Coding Strategy

Don’t look for a raise just yet, in most cases.

CMS may talk, but MACs don’t always listen — at least not quickly.

As we told you in last week’s Insider, CMS recently corrected several “technical errors” published in the 2010 Fee Schedule, and thanks to these corrections, Medicare will increase payment for several cardiology-related testing codes, including codes 75571-75574 (Heart CT) and 78451-78454 (Heart muscle SPECT imaging).

Although many practices are eager to see the payment boosts in their next Medicare payments, that may be an overly ambitious goal at this point.

“I inquired with a few MAC carriers such as Trailblazer, Noridian, and Palmetto, and was told different things by different Medicare payers,” says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CCC, CEMS, CMS, CEO of Terry Fletcher Consulting Inc.

“One did not even know there was a change,” she says. “Next, Noridian said that they will be making the adjustments when they get the directive from CMS. And Palmetto said they would need the provider to contact them and then batch retroactive to January the myocardial perfusion imaging claims and send a letter to request the increase,” she says.

Bottom line: Until CMS provides a clear answer to the MACs regarding when they must implement the changes, you may not see your pay increases, but keep an eye on your carrier’s Web site for information on when it intends to reprocess claims using the new rates.

@ Part B Insider. Editor: Torrey Kim, CPC

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Plus: The OIG recovered over $1.5 billion in fiscal year 2009, and is on the lookout to collect more.

With less than two weeks to go before Medicare payments once again threaten to decrease by 21 percent, a new report sheds light on the financial outcome of Congressional actions.

Although the 2010 Physician Fee Schedule originally included a conversion factor that would have been 21 percent lower than the 2009 level, practices haven’t felt that cut yet this year,because legislators have voted several times to freeze payments, which now use the conversion factor of $36.0791. That freeze will expire on May 31, after which your Medicare payments will drop considerably unless Congress steps in once more.

However, one government entity’s calculations show that the freeze is costly. According to a May 7 Congressional Budget Office report, freezing payments at the current levels for the rest of 2010 would cost the government… … $6.5 billion. The AMA has turned up the heat on Congress to replace the current payment method, releasing a print ad aimed at Congress to demonstrate that “more delays of permanent reform now increase the cost for taxpayers,” and that the association “calls on Congress to fix the flawed Medicare physician payment formula now.”

Congress has not yet introduced a bill to extend the payment freeze past May 31. Keep an eye on the Insider for more information as this story develops.

To read the Congressional Budget Office’s calculation sheet,visit www.cbo.gov/budget/factsheets/2010b/SGR-menu.pdf.

@ Part B Insider. Editor: Torrey Kim, CPC

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But because legislators missed the cutoff by one day, some claims were processed using a lower rate.

Although the government appeared poised to take a big bite out of your next Part B payments, you have another month before you have to worry about losing pay. That’s because the 21.2 percent Medicare pay cuts that practices have feared since January have been delayed until May 31.

Lawmakers returned from a two-week break on Monday, and appeared ready to take up legislation (H.R. 4851) that would extend the payment freeze to prevent cuts to your Medicare pay, but passage of the bill did not immediately materialize. Although CMS had instructed MACs to hold claims for 10 business days …

… as of April 1 in anticipation of a pay fix, that hold expired on April 14. Congress did eventually approve the bill, and the president signed it on the evening of April 15.

Still unclear is what MACs will do with claims that processed during the day on April 15. At that point, contractors were planning to pay claims with dates of service April 1 and thereafter using the 2010 conversion factor of $28.4061. This represents a 21.2 percent cut against the $36.0846 that you have been collecting. Because Congress has now retroactively changed the pay rate back to $36.0846, any payers that reimbursed you using the lower rate will have to make up the difference.

Prior to the vote, CMS reps assured practices that if the Senate did vote to extend the pay freeze, that they could put it into effect swiftly. “We are prepared that if Congress acts, we will move very quickly to make the necessary changes,” noted CMS’s Stewart Streimer during an April 13 CMS Open Door Forum.

“Repeated delays and continued uncertainty, combined with the fact that Medicare payments, even without the 21 percent cut, have not kept up with the cost of providing care to seniors demonstrates the need for a permanent solution to this annual problem,” noted the AMA in an April 16 statement.

Keep an eye on Part B Insider for more on the payment issues as the new May 31 deadline approaches.

@ Part B Insider, Editor: Torrey Kim

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Verify that you’re counting injections and levels correctly to keep claims clean.

The Office of Inspector General (OIG) Work Plan for 2010 includes a closer look at Medicare payments for transforaminal epidural injections. The Work Plan specifically states, “We will review Medicare claims to determine the appropriateness of Medicare Part B payments for transforaminal epidural injections.”

