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2012 Anesthesia Pain Management & Critical Care Changes
By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

12/12/2011

Each New Year brings a number of changes for documentation, coding, compliance, billing and reimbursement.  This coming year (2012) is no different.  From the Medicare payment cut of 24.6% t to new CPT codes, to increased government scrutiny – the business side of medicine becomes more complex next year.

The best way to ensure that you do not become the subject of an audit or experience an unexpected loss of revenue is to be informed about these changes that impact  your practice.  Below you will find a summary of changes that will impact your practice in 2012.  It is my hope that you will find this information useful in complying with all of the new rules and regulations for 2012.  I wish you all Happy Holidays and a very prosperous, healthy and Happy New Year.

2012 ANESTHESIA PAIN MANAGEMENT & CRITICAL CARE CHANGES
ANESTHESIA & CRITICAL CARE CHANGES

2012 MEDICARE ANESTHESIA CF (PAYMENT) REDUCTION

  • If Congress does not intervene, there will be a 26.2% cut in the National Average Anesthesia conversion factor which currently sits at $21.0515 per unit. If the cut is not averted, the National Average Anesthesia Conversion Factor will be reduced to $15.5264 per unit.  PLEASE CONTACT YOUR CONGRESSMAN AND VOICE YOUR OBJECTIONS TO THIS REDUCTION!!

HIPAA AUDITS

  • HIPAA audits are here!!!   In accordance with the American Recovery and Reinvestment Act of 2009 (ARRA), Section 13411 of the HITECH Act, the Department of Health and Human Services (DHHS) has contracted with KPMG to perform 150 HIPAA audits between November 2011 and December 2012.  Every covered entity (i.e., Providers, Provider Groups, Hospitals, ASCs, Physician Offices, Clinics) and business associate (e.g., Consultants, Billing Companies, Collection Agencies, Auditors, etc.) is eligible for an audit. When a covered entity is selected for an audit, the Office of Civil Rights (OCR) will notify the covered entity or business associate in writing between 30 and 90 days prior to the anticipated onsite visit.  This notification will explain the audit process, expectations and will also specify how and when to return the requested information and documents to the auditor.  Onsite visits may take between 3 and 10 business days depending on the complexity of the organization and the auditor’s need to access materials and staff.

INCENTIVE PROGRAMS

  • There are no new anesthesia codes and no new PQRS measures for 2012.  There are currently three PQRS measures that are reportable for anesthesia and they will remain for calendar year 2012:  (a) Measure #30 – Antibiotic Prophylactic Measure; (b) Measure #76 – Central Line Sterile Technique Measure; (c) Measure #193 – Perioperative Temperature Management Measure.  The threshold for successful reporting to receive payment for the measure will remain at 50% for each measure.  However, the bonus payment for 2012 will be 0.5% - down from the 2011 bonus payment of 1%.  If you are not currently reporting the PQRS measures, you may want to get started because in 2015, the PQRS bonus payment will convert to a PQRS penalty and instead of getting a bonus payment, you will be assessed a penalty 1.5%.  In 2016 and beyond, the penalty will increase to 2%.
  • EHR incentive program.  Are anesthesiologists eligible?  CMS intended to exclude anesthesiologists.  The initial regulations stated that if 90% or more of your cases are inpatient, you are not eligible for the incentive or the penalty.  There is just one problem.  For many anesthesiologists, 10% of their cases are in the outpatient hospital and/or ASC setting!  Stay Tuned.  The ASA is attempting to get CMS to revisit this rule.
  • E-Prescribing.  The E-Prescribing incentive program is based on two types of systems:  (1) “stand alone” (system for eRx only); and (2) EHR system with eRx functionality.  Per CMS representative in 2011, program requirements are essentially the same regardless of the system used.  Providers may adopt a “certified” EHR system – as defined at 42 CFR 495.4 and 45 CFR 170.102 – or they may adopt a “qualified” eRx system as defined in the 2011 MPFS final rule which states that a “qualified eRx system must meet the following four requirements:  (1) the system must generate a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers (PBMs), if available; (2) the system must be able to select medications, print prescriptions, electronically transmit prescriptions, and conduct all alerts; (3) the system should provide information related to lower cost, appropriate alternatives; and (4) the system should provide information on formulary or tiered formulary medications, patient eligibility and authorization requirements received electronically from patient’s drug plan.

