AdvancedAdvanced ChargeCharge MasterMaster StrategiesStrategies HFMA Western NY Chapter January 26-27, 2010 IntroductionsIntroductions

Mike Kovar is a Partner in Tatum LLC’s Health Care Consulting Practice. He has led over 400 charge master, revenue capture, and patient charge compliance reviews. He received his Masters’ in Business Administration from Loyola University of Chicago, is an advanced member of HFMA, and is a frequent speaker nationally on charge master and other revenue capture- related issues.

Colleen Hall is a Principal in the Health Care Practice of Tatum LLC. She has over 8 years of experience in the health care industry with a primary focus in charge capture and charge master analyses for hospital providers. Colleen has Big Four consulting experience as well as management experience with physician offices. Colleen is also a Certified Professional Coder (CPC).

2 ObjectivesObjectives ofof thethe SeminarSeminar

In our two day session, we will cover the following: ƒ CY 2010 CPT Changes ƒ CY 2010 OPPS Final Rule ƒ Latest on Health Care Reform ƒ Advanced charge capture strategies to ensure optimal reimbursement under the Medicare OPPS system and for other third-party payors

3 ChargeCharge MasterMaster

What is the Charge Master?

ƒ The charge master is the price book for the hospital.

ƒ It provides the link between service delivery and billing.

ƒ Is critical to the accurate billing of patient care services.

ƒ Is critical in decision support functions.

4 ChargeCharge MasterMaster

Charge master affects other systems

ƒ Order entry

ƒ Ancillary department systems such as RIS, LIS and Pharmacy systems

ƒ Bill editors/scrubbers

5 WhatWhat IsIs InIn thethe ChargeCharge Master?Master?

ƒ Service Code — It usually includes department number or a link to the department number. ƒ Description — Misconception that description seen in order entry or on charge sheet is what is on the bill. Description should be user friendly for patient accounting staff as well as patients. ƒ CPT Code (5-digit numeric code) or HCPCS Code (Alpha-digit plus 4 numeric digit code) — Either CPT Code or HCPCS Level II Codes are described in AMA CPT Code Manual or HCPCS Manual. ƒ UB-04 Revenue Code (4 digit code) — Links typically to CPT code and is pointer to clinical department where the service is provided. ƒ Price — It is the dollar amount billed to the patient/payor.

6 WhyWhy IsIs thethe ChargeCharge MasterMaster Important?Important?

Appropriate Reimbursement

Accurate Charge Master

Billing Service Analysis Compliance (Decision Support)

7 OtherOther ChargeCharge MasterMaster ConceptsConcepts

ƒ Billable versus non-billable -Medicare vs other payors -Hot and cold packs ƒ Fee Schedules - Medicare OPPS - Medicare Clinical Laboratory - Medicare Physician - Medicare Therapy Services - Other Payors

8 CPT/RevenueCPT/Revenue CodingCoding ConceptsConcepts

ƒ CPT Codes-Category I ƒ CPT Codes-Category II -Quality measurements ƒ CPT Codes-Category III -New Technology ƒ HCPCS National Level II Codes ƒ Revenue Codes-Four digit numeric designating department where service provided

9 ChargeCharge MasterMaster CodingCoding

Current Procedural Terminology or CPT Codes (Level I/Category I CPT)) Maintained and updated annually by the American Medical Association. ƒ New updated code manuals provided in November of each year. ƒ CMS now requires all CPT Coding revisions to be implemented by January 1. ƒ Focus on Appendix B of the CPT Coding Manual — Summary of Additions, Deletions, and Revisions — when evaluating the necessary changes to the charge master. ƒ CPT Code Categories: 9 Evaluation and Management CPT Codes 99201 – 99499 9 Anesthesia CPT Codes 00100 – 01999 9 Surgery CPT Codes 10021 – 69990 9 Radiology CPT Codes 70010 – 79999 9 Pathology & Laboratory CPT Codes 80048 – 89399 9 Medicine CPT Codes 90281 – 99199 ƒ Stay away from using the “unlisted procedure” codes XX999 – often misused by Hospitals. ƒ Look for CPT Codes with a (+) next to them — these are add-on procedures. ƒ CPT Codes can be hard coded in the charge master. (e.g., Laboratory, Radiology) or they can be assigned by Health Information Management (HIM) via the abstracting system (e.g., Operating Room Services).

10 ChargeCharge MasterMaster CodingCoding

Healthcare Common Procedure Coding System or HCPCS Codes (Level II) Maintained and revised throughout the year by the Centers for Medicare and Medicaid Services, or CMS. ƒ New HCPCS codes are effective January 1 of each year. ƒ HCPCS Code Categories: 9 A Codes A0021 – A9901 Transportation services, including ambulance, medical and surgical supplies and miscellaneous 9 B Codes B4034 – B9999 Enteral and Parental Therapy 9 C Codes C1000 – C9999 Temporary codes for use with OPPS 9 D Codes D0000 – D9999 Dental procedures 9 E Codes E0100 – E9999 Durable Medical Equipment 9 G Codes G0000 – G9999 Procedures and Professional Services 9 H Codes H0001 – H1005 Alcohol and Drug Abuse Treatment Services 9 J Codes J0120 – J8999 Drugs Administered Other Than Oral Method 9 K Codes K0000 – K9999 Durable Medical Equipment Regional Carriers 9 L Codes L0100 – L9999 Orthotic and Prosthetic Procedures 9 M Codes M0000 – M0302 Other Medical Services 9 P Codes P0000 – P9999 Pathology and Laboratory Services 9 Q Codes Q0000 – Q9999 Temporary 9 R Codes R0000 – R5999 Diagnostic Radiology Services 9 S Codes S0009 – S9999 National Codes (Non-Medicare) 9 T Codes T1000 – T2007 National Codes for State Medicaid Agencies 9 V Codes V0000 – V5999 Vision and Hearing Services

11 ChargeCharge MasterMaster CodingCoding

CPT and HCPCS Level II Modifiers ƒ Required by CMS to be reported for outpatient services ƒ Varying methods of modifier assignment: 9 Hard coded in the charge master 9 Assigned by HIM through the abstracting system 9 Assigned by the department staff through the charge entry system ƒ Modifiers required:

Level I (CPT) Level II (HCPCS) -25 -59 -78 -CA -FA -F5 -GA -LC -RC -T3 -T8 -27 -73 -79 -E1 -F1 -F6 -GG -LD -RT -T4 -T9 -50 -74 -91 -E2 -F2 -F7 -GH -LT -TA -T5 -52 -76 -58 -E3 -F3 -F8 -GY -QM -T1 -T6 -77 -E4 -F4 -F9 -GZ -QN -T2 -T7

ƒ Assignment of correct modifiers can be critical to reimbursement. + e.g., 25 modifier

12 ModifierModifier BasicsBasics

ƒ Modifiers are intended to notify payors that: -A service was provided by more than one physician and/or one location -A service was reduced or increased -A service was partially completed -An adjunctive service was performed -A bilateral procedure was performed -A service was performed more than once -Unusual circumstances occurred ƒ Commonly used Level I modifiers for OPPS include 25, 27, 50, 52, 59, 73, 74, 76, 77, and 91 ƒ Level II modifiers include LT, RT, CA, E1-E4, FA, F1-F9, GG, GH, LC, LD, RC, TA and T1-T9 ƒ Determine who assigns each modifier at your hospital -Is it hard-coded in the CDM, OE or the ancillary system (RIS)? -Is HIM assigning modifiers? -Is Patient Accounting assigning modifiers? Are the clinical departments involved? ƒ How do we monitor and track modifier assignment? (i.e. “59” modifier)

13 ModifierModifier BasicsBasics

ƒ 25 modifier-Significant, Separately Identifiable E&M Service by Same Physician on Same Day of a Procedure: -Commonly used in ED ƒ 27 modifier-Multiple OP Hospital E&M Encounters on Same Date -Used in ED and clinics ƒ 50 modifier-Bilateral Procedure -Used if bilateral is not indicated in the CPT description ƒ 52 modifier-Reduced Service -Payment may be reduced ƒ 59 modifier-Distinct Procedure or Service -Frequently misused to bypass CCI edits ƒ 73 modifier-Discontinued OP Procedure prior to Anesthesia ƒ 74 modifier-Discontinued OP Procedure after Anesthesia ƒ 76 modifier-Repeat Procedure Same Physician ƒ 77 modifier-Repeat Procedure Different Physician ƒ 91 modifier-Repeat Clinical Laboratory Diagnostic Test ƒ Level II HCPCS modifiers indicate “body location” of the service such as T1 left foot, second digit, etc.

14 ChargeCharge MasterMaster CodingCoding

CPT Category III Codes ƒ Maintained and updated semiannually by the AMA ƒ Temporary codes for emerging technologies, services, and procedures ƒ If a Category III Code is available, this code must be reported instead of a Category I unlisted CPT Code. ƒ These codes have a alpha character as the fifth digit (“T” now in use) ƒ Category III Codes are archived 5 years after inception ƒ Category Code III assignment does not imply coverage by Medicare ƒ Examples of Category III Codes include: 9 0003T Cervicography 9 0028T DEXA Body Composition scan 9 0066T CT colonography screening

15 OverviewOverview ofof APCsAPCs

In 2000, Medicare implemented the Outpatient Prospective Payment System (OPPS) for hospital outpatient services. Key Differences Pre- vs. Post-OPPS Pre Post

Reimbursement based upon Reimbursement based upon Ambulatory Patient cost in most cases Classification (APC) fee except Laboratory and schedule for all areas except Rehabilitation Laboratory and Rehabilitation

Capturing of all charges and having If costs captured, you would the correct CPT Coding assigned is probably be ok from a critical to reimbursement. The APC reimbursement perspective assigned for payment is determined by the CPT Codes.

Capturing all the appropriate charges and ensuring that all the correct CPT/HCPCS codes appear on the patient bill is now critical to reimbursement.

16 OverviewOverview ofof APCsAPCs

Key Reimbursement Methodology

Previous Medicare Outpatient Medicare Outpatient PPS Ancillary Area Reimbursement Methodology Reimbursement Methodology Radiology Cost Based APC Clinical Laboratory Fee Schedule Fee Schedule Anatomic Pathology/ Cytology Cost Based APC Cardiology Cost Based APC Pharmacy Cost Based APC Supplies Cost Based None, except cost based for pass-through items Chemotherapy Cost Based APC Observation Cost Based APC, if certain criteria are met Emergency Room Cost Based APC Clinics Cost Based APC Respiratory Therapy Cost Based APC Rehabilitation Services Fee Schedule Fee Schedule Psychiatric Services Cost Based APC Ambulatory Surgery Cost Based APC APCs are paid based upon relative weights with geographical adjustments. Therefore, the same procedure may have a different payment rate based upon what part of the country you are in.

17 APCAPC BasicsBasics

ƒ APC system was implemented by Medicare in 2000 ƒ Annual Update process -Federal Register proposed rule published July/August each year -Federal Register final rule published in November/December each year and implemented January of the next year -Medicare publishes Quarterly Updates in January, April, June, and October each year ƒ Familiarize yourself with the CMS website: cms.gov ƒ APC rates are based on claims data submitted by hospitals 2 years ago ƒ APC system is based on the status indicators assigned to each individual CPT/HCPCS code ƒ Packaging is a key concept (Status Indicator N) and does not mean do not bill for the service ƒ Surgical procedure discounting (Status Indicator T) results in a 50% payment discount ƒ Some CPT Codes paid under the Physician or Clinical Laboratory Fee schedules ƒ Other payors using an APC system any not pay the same way as Medicare

18 APCsAPCs OverviewOverview

Indicator Definition F Corneal Tissue Acquisition Cost; Certain CRNA Services Indicator Definition G Drug/Biological Pass-Through Indicates services that are paid under some other method: H Device Category Pass-Through, Therapeutic Radiophamaceuticals 9 Durable medical equipment, prosthetics and orthotics are paid under the DMEPOS fee K Non Pass-through Drug/Biological; Separate APC schedule Payment 9 Physical, occupational, and speech therapy are paid under the physician fee schedule L Influenza Vaccine; Pneumumoccal Pneumonia A 9 Ambulance services are paid under the Vaccine ambulance fee schedule M Service not billable to FI and not payable under OPPS 9 Erythropoietin (EPO) for end-stage renal disease (ESRD) is paid under a national rate N Service Is Packaged into APC Rate 9 Physician services for ESRD patients are billed to the Medicare carrier P Partial Hospitalization 9 Clinical diagnostic laboratory services are paid Q1 STVX Packaged under the laboratory fee schedule Q2 T Packaged 9 Screening mammography is paid by either the Q3 Composite lower charge or national rate structure R Blood and Blood Products B Codes not recognized by OPPS when submitted on an S Significant Procedure, Not Discounted When Multiple Outpatient Hospital Part B bill type (12x,13x, and 14x) T Procedure, Discounted When Multiple “T” Procedures C Inpatient only Performed

D Deleted Code V Visit to Clinic or Emergency department E Code not used by Medicare, Service Not Covered, etc. X Ancillary Service; Separate APC Payment Y Non-Implantable Durable Medical Equipment:; Not paid under OPPS

19 2010 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Payment System (ASC) Final Rule

ƒ Published in Federal Register on November 20, 2009

9 Display copy published on October 30, 2009

ƒ Comments were due by December 29, 2009 on the following only:

9 Payment classifications for HCPCS Codes in Addenda B, AA, and BB

9 Recognition of plasma protein fraction as blood product or biological for OPPS payment

9 Alternative coding schemes for new and established hospital clinic visits

9 Extending direct supervision requirements for partial hospitalization to CMHCs

9 Establishing direct supervision requirements for ASCs

20 Overall Impact of 2010 OPPS Changes

ƒ 1.9% increase in Medicare payments in 2010 to all Hospitals including cancer and children’s hospitals and CMHCs (3.9% increase in 2009).

