By Justin Vaughn, MDiv, CPC
Based on the 2017 versions of the Medicare Physician Fee Schedule (MPFS) and CPT coding manual, chronic pain providers can expect a few surprises in the coming year. A summary of the key changes in chronic pain management billing and coding and overall compliance for 2017 is provided below.
The non-anesthesia conversion factor (CF) for 2017 will be raised ever so slightly to $35.8887 from the current $35.8043.
Urine Drug Testing (UDT)
Increased Reimbursement for Confirmation Codes. The Final 2017 Clinical Laboratory Fee Schedule (CLFS) adopted a relatively significant rise in reimbursement as recommended within the Proposed Rule for the 4 Medicare UDT confirmation codes, as follows (unadjusted for geographic location):
- G0480 – from $79.95 to $116.85
- G0481 – from $123.00 to $159.90
- G0482 – from $166.05 to $202.95
- G0483 – from $215.25 to $252.15
The result is that each of the above codes will yield an increase of nearly $37.00 over the current year’s payment rate.
Added Requirement to Each Confirmation Code. The Centers for Medicare and Medicaid Services (CMS) is adding new language applicable to each of the 4 confirmation codes. Specifically, a confirmation test must utilize . . .
. . . (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift).
You will need to work with your lab director to ensure that your confirmation testing can accommodate these 2 new requirements; otherwise, you will not be able to bill these 4 confirmation codes.
Deleted Medicare Screening Codes. The 3 current Medicare G-codes for screening (G0477, G0478, and G0479) have been deleted.
Deleted CPT Screening Codes. The 5 current CPT codes for screening (80300, 80301, 80302, 80303, 80304) have also been deleted.
Replacement Screening Codes. The deleted Medicare and CPT screening codes will be replaced in 2017 by 3 new screening codes as found in CPT, and will be applicable to all payors:
- 80305 (direct optical observation; dipsticks, cups, cards, per DOS, bundles validation testing);
- 80306 (instrument assisted direct optical observation; per DOS, bundles validation testing); and
- 80307 (instrument chemistry analyzers, i.e., IA, per DOS).
Effect of Screening Changes. Last year, 2 of the 5 screening codes in the CPT manual allowed providers to bill 1 unit for each drug tested (80302 and 80304). The new codes only allow 1 unit of service regardless of the number of drugs or drug classes tested.
Drug Lists A & B Deleted. Additionally, last year, the CPT manual differentiated between drugs found in Drug List A versus Drug List B. This year, those lists have been removed from CPT.
New Medicare Confirmation Code for Less Sophisticated Testing. Code G0659 is a new Medicare designation for definitive tests being done at labs that “are performing a less sophisticated version” of confirmations. In essence, this new G-code is designed to be billed if your high complexity lab is not capturing the 2 new criteria, discussed above, that are now incorporated into the Medicare confirmation codes. The new G-code is defined below.
- Definition. G0659: “Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of a stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes.”
- Pricing. Per CMS, “the work performed in this test approximates the work performed in G0479 (IA screening).” Therefore, CMS proposes to price this new code at the same amount as G0479. (NOTE: G0479 has been renumbered as 80307.)
Deleted Codes. Codes 99143-45 and 99148-50 have been deleted.
Replacement Codes. The new moderate sedation codes mimic the current ones except that the time frame of 30 minutes has been reduced to 15 minutes, and the threshold to bill the primary code has been reduced from 16 minutes to 10 minutes.
Same MD/NPP Providing Sedation AND Performing Procedure:
- 99151 – 15 minutes, less than 5 years old
- 99152 – 15 minutes, 5 years or older
- 99153 – Each add’l 15 minutes of intra-service time
Different MD/NPP Providing Sedation:
- 99155 – 15 minutes, less than 5 years old
- 99156 – 15 minutes, 5 years or older
- 99157 – Each add’l 15 minutes of intra-service time
Lower Time Threshold. The new CPT codes reduce the amount of time required to bill moderate sedation, meaning it’s a bit easier now to get paid for these services.
- Total Minutes Reduced in Half. 0-30 minutes for the initial/primary code is reduced to 0-15 minutes.
- Billing Threshold is Atypical. 10 minutes of intra-service time is required to bill the first code (reduced from 16 minutes previously). Note, this is different from the typical rule that more than half of a time-based code is required to bill (which would be 8 minutes in this case).
- Add-on Code Time is Typical. However, beginning with the second code, which is an add-on code (billable after the first 15 minutes), the “more-than-half” rule relative to time does apply!
- Example. While 10 minutes is required to bill 99152 for this 15-minute code, 23 minutes is required to bill 99152 and 99153 in tandem (the full 15 minutes for 99152 and 8 minutes—1 minute past the midway point—for 99153).