Two new G codes for exemptions:  (1) the eligible profession or group practices in a rural area with limited high speed internet access (report G-code G9642); and (2) the eligible professional or group practice practices in an area with limited available
pharmacies for electronic prescribing (report G-code G8643).

E-Prescribing Program Changes for 2012 and beyond:  (1) to avoid the 2013 penalty (1.5%) a provider must report 10 eRxs in the first half of 2012 or 25 in all of 2011; (2) to avoid the 2014 penalty (2%) a provider must report 10 eRxs in the first half of 2013 or 25 in all of 2012; (3) for purposes of avoiding the 2013 or 2014 penalty a provider will be allowed to report a specific numerator on any claim and/or file one of four hardship exemptions – (a) limited internet, (b) limited pharmacy, (3) prohibited by law; (4) less than 100 prescriptions in the first 6 months.

Exclusion from Participation – A provider is not eligible for or subject to the penalty if any one of the following applies:  (1) Denominator (= outpatient E/M codes) represents less than 10% of total Medicare allowable (Jan – Jun); (2) less than 100 cases (Jan – Jun) with denominator codes; (3) not an MD, DO, podiatrist, NP, or PA by 6/30/12; or (4) do not have prescribing privileges (must report G8644 at least once on eligible claim before 6/30/12).

NOTE:  THUS MOST ANESTHESIOLOGISTS ARE EXCLUDED FROM PARTICIPATION IN THE E-PRESCRIBING INCENTIVE PROGRAM!!

NEW VALUE BASED PAYMENT MODIFIER IN 2015

  • There is a new Value Based Payment Modifier that will go into effect in 2015.  The new modifier will pay more to providers that provide better services at less cost than their peers. So, CMS’ intent is that you will get paid more for reduced costs and higher quality.  Cost and quality measures are to be adopted by CMS.  Section 1848(p)(4)(B)(iii) of the Act requires the Secretary of Health & Human Services to apply this new value based modifier beginning January 1, 2015 with respect to specific physicians and groups of physicians the Secretary determines appropriate.  It also requires the Secretary to apply the value modifier with respect to all physicians and groups of physicians (and may apply to eligible professionals as defined in subsection (k)(3)(B) of the Act as the Secretary determines appropriate) beginning not later than January 1, 2017.  I don’t yet know exactly how the modifier will be applied for anesthesia; however, I anticipate that the ASA will be involved in the process.