9 urban hospitals 2.0% 9 rural hospitals 1.6% 9 sole community rural hospitals 1.6% 9 major teaching hospitals 2.0% 9 minor teaching hospitals 1.9% 9 non-teaching hospitals 1.9% 9 governmental hospitals 1.8% 9 proprietary hospitals 2.0% 9 CMHCs -3.0%

21 Overall Impact of 2010 OPPS Changes (cont’d)

ƒ Decrease in community mental health centers (CMHCs) is due to the recalibration of the final payment rates. This includes revision of the APCs from one APC in 2008 to two APCs in 2009 based on number of services provided.

ƒ Urban hospitals with greater than 500 beds have the largest increase at 2.1%

ƒ Rural hospitals with more than 200 beds have the smallest increase at 1.4%

22 20102010 UpdatesUpdates AffectingAffecting OPPSOPPS PaymentsPayments

ƒ Approximately 130 million final action 2008 claims for services provided in a hospital outpatient setting were used to calculate the 2010 rates

ƒ Single/”pseudo” claims process used in previous years used for 2010 rate setting purposes

ƒ Most recent submitted, in most cases, cost reports beginning in CY 2007 used to calculate CCRs (cost-to-charge ratio) to be used to calculate median costs for the final CY 2010 OPPS payment rates

ƒ Revised revenue code-to-cost center crosswalk used to convert charges to cost in the rate setting process

23 20102010 NewNew PackagedPackaged RevenueRevenue CodesCodes

ƒ CMS is adding as newly packaged the following revenue codes in 2010:

9 0261 – IV Therapy: Infusion Pump

9 0392 – Administration, Processing and Storage of Blood and Blood Components; Processing and Storage

9 0623 – Medical Supplies - Extension of 27X, Surgical Dressings

9 0943 - Other Therapeutic Services (also see 095X, an extension of 094X), Cardiac Rehabilitation

9 0948 - Other Therapeutic Services (also see 095X, an extension of 094X), Pulmonary Rehabilitation

24 20102010 UpdatesUpdates AffectingAffecting OPPSOPPS PaymentsPayments

25 Continued next column

26 27 20102010 UpdatesUpdates AffectingAffecting OPPSOPPS PaymentsPayments

CY 2010 Approximate APC Median Final CY 2010 APC CY 2010 APC Title Cost 0128 Echocardiogram With Contrast $645 Level II Echocardiogram without 0269 contrast $447 Level III Echocardiogram Without 0270 Contrast $591 Level I Echocardiogram Without 0697 Contrast $262

28 20102010 UpdatesUpdates AffectingAffecting OPPSOPPS PaymentsPayments

ƒ Continuing with established composite APC policies for extended assessment and management, LDR prostate brachytherapy, cardiac electrophysiologic evaluation and ablation, mental health services, and multiple imaging services

ƒ Not adding any additional composite APCs in 2010 9 Per recommendation of the APC Panel, CMS to evaluate creating a composite APC for cardiac resynchronization

ƒ Implementing one change in packaging policy 9 CPT code 76098 (Radiological examination, surgical specimen) to status indicator Q2 (T-packaged) for 2010

29 20102010 UpdatesUpdates AffectingAffecting OPPSOPPS PaymentsPayments--OtherOther IssuesIssues

ƒ CY 2010 full market basket conversion factor of $67.406 versus a 2009 factor of $66.059 and a reduced market basket conversion factor of $66.086 versus a 2009 factor of $64.784. ƒ Final FY 2010 IPPS wage indices will be used to calculate CY 2010 OPPS payment rates (see htpp://www.cms.hhs.gov/providers/hopps) ƒ Effective for services provided on or after January 1, 2010, rural hospitals and SCHs (including EACHs) having 100 or fewer beds will no longer be eligible for hold harmless TOPs.

ƒ Continue policy of a budget neutral 7.1 percent payment adjustment for rural SCHs, including EACHs, for all services and procedures paid under the OPPS, excluding separately payable drugs and biologicals, devices paid under the pass-through payment policy, and items paid at charges reduced to costs.

30 20102010 UpdatesUpdates AffectingAffecting OPPSOPPS PaymentsPayments--OtherOther IssuesIssues

ƒ For hospitals, outlier payments that equal 50 percent of the amount by which the cost of furnishing the services exceeds 1.75 times the APC payment when both the 1.75 multiple threshold and $2,175 threshold (versus $1,800 in 2009) is met. 9 CMS estimates this will result in outlier payments equaling 1.0% of all OPPS payments 9 For hospitals failing to met the HOP QDRP, hospitals costs would be compared to reduced payments for outlier eligibility and calculation purposes ƒ For CMHCs, if the cost for partial hospitalization exceeds 3.4 times the PHP APC payment, the outlier payment is calculated as 50 percent of the amount by which the cost exceeds 3.4 times the APC payment rate. ƒ For cost reporting periods beginning in 2009, Medicare contractors will identify cost reports that require outlier reconciliation as part of the settlement process. 9 Hospital’s actual CCR for cost reporting period different than interim CCRs used to calculate outlier payments

31 20102010 UpdatesUpdates AffectingAffecting OPPSOPPS PaymentsPayments--OtherOther IssuesIssues

ƒ Calculation of Adjusted APC Payment

9 Step 1-where Xa = labor related portion of national unadjusted payment

• Xa = .60 * (national unadjusted payment rate) * applicable wage index

9 Step 2-where Y = non-labor related portion of national unadjusted payment

• Y= .40 * (national unadjusted payment rate)

9 Step 3

• Adjusted Medicare Payment= Xa + Y

9 Step 4- if SCH or EACH

• Adjusted SCH/EACH Payment= Adjusted Medicare Payment * 1.071

32 20102010 UpdatesUpdates AffectingAffecting OPPSOPPS PaymentsPayments--OtherOther IssuesIssues

ƒ National beneficiary copayment cannot exceed 40% of the APC payment in 2010 and all succeeding years and cannot be less than 20% of the OPD fee schedule amount

33 20102010 OPPSOPPS APCAPC GroupGroup PoliciesPolicies

ƒ 14 new Level II HCPCS codes created in the April and July 2009 update and assigned 2010 OPPS payment rates

34 20102010 OPPSOPPS APCAPC GroupGroup PoliciesPolicies

35 20102010 OPPSOPPS APCAPC GroupGroup PoliciesPolicies

36 20102010 OPPSOPPS APCAPC GroupGroup PoliciesPolicies

37 20102010 OPPSOPPS APCAPC GroupGroup PoliciesPolicies

ƒ 1 new Category I CPT code and 4 new Category III CPT codes created in July 2009 update and assigned APCs as appropriate

38 20102010 OPPSOPPS APCAPC GroupGroup PoliciesPolicies

39 20102010 OPPSOPPS APCAPC GroupGroup PoliciesPolicies

40 20102010 OPPSOPPS APCAPC GroupGroup PoliciesPolicies

ƒ CPT Code 0182T moved from new technology APC 1519 to APC 0313 (Brachytherapy) because its hospital resource costs are similar to those of other services assigned to APC 0313.

41 20102010 PaymentPayment ChangesChanges forfor DevicesDevices

ƒ Device dependent procedure policy continues 9 Devices with pass through status eligible for pass through payment for at least 2 years but not more than 3 years 9 Devices no longer eligible for pass through payment are packaged into the cost of the procedure ƒ Devices include pacemakers, AICDs, neurostimulators, and cochlear devices 9 L8680 Implantable neurostimulator electrode, each added to list (SI = B to N) ƒ Insertable/implantable biologicals will use the device pass-through process and payment methodology only. The device APC offset amounts will include the costs of implantable biologicals for the first time.

ƒ No devices with pass-through status expiring for 2010.

42 PaymentPayment ChangesChanges forfor Drugs,Drugs, Biologicals,Biologicals, RadiopharmaceuticalsRadiopharmaceuticals andand BloodBlood

ƒ 6 drugs with pass-through status ending December 31, 2009 (See Table 30 Federal Register)

ƒ 37 drugs/biologicals have pass-through status (SI=G) in 2010 (See Table 31 Federal Register) with payment of ASP + 6%

ƒ Device pass through methodology and payment will be used for implantable biologicals that are surgically inserted or implanted and have a newly approved pass through status on or after January 1, 2010

9 No longer paid at ASP + 6% but rather at charges adjusted to cost

9 Biological or synthetic material used to replace human skin is excluded from the device category

43 PaymentPayment ChangesChanges forfor Drugs,Drugs, Biologicals,Biologicals, RadiopharmaceuticalsRadiopharmaceuticals andand BloodBlood

ƒ For drugs and biologicals, there are the following changes:

9 For drugs and biologicals approved for pass through payment beginning January 1, 2010, the pass through payment eligibility period begins on the first date of payment under Part B

9 Pass through period would start on the first day of Part B payment

9 Pass through status would continue to expire annually

44 PaymentPayment ChangesChanges forfor Drugs,Drugs, Biologicals,Biologicals, RadiopharmaceuticalsRadiopharmaceuticals andand BloodBlood

ƒ Payment of pass-through drugs at ASP+6% or Part B CAP rate

ƒ $65 threshold (versus $60 in 2009) for separate payment (SI=K) of non-pass through drugs with payment at ASP+4% 9 Threshold updated annually using the PPI for prescription drugs 9 Overhead costs built into the payment

ƒ Anti-emetic drugs no longer exempt from $65 threshold 9 J2469 (Injection, palonosetron hcl, 25 mcg) will be paid as SI=K 9 Other five 5-HT3 anti-emetics will be packaged in 2010 (SI=N)

ƒ Packaging determinations will be made on a drug-specific basis rather than a HCPCS Code-specific basis for those HCPCS codes that describe the same drug or biological but different doses

45 PaymentPayment ChangesChanges forfor Drugs,Drugs, Biologicals,Biologicals, RadiopharmaceuticalsRadiopharmaceuticals andand BloodBlood (cont(cont’’d)d)

ƒ Blood clotting factors under OPPS to be paid at ASP+4 percent ƒ Continued separate payment for therapeutic radiopharmaceuticals that have a mean per day cost of more than $65

9 Where ASP is submitted by all manufacturers of a radiopharmaceutical, payment will be based upon ASP + 4%

9 Where ASP is not submitted by all manufacturers for a calendar year quarter, payment will be based on the mean unit cost (See Table 42 Federal Register)

46 OtherOther 20102010 OPPSOPPS PaymentPayment andand CodingCoding ChangesChanges ƒ Reimbursement for brachytherapy sources will now be based upon 2008 claims data adjusted to cost (see Table 45 Federal Register) 9 Brachytherapy sources (SI = U) eligible for outlier payments ƒ No changes for coding of drug administration 9 Full set of CPT codes used

ƒ Hospital coding and payment for visits 9 Continue to recognize same coding structure 9 Definition of “new” and “established” patients remains based upon whether or not the patient is registered as an inpatient or outpatient of the hospital within the past 3 years 9 No national visit level definitions • Distribution analysis still indicates a “bell shaped” distribution • Internal hospital guidelines should comport with principles in 2008 Final OPPS Rule

47 OtherOther 20102010 OPPSOPPS PaymentPayment andand CodingCoding ChangesChanges

ƒ Partial Hospitalization 9 Two Per Diem APCs continue • 172 Partial Hospitalization 3 Services • 173 Partial Hospitalization 4 or more Services 9 Hospital-based PHP data only to be used in the rate setting process ƒ 8 CPT Codes removed from the “Inpatient Only” list 9 See Table 56 Federal Register 9 Includes appendectomy

48 20102010 NonrecurringNonrecurring OPPSOPPS PolicyPolicy ChangesChanges

ƒ Kidney Disease Education Services 9 In CY 2010 MPFS final rule, a hospital, CAH, SNF, CORF, HHA, or hospice would not be a qualified person if the facility is located outside of a rural area unless the service is furnished in a hospital or CAH that is reclassified as rural 9 2010 MPFS payment for following HCPCS codes: • G0420 Educational services individual per hour (SI=A) • G0421 Educational services group per hour (SI=A)

49 20102010 NonrecurringNonrecurring OPPSOPPS PolicyPolicy ChangesChanges

ƒ Pulmonary Rehabilitation, Cardiac Rehabilitation, Intensive Cardiac Rehabilitation 9 HCPCS code G0424 pulmonary rehabilitation per hour (SI=S; Pmt = $50.46) • 60 minutes per session, 2 to 3 sessions per week and no more than 1 session per day 9 Cardiac Rehabilitation-CPT codes 93797 and 93798 • 60 minutes per session, minimum of 2 sessions per week and maximum of 2 sessions per day 9 Intensive Cardiac Rehabilitation • Series of 72 one hour sessions up to 6 sessions per day for up to 18 weeks • G0422 Intensive Cardiac Rehabilitation with exercise per hour (SI=S; Pmt= $38.36)) • G0423 Intensive Cardiac Rehabilitation without exercise per hour (SI=S; Pmt = $38.36) • Must be approved through NCD process

50 20102010 NonrecurringNonrecurring OPPSOPPS PolicyPolicy ChangesChanges

ƒ Pulmonary Rehabilitation, Cardiac Rehabilitation, Intensive Cardiac Rehabilitation 9 Direct supervision means that the physician must be present on the same campus, in the hospital, or the on-campus Provider Based Department and immediately available to furnish assistance

ƒ Stem Cell Transplant 9 Status indicators for the following CPT Code changed • 38205 Cell harvesting for transplant allogenic (SI=B)

51 20102010 NonrecurringNonrecurring OPPSOPPS PolicyPolicy ChangesChanges

ƒ Physician Supervision-Therapeutic Services 9 All nonphysician practitioners, specifically licensed clinical social worker, PA, NP, clinical nurse specialists, and nurse midwifes may directly supervise all hospital outpatient therapeutic services except PR, CR and ICR including in an off- campus Provider Based Department (PBD). 9 Direct supervision on hospital main campus • Supervising practitioner must be present on same campus • Must be available for immediate assistance • May also be in any other entity such as a physician’s office, SNF, etc. on campus

ƒ Physician Supervision-Diagnostic Services 9 For all diagnostic services, provided directly or under arrangement, whether provided in the main buildings of a hospital, in a PBD, or at a nonhospital location, the physician supervision requirements for individual tests listed in the MPFS Relative Value File are to be used 9 For services furnished directly or under arrangement at an off-campus PBD, direct supervision means the physician is present on the same campus

52 ReportingReporting QualityQuality DataData forfor AnnualAnnual PaymentPayment RateRate UpdatesUpdates ƒ Continue the 2.0 percent reduction in annual payment for hospitals that fail to meet the reporting requirements.

