Coding Billing

Coding&Billing Quarterly FEBRUARY 2015 EDITOR ALAN L. PLUMMER, MD ATS RUC Advisor Letter from the Editor Welcome to the January 2015 edition of the ATS Coding ADVISORY BOARD MEMBERS: and Billing Quarterly. The New Year will bring a number of KATINA NICOLACAKIS, MD important changes to medicine for practitioners of pulmonary, Chair, ATS Clinical Practice Committee ATS Alternate RUC Advisor critical care and sleep medicine. Below are some issues that ATS STEPHEN P. HOFFMANN, MD members and their staff need to be aware of and prepared for: Member, ATS Clinical Practice Committee ATS CPT Advisor ICD-10 Transition – Barring another last minute intervention MICHAEL NELSON, MD by Congress (which is possible but very unlikely), 2015 will Member, ATS Clinical Practice Committee be the year of the ICD-10 transition. I hope providers and ATS Alternate CPT Advisor practices are well underway preparing for the transition. Over the past year, the STEVE G. PETERS, MD Member, ATS Clinical Practice Committee ATS Coding and Billing Quarterly has featured articles on the transition. The April 2015 edition will cover ICD-10 for pediatric pulmonary services. Lung Cancer Screening Coverage – Earlier this month, the Centers for Medicare In This Issue and Medicaid Services (CMS) released its final coverage policy for lung cancer Low Dose CT Lung Cancer screening. In this issue, Dr. Kovitz describes the final coverage policy, its impact Screening Coverage - Implications on Medicare and private coverage, as well as tips for coding services related to for the Practitioner, page 2 screening. 2015 Brings New Extracorporeal Membrane Oxygenation New ECMO codes – Also covered in this issue is the new and expanded family of (ECMO)/Extracorporeal Life codes for EMCO services. Dr. Hussain describes the new codes and how they will Support (ECLS) Common likely be used by pediatric and adult providers. Procedural Terminology (CPT) codes, page 5 Sustainable Growth Rate Factor – Yes, the looming SGR problem is still with us. Despite the significant progress made by Congress last year, they still were unable Q&A, page 8 to pass a permanent fix to the SGR crisis and for the 17th time, passed a short- term patch. The short-term patch extended the 0.5% Medicare update through 2014 – please note, providers will see a 0.5% cut in reimbursement starting January 1, 2015 – and delayed the 24% SGR payment cut through March 31, 2015. So once again, Congress will start the New Year having to act fast on an SGR bill – or jeopardize destabilizing the Medicare program. While the above issues are on the ATS radar screen, I am confident 2015 will hold many more surprises and challenges for the pulmonary, critical care and sleep community. We will continue to do our best to share timely and accurate information with ATS members on billing, coding and regulatory compliance issues. Sincerely, Alan L. Plummer, MD Editor Physician’s Current Procedural Terminology (CPT®) codes, descriptions, and numeric modifiers are © 2014 by the American Medical Association. All rights reserved. 1 ATS Coding&BillingQuarterly FEBRUARY 2015 LOW DOSE CT (LDCT) LUNG CANCER SCREENING COVERAGE—IMPLICATIONS FOR THE PRACTITIONER Kevin L Kovitz, MD, MBA of the supporting data. According to the Affordable Care Professor of Medicine and Surgery, University of Illinois at Act, 3 all preventative services that received an A or B grade Chicago and Director, Chicago Chest Center from the USPSTF must be covered by private insurance at No Conflicts. no costs to the consumer.3 Commercial carriers are required National coverage for lung cancer screening has arrived. In incorporate category A and B recommendations with the February 2015, Centers for Medicare & Medicaid Services plans annual renewal. It is important to note that the annual (CMS) issued a final coverage policy. Heretofore, screening renewal date for private plans can happen through the programs have had varying levels of success in attracting calendar year. Private insurance coverage for lung cancers providers and patients alike with the major barrier being lack screening did not necessarily start in January for private of reimbursement. The purpose of this discussion is separate patients. Providers should consult with patients and insurance from the utility of screening. Rather, the focus is on obtaining companies to ensure lung cancer screening is covered. coverage for the patient encounters and scans required. The Age and Coverage Policy Affordable Care Act and the CMS lung cancer screening The coverage criteria are similar in all respects aside from policy significantly change coverage. age. This is not an issue in most situations as the 55-64 year There are 2 main areas to understand, CMS coverage and old and the 65-77 year old with commercial