Tuesday, September 13, 2016

CPT CODE 47562, 47563, 47564 - Laparoscopy, surgical; cholecystectomy

CPT Code Description

47562 Laparoscopy, surgical; cholecystectomy  - Average fee amount - $600 - $750

47563 - Laparoscopy, surgical; cholecystectomy with cholangiography

47564 - Laparoscopy, surgical; cholecystectomy with exploration of common duct - Average fee amount- $1050 - $1200

Billing Guidelines.

Medical Necessity Guidelines: Cholecystectomy-Open and Laparoscopic

Clinical Documentation and Prior Authorization Required - Tufts healh plan required authorization for below services.


** Cholecystectomy, Laparoscopic
** Cholecystectomy, Laparoscopic, Cholangiogram Intraoperative with Laparoscopic Cholecystectomy
** Cholecystectomy, Open
** Cholecystectomy, Open, Cholangiogram Intraoperative with Open Cholecystectomy


Medicare Contractor Medical Directors (CMDs) propose that CPT codes 47560, 47562, and 47563 are "potentially misvalued because the more extensive code has lower work RVUs than the less extensive codes."4 The ACS disagrees and believes that the CMDs may have overlooked the fact that 47560 (Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy) has a 000-day global period. Additionally, the CMDs may have looked at the CY2012 PFS where 47562 (Laparoscopy, surgical; cholecystectomy) and 47563 (Laparoscopy, surgical; cholecystectomy with
cholangiography) were incorrectly ranked. For the Cy2013 PFS, these codes are correctly ranked. CPT code 47560 has a 000-day global period and as a result there is a difference in work between it and codes 47562-47563, which both have 090- day global periods. CPT code 47560 describes a diagnostic laparoscopy plus laparoscopic-guidance for percutaneous insertion of a needle or catheter into the liver parenchyma to access the biliary tree for injection of contrast and performance of trans-hepatic cholangiography. CPT code 47562 describes a diagnostic laparoscopy and surgical removal of the gallbladder. CPT code 47563 describes a diagnostic laparoscopy and surgical removal of the gallbladder with the additional work of an intraoperative cholangiography.

The difference between CPT codes 47562 and 47563 is the work of the intraoperative cholangiography. This work is not the same as the total work included in code 47560. In addition, CPT codes 47562 and 47563 describe more complex surgical procedures that have a 090-day global period compared with 47560 which has a 000-day global period.



Additionally, CPT code 47563 was reviewed in October 2010. In addition, CPT code 47562, which had previously been reviewed in 1995 and 2005, was used as a stable reference service when valuing CPT code 47563. At that time the RUC recommended a wRVU of 12.11 for CPT code 47563, however, CMS reduced the value to 11.47. This resulted in a rank order anomaly for 2012
(47562 wRVU = 11.87; 47563 wRVU = 11.47).


In the CY 2013 PFS, CMS identified CPT codes 47562 and 47563 as potentially misvalued based on a public commenter that questioned the rank order. In January 2012, the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) agreed that the physician work had not changed since the October 2010 review and recommended reaffirmation of the RUC's original recommendation for correctly ranked work RVUs (11.87 for 47562 and 12.11 for 47563). However, for 2013, CMS did not agree with the RUC and instead further reduced the wRVU for 47562 to correct the rank order anomaly that CMS created when it reduced the wRVU for 47563. Although the wRVUs for 47562 and 47563 do not reflect the RUC review of survey data and RUC recommendation, their work RVUs are correctly ranked.


Code as Denominator - Definition

Any member who underwent an appendectomy or cholecystectomy (laparoscopic or other) during the 365 day period ending 30 days prior to the end of the measurement year.

Denominator Codes

Appendectomy or laparoscopic appendectomy   CPT code(s):  44950, 44955, 44960, 44970 Cholecystectomy or laparoscopic cholecystectomy

Cholecystectomy or laparoscopic cholecystectomy   CPT code(s):  47562, 47563, 47564, 47600, 47605, 47610, 47612, 47620

UHC payment policy


Laparoscopic cholecystectomy is a covered surgical procedure in which a diseased gall bladder is removed through the use of instruments introduced via cannulae, with vision of the operative field maintained by use of a high-resolution television camera-monitor system (video laparoscope).

Guidelines

For inpatient claims, report the diagnosis code for laparoscopic cholecystectomy. For all other claims, report the appropriate CPT code for laparoscopy, surgical; cholecystectomy (any method), and the appropriate CPT code for laparoscopy, surgical: cholecystectomy with cholangiography.