53 ReportingReporting QualityQuality DataData forfor AnnualAnnual PaymentPayment RateRate UpdatesUpdates ƒ Final data validation requirements for CY2010

9 For the CY 2011 payment determination, there will be the implementation of a validation program that will require hospitals to supply requested medical documentation to a CMS contractor for purposes of being validated • Random sample of 7,300 cases (20 cases per hospital) • Medical documentation will be requested from hospitals between April 1, 2009 and March 31, 2010. • Hospital to provide documentation within 45 days of receipt of request. • Medicare contractor to reabstract for the quality measures. • Failure to comply will result in 2.0 percent payment reduction

54 ReportingReporting QualityQuality DataData forfor AnnualAnnual PaymentPayment RateRate UpdatesUpdates

ƒ CY 2012 and beyond validation process has not been finalized ƒ Reconsideration and appeals process 9 Continue with 2009 reconsideration process: • Submit via QualityNet a “Reconsideration Request” form with all required information • CMS will provide a formal response to the hospital CEO notifying the hospital of the outcome of the reconsideration process • If hospital is dissatisfied with the response, the hospital can file a claim under 42 CFR Part 405, Subpart R (PRRB) ƒ No requirement in 2010 that ASCs report quality measurement data but will be addressed in a future rule-making. ƒ Urging hospitals to adopt Electronic Health Records (EHRs) to assist with data collection

55 HealthcareHealthcare--AssociatedAssociated ConditionsConditions

ƒ Hospital outpatient equivalent of hospital-acquired conditions in an inpatient setting 9 Extends Medicare concept of not paying more for preventable healthcare- associated conditions that occur as a result of care provided during an encounter

• Examples are medication errors, falls, etc.

9 Many public comments discussed in 2009 final rule. At this time, the principles behind IPPS HAS payment provisions are not expanding through a HOP-HAC program.

• Many operational challenges

• Will be addressed in a subsequent rule-making

56 HFMAHFMA’’ss RegulatoryRegulatory SoundSound BitesBites

An Overview of Proposed Healthcare Reforms Impacting Hospitals

Updated November 3, 2009 I. Drivers of Change ReadyReady forfor ChangeChange

Increased Levels of the Uninsured Coupled with Popular Support Make Action on Healthcare Reform Likely

Percentage Reporting That It Is Percentage of Uninsured Americans: “Important” or “Very Important” for the 2007 Compared to Estimated Current2,3 President to Accomplish1

17% 100% 93% ∆ +3.25% 90% 16% 88%

15%

14% 75% 2007 Current Improve Quality of Ensure Affordable Decrease the Care Care and Insurance Uninsured

Source: 1) DeNavas-Walt, C.B. Proctor, and J. Smith. Income, Poverty, and Health Insurance Coverage in the United States: 2007. U.S. Census Bureau., August 2008 2) Kaiser Family, Commission on the Uninsured, Rising Unemployment, Medicaid and the Uninsured, Jan 2009, http://www.kff.org/uninsured/upload/7850.pdf 3) Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.

58 I. Drivers of Change PushedPushed OutOut

Growth In Healthcare Insurance Costs Are Now Making Affordability Difficult for Individuals and Small Businesses

Cumulative Changes in Health Insurance Premiums, Inflation, and Workers’ Earnings, 1999-2008 140% 119% 120% 100% 80% 60% 40% 34%

20% 29% 0% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2000-2008. Health Insurance Premiums Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 2000-2008; Bureau of Labor Statistics, Seasonally Workers' Earnings Adjusted Data from the Current Employment Statistics Survey, 2000-2008 (April to Overall Inflation April).

59 I. Drivers of Change ExponentialExponential GrowthGrowth Already Unsustainable Healthcare Costs…

60 I. Drivers of Change BarriersBarriers toto AccessAccess

…Have Grown Faster Under a Universal Mandate, Endangering Gains in Insurance Coverage $12,000

1 $10,000 Average Per Capita Health Spending 1980 - 1990

March 26, 2008

$8,000 Massachusetts “Healthcare Cost Increases Mass. Budget – Controlling Them Said Key to Keeping $6,000 2 U.S. Universal Coverage ”

$4,000

$2,000

$0 1980 1985 1990 1995 2000 2005 2009 Coverage Mandate Effective July 1, 2007

Source: • Massachusetts Faces Costs of Big Health Care Plan; Sack, Kevin; The New York Times; March 16, 2009 • Healthcare Cost Increases Dominate Mass. Budget Debate; Dembner, Alice; The Boston Globe; March 26, 2008

61 I. Drivers of Change AA RoadRoad MapMap toto ReformReform Most of President Obama’s Ambitious Healthcare Goals Depend on Bending the Cost Curve

Causal Relationship Between the President’s Healthcare Goals

Catalyst Primary Secondary Tertiary Outcome Outcome Outcome Maintain Protect Families Coverage from Medical During Job Assure Bankruptcy Transitions Reduce Cost Affordable Growth Coverage Guarantee End Barriers for Choice of Docs Preexisting and Health Conditions Plans Invest in Improve Safety Prevention and and Patient Wellness Care

Source: 1) http://www.whitehouse.gov/issues/health_care/

62 I. DriversWhere Whereof Change thethe DollarsDollars AreAre Despite a Dramatic Decrease Over the Last 27 Years, Hospital Services Still Account for the Bulk of Health Expenditures

National Health Expenditure Comparison: 1980 to 2007

$233.4B $1,966.2B

(3)Other , 9.4% Other (3), 13.7% Nurs ing Home Care, 7.9% Nursing Home Care, 6.3% Other Medical Durables and Non-durables, 5.8% Other Medical Durables and Non-durables, 3.0% Prescription Drugs, 5.2% Prescription Drugs, 10.8% Home Health Care, 1.0% Other Professional(4) Home Health Care, 2.8% , 7.3% Other Professional (4) Physician Services, 20.2% , 7.5% Physician Services, 22.8%

Hospital Care, 43.3% Hos pital Care, 33.2%

Source: Centers for Medicare & Medicaid Services, Office of the Actuary. Data released January , 2009 (1) Excludes medical research and medical facilities1980 construction. 2007 (2) CMS completed a benchmark revision in 2006, introducing changes in methods, definitions and source data that are applied to the entire time series (back to 1960). For more information on this revision, see http://www.cms.hhs.gov/NationalHealthExpendData/downloads/benchmark.pdf. (3) “Other” includes net cost of insurance and administration, government public health activities, and other personal health care. (4) “Other professional” includes dental and other non-physician professional services.

63 I. Drivers of Change ConsciousConscious DecisionDecision oror Waste?Waste? The U.S. Healthcare System Overspends Compared to Other Developed Countries in Almost Every Major Category

2006 U.S. Healthcare Spending Compared with Average for Other Developed Countries Average Spending Above Average Spending

2,053 850

1,410 436 458

$ Billions 252

40 98 145 643 91 178 24 144 50 Costs Health Durables Spending Drugs and Drugs Home Care Home Nondurables Investment in in Investment Administrative Administrative Inpatient Care Inpatient Long-Term and Long-Term and Total Healthcare Outpatient Care* Outpatient

* Outpatient care includes physician and dentist offices, same-day visits to hospitals (including ED, ASC and imaging services), and other same day facilities

Source: Accounting for the Cost of U.S. Health Care: A New Look at Why Americans Spend More; McKinsey & Company; December 2008

64 II. Key Players AA CastCast ofof ThousandsThousands There Are a Number of Important Players Involved in Healthcare Reform

• The White House: • President Obama, Chief of Staff Rahm Emanuel, OMB Director Peter Orszag, and Director of Health Reform Nancy Ann DeParle

• U.S. House of Representatives (The “Tri-Committee”) • Ways and Means • Energy and Commerce • Education and Labor

• The U.S. Senate • Health, Education, Labor and Pensions (HELP91 Committee) • Finance (SFC)

• The Congressional Budget Office

• Industry Trade Groups

65 II. Key Players PresidentPresident ObamaObama WeighsWeighs InIn "Now Is When We Must Bring the Best Ideas of Both Parties Together, and Show the American People That Can Do What We Were Sent Here to Do.”

Insurance Market Reforms: •Ends discrimination based on preexisting conditions •Limits premium variance based on age and gender •Prevents coverage termination during episodes of illness •Caps out-of-pocket expenses, ends maximum annual or lifetime benefits

Provides Quality Affordable Choices: •Creates an insurance exchange for individuals and small businesses •Provides sliding scale tax credits to help purchase insurance •Offers small businesses tax credits for providing coverage •Creates a public option •Offers national “high risk” pool for those with preexisting91 conditions immediately

Funding Reform: •Uses savings in the health system and fees on industry components to pay for reform •Implements delivery system reforms to control cost and improve quality •Creates an independent commission of medical experts to eliminate fraud and waste •Orders immediate malpractice reform demonstration projects •Mandates insurance for businesses and individuals

Source: http://i.cdn.turner.com/cnn/2009/images/09/09/obama.plan.pdf

66 II. Key Players U.S.U.S. HouseHouse ofof RepresentativesRepresentatives A Vote on the House Bill Is Imminent

Status: •A manager’s amendment to the bill is expected this week (11/2). Debate will begin on 11/6 with a vote anticipated by 11/10.

Cost •The CBO estimates that it will cost $829B.

Coverage: •Provides coverage for an additional 36 million Americans.

Key Components: •Mandates for individuals and businesses with exemptions for small businesses •Graduated surtax on the wealthy to pay for expanded coverage91 •Creates a public insurance plan with negotiated rates •Funding to create not-for-profit insurance cooperatives •Expands eligibility for entitlement programs and provides assistance purchasing insurance •Guaranteed insurance issue with premium variation limited to 2:1 •Creates a federal insurance exchange and allows states to develop their own •Mandates insurance “administrative” simplification •Cuts payments to providers and encourages delivery system reform

67 II. Key Players TheThe U.S.U.S. SenateSenate The Senate Timeline Is Less Clear Status: • Negotiations continue to combine the Senate Finance Committee and Health, Education, Labor, and Pensions Committee bills. CBO scores are not anticipated until late this week (11/2) making floor action unlikely until after the Veteran’s Day holiday.

Cost • Unknown: Anticipated to be less than $900B

Coverage: • Unknown: Coverage anticipated to increase by 29M to 36M Americans

Key Components: • Mandates for individuals – how strong? • Employer responsibility – how much? 91 • Taxes issuers of “Cadillac” coverage – what constitutes a Caddy? • Public plan with state opt-out • Funding to establish cooperatives • Expands eligibility for entitlement programs and provides assistance purchasing insurance • Guaranteed insurance issue with limited premium variation – how much? • Creates insurance exchanges • Mandates insurance “administrative” simplification • Cuts payments to providers and encourages delivery system reform

68 III. Likely Reforms DecreasingDecreasing thethe UninsuredUninsured The House bill’s proposed insurance …would reduce the uninsured by an reforms… estimated 36 million.

Estimated Number of Uninsured Key Insurance Reforms Post-Reform

•Creation of Insurance Exchanges for the 60 54 Individual and Small Group Markets •Expansion of Medicaid for All to 150% FPL 40 •Provision of Sliding Scale Tax Credits Within ∆ -66% the Exchange from 151% to 400% FPL 18 •Mandates Insurance Coverage for Individuals 9120 •Penalizes Employers Who Don’t Provide Coverage 0 •Elimination of Exclusionary Insurance Practices (Millions) Uninsured Americans Current Proposed

69 III. Likely Reforms: Public Plan GoingGoing PublicPublic

As Structured in the House Bill, the Public Option Only Enrolls Six Million Americans

Analysis of Coverage Expansion Vehicles Key Components of Public Option Additional 36 Million Americans

Provided By Employer Exchange – •HHS Negotiates Rates with Providers 14% Commercial Payers •Will Adopt Medicare Payment System Reforms 36% •Not Required to Participate in Medicare •Offered Through the Exchange 36% •Provided with a Repayable Start-Up Loan Medicaid 14% •Must Survive on Premiums Collected

Public Option

70 I. Coverage Expansion PublicPublic CoCo--opsops Public Cooperatives Are Proposed to Bring Additional Competition to the Individual and Small Group Insurance Markets

Key Components of Co-op Plan

¾ Authorizes $5 billion in funding to assist with start-up costs and state solvency requirements • Priority given to statewide proposals and integrated care models • Have significant level of support from nongovernmental sources • Funds will be repayable over 10 years ¾ Provides funding for at least one co-op per state • Multiple awards per state will be allowed

71 III. Likely Reforms AA SmallerSmaller BasketBasket Changes5 to the Medicare Market Basket Update Will Reduce Spending over 10 Years by 3 Reducing the Update Factor and Adjusting for Productivity Gains

1 Reimbursement Impact of Update Factor Reduction* -1 Illustrative Example Based on SFC Bill: 450-Bed Hospital with $100M in Total Medicare Payments -3 -5 -7 -9 -11 $ Millions 91 -13 .25% Reduction .20% Reduction Factor + Factor Productivity Adj. -15 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Productivity adjustments Reduces payments by begin in 2012 ~$11M in year 10

*Productivity adjustments are incorporated into this example assuming the average aggregate decrease from 2012 to 2019 is one percentage point.