ASA CROSSWALK CHANGES

  • The following procedures/codes will have higher paying (base unit) crossover over codes in 2012:  (1) CPT code 11004 – Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum.  The old crossover code options for this procedure were 00400, 00920 and 00940 (all of which were 3 base units).  The new (higher paying base unit) crossover code for this procedure crosses to the radical perineal ASA anesthesia code 00904 - which is 7 base units.  There are no alternate crosses for 2012; (2) CPT code 24155 – Resection of elbow joint (arthrectomy).  The old crossover code for this procedure was 01740 (4 base units).  The new (higher paying base unit) crossover code for this procedure crosses to ASA anesthesia code 01756 - which is 6 base units.  There are no alternate crosses for 2012; (3) CPT code 57426 – Revision (including removal) of prosthetic vaginal graft, laparascopic approach. The old crossover code for this procedure was 00940 (3 base units).  The new (higher paying base unit) crossover code for this procedure crosses to ASA anesthesia code 00840 - which is 6 base units.  There are no alternate crosses for 2012.
  • The following procedures/codes will have lower paying (base unit) crossover over codes in 2012:  (1) CPT code 48511 – External drainage, pseudocyst of pancreas; percutaneous. The old crossover code for this procedure was 00790 (7 base units).  The new (lower paying base unit) crossover code for this procedure crosses to ASA anesthesia code 00700 - which is 4 base units.  There are no alternate crosses for 2012; (2) CPT code 49041 – Drainage of subdiaphragmatic or subphrenic abscess; percutaneous. The old crossover code for this procedure was 00790 (7 base units).  The new (lower paying base unit) crossover code for this procedure crosses to ASA anesthesia code 00700 - which is 4 base units.  There are no alternate crosses for 2012.
  • The following procedures/codes have had their primary crossover codes changed to the alternate crossover code and the alternate crossover code is now the primary crossover code; however, there is no change in base units for either code:  (1) CPT code 23140 – Excision or curettage of bone cyst or benign tumor of clavicle or scapula; (2) CPT code 23145 – Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft (includes obtaining graft); and (3) CPT code 23146 - Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograft.  The old primary crossover code for these procedures was 01630 and the alternate crossover code was 00450 (both codes are 5 base units).  Now, for 2012, the primary crossover code for these procedures is 00450 and the alternate crossover code is now 01630 (both codes are still 5 base units).
  • The following procedures/codes have had their CPT code definitions changed and are now defined as ADD-ON CODES, NOT A PRIMARY PROCEDURE CODE, however their base units have not changed:  (1) CPT code 22522 – Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (list separately in addition to code for separate procedure).  Crossover code is still 00670 (13 base units); and (2) CPT code 29826 – Arthroscopy, shoulder, surgical; decompression subacromial space with partial acromioplasty, with coracoacromial ligament release, when performed.  Crossover code is still 01630 (5 base units).
  • The following procedure/code has had its CPT code definition changed and now states percutaneous implantation of neurostimulator electrode “array” instead of “electrodes:"  (1) CPT code 64561 – Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement).  The primary crossover code for this procedure is 00300 (5 base units) and has not changed.  However, the alternate crossover code 00400 (3 base units) has been deleted.  Therefore, going forward, for 2012 the only crossover for this code is 00300.
  • The ASA has concluded that “ANESTHESIA IS NOT TYPICALLY REQUIRED”  for the following procedures/codes:  (1) CPT (Skin) Codes 11055, 11056 and 11057 – Paring or cutting of benign hyperkeratotic lesion(s); (2) CPT (Skin) Codes 11950, 11951, 11952, and 11954 – Subcutaneous injection of filling material (e.g. collagen); (3) CPT (Skin) Codes 15788, 15789, 15792, and 15793 – Chemical peel, facial or non-facial, epidermal or dermal; (4) CPT (skin) code 17340 -  Cryotherapy (CO2 slush, liquid N2) for acne; (5) CPT (skin) code 17360 -  Chemical exfoliation for acne (e.g., acne paste, acid); (6) CPT (skin) code 17380 – Electrolysis epilation, each 30 minutes; (7) CPT ( Bone/Tissue Graft/Implant) code 20950 – Monitoring of interstitial fluid pressure (includes insertion of device, e.g., wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome; (8) CPT ( Bone/Tissue Graft/Implant) code 20974 –  Electrical stimulation to aid bone healing; noninvasive (nonoperative); (9) CPT (Head Prostheses) codes 21076, 21077, and 21079 – Impression and custom preparation; surgical obturator, or orbital, or interim obturator prostheses, respectively.