APPLICABLE CODES

The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.


CPT Code Description

47562 Laparoscopy, surgical; cholecystectomy
47563 Laparoscopy, surgical; cholecystectomy with cholangiography
47564 Laparoscopy, surgical; cholecystectomy with exploration of common duct


Monday, September 12, 2016

Fragmented Billing of Services Included in the Global Package



Since the Medicare fee schedule amount for surgical procedures includes all services that are part of the global surgery package, A/B MACs (B) do not pay more than that amount when a bill is fragmented. When total charges for fragmented services exceed the global fee, process the claim as a fee schedule reduction (except where stated policies, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care, result in payment that is higher than the global surgery allowed amount). A/B MACs (B) do not attribute such reductions to medical review savings except where the usual medical review process results in recoding of a service, and the recoded service is included in the global surgery package.

The maximum a nonparticipating physician may bill a beneficiary on an unassigned claim for services included in the global surgery package is the limiting charge for the surgical procedure.

In addition, the limitation of liability provision (§1879 of the Act) does not apply to these determinations since they are fee schedule reductions, not denials based upon medical necessity or custodial care.

Claims for surgeries billed with a “-22” or “-52” modifier, are priced by individual consideration if the statement and documentation required. If the statement and documentation are not submitted with the claim, pricing for “-22” is it the fee schedule rate for the same surgery submitted without the “-22” modifier. Pricing for “-52” is not done without the required documentation.

Separate payment is allowed for visits and procedures billed with modifier “-78,” “-79,” “-24,” “-25,” “-57,” or “-58.” Modifier “-24” must be accompanied by sufficient documentation that the visit is unrelated to the surgery. Also, when used with the critical care codes, modifiers “-24” and “-25” must be accompanied by documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed.

A/B MACs (B) do not allow separate payment for evaluation and management services furnished on the same day or during the postoperative period of a surgery if the services are billed without modifier “-24,” “-25,” or “-57.” These services should be denied. A/B MACs (B) do not allow separate payment for visits during the postoperative period that are billed with the modifier “-24” but without sufficient documentation. These services should also be denied. Modifier “-24” is intended for use with services that are absolutely unrelated to the surgery. It is not to be used for the medical management of a patient by the surgeon following surgery. Recognize modifier “-24” only for care following discharge unless:

• The care is for immunotherapy management furnished by the transplant surgeon;

• The care is for critical care for a burn or trauma patient; or

• The documentation demonstrates that the visit occurred during a subsequent hospitalization and the diagnosis supports the fact that it is unrelated to the original surgery.

A/B MACs (B) do not allow separate payment for an additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior procedure and if billed without modifier “-58,” “-78,” or “-79.” These services should be denied. Codes with the global surgery indicator of “XXX” in the MFSDB can be paid separately without a modifier.

Wednesday, September 7, 2016

CPT CODE 97010 - 97012 - Modality procedure service

97010 - Application of a modality to 1 or more areas; hot or cold packs Average fee amount $5 -$10

97012 - Application of a modality to 1 or more areas; traction, mechanical Average fee amount $ 13 - $20


Mechanical Traction:

CPT 97012 Mechanical traction is described as force used to create a degree of tension of soft tissues and/or to allow for a separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration of time, and angle of the pull (degrees) using mechanical means. Used in describing cervical and pelvic traction that are intermittent or static (describing the length of time traction is applied), or autotraction (use of the body’s own weight to create the force). A common question is whether a roller table type of traction meets the above-noted requirements. According to the ACA’s interpretation, table type traction would normally meet the requirements of autotraction.

It should also be noted that manual traction, using one's hands or a towel to perform the traction, is identified under manual therapy CPT 97140 and, presumably, would not be recognized under mechanical traction. ..


Billing and Coding Guidelines

Optum will not separately reimburse for CPT code 97010. Payment for CPT 97010 is considered bundled into the fee provided for other services.

The 97010 CPT code is described in the CPT manual as a supervised modality:

Any physical agent applied to produce therapeutic changes to biologic tissue; includes but not limited to thermal, acoustic, light, mechanical, or electric energy. The application of a modality that does not require direct (one-on-one) patient contact by the provider. Application of a modality to one or more areas; hot or cold packs.

CMS national policy effective January 1, 1997 precludes separate payment for hot packs/cold packs (CPT 97010). Regardless of whether billed alone or in conjunction with another code, CMS does not make payment separately for this code.