Deletion of Appendix G. Appendix G, which lists all the codes that bundle moderate sedation, has been removed from the CPT manual. The implication of this is that moderate sedation is no longer bundled with any CPT code. Medicare has indicated its agreement with the AMA’s position on this issue. For Medicare, any bundled procedure listed in Appendix G of CPT 2016 will have its work-RVU reduced by .25 as a result of this change. So, if you are billing a code that was on Appendix G in 2016, you are going to have to bill 99152 (moderate sedation, 5 years or older) just to stay even with 2016 Medicare reimbursement.
Interlaminar Epidural Codes
Deleted Codes. The 2017 CPT manual deletes the 4 widely-recognized epidural codes (62310, 62311, 62318, and 62319).
Replacement Codes. In the place of the current epidural codes will be the following newly created codes:
- 62320 – C/T; no fluoro; no indwelling catheter
- 62321 – C/T; w/ fluoro; no indwelling catheter
- 62322 – L/S; no fluoro; no indwelling catheter
- 62323 – L/S; w/ fluoro; no indwelling catheter
- 62324 – C/T; no fluoro; w/indwelling catheter
- 62325 – C/T; w/ fluoro; w/indwelling catheter
- 62326 – L/S; no fluoro; w/indwelling catheter
- 62327 – L/S; w/ fluoro; w/indwelling catheter
Purpose. The purpose of exchanging the 4 current codes with these 8 new codes is to distinguish between interlaminar epidurals done with, versus without, fluoroscopy. The payment rates related to this new epidural coding regime are reflected below:
Code Office RVU/Pay Facility RVU/Pay
62320 4.75/$171 2.94/$105.84
62321 7.06/$254.16 3.17/$114.12
62322 4.43/$159.48 2.53/$91.08
62323 6.93/$249.48 2.89/$104.04
62324 4.15/$149.40 2.68/$96.48
62325 6.26/$225.36 3.08/$110.88
62326 4.36/$156.96 2.63/$94.68
62327 6.38/$229.68 2.80/$100.80
Add-on Codes. Fluoroscopy codes 77002 and 77003 are newly designated as add-on codes. The “+” designation beside 77002 and 77003 means these codes can only be billed with another code—which in practical terms doesn’t amount to much of a change as this is how we’ve always billed these codes.
Procedures for 77003. Fluoroscopy code 77003 is limited to being billed with the following 9 surgical codes only:
- 61050/61055 – C1-C2 puncture
- 62267 – percutaneous aspiration of disc for dx purpose
- 62270/62272 – lumbar spinal puncture, dx/therapeutic
- 62280-82 – neurolytic injection into spinal canal or epidural space
- 62284 – lumbar myelography injection
- 64510 – injection stellate ganglion
- 64517 – injection superior hypogastric plexus
- 64520 – injection paravertebral sympathetic, lumbar/thoracic
- 64610 – destruction trigeminal nerve, 2nd and 3rd branches
Interlaminar Epidurals Cannot be Billed with 77003. Last year, the CPT manual allowed 77003 to be billed with interlaminar epidurals (Medicare did not). This year, 77003 will not be billed with any epidural codes, because the use (or non-use) of fluoroscopy with interlaminar epidurals is built into the new epidural codes.
Procedures for 77002. There are approximately 50 procedures that the 2017 CPT manual allows to be billed with fluoroscopy code 77002. The ones to note are as follows:
- 20550, 20551, 20552, 20553 – tendon, ligament, and TPI;
- 20600, 20605, 20610 – small, intermediate, large joints;
- 64505 – sphenopalatine ganglion; and
- 64600 – destruction of trigeminal nerve.
JW Modifier for Wastage
Pursuant to MLN Article MM9603, effective the first of next year, providers are required to use the JW modifier to bill for discarded Part B drugs in single use vials. The discarded amount must be documented in the medical record. The rule applies to all Medicare carriers. If you do not use JW, upon audit the unused portion will be disallowed. When coding for the drug and the wastage, you should reflect these as 2 separate line items, as described below:
- Bill the amount used on the first line (with no JW), i.e., J1030 – 5 units
- Bill the amount wasted on the second line item, i.e., J1030 JW – 5 units
Prolonged Non-Face-to-Face E/M Services
Medicare Payment Initiated. Medicare will now pay for these services, as represented by 99358 (first hour) and 99359 (each additional 30 minutes), and adopts the CPT descriptors and introductory comments for these codes.
- 99358 – Prolonged E/M service before and/or after direct patient care, first hour
- 99359 – Each additional 30 minutes (add-on code)
Limited to Physicians and NPPs. The services must be performed by the physician or NPP, not clinical staff, and cannot be items that are typical staff scope of services.