ASA RVG (RELATIVE VALUE GUIDE) CHANGES

  • New RVG comments – There is a new RVG comment for anesthesia code 01844 (anesthesia for vascular shunt, or shunt revision, any type (e.g. dialysis).  The new comment clarifies that this code is not be used for “excision or removal of infected grafts” and further instructs that instead, one should “report an anesthesia code from the affected arterial anatomical location."
  • ASA Position on Anesthesia for Chronic Pain – In October 2010, the ASA took the position that “the majority of minor pain procedures, under most routine circumstances, do not require anesthesia care other than local anesthesia."  Additionally, this year (2012) the ASA states on (page 65 of the 2012 RVG) conditions supporting anesthesia for minor pain procedures to be as follows:  (1) “major co-morbidities and mental or psychological impediments to cooperation are examples."  Sympathetic blocks, Radiofrequency, discography, percutaneous discectomy and trial spinal cord stimulator, continuous catheters may warrant IV sedation, and at times MAC (Monitored Anesthesia Care).  NOTE:  MAC anesthesia for diagnostic/therapeutic injections and MAC anesthesia for GI cases are RAC targets – so it is important that you ensure that you document these “conditions supporting anesthesia for these procedures."
  • Base unit assignments deleted for single/continuous epidural/spinal injection codes, facet injection codes and transforaminal epidural codes – The 2012 ASA RVG deleted the base unit assignment codes for CPT codes 62310, 62311, 62318, 62319, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, and 64495.  The base unit assignments on these codes have been removed and replaced with the IC (Individual Consideration) designation – which means that “individual consideration” may be taken in determining the value for payment of these procedures.  This could affect the way your 3rd party payers reimburse for these services.  I highly recommend that when negotiating contracts for payment you make sure the language in your contracts are based on the previous base unit assignments for these procedures, otherwise, you may be at risk for a reduction in payment.


CHRONIC PAIN MANAGEMENT AND CRITICAL CARE CHANGES


2012 MEDICARE FEE SCHEDULE:  CF FOR FLAT FEES

  • 27.4% Medicare Payment Reduction – Acute/Chronic Pain Management Providers and Critical Care Providers will see a 27.4% reduction in Medicare payments in 2012 if congress does not act to avert this cut.  The current national (non-anesthesia) payment conversion factor for flat fee services (e.g. Swan Ganz Catheters, ISBs, E&M services, facet joint injections, critical care services, etc.) is $33.9764.  However if the cut is not averted, the national (non-anesthesia) conversion factor for 2012 will be $24.6712.  President Obama has a bill pending in Congress called the “doc fix” bill which would fix the sustainable growth rate (SGR) -- which is the current conversion factor mechanism.

ASA RVG (RELATIVE VALUE GUIDE) CHANGES FOR CHRONIC PAIN

  • New & Deleted ASA RVG Codes – In accordance with the 2012 CPT manual, the 2012 ASA RVG has added some new Chronic Pain Codes for electronic analysis programmable pump (codes 62369 and 62370) as well as some new facet nerve destruction codes (codes 64633, 64634, 64635, 64636).  The old codes for facet nerve destruction (64622 through 64627) have been removed and replaced with the new codes (64633 through 64636).  Additionally, the 2012 ASA RVG has deleted the SI joint arthrography code 73542, in accordance with the 2012 CPT manual as well.
  • Base unit assignments deleted for single/continuous epidural/spinal injection codes, facet injection codes and transforaminal epidural codes – The 2012 ASA RVG deleted the base unit assignment codes for CPT codes 62310, 62311, 62318, 62319, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, and 64495.  The base unit assignments on these codes have been removed and replaced with the IC (Individual Consideration) designation – which means that “individual consideration” may be taken in determining the value for payment of these procedures.  This could affect the way your 3rd party payers reimburse for these services.  I highly recommend that when negotiating contracts for payment you make sure the language in your contracts are based on the previous base unit assignments for these procedures, otherwise, you may be at risk for a reduction in payment.

NEW AND DELETED CPT CODES

  • The 2012 CPT manual includes new codes for electronic analysis of programmable pumps: (1) CPT Code 62369 – Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status; with reprogramming and refill; (2) CPT code 62370 – Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status; with reprogramming and refill (requiring physician’s skill).

Currently, in order to bill for electronic analysis of the programmable pump with reprogramming, with refill, Pain Physicians and coders must employ a 2-code methodology: 62368 and 95990 (non MD) or 95991 (MD).    In accordance with the 2012 CPT (new and revised codes for these services), a 1-code methodology will apply for this service – 62369 (non MD) or 62370 (MD).

  • The 2012 CPT manual includes new codes for facet joint nerve destruction: (1) CPT code 64633 – Destruction by neurolytic agent, paravertebral facet join nerve(s) with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint; (2) CPT code 64634 – cervical or thoracic, each additional facet joint; (add on code) (3) CPT code 64635 – Destruction by neurolytic agent, paravertebral facet join nerve(s) with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint; (4) CPT code 64635 – lumbar or sacral, each additional facet joint (add on code).  NOTE:  The new codes are out of numerical sequence in the 2012 CPT manual.  The old codes 64622 – 64627 have been deleted from the 2012 CPT manual.  The codes may still be reported bilaterally and for each nerve destroyed.