Physical Medicine & Rehabilitation (PM&R): Supervised Modalities – Update to article in September 2006

This article details a revision to the information that was published in the September 2006 Network Bulletin relating to a new reimbursement policy for 2 supervised therapy modalities,  CPT codes 97010 and 97014. Since that time, information has been obtained clarifying the most appropriate HCPCS code to be billed in lieu of 97014.

When unattended electrical stimulation is delivered, 97014 is no longer considered the most appropriate code to describe the treatment. Rather, practitioners utilizing this modality should submit an appropriate HCPCS code (G0283) which better describes the service being rendered.

Billing - CPT Codes: Permitted

In the same 15-minute time period, one therapist may bill for more than one therapy service occurring in the same 15-minute time period where "supervised modalities" are defined by CPT as untimed and unattended -- not requiring the presence of the therapist (CPT codes 97010 - 97028). One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one patient contact. However, any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist.

CPT codes 97010 describe Physical Medicine and Rehabilitation modalities that do not require direct (one-on-one) patient contact by the provider.

Reimbursement Guidelines

Consistent with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare Community Plan will not reimburse CPT codes 97010. Reimbursement for 97010 is included in the payment for other services.


You must still document that you provided the hot/cold pack to the patient, its purpose, and the duration of treatment in the patient’s medical record. Medicare carriers and FIs differ on whether to bill 97010 on the claim and whether a dollar amount should be attached. Check with your Medicare carrier or fiscal intermediatry (FI) for specific information. Just because Medicare doesn’t pay for hot or cold packs, doesn’t mean that the same is true of other insurance payers. If other payers reimburse for hot and cold packs, suppliers and providers of therapy services should bill those payers for the services rendered.

97012—Mechanical traction. This includes both cervical and lumbar-pelvic mechanical traction. This CPT code does not include over-the-door cervical traction or other noncovered forms of traction. Specific indications for mechanical traction include cervical or lumbar radiculopathy, lumbago, sciatica, disc herniation, and other back disorders.


Procedure Code 97012, Mechanical Traction/Spinalator

The American Chiropractic Association (ACA) receives numerous requests for clarification on describing the work associated with mechanical traction.

According to CPT, mechanical traction is described as the force used to create a degree of tension of soft tissues and/or to allow for separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration (time), and angle of pull (degrees) using mechanical means. Terms often used in describing pelvic/cervical traction are intermittent or static (describing the length of time traction is applied), or autotraction (use of the body's own weight to create the force).

A common question is whether roller table type traction meets the above requirement. Roller table type traction normally meets the requirement of autotraction, the use of the body's own weight to create the force.

It is the position of the American Chiropractic Association that modalities such as mechanical traction are not included in the work of the CMT codes. Code 97012 should be used to describe these services, subject to documented medical necessity.


Sunday, September 4, 2016

CPT CODE 49082, 49083 - Abdominal paracentesis


CPT CODE 49082 - Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance -Average fee amount $200

CPT CODE 49083 - Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance -Average fee amount $280 - $320

New/Deleted CPT Codes for Abdominal Paracentesis and Peritoneal Lavage

For 2012, three new CPT codes for abdominal paracentesis and peritoneal lavage have been created. These replace codes 49080 and 49081, abdominal paracentesis, initial and subsequent procedures, respectively.

The new codes for abdominal paracentesis, 49082 and 49083, describe the procedure performed without or with imaging guidance. If the health-care professional performs abdominal paracentesis without imaging guidance, code 49082, Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance. If abdominal paracentesis is performed with imaging guidance (regardless of the method used), code 49083, Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance.

Code 49084, Peritoneal lavage, including imaging guidance, when performed is used to describe the procedure where a vertical skin incision is made, the linea alba is divided and the peritoneum entered after it has been picked up to prevent bowel perforation. A catheter is inserted towards the pelvis and aspiration of material is attempted using a syringe. If no blood is aspirated, warm saline is infused and after a few minutes, the effluent is drained and sent for analysis.

Parentheticals are included with codes 49083 and 49084 instructing the provider not to report these codes with separate imaging codes, including ultrasonic guidance code 76942, fluoroscopic guidance code 77002, computed tomography guidance code 77012, and/or magnetic resonance guidance code 77021.


