Compliance Matters A Healthcare Compliance Newsletter December 2014 | Volume 13 Issue 4 In this issue: October 1, 2015 ICD-10 Compliance Date Remains Firm _____________________________________ 2 National Correct Coding Initiative Edits (NCCI) ___________________________________________ 3 CMS Finalizes New Safeguards to Reduce Medicare Fraud ___________________________________ 4 Medicare Administrative Contractor (MAC) Updates: Jurisdiction JJ ____________________________ 5 Preventive and Screening Services Update _______________________________________________ 5 ESRD Laboratory Services: Elimination of the 50/50 Rule April 2015 ___________________________ 6 CMS Creates New Chief Data Officer Post _______________________________________________ 7 Modified Requirements for Medicare Coverage of Ultrasound Screening for Abdominal Aortic Aneurysms (AAA) and Screening Fecal-Occult Blood Tests (FOBT) _____________________________________ 8 Testing with CMS FAQs: International Classification of Diseases, 10th Edition (ICD-10) End-to-End Testing __ 9 Payment for G0101 and Q0091 in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) that Bill Under the All-Inclusive Rate (AIR) System _________________________________ 11 CMS 2015 Changes to HCPS Level II Codes ______________________________________________ 11 CPT® Changes for 2015 _____________________________________________________________ 12 The Compliance Matters Holiday Team __________________________________________________ 18 Happy Ho Ho Holidays! Compliance Matters and specificity of ICD-10-CM/PCS will likely assist October 1, 2015 ICD-10 in developing increasingly sophisticated electronic Compliance Date Remains coding tools that will help you more quickly select Firm codes.” Some have argued that the proliferation of ICD- On July 31, the U.S. Department of Health & 10 codes will spell the end of the superbill. But Human Services (HHS) issued a rule finalizing because most physician practices use a relatively October 1, 2015 as the compliance date for small number of diagnoses related to their healthcare providers, health plans, and healthcare specialty, they can continue to use super bills clearinghouses to implement ICD-10-CM. Although containing the most common diagnosis codes previous deadlines were moved “to allow insurance reported in their practice, and supplement with companies and others in the health care industry additional tools. time to ramp up their operations to ensure their systems and business processes are ready,” HHS Furthermore, the cost of ICD-10 implementation has dubbed further delay of ICD-10 a myth, and has been greatly exaggerated, causing widespread announced “no plans to extend the compliance discouragement from starting training. Recent date for implementation of ICD-10-CM/PCS; surveys have demonstrated costs could average therefore, covered entities should plan to complete only $3,500 per provider. the steps required to implement ICD-10-CM/PCS Additionally, as we head into 2015, the methods on October 1, 2015.” promulgated by the Coalition for ICD-10, and other ICD-10-CM implementation is inevitable for several implementation proponents should serve as a key reasons. Most significantly, the ICD-9-CM code springboard for the industry to continue pushing set currently in use contains “outdated, obsolete Congress to refuse any new delays. terms that are inconsistent with current medical practice, new technology, and preventive services,” as stated in the July 2014 press release, and lacks CMS July 31, 2014 Press Release: http://www.cms. the needed flexibility to keep up with changes. gov/Newsroom/MediaReleaseDatabase/Press- ICD-9-CM hasn’t received regular updates in releases/2014-Press-releases-items/2014-07-31.html several years. And because ICD-9 will receive no ICD-10 Myths and Facts: http://www.cms. updates beyond 2015, even non-covered entities gov/Medicare/Coding/ICD10/Downloads/ICD- are best served by the transition to ICD-10 10MythsandFacts.pdf Skipping ICD-10 and holding out for ICD-11, as some have proposed, isn’t a viable solution. As reported in FierceHealthIT, ICD-11 isn’t expected to be ready for use for at least a decade, and perhaps much longer. The American Medical Association’s Board of Trustees estimates that ICD-11 won’t be available for use in the U.S. for 20 years, and expressed reservations about skipping ICD-10, stating that such a move “is fraught with its own pitfalls and therefore, based on current information available, is not recommended.” “Just as an increase in the number of words in a dictionary doesn’t make it more difficult to use, the greater number of codes in ICD-10-CM/PCS doesn’t necessarily make it more complex to use,” CMS argues. “In fact, the greater number of codes in ICD-10-CM/PCS make it