72 III. Likely Reforms ReducedReduced DSHDSH The House Bill Reduces Medicare and Medicaid DSH By $20.3 Billion

Anticipated Medicare DSH Reductions Based on House Bill

Medicare Medicaid

0 -3.0 -3.5 -3.8 -3 -1.5

$ Billions -2.5 -6 -4.5 -6.0 -6.0

-9 -9.8 -12 2017 2018 2019

73 II. Payment Reduction IndependentIndependent MedicareMedicare CommissionCommission (IMC)(IMC) The Senate Finance Bill Establishes a Committee Separate from MedPAC to Contain Cost Growth If Medicare Projected Growth Is Mandated Percentage Point Greater than CPI-M Reductions in Medicare Growth Rate

Due Date: Action:

Jan 1. IMC Submits Cost Reduction Proposal to Congress 2.00 Feb 1 MedPAC Presents Its Analysis of IMC Proposal 1.00

April 1 SFC and House Committees 0.00 Report Out Amended Proposal -0.5 -1 -1.00 -1.25 April 16 Chairman’s Mark Brought to -1.5 Senate Floor in 15 days -2.00 2015 2016 2017 2018 Aug 15 If Package Is Not Passed, Original Proposal Goes into Effect

Caveat: IMC recommendations will not apply to hospitals until 2019

74 III. Likely Reforms HealthcareHealthcare DeliveryDelivery SystemSystem ReformReform Both Bills Include Payment Reforms Aimed at Improving the Delivery System

Increase Healthcare “Value” 1. The Goal Improve Quality Reduce Costs Acquired Conditions Reduce Preventable Bundled Payments Accountable Care Reduce Hospital Readmissions Organizations Value-Based Purchasing

2. Tactics

3. Prerequisite Electronic Health Records

75 III. Likely Reforms EHREHR InfrastructureInfrastructure The Stimulus Package Lays the Groundwork for Healthcare System Reform by Providing Carrots and Sticks for Electronic Health Record Adoption

Small Carrot… …Big Stick Percentage of HIT Medicare Share Payments Percentage of Market Basket Update Received Based on When Eligible Received by Non-Adopters

Year 1 Year 2 Year 3 Year 4 100%

100% 75% 75% 75% 50% 50% 50%

25% 25% 25%

0% 0% 2010 - 2014 2015 2016 2015 2016 2017 1st Eligible in: 2013

76 III. Likely Reforms PayPay forfor PerformancePerformance A Value-Based Purchasing Program Would Reduce MS-DRG Payments Overall, But Provide “Bonuses” for High Quality Providers 3% MS-DRG Payment Reduction Under Senate Finance Committee Value-Based Purchasing Proposal

1%

-1% -1.00% -1.25% -1.50% -1.75% -2.00% -3% 2013 2014 2015 2016 2017 Withholds would continue at 2% of all MS-DRG payments after 2017

77 III. Likely Reforms ReducingReducing ReadmissionsReadmissions Almost twenty percent of Medicare patients …resulting in $15B in cost to the program… are readmitted within 30 days… 2005 Medicare Payments Related to Readmits

Unavoidable Readmits: Average Medicare 30-Day Readmission Rate $3B Potentially Avoidable Readmits: $12B

…leading the House to reduce payments for preventable readmissions beginning in FFY 2012.

Key Attributes of Proposed Readmit Policy Minimum Proposed Payment Withhold for All MS- DRGs Over the Threshold •Will begin with three conditions and be expanded in 2013 at the discretion of the HHS secretary -1% -1% •Payments reduced on all MS-DRG payments for -2% facilities with higher than average readmissions -3% -3% • Reduction will be the greater of a “readmission ratio” or a “floor amount” -5% -5% •Targeted hospitals will receive bonus payments to improve transitional care services -7% 2012 2013 2014 2015 and After

78 III. Likely Reforms CareCare CoordinationCoordination && CollaborationCollaboration The House Bill Creates a Pilot Program to Test Accountable Care Organizations’ Ability to Improve Quality and Reduce Cost

What Is an ACO1?

How Would the Incentives Work?

• Pilot will start by January 1, 2012

• Medicare beneficiaries assigned to an ACO • Not required to receive care there

• ACO reports quality measures

• Docs share savings generated if quality and cost guidelines met

Source: The Brookings Institute; Issue Brief: Accountable Care Organizations; March 2009

79 III. Likely Reforms GlobalGlobal PaymentsPayments The Legislation Will Include Expanded Bundled Payment Demonstration Projects Sample Inpatient Stay 1: Current Payment Methodology:

MS-DRG Pmt Physician Fee Home Health Readmission: Schedule (PFS) PPS Episode MS-DRG Pmt

- 3 Days Admit Discharge + 7 days + 14 days + 19 days+ 27 days + 30 days

30 Day Episode of Care

2: Proposed Bundled Payment System: MAC Payment

MS-DRG + PFS+ Avg. Medicare Negotiated Pmts PAC Cost – “Efficiencies” Provider – Readmissions

80 III. Likely Reforms ShiftingShifting RiskRisk Payment System Reforms Will Require Providers to Bear Greater Population-Based Financial Risk

Degree of Population Risk Transferred to Provider by Payment System

Low High Pay for Pay for Episodic Fee for Service Coordination Performance Payments Shared Savings Capitation

Paid for each unit of Additional per Payments tied to Payment based Shared savings Providers share service w/o constraint capita payment objective on delivery of from better care savings from on spending based on ability to measures of services within coordination better care manage care performance a given and disease coordination timeframe management and disease management Reform: Reform: Reform: -Value Based - Bundled Pmt -ACO’s Purchasing/ HAI -Readmit Policy

81 III. Likely Reforms TaxTax--ExemptExempt CriteriaCriteria Uneven provision of community benefit combined …has led the SFC to propose new with100% anticipated decreases in the uninsured… requirements for tax-exempt hospitals.

80% IRS 990 Survey : Allocation of Community Benefit Provided Additional Requirements for 60% Tax-Exempt Hospitals

40% 40% 1. Conduct a community health needs survey 91% and develop a plan to address needs 20% 60% 2. Adopt, implement, and widely publicize a 0% 9% financial assistance policy Total Hospital Total Community Benefit Provided Respondents 3. Bill patients who qualify for assistance no more than amount billed to insured patients Estimated Number of Uninsured Post-Reform 60 54 4. Use extraordinary collection methods only after a reasonable first attempt ∆ -66% 40 (Millions) 20 18 Uninsured Americans Current Proposed

0

82 III. Likely Reforms AdministrativeAdministrative SimplificationSimplification The House Bill Establishes Far-Reaching Goals for Reducing Administrative Costs

Key Guidelines for Administrative Simplification

•Unique with no conflicting or redundant standards •Permit no additions or constraints for electronic transactions, including companion guides •Require minimal augmentation by paper transactions or clarification by further communications •Enable the real-time determination of financial responsibility at the POS •Enable, where feasible, near real-time adjudication of claims •Facilitate timely acknowledgment, response, and status reporting applicable to any electronic transaction •Describe all data elements in unambiguous terms •Harmonize all common data elements across administrative and clinical transaction standards

83 III. Likely Reforms MalpracticeMalpractice ReformReform Full malpractice reform could reduce …causing the President to explore demonstration healthcare expenditures between 5% to projects proposed by the Bush Administration. 9%...

Total Cost of US Health Care Potential Malpractice Reform System ~$2 Trillion Demonstrations

Full Malpractice •Early disclosure of mistakes accompanied Reform Could Save 5% Upwards of $100B by a negotiated settlement 100% •Panel of medical experts certifies the merits of a case before it is brought to trial 75% •Mediated arbitration in place of lawsuits 95% 50%

25%

0% Sources: 1) Kessler, Daniel P. and McClellan, Mark B., “Do Doctors Practice Defensive Medicine?”, National Bureau of Economic Research Working Paper No. W5466, February 1996 2) http://www.washingtonpost.com/wp-dyn/content/article/2009/09/10/AR2009091001865.html 3) http://www.cbsnews.com/blogs/2009/09/14/politics/politicalhotsheet/entry5310795.shtml

84 III. Likely Reforms BigBig Cuts?Cuts? The SGR Formula Demands a 21% Payment Reduction to Achieve Target Spending…What Will Congress Do?

CY 2009 Conversion Factor Compared to Proposed CY 2010 $40.00

36.0666

-21.2%

$30.00 28.4205

$20.00 CY 2009 Proposed CY 2010

85 III. Likely Reforms ImagingImaging UtilizationUtilization Advanced Imaging Equipment Is Used More Than Is Assumed…the Final Physician Rule Phases in an Increase in Utilization Rate over Four Years

Equipment Utilization Rate for Advanced Imaging Services 100% 90%

75% + 80%

50% 50%

25%

0% Current Proposed

86 III. Likely Reforms: Implications ImplicationsImplications forfor HospitalsHospitals

Reform Brings Challenges and Opportunities for Providers

Challenges Opportunities •Coverage gains achieved through payers •Uninsured population decreases reimbursing less than cost •Greater demand for services •Population health risk shifted to hospitals •EHRs facilitate care coordination •Pay for performance expands •Payment for disease mgmt increases •Quality measures move from process-based •Administrative simplification reduces cost to outcome-based •Prohibitions on gain-sharing will be •Reimbursement shifts from volume to value relaxed •Tax-exempt status challenges •Physicians will be more open to •Increased physician integration required employment/collaboration

87 III. Likely Reforms: Implications ActionsActions forfor HospitalsHospitals

If Enacted, the Proposed Reforms Will Have a Significant Impact on How Hospitals Operate… Key Action Steps • Improve cash collections and revenue cycle operations

• Examine existing processes to identify those that should be re-engineered to take advantage of EHRs

• Evaluate performance on current quality measures and begin a campaign to improve them

• Work to understand the causes of “preventable” readmissions and develop an action plan to eliminate them

• Strive to continuously improve operating efficiency

• Develop a more integrated relationship with physicians

88 III. Likely Reforms: Implications ActionsActions forfor HospitalsHospitals

…and Plan for the Future

Key Action Steps • Develop the ability to effectively understand, price and manage population health risk

• Use scenario planning when making capital budgeting decisions

• Convene a high level work group to discuss how your organization’s business model will have to change if these proposals become law

89 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

ƒ For PT, OT, and Speech Therapy, payment is at 80% of the lesser of the actual charge or the applicable -fee schedule amount 9 “always therapy” HCPCS must be performed by a qualified therapist under a certified therapy plan of care 9 “sometimes therapy” HCPCS maybe performed by an individual outside of a certified therapy plan of care • To be paid under OPPS for “sometimes therapy” without a certified plan of care, do not append a GP, GO, or GN modifier and do not use a therapy revenue code: 42X, 43X, or 44X • See list of “Sometimes therapy” HCPCS on next page

90 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

91 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

ƒ Revisions to the Multiple Imaging Composite APCs 9 CPT 74261 (CT Colonography, diagnostic w/o contrast) and 74262 (CT Colonography, diagnostic, w/ contrast or w/o followed by w/contrast) added 9 CPT 0067T (CT Colonography diagnostic) deleted ƒ Kidney Disease Education (KDE) added as a covered for rural providers only 9 G0420 Individual Education, per session, per one hour 9 G0421 Group Education, per session, per one hour ƒ Brachytherapy sources to be paid prospectively in 2010 9 Bill the number of units of the appropriate source HCPCS C-code based on the number of sources in the strand and do not bill as one unit per strand.

92 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

93 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

94 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

ƒ “Hospitals are strongly encouraged to report charges for all drugs, biologicals, and radiopharmaceuticals regardless of whether the items are paid separately or packaged, using the correct HCPCS Codes” • CMS encourages but does not require Revenue Code 636 for all drugs billed with a HCPCS Code. ƒ RC 636 only required when the drug is paid separately

95 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

96 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

97 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

98 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

99 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

100 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

101 JanuaryJanuary 20102010 OPPSOPPS UpdateUpdate

ƒ When administering H1N1, bill the following: 9 CPT G9141 should be continue to be used for H1N1 administration even though CPT 90470 was created by the AMA in 2010 for the administration • 90470 is assigned SI=E in OPPS

102 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New codes in Audiology

Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 92540 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording

Tympanometry and reflex threshold 92550 measurements

Acoustic immittance testing, includes tympanometry (impedance testing), 92570 acoustic reflex threshold testing, and acoustic reflex decay testing

103 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Audiology

Caloric vestibular test, each irrigation (binaural, 92533 bithermal stimulation constitutes 4 tests) Caloric vestibular test, each irrigation (binaural, 92543 bithermal stimulation constitutes 4 tests), with recording 92568 Acoustic reflex testing, threshold

104 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Audiology

92569 Acoustic reflex testing; decay

105 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Cardiology

Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report 36147 Cardiology Interventional (includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)

Intravascular catheter-based coronary vessel or graft spectroscopy (eg, infrared) during diagnostic evaluation 0205T and/or therapeutic intervention including imaging Cardiology Interventional supervision, interpretation, and report, each vessel (List separately in addition to code for primary procedure)

106 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Cardiology INTENSIVE CARDIAC REHABILITATION; WITH G0422 OR WITHOUT CONTINUOUS ECG Cardiac Rehabilitation MONITORING WITH EXERCISE, PER SESSION INTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT CONTINUOUS ECG G0423 Cardiac Rehabilitation MONITORING; WITHOUT EXERCISE, PER SESSION Interrogation of ventricular assist device (VAD), in person, with physician analysis of device parameters (eg, drivelines, alarms, power surges), 93750 Cardiology review of device function (eg, flow and volume status, septum status, recovery), with programming, if performed, and report Algorithmic analysis, remote, of 0206T electrocardiographic-derived data with computer Cardiology probability assessment, including report

107 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Cardiology

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal 93279 Cardiology permanent programmed values with physician analysis, review and report; single lead pacemaker system Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal 93280 Cardiology permanent programmed values with physician analysis, review and report; dual lead pacemaker system Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal 93281 Cardiology permanent programmed values with physician analysis, review and report; multiple lead pacemaker system

108 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Cardiology

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal 93282 Cardiology permanent programmed values with physician analysis, review and report; single lead implantable cardioverter-defibrillator system Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal 93283 Cardiology permanent programmed values with physician analysis, review and report; dual lead implantable cardioverter-defibrillator system Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal 93284 Cardiology permanent programmed values with physician analysis, review and report; multiple lead implantable cardioverter-defibrillator system