The new facet joint nerve destruction codes also have new CPT Parentheticals (guidance) preceding the codes that explain that Imaging guidance [fluoroscopy {77003}, CT] are now bundled with the facet joint nerve destruction codes.  It also instructs that if CT or fluoroscopy imaging is not used, you must report the service with unlisted nervous system CPT code 64999.  The parentheticals (guidance) goes on to state that for paravertebral destruction by neurolysis of the T12-L1 joint, or nerves innervating that joint, use CPT code 64633.

Currently nerves are levels when coding the facet joint nerve destruction services.  The current verbiage in CPT codes 64622 – 64627 is “nerve” and “single level”.  Therefore, L2, L3, L4 currently equals 3 levels.  However, the new verbiage in the 2012 CPT manual for the new facet joint nerve destruction codes (64633 – 64636) is “nerve(s)” & “single facet joint”, which means that it is now based on the joints treated.  The “2012 CPT Changes Manual” specifically clarifies this with the following language:   “Prior to 2012, the unit of service used to report these procedures was a single nerve at a single vertebral level.  However, two nerves innervate each facet joint.  One or two facet joints at the same level potentially could be treated.  As such, the vertebral level is of less significance than the number of facet joints treated.  It is important to note that the number of nerves injected for a single facet joint does not affect code selection.  Therefore, the new codes indicate ‘nerve(s)’ in the descriptors.” 

Therefore, in 2012 L1-L2, L2-L3, L3-L4 now equate to 3 levels, even if 4 nerves are RF’ed.  Documentation will need to change.  Instead of nerves being documented, you will need to state the levels.  If you have templates, they will need to change.  Remember that fluoroscopy is now bundled into these procedures. However, there is no limit on the number of levels that are billable.

  • There are 3 new EMG codes in the 2012 CPT manual.  CPT codes 95885 and 95886 – Needle electromyography, each extremity, with related paraspinal areas, when performed done with nerve conduction, amplitude and latency/velocity study; limited (95885) or complete (95886).  CPT code 95887 – Needle electromyography, non-extremity (cranial nerve supplied or axial muscle(s) done with nerve conduction, amplitude and latency/velocity study is also a new for code for CPT 2012.
  • The 2012 CPT manual now has established T codes for the MILD (Minimally Invasive Lumbar Decompression) procedure.  CPT code 0274T is for the MILD procedure performed on cervical or thoracic spine and CPT code 0275T is for the MILD procedure performed on the lumbar spine.  T codes are category III (three) temporary codes  for emerging technology services and have a sunset of 5 years – which means that if the codes are not utilized enough to establish a standard category I (one) CPT code, it will be removed and you will have to revert back to utilizing the Category I (one) unlisted code.

Additionally, these codes have parenthetical statements (clarifications)  that state: (1) for laminotomy/hemilaminectomy performed  using an open and endoscopically assisted approach, see codes 63020 – 63035); and (2) For percutaneous decompression of the nucleus polposus of   intervertebral disc utilizing need based technique, use code 62287).

  • The 2012 CPT manual deletes CPT code 73542.  Sacroiliac joint arthrography code 73542 has been deleted.  The 2012 CPT manual instructs that “73542 has been deleted, for arthrography use 27096”.  This means that arthrography is now bundled with (included in) the SI joint injection code 27096.

