Monday, March 23, 2015

New CPT Codes Not Recognized in CY 2015 by Medicare

In the final rule, CMS set the value of all other new lower GI endoscopy CPT codes at 0.00 RVUs. CMS has provided guidance as to how physicians should report new endoscopic procedures that CMS has assigned 0.00 RVUs. CMS’s intent is for physicians to bill these endoscopic services as they would have in CY 2014. Therefore, for Medicare beneficiaries, new procedures that do not have G-code crosswalks should continue to be reported as they were in 2014, noting that code G6021 should be used for unlisted procedure, intestine.

CPT 2015 Code Description CMS CY 2015 Crosswalk
44381 Small bowel endoscopy w/dilation 44380, G6021
44403 Colonoscopy through stoma w/EMR  44388, G6021
44404 C-stoma w/submucosal injection 44388, G6021
44405 C-stoma w/dilation 44388, G6021
44406 C-stoma w/ultrasound 44388, G6021
44407 C-stoma w/US-guided FNA  44388, G6021
44408 C-stoma w/decompression 44388, G6021
45349 Flexible sigmoidoscopy w/EMR 45330, G6021
45350 Flexible sigmoidoscopy w/band ligation
(e.g. hemorrhoids)
45330, G6021
45390 Colonoscopy w/EMR 45378, G6021
45393 Colonoscopy w/decompression 45378, G6021
45398 Colonoscopy w/band ligation (e.g. hemorrhoids) 45378, G6021

When to report CPT and HCPCS G-codes for physician services provided to Medicare (fee-for-service, Medicare Advantage) patients in 2015?
If the code has not changed from 2014 to 2015:
              • Report the CPT code.
              • CMS fees are based on 2014 values.
If the code has changed from 2014 to 2015:
              • Report the G code.
              • CMS fees are based on 2014 values.
If the code is new for 2015:
              • Report the CY 2014 CPT code(s) and/or G6021, as appropriate.
              • Do not report the CPT 2015 codes, as they are not valued by CMS during CY 2015.
Physicians are encouraged to reach out to payors regarding guidance on how to report the new 2015 CPT codes for non-Medicare (e.g. commercial, HMO, PPO, Medicaid, Tricare, etc.) lines of service.

Which CPT and HCPCS G-codes should the ASC or HOPD use when submitting a claim for facility services provided to Medicare beneficiaries in 2015?

  • The facility should report the new CPT codes for 2015.
  • The facility should not report HCPCS codes G6018-G6028.
  • The facility should continue to report HCPCS codes G0104, G0105 and G0121, as appropriate.

Proposing Values for New CPT Codes to Non Medicare Payors
Many payors have not announced whether they will recognize the new CPT codes and, if so, what the value of the codes should be. When beginning a dialogue with payors, it may be helpful for physicians to look at the values for the base codes and the value of the increment. The increment (from the upper GI endoscopy codes) could be added to a lower GI endoscopy base code to propose a reimbursement rate or calculate an RVU for the new lower GI endoscopy codes.

The physician work increments (from the 2015 Final Rule) for upper GI endoscopy procedures are as follows. Note that this does not account for practice expense and malpractice liability differences between the base code and increment procedure.

Procedure wRVU Increment Over Base Code
Submucosal injection  0.3
Balloon dilation  0.58
Endoscopic ultrasound (EUS)  1.38
Stent placement  1.98
Ablation  2.07
EUS with fine needle aspiration (FNA)  2.07
Endoscopic mucosal resection (EMR)  2.78

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