109 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Cardiology

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal 93285 Cardiology permanent programmed values with physician analysis, review and report; implantable loop recorder system Peri-procedural device evaluation (in person) and programming of device system parameters before 93286 or after a surgery, procedure, or test with Cardiology physician analysis, review and report; single, dual, or multiple lead pacemaker system Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with 93287 Cardiology physician analysis, review and report; single, dual, or multiple lead implantable cardioverter- defibrillator system

110 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Cardiology

Insertion of a single transvenous electrode, 33216 Interventional Cardiology permanent pacemaker or cardioverter-defibrillator Insertion of 2 transvenous electrodes, permanent 33217 Interventional Cardiology pacemaker or cardioverter-defibrillator Repair of 2 transvenous electrodes for a dual 33220 chamber permanent pacemaker or dual chamber Interventional Cardiology pacing cardioverter-defibrillator Revision of skin pocket for cardioverter- 33223 Interventional Cardiology defibrillator Injection procedure during cardiac catheterization; for selective opacification of 93540 Interventional Cardiology aortocoronary venous bypass grafts, 1 or more coronary arteries

111 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Cardiology

TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; FOR Interventional G0392 MAINTENANCE OF HEMODIALYSIS Cardiology ACCESS, ARTERIOVENOUS FISTULA OR GRAFT; ARTERIAL

112 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Radiology

Computed tomographic (CT) colonography, 74261 diagnostic, including image postprocessing; CT without contrast material Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with 74262 CT contrast material(s) including non-contrast images, if performed Computed tomographic (CT) colonography, 74263 CT screening, including image postprocessing Computed tomography, heart, without contrast 75571 material, with quantitative evaluation of coronary CT calcium

113 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Radiology

Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 75572 3D image postprocessing, assessment of cardiac CT function, and evaluation of venous structures, if performed) Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image 75573 CT postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed) Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including 75574 CT evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)

114 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Radiology

Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional 36148 Interventional Radiology access for therapeutic intervention (List separately in addition to code for primary procedure) Removal of spinal neurostimulator electrode 63661 percutaneous array(s), including fluoroscopy, when Interventional Radiology performed Removal of spinal neurostimulator electrode 63662 plate/paddle(s) placed via laminotomy or laminectomy, Interventional Radiology including fluoroscopy, when performed

115 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Radiology Revision including replacement, when performed, of 63663 spinal neurostimulator electrode percutaneous array(s), Interventional Radiology including fluoroscopy, when performed Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed 63664 Interventional Radiology via laminotomy or laminectomy, including fluoroscopy, when performed Angiography, arteriovenous shunt (eg, dialysis patient fistula/graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary 75791 Interventional Radiology imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological supervision and interpretation

116 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Radiology

Cardiac magnetic resonance imaging for velocity flow 75565 mapping (List separately in addition to code for primary MRI procedure)

117 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Radiology Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or 78451 Nuclear Medicine gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or 78452 gated technique, additional quantification, when Nuclear Medicine performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction 78453 by first pass or gated technique, additional Nuclear Medicine quantification, when performed); single study, at rest or stress (exercise or pharmacologic)

118 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Radiology

Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional 78454 Nuclear Medicine quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection A9581 INJECTION, GADOXETATE DISODIUM, 1 ML Nuclear Medicine IODINE I-123 IOBENGUANE, DIAGNOSTIC, PER A9582 Nuclear Medicine STUDY DOSE, UP TO 15 MILLICURIES A9583 INJECTION, GADOFOSVESET TRISODIUM, 1 ML Nuclear Medicine SAMARIUM SM-153 LEXIDRONAM, THERAPEUTIC, A9604 Nuclear Medicine PER TREATMENT DOSE, UP TO 150 MILLICURIES

119 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Radiology

INJECTION, NON-RADIOACTIVE, NON-CONTRAST, Q9968 VISUALIZATION ADJUNCT (E.G., METHYLENE BLUE, Radiology ISOSULFAN BLUE), 1 MG

120 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Radiology Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate 36565 Interventional Radiology venous access sites; without subcutaneous port or pump (eg, Tesio type catheter)

Insertion of tunneled centrally inserted central venous 36566 access device, requiring 2 catheters via 2 separate Interventional Radiology venous access sites; with subcutaneous port(s) Repositioning of a naso- or oro-gastric feeding tube, 43761 Interventional Radiology through the duodenum for enteric nutrition Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, 72291 or sacral augmentation (sacroplasty), including cavity Interventional Radiology creation, per vertebral body or sacrum; under fluoroscopic guidance Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, 72292 or sacral augmentation (sacroplasty), including cavity Interventional Radiology creation, per vertebral body or sacrum; under CT guidance

121 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Radiology

Image guided pl acement, metallic localization clip, 19295 percutaneous, duri ng breast biopsy/aspiration (List Mammography separately in addition to code for primary procedure)

122 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Radiology

TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, A9500 Nuclear Medicine PER STUDY DOSE

123 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Radiology

Radiologic examination, nasal bones, complete, 70160 Radiology minimum of 3 views

124 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Radiology

Computed tomographic (CT) colonography (ie, 0066T CT virtual colonoscopy); screening Computed tomographic (CT) colonography (ie, 0067T CT virtual colonoscopy); diagnostic Computed tomography, heart, without contrast 0144T material, including image postprocessing and CT quantitative evaluation of coronary calcium

Computed tomography, heart, with contrast material(s), including noncontrast images, if 0145T CT performed, cardiac gating and 3D image postprocessing; cardiac structure and morphology

125 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Radiology

C om puted tom ography, heart, w ith contrast m aterial(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; com puted tom ographic 0146T CT angiography of coronary arteries (including native and anom alous coronary arteries, coronary bypass g ra fts ) , w ith o u t q u a n tita tiv e e v a lu a tio n o f c o r o n a r y c a lciu m C om puted tom ography, heart, w ith contrast m aterial(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; com puted tom ographic 0147T CT angiography of coronary arteries (including native and anom alous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary c a lciu m C om puted tom ography, heart, w ith contrast m aterial(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; cardiac structure and m orphology 0148T CT and com puted tom ographic angiography of coronary arteries (including native and anom alous c oron ary arteries, c o ro na ry b yp as s g ra fts), w itho ut quantitative evaluation of coronary calcium

126 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Radiology

Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image postprocessing; cardiac structure and morphology 0149T CT and computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium Computed tomography, heart, with contrast material(s), including noncontrast images, if 0150T performed, cardiac gating and 3D image CT postprocessing; cardiac structure and morphology in co ng enital heart disease Computed tomography, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image 0151T postprocessing, function evaluation (left and right CT ventricular function, ejection-fraction and segmental wall motion) (List separately in addition to code for primary procedure)

127 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Radiology

Introduction of needle or intracatheter; 36145 arteriovenous shunt created for dialysis (cannula, Interventional Radiology fistula, or graft) Angiography, arteriovenous shunt (eg, dialysis 75790 Interventional Radiology patient), radiological supervision and interpretation

128 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Radiology

Cardiac magnetic resonance imaging for 75558 morphology and function without contrast material; MRI with flow/velocity quantification Cardiac magnetic resonance imaging for 75560 morphology and function without contrast material; MRI with flow/velocity quantification and stress

Cardiac magnetic resonance imaging for morphology and function without contrast 75562 MRI material(s), followed by contrast material(s) and further sequences; with flow/velocity quantification Cardiac magnetic resonance imaging for morphology and function without contrast 75564 material(s), followed by contrast material(s) and MRI further sequences; with flow/velocity quantification and stress

129 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Radiology Myocardial perfusion imaging; (planar) single 78460 study, at rest or stress (exercise and/or Nuclear Medicine pharmacologic), with or without quantification Myocardial perfusion imaging; multiple studies (planar), at rest and/or stress (exercise and/or 78461 Nuclear Medicine pharmacologic), and redistribution and/or rest injection, with or without quantification Myocardial perfusion imaging; tomographic (SPECT), single study (including attenuation 78464 correction when performed), at rest or stress Nuclear Medicine (exercise and/or pharmacologic), with or without quantification Myocardial perfusion imaging; tomographic (SPECT), multiple studies (including attenuation 78465 correction when performed), at rest and/or stress Nuclear Medicine (exercise and/or pharmacologic) and redistribution and/or rest injection, with or without quantification

130 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Radiology

Myocardial perfusion study with wall motion, 78478 qualitative or quantitative study (List separately in Nuclear Medicine addition to code for primary procedure) Myocardial perfusion study with ejection fraction 78480 (List separately in addition to code for primary Nuclear Medicine procedure) SAMARIUM SM-153 LEXIDRONAMM, A9605 Nuclear Medicine THERAPEUTIC, PER 50 MILLICURIES C9246 INJECTION, GADOXETATE DISODIUM, PER ML Nuclear Medicine IOBENGUANE, I-123, DIAGNOSTIC, PER STUDY C9247 Nuclear Medicine DOSE, UP TO 10 MILLICURIES

131 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in ED/Clinics

Pneumococcal conjugate vaccine, 13 valent, for 90670 ED/Clinics intramuscular use

132 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in ED/Clinics

Respiratory syncytial virus, monoclonal antibody, 90378 Clinic recombinant, for intramuscular use, 50 mg, each Immunization administration (includes percutaneous, 90471 intradermal, subcutaneous, or intramuscular injections); Clinic 1 vaccine (single or combination vaccine/toxoid)

Immunization administration by intranasal or oral route; 90473 Clinic 1 vaccine (single or combination vaccine/toxoid) Pneumococcal conjugate vaccine, 7 valent, for 90669 Clinic intramuscular use Application of body cast, shoulder to hips; including 1 29044 ED thigh 29305 Application of hip spica cast; 1 leg ED Application of hip spica cast; 1 and one-half spica or 29325 ED both legs

133 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Endoscopy Bronchoscopy, rigid or flexible, including fluoroscopic 31626 guidance, when performed; with placement of fiducial Endoscopy markers, single or multiple Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with computer-assisted, 31627 Endoscopy image-guided navigation (List separately in addition to code for primary procedure[s])

134 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Endoscopy

Bronchoscopy, rigid or flexible, including fluoroscopic 31622 guidance, when performed; diagnostic, with cell Endoscopy washing, when performed (separate procedure) Bronchoscopy, rigid or flexible, including fluoroscopic 31623 guidance, when performed; with brushing or protected Endoscopy brushings Bronchoscopy, rigid or flexible, including fluoroscopic 31624 guidance, when performed; with bronchial alveolar Endoscopy lavage Bronchoscopy, rigid or flexible, including fluoroscopic 31625 guidance, when performed; with bronchial or Endoscopy endobronchial biopsy(s), single or multiple sites Bronchoscopy, rigid or flexible, including fluoroscopic 31628 guidance, when performed; with transbronchial lung Endoscopy biopsy(s), single lobe Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle 31629 Endoscopy aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)

135 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Endoscopy

Bronchoscopy, rigid or flexible, including fluoroscopic 31630 guidance, when performed; with tracheal/bronchial Endoscopy dilation or closed reduction of fracture Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of tracheal 31631 Endoscopy stent(s) (includes tracheal/bronchial dilation as required) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung 31632 Endoscopy biopsy(s), each additional lobe (List separately in addition to code for primary procedure)

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle 31633 Endoscopy aspiration biopsy(s), each additional lobe (List separately in addition to code for primary procedure) Bronchoscopy, rigid or flexible, including fluoroscopic 31635 guidance, when performed; with removal of foreign Endoscopy body Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of bronchial 31636 Endoscopy stent(s) (includes tracheal/bronchial dilation as required), initial bronchus

136 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Endoscopy

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; each additional major 31637 Endoscopy bronchus stented (List separately in addition to code for primary procedure) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with revision of tracheal or 31638 Endoscopy bronchial stent inserted at previous session (includes tracheal/bronchial dilation as required)

Bronchoscopy, rigid or flexible, including fluoroscopic 31640 Endoscopy guidance, when performed; with excision of tumor

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with destruction of tumor or 31641 Endoscopy relief of stenosis by any method other than excision (eg, laser therapy, cryotherapy)

Bronchoscopy, rigid or flexible, including fluoroscopic 31643 guidance, when performed; with placement of Endoscopy catheter(s) for intracavitary radioelement application

137 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Endoscopy

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration 31645 Endoscopy of tracheobronchial tree, initial (eg, drainage of lung abscess) Bronchoscopy, rigid or flexible, including fluoroscopic 31646 guidance, when performed; with therapeutic aspiration Endoscopy of tracheobronchial tree, subsequent

Bronchoscopy, rigid or flexible, including fluoroscopic 31656 guidance, when performed; with injection of contrast Endoscopy material for segmental bronchography (fiberscope only)

138 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Kidney Disease Education

FACE-TO-FACE EDUCATIONAL SERVICES RELATED G0420 TO THE CARE OF CHRONIC KIDNEY DISEASE; Kidney Disease Education INDIVIDUAL, PER SESSION, PER ONE HOUR

FACE-TO-FACE EDUCATIONAL SERVICES RELATED G0421 TO THE CARE OF CHRONIC KIDNEY DISEASE; Kidney Disease Education GROUP, PER SESSION, PER ONE HOUR

139 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Laboratory 83987 pH; exhaled breath condensate Laboratory 84145 Procalcitonin (PCT) Laboratory Thromboxane metabolite(s), including thromboxane if 84431 Laboratory performed, urine 86305 Human epididymis protein 4 (HE4) Laboratory Cellular function assay involving stimulation (eg, 86352 mitogen or antigen) and detection of biomarker (eg, Laboratory ATP) 86780 Antibody; Treponema pallidum Laboratory Human leukocyte antigen (HLA) crossmatch, non- 86825 cytotoxic (eg, using flow cytometry); first serum sample Laboratory or dilution Human leukocyte antigen (HLA) crossmatch, non- cytotoxic (eg, using flow cytometry); each additional 86826 Laboratory serum sample or sample dilution (List separately in addition to primary procedure)