REVISED AMENDED MODIFIED CPT CODES AND 2012 CPT AMA PARANTHETICALS CLARIFICATIONS & COMMENTS

 

  • The SI Joint Injection code (27096) has been amended.  The 2012 CPT manual includes a revised SIJ (27096) code that states that fluoroscopy is bundled into code 27096.  Specifically, the new descriptor now states “with image guidance”.  There is also a new parenthetical under CPT code 77003 (Fluoroscopy) that now states “Do not report 77003 with 27096”.  Additionally, the 2012 CPT manual states that “if CT or fluoroscopic imaging is not performed, use 20552”.  CPT code 20552 is the code for single of multiple injection trigger point injections.  Arthrography (code 73542) is also included in the coder descriptor for this procedure – which means it too is bundled into the procedure.
  • Ultrasound no longer separately reportable with SI joint injection, Transforaminals, and Facets.  CPT code 76942 (ultrasound for needle placement) contains a new parenthetical that states that you can no longer bill ultrasound for needle placement  with SI joint injections, transforaminals, and facets.  That includes the ultrasound T Codes which have ultrasound bundled into the T codes - (0228T, 0229T, 0230T, 0231T, 0213T, 0214T, 0215T, 0216T, 0217T).
  • The 2012 CPT manual contains a new parenthetical with fluoroscopy code 77003.  Specifically, the code has been amended to delete coverage for SIJ and RF. There used to have 5 services for which fluoroscopy was separately billable -- SIJ, RF, facets, transforaminals and epidurals.  Now, fluoroscopy is separately billable only with epidurals (translaminars) and caudals.
  • There is a new Facet parenthetical preceding the facet codes (64490 – 64495) which states that “Image guidance [fluoroscopy or CT] and any injection of contrast are inclusive (bundled) components of 64490 – 64495.  Imaging guidance and localization are required for the performance of paravertebral facet joint injections described by code 64490 – 64495.  If imaging is not used, report 20552 – 20553.  If ultrasound guidance is used, report 0213T – 0218T.”
  • The 2012 CPT manual contains new CPT codes for “trial neurostimulator array for subcutaneous field stimulation” – 0282T.  The other new codes in this area are 0283T – permanent implantation w/ generator, 0284T – revision, removal, and 0285T – electronic analysis.
  • The 2012 CPT manual contains revised Vertebroplasty / Kyphoplasty codes.  The vertebroplasty / kyphoplasty codes 22520 – 22525 now includes bone biopsy in the code descriptor – which means bone biopsy code 20225 is bundled with these services.  Additionally, closed treatment of vertebral fracture (codes 22310 – 22315) and open treatment of vertebral fracture codes (22325, 22327) are also bundled with these services.
  • The 2012 CPT manual contains amended pump refill codes.  The pump refill codes 95990 and 95991 have been amended to “include electronic analysis of pump when performed”.  There is also a new parenthetical that states “Do not report 95990, 95991 in conjunction with 62367 – 62370.  For analysis and/or reprogramming of implantable infusion pump, se 62367 – 62370”.  Therefore, you can no longer bill the refill code with the analysis code because the refill code now includes the analysis. So, you cannot bill 62368 with 95990 or 95991.  Use the 1-code method: 62369 or 62360.  Be sure to amend your charge tickets.  In order to bill code 62370, the PHYSICIAN MUST PEFORM ALL THREE COMPONENTS – refill, reprogramming and analysis.
  • The 2012 CPT manual contains amended neurostimulator analysis-programming codes.  Specifically, CPT code 95971 (simple programming) has revised guidelines which state that in order to bill this code you must perform changes to 3 or fewer of the following parameters:  rate, pulse amplitude, pulse frequency, eight or more electrode contacts, cycling, stimulation train duration, train pacing, number of programs, number of channels, alternating electron polarities, dose time (stimulation parameters changing in time periods of minutes including dose lockout times), more than one clinical feature (e.g. rigidity, dyskinesia, tremor).  The complex code (95972) states that in order to bill the code (95972) you must perform changes to 4 or more of the above parameters.

Additionally, CPT code 95972 states “first hour”.  There is a new parenthetical that states that if analysis/programming takes 30 minutes or less, the coder must append modifier 52 (reduced services modifier – which means reduced payment for the service. Therefore, you must have 31 minutes or more to escape the 52 modifier.  Documentation will have to state time involved (start and end time).  If the product rep programs the device the Physician cannot bill for the code.