Misuse of column two code with column one code

For example, CPT code 49322 describes a surgical laparoscopy with aspiration of single or multiple cavities or cysts (eg, ovarian cyst). CPT code 49082 describes an abdominal paracentesis (diagnostic or therapeutic) without imaging guidance. It is a misuse of CPT code 49082 to report it in addition to CPT code 49322 at the same patient encounter since the procedure described by CPT code 49322 includes the procedure described by CPT code 49082.


Medicaid - Maximum fee pricing assigned to CPT code 49083

Effective November 1, 2013, the Indiana Health Coverage Programs (IHCP) has assigned maximum fee pricing to Current Procedural Terminology (CPT) code 49083 – Abdominal paracentesis (diagnostic or therapeutic) with imaging guidance. The maximum fee for CPT code 49083 is $412.39. For dates of service on or after November 1, 2013, the IHCP will reim- burse providers billing claims for CPT code 49083 as an outpatient service.


The AMA added three new codes in the digestive system subsection, including two for abdominal paracentesis (diagnostic or therapeutic):

* 49082: Without imaging guidance

* 49083: With imaging guidance

Coders should report the third new code, 49084, to denote peritoneal lavage, including imaging guidance, when performed. This is an open procedure that physicians typically perform on acute unstable patients. Physicians use it to assess a patient’s blood for enteric contents and for additional laboratory analysis, Sarasin says.

Remember that aspiration involves removal of the catheter or needle at the conclusion of the procedure. Do not use codes 49082-49083 for drainage procedures in which a catheter is left indwelling.

Code 49083 includes imaging guidance, so guidance should not be reported separately.

In the case of ultrasound-guided paracentesis, code 49083 includes the limited ultrasound exam performed prior to paracentesis in order to determine the amount and location of the fluid. According to Clinical Examples in Radiology (Winter 2012), “This type of limited sonography is a necessary component of any ultrasound guidance procedure” and should not be coded separately.

If the preliminary ultrasound images do not show any fluid, paracentesis will not be performed. In this situation it is appropriate to report a limited ultrasound exam of the abdomen (76705) for the preliminary imaging.



Tuesday, August 30, 2016

Prepayment Edits to Detect Separate Billing of Services Included in the Global Package


In addition to the correct coding edits, A/B MACs (B) must be capable of detecting certain other services included in the payment for a major or minor surgery or for an endoscopy. On a prepayment basis, A/B MACs (B) identify the services that meet the following conditions:

• Preoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure; or

• Same day or postoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure or endoscopy;
and -

• Services that were furnished within the prescribed global period of the surgical procedure;

• Services that are billed without modifier “-78,” “-79,” “-24,” “25,” or “-57” or are billed with modifier “-24” but without the required documentation; and

• Services that are billed with the same provider or group number as the surgical procedure or endoscopy. Also, edit for any visits billed separately during the postoperative period without modifier “-24” by a physician who billed for the postoperative care only with modifier “-55.”

A/B MACs (B) use the following evaluation and management codes in establishing edits for visits included in the global package. CPT codes 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99271, 99272, 99273, 99274, and 99275 have been transferred from the excluded category and are now included in the global surgery edits.


Evaluation and Management Codes for A/B MAC (B) Edits

92012
92014
99211
99212
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99261
99262
99263
99271
99272
99273
99274
99275
99291
99292
99301
99302
99303
99311
99312
99313
99315
99316
99331
99332
99333
99347
99348
99349
99350
99374
99375
99377
99378


NOTE: In order for codes 99291 or 99292 to be paid for services furnished during the preoperative or postoperative period, modifier “-25” or “-24,” respectively, must be used to indicate that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed.

If a surgeon is admitting a patient to a nursing facility for a condition not related to the global surgical procedure, the physician should bill for the nursing facility admission and care with a “-24” modifier and appropriate documentation. If a surgeon is admitting a patient to a nursing facility and the patient’s admission to that facility relates to the global surgical procedure, the nursing facility admission and any services related to the global surgical procedure are included in the global surgery fee.


Services billed with the modifier “-25,” “-57,” “-58,” “-78,” or “-79.”

Exceptions

See §§40.2.A.8, 40.2.A.9, and 40.4.A for instances where prepayment review is required for modifier “-25.” In addition, prepayment review is necessary for CPT codes 90935, 90937, 90945, and 90947 when a visit and modifier “-25” are billed with these services


Exclude the following codes from the prepayment edits required in §40.3.B.
92002
92004
99201
99202
99203
99204
99205
99281
99282
99283
99284
99285
99321
99322
99323
99341
99342
99343
99344
99345

Most read colonoscopy CPT codes