diabetes or
hypertension must be present, and (3) there was previously
unsuccessful medical treatment of obesity.
• Several forms of surgery are allowed, while others are disallowed.
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Tricare
• Policies do not include appropriate
diagnosis coding; they include
– Included
– Excluded
– Provides cost coverage depending on the
procedure or service
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Tricare
• Pricing exampleOffice Visits /
Consultations
TRICARE
Prime
TRICARE
Extra
TRICARE
Standard
ADFM None 15% 20%*
Retirees and
Others
$12 20% 25%*
Standard and Extra cost shares are applied after the deductible is
met.
*TRICARE Standard beneficiaries may be required to pay up to 15%
above the TRICARE allowed amount when using a provider that does
not participate in TRICARE.
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Never-Event Policies
• Never-events - serious events or medical errors
that are clearly identifiable and preventable.
• New policies have been implemented to
supplement Medicare’s policies on wrong
procedure, wrong patient, and wrong body site.
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Never-Event Policies
• New policies include the following list of
hospital acquired conditions:– Pressure ulcers stages III & IV
– Catheter-associated urinary tract infections
– Vascular catheter-associated infection
– Surgical site infection, mediastinitis, following
coronary artery bypass graft (CABG)
– Air embolism
– Blood incompatibility
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Never-Event Policies– Foreign object retained after surgery
– Falls and trauma (fracture, dislocation, intracranial
injury, crushing injury, burn, electric shock)
– Surgical-site infections following certain orthopedic
procedures
– Surgical-site infections following bariatric surgery for
obesity
– Manifestations of poor glycemic control
– Deep vein thrombosis and pulmonary embolism
following certain orthopedic procedures
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Impact of ICD-10
• ICD-10 implementation will have a huge
impact on healthcare policies
– All existing policies will be updated reflecting
the higher specificity
– Expect new policies to be created
– Think strategically about how to update your
policies in a quick and efficient way
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• What do I do if no policy exists?
– Does the page require a login?
• Apply or signup for a user name and password
– If no written policy or web page
• Create a cheat sheet list with phone numbers of
your contracted payers to call for verification and
clarification on established policies
– Beyond the policy page
• To go beyond the policy page you might have to
review your contracts to ensure that the services
outlined are geared to what your practice offers.
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Best Practices• Carefully read the policies, LCDs, NCDs or
whatever your carriers have available for you
• If unavailable contact the carrier to verify the
information needed
• See if your carriers have a list serve or other
email listings that would keep you up-to-date
about any policy changes
• Do not keep old policies or store policies without
updating the information
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Resources• Tricare -
https://www.hnfs.net/common/benefits/benefits_limitations_exclusio
ns.htm
• Centers for Medicare and Medicaid Services (CMS) -
http://www.cms.gov/mcd/index_local_alpha.asp?from=alphalmrp&let
ter=A;
http://www.cms.gov/NationalCorrectCodInitEd/01_overview.asp#To
pOfPage
• Aetna - http://www.aetna.com/healthcare-professionals/policies-
guidelines/medical_clinical_policy_bulletins.html
• Understanding Health Insurance-A Guide to Billing and
Reimbursement – by Michelle A. Green & JoAnn C. Rowell
• Blue Cross Blue Shield -http://www.bcbs.com/coverage/the-blues-
and-medicare/index.html