  • The 2012 CPT manual contains amended guidelines for the “Spine and Spinal Cord” codes 62310 through 62319.  These new guidelines specify:
  • Fluoroscopy (for localization – code 77003) may be used and reported separately in addition to single injection epidural or intrathecal cervical/thoracic (62310) or lumbosacral (62311) procedures (e.g. CESI or LESI injections)
  • If you place and use a catheter to administer one or more epidural or subarachnoid injections on a single calendar day, you cannot bill the indwelling catheter codes (62318, 62319).  You must bill the single injection codes 62310 or 62311.  Some physicians perform a “threading” technique where they thread a catheter into the epidural space and inject substances at one or more levels and then remove the catheter.  These physicians thought they could bill for the catheter codes-62318, 62319.  The catheter codes (62318-19) require leaving the catheter in for greater than one calendar day.
  • When billing epidurals, and using a catheter, the level is determined by “the region at which the catheter entered to body” (e.g. lumbar).
  • Codes 62310 – 62319 should be reported only once, when the substance injected spreads or catheter tip insertion moves into another spinal region (e.g. 62311 [cervical or thoracic epidural injection(s)] is reported only once for injection or catheter insertion at L3-4 with spread of the substance or placement of the catheter tip to the thoracic region).


Additionally, there is new verbiage for codes 62310 – 62319.  The code descriptors have been changed to support the new guidelines.  For example, the code descriptors for 62310 & 62311 which current reads “Injection, single not via indwelling catheter” has been changed to “including needle or catheter placement”.   The code descriptors for codes 62318 & 62319 have also been changed to support the new guidelines, and now state “including indwelling catheter placement”.

  • The 2012 CPT manual has a revised descriptor for percutaneous decompression of disc material (code 62287) as well as new parenthetical statements.  The code descriptor for 62287 now includes the following new language: “utilizing needle based technique to remove the disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s) when performed” – which means the procedure now requires a needle based approach and bundles fluoroscopy into the code.  This means that fluoroscopy is no longer separately billable in addition to this procedure.

Additionally, there are new parenthetical statements for this procedure that specify:  (1) CPT code 62287 includes endoscopic approach; (2) You cannot bill the following procedures with code 62287 -  fluoroscopy (77003), or injection procedure for discography (62290) or discography (72295) or CT guidance (77012) or diagnostic percutaneous aspiration within the nucleus polposus (62267) or lumbar/sacral epidural or intrathecal injection of substance (62311); (3) For non-needle based technique for percutaneous decompression of nucleus polposus of intervertebral disc, use codes 0276T, 0277T.

  • The 2012 CPT manual has a new parenthetical comment for pulsed radiofrequency.  This comment is listed at the beginning of the “Destruction” code section and specifies that: (1) For therapies which are not destructive of the target nerve, [e.g. pulsed radiofrequency], use 64999.  CPT is saying here that the appropriate code for this service is unlisted nervous system procedure code 64999 and that is the code that must be billed for the service.
  • The AMA clarifies appropriate coding (64999) for aspiration of synovial cyst of facet joint.  In the July 2011 edition of the CPT Assistant, AMA clarified that there is no specific code for  this service and that it must be billed utilizing unlisted nervous system procedure code 64999 and if fluoroscopy is utilized, bill 77003 in addition to the service.
  • The 2012 CPT manual (E&M guidelines) further clarify the definition of a new patient.  The amended guidelines now state:  A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.  Specialty determined by Medicare 855 form or other payer enrollment forms.
  • The 2012 CPT manual has new clarifications for the (inpatient) Prolonged Services E&M codes 99356 – 99357.  These codes now include non-face-to-face time in the hospital, such as unit/floor time and also now includes NPs and PAs, not just MDs.  The codes start at 30 minutes over the stated time listed for the relevant procedure code, for example:

•    99231 = 15 + 30
•    99232 = 25 + 30
•    99233 = 35 + 30

MEDICAID RACS (MICS – MEDICAID INTEGRITY CONTRACTORS)

  • Medicaid RACs (MICs).  Beginning in January 2011, Medicaid will have its own “RACs” (Recovery Audit Contractor) program.  They will be called MICs (Medicaid Integrity Contractors).  Just like the Medicare RACs, the mission of the Medicaid MICs will be to detect and correct improper payments from the Medicaid program. Additionally, just like the Medicare RACs, MICs will have a 3 year look back period and will be paid on a contingency fee basis of 12.5%.  In other words, just like the Medicare RACs, MICs will be incentivized to audit you and find errors that have resulted in improper payment.  For example, if they uncover $1 million in overpayments from a provider, provider group or hospital, they will receive 12.5% of that as their fee.