140 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Laboratory Culture, typing; identification by nucleic acid (DNA or 87150 RNA) probe, amplified probe technique, per culture or Labo ratory isolate, each org anism p robed Culture, typing; identification by nucleic acid sequencing 87153 method, each isolate (eg, sequencing of the 16S rRNA Labo ratory gene) Infectious agent detection by nucleic acid (DNA or 87493 RNA); Clostridium difficile, toxin gene(s), amplified Labo ratory probe technique Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic 88387 Labo ratory acid-based molecular studies); each tissue preparation (eg, a single lymph node) Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); in conjunction with a 88388 touch im print, intraoperative consultation, or frozen Labo ratory section, each tissue preparation (eg, a single lymph node) (List separately in addition to code for primary procedure) 88738 Hemoglobin (Hgb), quantitative, transcutaneous Labo ratory

141 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Laboratory

89398 Unlisted reproductive medicine laboratory procedure Laboratory

DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG G0430 CLASSES OTHER THAN CHROMATOGRAPHIC Laboratory METHOD, EACH PROCEDURE DRUG SCREEN, QUALITATIVE; SINGLE DRUG G0431 CLASS METHOD (E.G., IMMUNOASSAY, ENZYME Laboratory ASSAY), EACH DRUG CLASS

142 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Laboratory

Obstetric panel This panel must include the following: Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count 80055 (85007 or 85009) Hepatitis B surface antigen (HBsAg) Laboratory (87340) Antibody, rubella (86762) Syphilis test, non- treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592) Antibody screen, RBC, each serum technique (86850) Blood typing, ABO (86900) AND Blood typing, Rh (D) (86901)

82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed Laboratory Vitamin D; 1, 25 dihydroxy, includes fraction(s), if 82652 Laboratory performed

143 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Laboratory

Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, 82784 Laboratory each 82785 Gammaglobulin (immunoglobulin); IgE Laboratory Gammaglobulin (immunoglobulin); immunoglobulin 82787 Laboratory subclasses (eg, IgG1, 2, 3, or 4), each Glucose; tolerance test (GTT), 3 specimens (includes 82951 Laboratory glucose) Glucose; tolerance test, each additional beyond 3 82952 Laboratory specimens Immunoassay for analyte other than infectious agent 83516 antibody or infectious agent antigen; qualitative or Laboratory semiquantitative, multiple step method

144 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Laboratory

Immunoassay for analyte other than infectious agent 83518 antibody or infectious agent antigen; qualitative or Laboratory semiquantitative, single step method (eg, reagent strip) Immunoassay for analyte other than infectious agent 83519 antibody or infectious agent antigen; quantitative, by Laboratory radioimmunoassay (eg, RIA) Immunoassay for analyte other than infectious agent 83520 antibody or infectious agent antigen; quantitative, not Laboratory otherwise specified 83986 pH; body fluid, not otherwise specified Laboratory Blood count; reticulocytes, automated, including 1 or more cellular parameters (eg, reticulocyte hemoglobin 85046 content [CHr], immature reticulocyte fraction [IRF], Laboratory reticulocyte volume [MRV], RNA content), direct measurement 85240 Clotting; factor VIII (AHG), 1-stage Laboratory Syphilis test, non-treponemal antibody; qualitative (eg, 86592 Laboratory VDRL, RPR, ART) 86593 Syphilis test, non-treponemal antibody; quantitative Laboratory

145 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Laboratory Culture, typing; identification by nucleic acid (DNA or 87149 RNA) probe, direct probe technique, per culture or Laboratory isolate, each organism probed 88045 Necropsy (autopsy); coroner's call Laboratory Special stains; Group I for microorganisms (eg, Gridley, 88312 acid fast, methenamine silver), including interpretation Laboratory and report, each Special stains; Group II, all other (eg, iron, trichrome), 88313 except immunocytochemistry and immunoperoxidase Laboratory stains, including interpretation and report, each

Special stains; histochemical staining with frozen 88314 section(s), including interpretation and report (List Laboratory separately in addition to code for primary procedure) Pathology consultation during surgery; each additional 88332 Laboratory tissue block with frozen section(s)

146 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Laboratory 82307 Calciferol (Vitamin D) Laboratory Anti body; Treponema pall idum, conf irmatory test 86781 Laboratory (eg, FTA-abs)

147 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Neurology

Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and 95905 Neurology latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report

148 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Neurology Needle electromyography; 1 extremity with or without 95860 Neurology related paraspinal areas Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or 95870 Neurology bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters

Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), 95921 including 2 or more of the following: heart rate response Neurology to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: 95923 quantitative sudomotor axon reflex test (QSART), Neurology silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential Neuromuscular junction testing (repetitive stimulation, 95937 Neurology paired stimuli), each nerve, any 1 method

149 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Pain Management Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 64490 Pain Management innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 64491 innervating that joint) with image guidance (fluoroscopy Pain Management or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy 64492 Pain Management or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

150 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Pain Management Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 64493 Pain Management innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 64494 innervating that joint) with image guidance (fluoroscopy Pain Management or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy 64495 Pain Management or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

151 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Pain Management

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or 77003 therapeutic injection procedures (epidural, Pain Management transforaminal epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction

152 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Pharmacy C9254 INJECTION, LACOSAMIDE, 1 MG Pharmacy C9255 INJECTION, PALIPERIDONE PALMITATE, 1 MG Pharmacy INJECTION, DEXAMETHASONE INTRAVITREAL C9256 Pharmacy IMPLANT, 0.1 MG C9257 INJECTION, BEVACIZUMAB, 0.25 MG Pharmacy J0461 INJECTION, ATROPINE SULFATE, 0.01 MG Pharmacy INJECTION, PENICILLIN G BENZATHINE AND J0559 Pharmacy PENICILLIN G PROCAINE, 2500 UNITS J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS Pharmacy INJECTION, C1 ESTERASE INHIBITOR (HUMAN), 10 J0598 Pharmacy UNITS J0718 INJECTION, CERTOLIZUMAB PEGOL, 1 MG Pharmacy INJECTION, COSYNTROPIN, NOT OTHERWISE J0833 Pharmacy SPECIFIED, 0.25 MG J0834 INJECTION, COSYNTROPIN (CORTROSYN), 0.25 MG Pharmacy

153 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Pharmacy

INJECTION, HUMAN FIBRINOGEN CONCENTRATE, J1680 Pharmacy 100 MG J2562 INJECTION, PLERIXAFOR, 1 MG Pharmacy J2793 INJECTION, RILONACEPT, 1 MG Pharmacy J2796 INJECTION, ROMIPLOSTIM, 10 MICROGRAMS Pharmacy INJECTION, FACTOR VIII (ANTIHEMOPHILIC J7185 Pharmacy FACTOR, RECOMBINANT) (XYNTHA), PER I.U. HYALURONAN OR DERIVATIVE, SYNVISC OR J7325 SYNVISC-ONE, FOR INTRA-ARTICULAR INJECTION, Pharmacy 1 MG J9155 INJECTION, DEGARELIX, 1 MG Pharmacy J9171 INJECTION, DOCETAXEL, 1 MG Pharmacy

154 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Pharmacy

J9328 INJECTION, TEMOZOLOMIDE, 1 MG Pharmacy INJECTION, FERUMOXYTOL, FOR TREATMENT OF Q0138 Pharmacy IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE) INJECTION, FERUMOXYTOL, FOR TREATMENT OF Q0139 IRON DEFICIENCY ANEMIA, 1 MG (FOR ESRD ON Pharmacy DIALYSIS)

155 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Pharmacy

INJECTION, ONABOTULINUMTOXINA, 1 J0585 Pharmacy UNIT

INJECTION, RIMABOTULINUMTOXINB, 100 J0587 Pharmacy UNITS

FACTOR VIII (ANTIHEMOPHILIC FACTOR, J7192 RECOMBINANT) PER I.U., NOT OTHERWISE Pharmacy SPECIFIED

INJECTION, FOSPHENYTOIN, 50 MG Q2009 Pharmacy PHENYTOIN EQUIVALENT

156 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Pharmacy A9535 INJECTION, METHYLENE BLUE, 1 ML Pharmacy C9245 INJECTION, ROMIPLOSTIM, 10 MCG Pharmacy C9249 INJECTION, CERTOLIZUMAB PEGOL, 1 MG Pharmacy INJECTION, C1 ESTERASE INHIBITOR C9251 Pharmacy (HUMAN), 10 UNITS C9252 INJECTION, PLERIXAFOR, 1 MG Pharmacy C9253 INJECTION, TEMOZOLOMIDE, 1 MG Pharmacy INJECTION, ATROPINE SULFATE, UP TO 0.3 J0460 Pharmacy MG INJECTION, PENICILLIN G BENZATHINE AND J0530 PENICILLIN G PROCAINE, UP TO 600,000 Pharmacy UNITS INJECTION, PENICILLIN G BENZATHINE AND J0540 PENICILLIN G PROCAINE, UP TO 1,200,000 Pharmacy UNITS

157 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Deleted Codes in Pharmacy INJECTION, PENICILLIN G BENZATHINE AND J0550 PENICILLIN G PROCAINE, UP TO 2,400,000 Pharmacy UNITS J0835 INJECTION, COSYNTROPIN, PER 0.25 MG Pharmacy INJECTION, RESPIRATORY SYNCYTIAL VIRUS J1565 Pharmacy IMMUNE GLOBULIN, INTRAVENOUS, 50 MG

HYALURONAN OR DERIVATIVE, SYNVISC, FOR J7322 Pharmacy INTRA-ARTICULAR INJECTION, PER DOSE J9170 INJECTION, DOCETAXEL, 20 MG Pharmacy INJECTION, FACTOR VIII (ANTIHEMOPHILIC Q2023 Pharmacy FACTOR, RECOMBINANT) (XYNTHA), PER I.U. Q2024 INJECTION, BEVACIZUMAB, 0.25 MG Pharmacy

158 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Rehab

ADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, CONCENTRIC ADJUSTABLE TORSION L2861 Rehabilitation STYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, EACH ADDITION TO UPPER EXTREMITY JOINT, WRIST OR ELBOW, CONCENTRIC ADJUSTABLE TORSION L3891 Rehabilitation STYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, EACH

PULMONARY REHABILITATION, INCLUDING G0424 EXERCISE (INCLUDES MONITORING), ONE HOUR, Pulmonary Rehabilitation PER SESSION, UP TO TWO SESSIONS PER DAY

159 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Rehab Application of a modality to 1 or more areas; electrical 97032 Rehabilitation stimulation (manual), each 15 minutes Application of a modality to 1 or more areas; 97033 Rehabilitation iontophoresis, each 15 minutes Application of a modality to 1 or more areas; contrast 97034 Rehabilitation baths, each 15 minutes Application of a modality to 1 or more areas; 97035 Rehabilitation ultrasound, each 15 minutes Application of a modality to 1 or more areas; Hubbard 97036 Rehabilitation tank, each 15 minutes Therapeutic procedure, 1 or more areas, each 15 97110 minutes; therapeutic exercises to develop strength and Rehabilitation endurance, range of motion and flexibility Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, 97112 balance, coordination, kinesthetic sense, posture, Rehabilitation and/or proprioception for sitting and/or standing activities

160 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Rehab

Therapeutic procedure, 1 or more areas, each 15 97113 Rehabilitation minutes; aquatic therapy with therapeutic exercises Therapeutic procedure, 1 or more areas, each 15 97116 Rehabilitation minutes; gait training (includes stair climbing) Therapeutic procedure, 1 or more areas, each 15 97124 minutes; massage, including effleurage, petrissage Rehabilitation and/or tapotement (stroking, compression, percussion) Manual therapy techniques (eg, mobilization/ 97140 manipulation, manual lymphatic drainage, manual Rehabilitation tracti on), 1 or more regions, each 15 minutes

161 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Radiation Therapy Placement of interstitial device(s) for radiation therapy 32553 guidance (eg, fiducial markers, dosimeter), Radiation Therapy percutaneous, intra-thoracic, single or multiple Multi-leaf collimator (MLC) device(s) for intensity 77338 modulated radiation therapy (IMRT), design and Radiation Therapy construction per IMRT plan Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 0197T Radiation Therapy 3D positional tracking, gating, 3D surface tracking), each fraction of treatment

162 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Radiation Therapy

PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY/SURGERY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), FOR OTHER C9728 THAN THE FOLLOWING SITES (ANY APPROACH): Radiation Therapy ABDOMEN, PELVIS, PROSTATE, RETROPERITONEUM, THORAX, SINGLE OR MULTIPLE

163 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Respiratory Therapy

Measurement of spirometric forced expiratory flows in 94011 Respiratory Therapy an infant or child through 2 years of age Measurement of spirometric forced expiratory flows, 94012 before and after bronchodilator, in an infant or child Respiratory Therapy through 2 years of age Measurement of lung volumes (ie, functional residual capacity [FRC], forced vital capacity [FVC], and 94013 Respiratory Therapy expiratory reserve volume [ERV]) in an infant or child through 2 years of age

164 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ New Codes in Sleep Lab

Sleep study, unattended, simultaneous recording; heart 0203T rate, oxygen saturation, respiratory analysis (eg, by Sleep Lab airflow or peripheral arterial tone) and sleep time Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and 0204T Sleep Lab respiratory analysis (eg, by airflow or peripheral arterial tone)

165 SummarySummary ofof 20102010 CPTCPT CodeCode ChangesChanges

ƒ Revised Codes in Sleep Lab

Sleep study, unattended, simultaneous recording of, 95806 heart rate, oxygen saturation, respiratory airflow, and Sleep Lab respiratory effort (eg, thoracoabdominal movement)

166 MaintenanceMaintenance ofof thethe ChargeCharge MasterMaster

Keeping the charge master up-to-date is a major challenge for any healthcare organization with many internal and external factors impacting the charge master.