easier for you to find the right code.” As well, “the improved structure December 2014 | Volume 13 Issue 4 Page 2 Compliance Matters associated modifiers, the two procedure codes may National Correct Coding be reported together. NCCI-associated modifiers Initiative Edits (NCCI) may not be used to bypass an edit unless the criteria for use of the modifier are met. Back in 1996, the Centers for Medicare and Each active NCCI edit has a modifier indicator of Medicaid Services (CMS) developed the National 0 or 1. A modifier indicator of “0” indicates that an Correct Coding Initiative (NCCI) to promote correct edit can never be bypassed even if a modifier is coding and prevent inappropriate payment of used. In other words, the Column 2 code of the edit Medicare Part B claims. As this is an automated will be denied. A modifier indicator of “1” indicates prepayment review by CMS, the NCCI edits reduce that an edit may be bypassed with an appropriate payment error by identifying coding errors made modifier appended to the Column 1 and/or Column by providers. In 2009, 7.8 % of Medicare dollars did 2 code. not comply with one of more Medicare coverage, coding, billing or payment rules, translating into The NCCI-associated modifiers are: E1, E2, E3, E4, $24.1 billion dollars in Medicare overpayments and FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, LT, RC, underpayments annually. RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, 25, 27, 58, 59, 78, 79, and 91. The NCCI edits define when two HCPCS/CPT ® procedure codes may not be reported together In January 1, 2013, additional modifiers were added except under special circumstances. CMS based to the list of NCCI-associated modifiers that will the NCCI coding policies on current coding allow an edit to be bypassed when the modifier is conventions, coding guidelines, national and local used correctly (i.e., edits with modifier indicator Medicare policies (NCDs and LCDs), and standard of “1”). These were LM (left main coronary artery), medical and surgical practice. Coding polices and RI (ramus intermedius), 24 (unrelated evaluation guidelines require that procedures are reported and management service by the same physician with the most comprehensive CPT® code that during a postoperative period), and 57 (decision describes the services performed. For example, for surgery). a coder should not report a Basic Metabolic Panel (BMP, CPT® 80047) with a Comprehensive Metabolic Panel CMP,CPT® code 80053) as all the analytes in CPT® 80047 BMP are a subset of the Comprehensive Metabolic Panel and would have been already performed as part of that procedure. Effective Jan 15, 2015, new more specific modifiers become effective (see also Compliance Matters, As a claim is processed by the Medicare contractor, Sept 2014) supplementing Modifier -59 (Distinct the system tests every pair of procedure codes to Procedural Service). determine if they comply with the NCCI edit policy. This means every code pair reported for the same • XE Separate Encounter: A Service That Is date of service for the same beneficiary by the Distinct Because It Occurred During A Separate same provider is reviewed against the NCCI-edit Encounter tables. If a pair of codes on the claim matches • XS Separate Structure: A Service That Is (“hits”) a pair in the NCCI edit table, the “Column Distinct Because It Was Performed On A Two” code of the edit pair is denied for payment. Separate Organ/Structure Using the CMP/BMP example above, in the NCCI edit tables, CPT® 80047 is the “Column Two” code • XP Separate Practitioner: A Service That and would have payment denied. Is Distinct Because It Was Performed By A Different Practitioner NCCI-associated modifiers are used to indicate the special circumstances such as when the procedures • XU Unusual Non-Overlapping Service: The Use are performed at different anatomic sites, a Of A Service That Is Distinct Because It Does separate procedure or repeat clinical diagnostic Not Overlap Usual Components Of The Main laboratory test. If an edit allows use of NCCI- Service December 2014 | Volume 13 Issue 4 Page 3 Compliance Matters These modifiers, collectively referred to as “The changes announced today are common- -X{EPSU} modifiers, define specific subsets of the sense safeguards to preserve Medicare for -59 modifier. CMS will not stop recognizing the -59 generations to come, while making the rules modifier but notes that CPT instructions state that more consistent for all providers that work the -59 modifier should not be used when a more with us,” Administrator Tavenner said. “The descriptive modifier is available. CMS will continue Administration is committed to using all to recognize the -59 modifier in many instances appropriate tools as part of its comprehensive but