insurance or commercial carrier coverage. Medicare should be covered. The most common scenario is CMS Coverage of the younger patient with commercial insurance and the From a CMS perspective, we can take the specific older group with Medicare. Interestingly, the 78-80 year old criteria from their announcement.1 The ATS, like many with Medicare is not covered unless they have commercial organizations, submitted comments to improve and clarify insurance as primary coverage. The commercially insured the initial CMS proposal. Specifically, the ATS recommended older patient is likely to represent a small group and CMS extending the screening coverage to include Medicare coverage is an issue if one is of the opinion that screening beneficiaries aged 75-80, sought clarification on the shared needs to be done in this age group. decision making visits, recommended clarifying language Coding on the term “asymptomatic” and noted the importance of Coding is multifactorial. However, there is no specific CPT a multidisciplinary team in diagnosing and managing lung code for the Evaluation and Management of a patient that cancer. The final CMS policy addresses these issues, with presents for Lung Cancer Screening evaluation. Traditional the age reaching 77, shared decision making clarified, and outpatient consults (where applicable), new patient or “asymptomatic” focused to symptoms related to lung cancer. established patient E & M coding should be used. The E & Practitioners and programs should carefully review the final M selected must be commensurate with the level of service policy prior to establishing a site-specific screening protocol. as determined by specific actions or counseling as one would The CMS proposal is very detailed, mostly follows the with any visit. The diagnoses may include, but are not limited National Lung Screening Trial (NLST) criteria, and to: special screening for malignant neoplasm of the respiratory requires specific personnel, shared decision making with organs, V76.0 (ICD-9) or Z12.2 (ICD-10)4 and all diagnoses the patient, specific documentation, smoking cessation appropriate to the patient’s problems. Consider including counseling, detailed orders, specific radiology requirements, a code for the tobacco history such as nicotine dependence and participation in a registry. The specific CMS decision (ICD-9 305.1, ICD-10 F17.200) or history of same (ICD-9 summary of the policy, copied directly from the website, is V15.82, ICD-10 Z87.891). The tobacco code is not specified noted below1 for reference as there are extensive and very but makes sense as these patients need a smoking history and detailed requirements. Please review these carefully. pack years need to be documented in order to qualify for Private Insurance screening. The radiologist will have a specific HCPCS code of S8032 Commercial carriers face a different issue. As most are aware, Low-dose computed tomography for lung cancer screening.5 the USPSTF has recommended lung cancer screening for a broader age range.2 The grade of B was given for the validity continued on page 3 2 Physician’s Current Procedural Terminology (CPT®) codes, descriptions, and numeric modifiers are © 2014 by the American Medical Association. All rights reserved. ATS Coding&BillingQuarterly FEBRUARY 2015 continued from page 2 The above summary reflects the current point in time. by a physician (as defined in Section 1861(r)(1) of Practitioners and programs are urged to carefully review the the Social Security Act) or qualified non-physician final policy before establishing program policies. Additionally, practitioner (meaning a physician assistant, nurse it is important to review the policies of individual commercial practitioner, or clinical nurse specialist as defined in carriers as they often differ from CMS. §1861(aa)(5) of the Social Security Act). A lung cancer screening counseling and shared decision making visit References includes the following elements (and is appropriately 1. http://www.cms.gov/medicare-coverage-database/details/ documented in the beneficiary’s medical records): nca-decision-memo.aspx?NCAId=274 accessed 2/10/15). • Determination of beneficiary eligibility including age, See below. absence of signs or symptoms of lung cancer, a specific calculation of cigarette smoking pack-years; and if a former 2. Moyer VA on behalf of the U.S. Preventive Services Task smoker, the number of years since quitting; Force. Screening for lung cancer: U.S. preventive services task force recommendation statement. Ann Intern Med. • Shared decision making, including the use of one or more 2014;160(5):330-338. decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive 3. http://www.law.cornell.edu/cfr/text/29/2590.715-2713

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