Routine Additions Changing ofÊNew Payor LineÊItems Regulations

Annual CPT/HCPCS Charge Code Productivity Changes Statistic Master Changes

New Programs Service Starting at the Pricing Hospital Changes

167 MaintenanceMaintenance ofof thethe ChargeCharge MasterMaster

Key Factors in Successful Maintenance ƒ Formal comprehensive internal review each year — process led by the top (i.e., CFO initiated) ƒ Charge master coordinator assigned to lead the day-to-day maintenance tasks ƒ Involvement of the clinical department staff in the process ƒ Formation of a multidisciplinary approach: clinical department, finance, patient financial services, decision support, health information management, compliance, managed care contracting and information systems ƒ Official sign-off process for revisions, additions, and inactivations ƒ Charge master analysis performed by an external vendor every four-to-five years

Some computer software has been developed in recent years to assist in charge master maintenance with wide ranging capabilities — NO SOFTWARE PACKAGE CAN DO THE COMPLETE JOB ON ITS OWN!

168 MaintenanceMaintenance ofof thethe ChargeCharge MasterMaster

Charge master software tools ƒ Identify CPT Code additions, revisions, deletions ƒ Primarily Medicare focused ƒ “Tool only as good as the carpenter” ƒ Use of a tool does not eliminate the need to meet with the departments ƒ Major software vendors include: MedAssets, Craneware, 3M, Code Correct, IHS, and others ƒ Know all associated costs of using a tool-both external and internal ƒ Check references

169 MaintenanceMaintenance ofof thethe ChargeCharge MasterMaster

Throughout the year new charges will be added to the charge master.

Key Factors to Consider: ƒ Establish new charges based upon the costs to provide the service ƒ Consider market sensitivity to the price for the new item ƒ Develop a form to be used by the clinical department to request a new charge ƒ Establish a formal approval process ƒ Make additions in a timely manner!!!

170 PricingPricing ofof ServicesServices

ƒ What is pricing based on? -Cost -Market rates -across the board increases ƒ Are supplies and drug charges based on cost or other factors such as ASP? ƒ How does pricing affect payments from managed care payors? -Lower of fee schedule or charges? -Implantables/high cost drugs based on accurate cost? ƒ Has a strategic pricing study been performed at your hospital? ƒ Are your rates defensible and “patient friendly”? ƒ Do outside constituents such as unions, employers, state hospital association have access to your charges?

171 ManagedManaged CareCare ContractContract BasicsBasics

ƒ What are my 3-5 largest non-governmental payors? 9 How is each contract paid? • Inpatient versus outpatient • Major OP departments: charge-based/ fee schedule ƒ Obtain rate sheets for the top 3-5 payors ƒ Review contract terms/ provider manuals/ remittance advices, etc. ƒ If contracts base payments on revenue codes, are the revenue codes in the CDM correct and appearing on the claims accurately? 9 Revenue Code 350 vs. 351, 352, etc. 9 Revenue Code 636 vs. 250, 259, 637, etc. ƒ If reimbursement is fee schedule driven, is there a lower of fee schedule or charge provision? 9 Are surgical procedures paid correctly? For second surgical procedure, is a token $1.00 charge used? ƒ Review 5-10 claims for various IP and OP services for each major payor-EVEN IF YOU HAVE A MANAGED CARE CONTRACTING SYSTEM 9 Compare claim to remittance advice to contract

172 ChargeCharge MasterMaster AssessmentAssessment ProcessProcess

ƒ Charge master does not stand alone-look at all the systems that interface with the CDM -Order entry -Radiology. Laboratory Information System, etc. -Bill Scrubbers ƒ Is the charge master set up to optimize payments to payors other than Medicare? ƒ Are we paid and are we paid correctly for the services provided? ƒ Assessment should include the following key components -Review of CDM, revenue and usage, and Medicare and managed care payor contacts and fee schedules -Interviews with Department, HIM, PFS and IT -Charge capture process walk-through -Claims review including itemized bill, UB, medical record and remittance advice -Quantification of opportunities -Review of opportunities with the department -Implementation assistance and follow-up/tracking

173 LaboratoryLaboratory –– MajorMajor IssuesIssues ToTo AddressAddress

9 Procedures • A venipuncture charge should be captured for blood specimens received by the Laboratory. ƒ Can be charged one time per patient encounter – should not be charged for each vial of blood collected ƒ Effective January 1, 2005 HCPCS code G0001 should no longer be reported for venipuncture. Instead Hospitals should report 36415 – Collection of venous blood by venipuncture and 36416 – Collection of capillary blood (eg, finger, heal, ear stick) • Does the microbiology section of the charge master have all the necessary types of charges? ƒ Cultures (CPT Codes 87040, 87045 – 87046, 87070 – 87073, 87086 – 87088) ƒ Identifications (87077) ƒ Sensitivity (87184, 87186) • Use of modifier – 91 (Repeat Clinical Diagnostic Laboratory Test) – append to second laboratory test that is repeated by order of a physician for medically necessary reasons. • Pathology and cytology CPT Codes 88000 - 88399. ƒ Use UB-04 Revenue Code 31X ƒ Surgical pathology levels (CPT Codes 88300 – 88309) assigned according to specimen type ƒ Charge decalcification (88311) and any special stains (88312 – 88314) separately

174 LaboratoryLaboratory –– MajorMajor IssuesIssues ToTo AddressAddress

• Is screening vs. diagnostic tests (e.g. pap smears) broken out separately on the charge master • Report CPT Code according to methodology used (e.g., thin prep vs. smear)

ƒ P3000 – Screening, Smear

ƒ G0123 – Screening, Thin Prep

ƒ 88164 – 88167, Diagnostic, Smear

ƒ 88142 – 88143, Diagnostic, Thin Prep

• Review Medicare’s National Coverage Decision’s (NCDs) and any Local Medical Review Policies (LMRPs).

• Is the Laboratory Information System (LIS) up-to-date and mapped correctly to the charge master?

• Does the charge master have a large number of miscellaneous CPT codes in it?

• Coding of constituents vs. methodology

• What is the frequency of the charge master changes being requested by the Laboratory?

9 Supplies

• Not applicable in this department.

9 Pharmaceuticals

• Not applicable in this department.

175 BloodBlood BankBank –– MajorMajor IssuesIssues ToTo AddressAddress

9 Procedures ƒ Typing “ABO & RH (D)” (86900, 86901) should be high volume ƒ Crossmatch (86920 – 86923) – One charge for each unit of blood crossmatched. Crossmatches should exceed units of blood ƒ Antibody Screen (86850)-once per cross match ƒ One blood administration charge (36430) no matter how many units of blood transfused

176 BloodBlood BankBank –– MajorMajor IssuesIssues ToTo AddressAddress

9 Blood Products • What blood product charges are on your charge master (e.g. P9010, P9016, P9023)? • Blood product HCPCS coding: See 2010 Federal Register Addendum B. Also verify that the appropriate number of units for blood product charges are passing correctly to the bill. • Revenue and Usage should show high numbers of packed cells used • More than one alternative for packed cells HCPCS codes should be on the charge master 9 Clinical System Interface • Is there a separate blood bank software system? How is it linked to the billing systems? Is the mapping interface synchronized appropriately? • If charge slips are used, how they accurate and up-to-date?.

177 EmergencyEmergency RoomRoom –– MajorMajor IssuesIssues ToTo AddressAddress

ƒ E& M Levels 9 Do you have 6 levels (99281 through 99285, Plus Critical Care – 99291)? 9 What Revenue Codes are used? 9 Do we charge for triage only visits? 9 Do we charge for patient return visits for suture removal? 9 Does the distribution of OP visits look “bell-shaped”? • If not, why not? You need to investigate this 9 If you are providing trauma services, do you use the trauma activation charges? 9 Compare your visit levels to the number of visits that the physicians are billing? Do they match?

178 EmergencyEmergency RoomRoom –– MajorMajor IssuesIssues ToTo AddressAddress

ƒ Procedures 9 Surgical Procedures • How are surgical procedures captured at your hospital? ƒ Individual charge master line items ƒ Generic surgical charge with HIM coding ƒ HIM coding and charge capture • Ask HIM, if they are doing the coding if injections and immunizations are considered surgical procedure. • What percentage of OP visits have a surgical procedure? ƒ Good benchmark is at least 15% ƒ If there are not a high volume of laceration repairs, why not?

179 EmergencyEmergency RoomRoom –– MajorMajor IssuesIssues ToTo AddressAddress ƒ Procedures 9 Injections, Infusions and Immunizations? • Does your charge master have line items for injections, immunizations and infusions (including blood administration)? • Who captures the charges? ER or HIM? Are they trained? • Are the pushes the highest volumes? What is the volume of infusions? • Are tetanus immunizations high volume? • 15% of the visit should have an injection or infusions

180 EmergencyEmergency RoomRoom –– MajorMajor IssuesIssues ToTo AddressAddress ƒ Procedures 9 Clinical Laboratory Tests • Does your charge master have a line item for? Is there volume? Who captures the charges? Are Laboratory Revenue Codes (30X) used? ƒ Blood Glucose (CPT Code 82948) ƒ Urine Dips (CPT Code 81002) ƒ Occult Blood Tests (CPT Codes 82270, 82271, 82272) ƒ Venipuncture (CPT Code 36415) ƒ Rapid Strep (CPT Code 87880)

181 EmergencyEmergency RoomRoom –– MajorMajor IssuesIssues ToTo AddressAddress ƒ Procedures 9 Other Non-Surgical Procedures • Does your charge master have line items for? What are the volumes? Who captures the charges? Are the correct Revenue Codes used? ƒ Pulse Oximetry (CPT Codes 94760, 94761) ƒ Aerosol Treatments (CPT Code 94640) ƒ EKGs (CPT Code 93005) ƒ Portable Ultrasound

182 PrimerPrimer onon InjectionsInjections andand InfusionsInfusions

ƒ Review the Medicare instructions on CPT coding and billing of injections and infusions 9 In “gray areas”, the FI may have clarifying instructions ƒ Use the hierarchy of injection and infusion coding detailed in the CPT Manual ƒ Initial code should be selected using the following hierarchy: 9 Chemotherapy services (96401-96549) are primary to: 9 Therapeutic, prophylactic, and diagnostic services (96365-96379) which are primary to: 9 Hydration services (96360, 96361) 9 Additionally, infusions (96365-96371) are primary to pushes (96374, 96375, 96376) which are primary to injections (96372, 96373)

183 PrimerPrimer onon InjectionsInjections andand InfusionsInfusions

ƒ Only one initial code should be selected unless protocol requires two separate IV sites be used. ƒ Initial code that best describes the primary reason for the encounter should be used ƒ If an injection or infusion is either subsequent or concurrent, even if it is the first such service in a group of services, the “subsequent” code should be used 9 First IV push subsequent to an IV infusion should use CPT Code 96375 or 96376- subsequent push ƒ Hydration codes are for infusion of pre-packaged fluid and electrolytes but not for infusion of drugs ƒ When fluids used to infuse a drug, the hydration is not separately billable

184 EmergencyEmergency RoomRoom –– MajorMajor IssuesIssues ToTo AddressAddress

ƒ Supplies 9 Does your charge master have line items for supplies? How are the prices in comparison to other areas of the Hospital for the same supply? 9 If yes, are they assigned the appropriate revenue codes (e.g. 27X) 9 Is your hospital’s policy to bundle supply charges into the visit or procedure charge? If yes, does the prices accurately reflect costs. 9 If Pyxis is used, what is billed through Pyxis and what is not billed through Pyxis? 9 How are crutches, canes, DME handled?

185 EmergencyEmergency RoomRoom –– MajorMajor IssuesIssues ToTo AddressAddress

ƒ Pharmaceuticals • Does your charge master have separate charges for drugs? If yes, are they coded with the necessary HCPCS (e.g. J and Q) codes and revenue codes (e.g. 636) • How are take home drugs handled? • How are self-administerable drugs handled? • Is Pyxis used to capture the charges? Are all drugs billed through Pyxis? ƒ Clinical System Interface • Is a clinical system used to capture charges? Were the interfaces mapped correctly? • If a charge slip is used to capture charges, is it complete? Do nurses write in lots of items manually? When was the charge slip last verified for accuracy?

186 SuppliesSupplies –– MajorMajor IssuesIssues ToTo AddressAddress

ƒ No clear guidelines for what is patient chargeable – “community standard” 9 Research the specific regulations that your FI has published

ƒ The Hospital should establish it’s own criteria for supply charging if specific FI guidance does not exist. Consider the following as in crafting the non-chargeable policy: 9 Routine items used on every case (e.g., drapes, gowns, gloves) 9 Non-patient specific supplies 9 Reusable Equipment

187 SuppliesSupplies –– MajorMajor IssuesIssues ToTo AddressAddress

ƒ Consider putting in place a policy for having a cost threshold for establishing a supply charge: 9 e.g., Any item having a cost less then $5 will not be charged for

ƒ Important specific UB-04 Revenue codes for supplies: 9 270 – General 9 272 – Sterile Supply 9 274 – Prosthetic/Orthotic Device (not reportable for Medicare Outpatients under OPPS) 9 275 – Pacemaker 9 276 – Intraocular Lens (IOL) 9 278 – Other Implants

188 SuppliesSupplies –– MajorMajor IssuesIssues ToTo AddressAddress

ƒ For CY 2010 Medicare will continue editing claims for selected “Device – Dependent” APCs. Claims will be returned for correction is C Code is not present. ƒ Review your contracts with other payors regarding C Code requirements.

ƒ Be sure that you are charging for high cost supplies in the following areas: • Operating Room (e.g., stents, catheters, implants) • Cardiology (e.g., stents, catheters, guidewires, pacemakers and leads) • Radiology (e.g., stents, catheters and guidewires)

ƒ Look for specific coding requirements in your payor contracts for “carve outs.”

189 OncologyOncology –– MajorMajor IssuesIssues ToTo AddressAddress 9 Visits • Are visit levels available for use? How are they used? Do they correctly apply the “new” and “established” patient criteria? • Does the distribution of visit levels make sense? • Does the clinic have clear criteria for the nursing staff to select the visit level charges? • Is a visit level charged each time there is a chemotherapy administration? (If yes, you have a compliance issue)

190 OncologyOncology –– MajorMajor IssuesIssues ToTo AddressAddress • Does your charge master have all the necessary chemotherapy infusion and injection charges? ƒ 2010 CPT Codes should be used for outpatient infusion services (96409, 96411, 96413, and 96415 for Chemo IV Push Technique and 96360-96368 for IV Infusion Technique) Are the correct Revenue Codes used? ƒ Does the nursing staff have clear criteria for selecting the appropriate charges? Refer to Transmittal 902, dated April, 7 2006 – Subject: Hospital Outpatient Prospective Payment System (OPPS) Manual Revision: Clarification of Coding and Payment for Drug Administration. ƒ Does the nursing staff or HIM understand the hierarchy of coding injections and infusions? ƒ Does the distribution make sense? Are there lots of infusions? ƒ How are routine flushing of ports handled?