INCENTIVE PROGRAMS

  • PQRS.  There are now new pain specific PQRS measures.  However, please keep in mind that effective January 1, 2015, if you are not reporting the PQRS measures for your specialty, you will be penalized 1.5% of your total Medicare allowable payments and in 2016 the penalty will increase to 2%.
  • E-Prescribing.  The E-Prescribing incentive for 2012 is 1%.   The incentive for 2013 will be 0.5%.  The program is based on two types of systems:  (1) “stand alone” (system for eRx only); and (2) EHR system with eRx functionality.  Per CMS representative in 2011, program requirements are essentially the same regardless of the system used.  Providers may adopt a “certified” EHR system – as defined at 42 CFR 495.4 and 45 CFR 170.102 – or they may adopt a “qualified” eRx system as defined in the 2011 MPFS final rule which states that a “qualified eRx system must meet the following four requirements:  (1) the system must generate a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers (PBMs), if available; (2) the system must be able to select medications, print prescriptions, electronically transmit prescriptions, and conduct all alerts; (3) the system should provide information related to lower cost, appropriate alternatives; and (4) the system should provide information on formulary or tiered formulary medications, patient eligibility and authorization requirements received electronically from patient’s drug plan.

Two new G codes for exemptions:  (1) the eligible professional or group practices in a rural area with limited high speed internet access (report G-code G9642); and (2) the eligible professional or group practice practices in an area with limited available pharmacies for electronic prescribing (report G-code G8643).

E-Prescribing Program Changes for 2012 and beyond:  (1) to avoid the 2013 penalty (1.5%) a provider must report 10 eRxs in the first half of 2012 or 25 in all of 2011; (2) to avoid the 2014 penalty (2%) a provider must report 10 eRxs in the first half of 2013 or 25 in all of 2012; (3) for purposes of avoiding the 2013 or 2014 penalty a provider will be allowed to report a specific numerator on any claim and/or file one of four hardship exemptions – (a) limited internet, (b) limited pharmacy, (3) prohibited by law; (4) less than 100 prescriptions in the first 6 months.

Exclusion from Participation – A provider is not eligible for, or subject to the penalty, if any one of the following applies:  (1) Denominator (= outpatient E/M codes) represents less than 10% of total Medicare allowable (Jan – Jun); (2) less than 100 cases (Jan – Jun) with denominator codes; (3) not an MD, DO, podiatrist, NP, or PA by 6/30/12; or (4) do not have prescribing privileges (must report G8644 at least once on eligible claim before 6/30/12).

  • There is a new Value Based Payment Modifier that will go into effect in 2015.  The new modifier will pay more to providers that provide better services at less cost than their peers. So, CMS’ intent is that you will get paid more for reduced costs and higher quality.  Cost and quality measures are to be adopted by CMS.  Section 1848(p)(4)(B)(iii) of the Act requires the Secretary of Health & Human Services to apply this new value based modifier beginning January 1, 2015 with respect to specific physicians and groups of physicians the Secretary determines appropriate.  It also requires the Secretary to apply the value modifier with respect to all physicians and groups of physicians (and may apply to eligible professionals as defined in subsection (k)(3)(B) of the Act as the Secretary determines appropriate) beginning not later than January 1, 2017.

We will keep you informed of any congressional action or changes to the 2012 Medicare fee schedule over the next 45 days.  In the meantime, we strongly recommend that you contact your congressman and voice your discontent with the current established Medicare Fee Schedule for 2012.  If congress does not intervene, it will mean a significant cut in payment for all physicians (26.2% cut for timed anesthesia services and 27.4% cut for all other physician services).

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

 

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