Stay out of the OIG crosshairs by ensuring that your pain management specialist documents each procedure thoroughly. Follow these steps to count levels and assign the appropriate codes correctly.

1. Understand What ‘Transforaminal’ Means

Physicians often administer transforaminal epidurals laterally through the selected neuroforamen under fluoroscopy, says Joanne Mehmert, CPC, CCS-P, president of Joanne Mehmert and Associates in Kansas City, Mo. Once there, the physician performs an injection at the nerve root area to help relieve the patient’s pain. The medication goes into the anterior epidural space, “bathing” a specific spinal nerve as it exits the spinal cord.

CPT includes four codes to represent transforaminal epidural injections, which you choose between based on the injection site and number of injections:

• 64479 — Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level (2009 national average Medicare reimbursement of $114.69 facility/ $253.55 non-facility)
• +64480 — … cervical or thoracic, each additional level (List separately in addition to code for primary procedure) ($75.02 facility/$127.68 non-facility)
• 64483 — … lumbar or sacral, single level ($100.99 facility/$246.70 non-facility)
• +64484 — … lumbar or sacral, each additional level (List separately in addition to code for primary procedure) ($63.84 facility/$125.15 non-facility).

Procedure note: Although you report the same codes, a transforaminal injection is different from a selective nerve root block (SNRB). With SNRB, your provider injects right beside the nerve root where the nerve exits the foramen. The injection occurs outside the spine, which differs from a transforaminal. Coders sometimes interchange the terms, but knowing the difference in technique will help you better understand your physician’s documentation.

2. Pay Attention When Counting Levels

Although the transforaminal injection descriptors specify spinal levels, your physician actually targets the space between vertebrae — the interspace. This difference in code terminology and the procedure can confuse coders, so help your chances with the OIG by knowing how to count levels correctly. Remember you’re counting interspaces, not vertebral bodies.

Tip: When the provider inserts the needle through the foramen into the interspace between discs (for example, at L4-L5), that is a spinal level you code with 64483. If your  provider inserts another needle into the next interspace (for example, at L5-S1), consider that a second spinal level and code report +64484 along with 64483.

Important: If your provider injects both sides of the same level, report a bilateral injection, not separate levels. “Even though payers require various claim formats, that doesn’t mean that each side at the same spinal level is a different level,” Mehmert explains.

Next step: Then check your payer’s guidelines for bilateral reporting. “Most of the insurance companies I deal with state to use the 50 modifier (Bilateral procedure) and file on one line,” says Dawn Shanahan, CPC, supervisor of coding for Florida Gulf to Bay Anesthesiology Associates in Tampa. In that case, code a bilateral transforaminal injection at L4-L5 as 64483-50 rather than 64483 with +64484.

Codes 64479-64484 have a bilateral surgery indicator of “1.” They are considered unilateral procedures and most insurers will pay 150 percent for a bilateral block from this code family. When reporting a unilateral block with 64479-64484, include modifier LT (Left side) or RT (Right side) as appropriate so the payer fully understands the procedure.

3. Verify Whether Fluoroscopy Code Applies

“Although CPT does not specifically state that fluoroscopy must used to report these codes, it’s almost a universal industry standard to use fluoro,” Mehmert says. When your physician uses fluoroscopic guidance report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, or sacroiliac joint], including neurolytic agent destruction) in addition to the procedure code.

“There needs to be a mention of the fluoroscopy in the documentation as well as a hard copy of the film in the patient’s medical record,” Shanahan says. “My physician mentions the use of fluoro as well as the type and amount of dye used or if the dye was not used and why.”

Watch guides: Know your payers, because insurance companies have different guidelines for how many levels can be injected during the same encounter, the time between procedures, and other parameters. “For example, Blue Cross/Blue Shield of Florida presently states that a patient can receive diagnostic injections no sooner than every week, whereas the therapeutic injection time is no sooner than eight weeks,” Shanahan says.

Other payers, however, have policies that deny treatment as not reasonable or medically necessary when your physician administers combinations of epidural, facet, lumbar sympathetic, or bilateral sacroiliac joint blocks on the same day.

CPT includes many parenthetical notes explaining when you can — or cannot — report 77003 with various injection procedures. None of the notes, however, restrict you from submitting 77003 with transforaminal epidural codes 64479-64484. Because your physician needs to use fluoroscopy or a CT scan to confirm needle placement in the transforaminal epidural space, you might raise payer eyebrows if you don’t report 77003 with the injection codes.

@ Anesthesia & Pain Management Coding Alert

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