191 OncologyOncology –– CDMCDM AnalysisAnalysis CheckCheck ListList 9 Chemotherapy Drugs (Very Expensive) • Do the charge master line items have the necessary HCPCS codes assigned (e.g. HCPCS Codes J9000 though J9999)? Use Addendum B line items with SI=G or K to verify accuracy of CDM. • Are anti-emetics set up with the correct HCPCS codes and billed correctly? • Have you reviewed the coding requirements of your other payors for chemotherapy drugs? • Analyze a claims sample to verify that drug charges are passing correctly to the patients bill. Make sure the rounding rules are applied correctly. You should receive a list of the top 10 used drugs ( by volume) and analyze. Data required for this analysis would include: ƒ Current charge master ƒ Final UB Claim ƒ Hospital Detailed Bill ƒ Associated Medical Documentation ƒ Remittance Advice

192 OncologyOncology –– CDMCDM AnalysisAnalysis CheckCheck ListList

9 Clinical System Interfaces • Are the procedure and visit charges captured in the a clinical system? Is the system mapped correctly to the billing system? How about drugs? If Pyxis is used, is it mapped correctly to the billing system? If a “units” conversion table is used, do the conversions work correctly in the billing system? • If a charge slip is used, is it comprehensive? Are items regularly written in by Nursing? Is the slip accurate and user friendly?

193 InterventionalInterventional RadiologyRadiology--MajorMajor IssuesIssues ToTo AddressAddress 9 Angiography Procedures • Does your charge master list every imaging (CPT 75XXX) and surgical component (CPT 36XXX) charge possibility? ƒ If yes, who captures the charges? A coder in the department? The technologist performing the procedure? HIM? HIM and the Department? ƒ Do the volumes of imaging and surgical line items make sense? Should you have more surgical than imaging charge volumes? • Does your charge master include all the imaging components CPT Codes and a generic surgical procedure charge master line item? ƒ Who capture the imaging component? If HIM is involved in the process, can they override the imaging component selected by Radiology? Does that process work? ƒ Who captures the surgical component? Who then assigns the CPT Code to the generic surgical procedure line? Department coder? HIM?

194 InterventionalInterventional RadiologyRadiology--MajorMajor IssuesIssues ToTo AddressAddress 9 Supplies • Does your charge master have line items for the expensive supplies used in the department (e.g. catheters, stents, and guide wires)? • Do the line items have the appropriate HCPCS codes assigned? Do you know what non-Medicare payors require? • Do the line items have the appropriate Revenue Codes assigned (e.g. 270 and 278)? • Is your charge master setup correctly to charge for supplies that may be “carve-outs” for third-party payors. • Does your charge master have line items for Low Osmolar Contrast Material? Are they HCPCS Coded correctly (Q9965-Q9967)?

195 InterventionalInterventional RadiologyRadiology--MajorMajor IssuesIssues ToTo AddressAddress 9 Clinical System Interfaces • If an RIS is used, is it mapped correctly to the billing system? • If CPT code assignment is being performed by HIM, is the Medical records abstracting system interfaced correctly with the billing system? • If a charge slip is used, is it comprehensive and accurate? Is it user friendly? When was it lasted updated?

196 NuclearNuclear MedicineMedicine--MajorMajor IssuesIssues toto AddressAddress

Procedures • Does the charge master include all the nuclear medicine procedures performed? Using the CPT Manual, have Nuclear Medicine identify which procedures are being performed. Compare the CPT list to the charge master. • If you are the typical Hospital, nuclear stress tests are the highest volume procedure performed in Nuclear Medicine.. ƒ Review 5-10 Nuclear stress test claims. Six charges should typically be captured 1.Myocardial Perfusion Imaging - CPT Codes 78460 through 78465 2.Wall Motion Study (if applicable) - CPT Code 78478 3.Ejection Fraction (if applicable) - CPT Code 78480 4.The Radiopharmaceutical 5.Stress Test - CPT Code 93017 (This service is commonly done in Cardiology) 6.Stressing Pharmaceutical (if applicable)

197 NuclearNuclear MedicineMedicine--MajorMajor IssuesIssues ToTo AddressAddress

ƒ Radiopharmaceuticals 9 Do the line items have the necessary HCPCS Codes assigned? Have you reviewed the 2010 Federal Register - Addendum B to verify that you have the most current HCPCS codes (SI=G, K, N) and units of service descriptions? The update from the Society of Nuclear Medicine can help with this analysis. 9 Is C9898 (Radiopharmaceutical provided during a hospital inpatient stay) on the hospital charge master? Is there volume? Does the Department know how to use it? 9 Have you analyzed a claims sample to validate that charges are being captured and passed correctly to the bill? Are the radiopharmaceutical units appearing correctly on the bill? Are the rounding rules applied correctly?

198 NuclearNuclear MedicineMedicine--MajorMajor IssuesIssues ToTo AddressAddress

ƒ Clinical System Interfaces 9 Is the RIS mapped correctly to the billing system? Does the RIS or billing system have a “unit multiplier” table? When was the table last verified? 9 If a charge slip is used, is it complete and accurate? When was it last updated?

199 CTCT && UltrasoundUltrasound--MajorMajor IssuesIssues ToTo AddressAddress 9 Procedures-CT • Does the charge master contain the complete list of CT and CTA without and with contrast? Does your charge master have line items for Low Osmolar Contrast Material? Are they HCPCS Coded correctly (Q9965-Q9967)?

• How are surgical procedures under CT guidance charged for? ƒ Hard Coded with all CPT Codes in the charge master ƒ HIM/Department Coder (HIM or department coder assigns the CPT/HCPCS Codes for all procedures) ƒ Combination (Some CPT/HCPCS come from the charge master and some from HIM/department coder). Are the CPT codes passing the Medicare records abstracting interface accurately onto the bill? ƒ How does the volume of CT Guidance (CPT Codes 77011, 77012, 77013, 77014) line items compare to the associated surgical procedure charges? The volumes should be close.

200 CTCT && UltrasoundUltrasound--MajorMajor IssuesIssues ToTo AddressAddress 9 Procedures-Ultrasound • Does the charge master contain the complete list of ultrasound procedures? Who is responsible for assigning modifiers?

• How are surgical procedures under US guidance charged for? ƒ Hard Coded with all CPT Codes in the charge master ƒ HIM/Department Coder (HIM or department coder assigns the CPT/HCPCS Codes for all procedures) ƒ Combination (Some CPT/HCPCS come from the charge master and some from HIM/department coder). Are the CPT codes passing the Medicare records abstracting interface accurately onto the bill? ƒ Hw does the volume of ultrasound guidance line items (CPT Codes 76930, 76932, 76937, 76940, 76941, 76942, 76945, 76946, 76950, 76965) compare to associated surgical procedures? The volumes should be close.

201 CardiacCardiac CatheterizationCatheterization--MajorMajor IssuesIssues ToTo AddressAddress

9 Procedures • Three components are mandatory for each catheterization procedure: ƒ Component #1-Catheterization ƒ Right (CPT 93501, 93539) ƒ Left ( CPT 93510, 93511, 93514) ƒ Right & Left (CPT 93524, 93525, 93527, 93528, 93529, 93531, 93532, 93533) ƒ Component #2-Injection Procedure ƒ CPT 93539, 93540, 93541, 93542, 93543, 93544, 93545 ƒ Component #3-Imaging: ƒ CPT 93555, 93556 • How are the charges captured? Department Coder? HIM? Department Nurses?:

202 CardiacCardiac CatheterizationCatheterization--MajorMajor IssuesIssues ToTo AddressAddress

9 Supplies • Low osmolar contrast material (HCPCS Q9965-Q9967) • Guide wires (C1769) • Introducer (C1894) • Catheter (C1887) • Closure device (C1760) 9 Clinical System Interfaces • If an clinical information system is used, is it mapped correctly to the billing system? • If CPT code assignment is being performed by HIM, is the Medical Records abstracting system interfaced correctly with the billing system? • If a charge slip is used, is it comprehensive and accurate? Is it user friendly? When was it lasted updated?

203 ElectrophysiologyElectrophysiology LabLab –– MajorMajor IssuesIssues ToTo AddressAddress

9 Procedures • Primary Procedure-EP evaluations (one of the two below for every case): ƒ CPT Code 93619 – EP evaluations without arrhythmia inductions, or ƒ CPT Code 93620 – with arrhythmia induction • Add-on Procedure-Can be on a claim and cannot be on a claim without one of the above ƒ 93609 – Intraventricular and/or intra-atrial mapping of tachycardia sites ƒ 93613 – Intracardiac eletrophysiologic 3D mapping (High Frequency) ƒ 93621 – left atrial pacing and recording from coronary sinus or left atrium ƒ 93622 – left ventricular pacing and recording ƒ 93623 – Programmed stimulation and pacing after IV drug infusion (High Frequency)

204 ElectrophysiologyElectrophysiology LabLab –– MajorMajor IssuesIssues ToTo AddressAddress

9 Procedures • Ablations (Usually require 93619 or 93620): ƒ CPT Code 93650 – Ablation AV Node ƒ CPT Code 93651 – Ablation, treatment of supraventricular tachycardia ƒ CPT Code 93652 – Ablation, treatment of ventricular tachycardia • Add-on procedures to 93651 and 93652: ƒ 93662 – Intracardiac echocardiography ƒ 93609 – Intraventricular and/or intra-atrial mapping of tachycardia sites ƒ 93613 – Intracardiac eletrophysiologic 3D mapping

205 ElectrophysiologyElectrophysiology LabLab –– MajorMajor IssuesIssues ToTo AddressAddress

9 Supplies • Does your charge master contain line items for the expensive supplies that are used by the department? ƒ EP catheters ƒ Ablation catheters ƒ Introducers • Do the line items have the necessary HCPCS Codes assigned to them? Do you know the coding requirements for your non-Medicare payors? • Have you reviewed the Device Dependant APC list for Medicare HCPCS coding requirements for outpatients? Medicare edits claims for selected “Device – Dependent” APCs. Claims will be returned for correction if the C Code is not present.

206 ElectrophysiologyElectrophysiology LabLab –– MajorMajor IssuesIssues ToTo AddressAddress

9 Clinical System Interfaces • If an clinical information system is used, is it mapped correctly to the billing system? • If CPT code assignment is being performed by HIM, is the Medical Records abstracting system interfaced correctly with the billing system? • If a charge slip is used, is it comprehensive and accurate? Is it user friendly? When was it lasted updated?

207 InterventionalInterventional CardiologyCardiology--MajorMajor IssuesIssues ToTo AddressAddress 9 Procedures • How is your charge master set up to charge for procedures? ƒ Hard Coded (All CPT/HCPCS Codes come from the charge master) ƒ HIM/Department Coder (HIM or department coder assigns the CPT/HCPCS Codes for all procedures) ƒ Combination (Some CPT/HCPCS come from the charge master and some from HIM/department coder) • Are there CDM line items for all components of stent insertions? ƒ Surgical procedure (92980, 92981) ƒ Stent (C1874, etc.)

208 InterventionalInterventional CardiologyCardiology--MajorMajor IssuesIssues ToTo AddressAddress 9 Procedures • Are there CDM line items for all components of angioplasties? ƒ Surgical procedure (92982, 92984) ƒ Catheter (C1726, etc.) • Are there CDM line items for all components of peripheral vascular procedures? ƒ Surgical procedure (36000, etc.) ƒ Imaging (75630, etc.) 9 Clinical System Interfaces • Are there CDM line items for all components of angioplasties? ƒ Surgical procedure (92982, 92984) ƒ Catheter (C1726, etc.)

209 InterventionalInterventional CardiologyCardiology--MajorMajor IssuesIssues ToTo AddressAddress 9 Clinical System Interfaces • If an clinical information system is used, is it mapped correctly to the billing system? • If CPT code assignment is being performed by HIM, is the Medical Records abstracting system interfaced correctly with the billing system? • If a charge slip is used, is it comprehensive and accurate? Is it user friendly? When was it lasted updated?

210 CardiologyCardiology (Non(Non--invasive)invasive) –– MajorMajor IssuesIssues ToTo AddressAddress ƒ Echocardiography 9 Echocardiography are typically performed as three components: • Echocardiography only– CPT Code 93307 (If performed without both 93320 and 93325) • Doppler – CPT Code 93320 (If done without 93307) • Color Flow Velocity Mapping – CPT Code 93325 (If done without 93307) • Use 93306 if 93307 + 93320 +93325 is performed • If you are using contrast material remember to review HCPCS Codes C9202 (Optison) and C9116 (Definity) ƒ Transesophageal Echocardiograms 9 Transesophageal echocardiography are sometimes performed as three components: • Transesophageal echocardiography – CPT Code 93312 • Doppler – CPT Code 93320 • Color Flow Velocity Mapping – CPT Code 93325

211 CardiologyCardiology (Non(Non--invasive)invasive) –– MajorMajor IssuesIssues ToTo AddressAddress

ƒ Stress Echocardiograms 9 Stress echocardiograms should be billed as a single line item in 2010 • Stress echocardiography – CPT Code 93351

ƒ HCPCS codes created for echocardiography with contrast: C8921 through C8927 ƒ For cardiac rehabilitation services, CPT 93797 and 93798 are to charged per visit

212 WrapWrap upup andand Question/Question/ AnswersAnswers

213 214 PresenterPresenter InformationInformation

Mike Kovar Partner Tatum LLC 410-916-0824 [email protected]

Colleen Hall Principal Tatum LLC 412-337-1595 [email protected]

215