Reimbursement Amount. Code 99358 pays 3.16 RVUs ($114), and 99359 pays 1.52 RVUs ($54).
Date and Time Issues. Time can be discontinuous; 99358 is only reportable at the 30-minute threshold; 99359 is reportable at the 15-minute threshold. The date of service can be a different from the date of the underlying E/M service to which the non-face-to-face service is related, such as review of medical records. These codes can be billed as follow-up to, or in preparation for, any other face-to-face E&M code at any level.
Definitions of Percutaneous, Endoscopic, and Open; Visualization
Immediately prior to the CPT manual’s treatment of CPT code 63001, the manual provides new definitions of “percutaneous,” “endoscopic,” and “open” in connection with spinal procedures. The manual clarifies that if a procedure isn’t classified as endoscopic or percutaneous, the assumption is that the code is designed to apply to an open procedure. Below, are the new definitions.
- Percutaneous: Image-guided procedures (e.g., CT or fluoro) performed with indirect visualization of the spine without the use of any device that allows visualization through a surgical incision.
- Endoscopic: Spinal procedures performed with continuous direct visualization (e.g., eye, microscope or endoscope) of the spine through a surgical opening.
- Open: Spinal procedures performed with continuous direct visualization of the spine through a surgical opening.
- Indirect Visualization: Image guided (eg. CT or fluoroscopy), not light-based visualization.
- Direct Visualization: Light-based visualization; can be performed by eye, or with surgical loupes, microscope, or endoscope.
Endoscopic Decompression of Nerve Roots
New code 62380 provides for the endoscopic decompression of the spinal cord or nerve roots, but requires laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated disc, 1 interspace, lumbar.
Exceptions to Direct Supervision. There are two new exceptions to the “incident-to” billing concept where the MD does not have to be in the office to bill under this concept, i.e., only “general supervision” is required. Those two exceptions are transitional care management (99495-96) and chronic care management (99490).
Definition of General Supervision. “General Supervision” is defined now at 42 CFR 410.26 as follows:
. . . the service is furnished under the physician’s (or other practitioner’s) overall direction and control, but the physician’s (or other practitioner’s) presence is not required during the performance of the service.
Bill Under the Supervising Physician. Additionally, CMS now states that the supervising practitioner for billing purposes “need not be the same physician (or other practitioner) who is treating the patient more broadly. However, only the supervising physician (or other practitioner) may bill Medicare for incident to services.” So, if the regular physician is out of the office, the physician who is in-house and supervising that day must bill the mid-level’s service if incident-to billing is utilized. The mid-level should document who the supervising physician is and that he/she is in the office and immediately available.
99024 for Bundled Visits
Visits During Global. This is the code for an E/M visit performed during the global period.
Required Billing. Effective July 1, 2017, practitioners in a group of 10 or more “practitioners” in the following 9 states must bill 99024 for visits during the global period: FL, KY, LA, NV, NJ, ND, OH, OR, and RI.
Which Codes. CMS will publish a list of procedures regarding which the 99024 code must be billed. Consult the CMS website.
Penalty for Failure to Report. If you don’t report, CMS may impose a 5% penalty in the future to “encourage” this reporting.
Deleted Codes. The physical therapy (PT) and occupational therapy (OT) codes 97001-04 will no longer be available in 2017.
Replacement Codes. These 4 codes were replaced by 8 new codes, 97161-68.
Evaluation Codes Based on Complexity. Essentially, 2017 CPT translates the current single PT evaluation code into multiple codes that are dependent upon the level of complexity employed (typically 20/30/45 minutes). This will also be the case with the OT evaluation; 1 code will now be multiple codes. The PT and OT re-evaluation codes have also been replaced.
Always Therapy Codes. The new PT codes are “always therapy codes,” meaning that they are always considered PT codes and require the GP modifier (services delivered under an outpatient PT plan of care).
2017 Medicare Therapy Caps. The 2017 therapy cap for Medicare is $1,980.
Cryoablation of Nerves Have Temporary Codes
- 0440T – upper extremity, including imaging
- 0441T – lower extremity, including imaging
- 0442T – “truncal” nerve (i.e., brachial plexus or pudendal), including imaging
New Modifier 95. Append modifier 95 to any of the codes listed in Appendix P of the CPT manual (approximately 75 codes, most of which are E&M and psych codes).
New Place of Service (POS). Both the facility where the patient is and the location where the practitioner is must utilize POS 02.
Billing Requirements. In order to bill these telehealth services, the following requirements must be met:
- The service furnished must be on the list of telehealth services;
- The service must be furnished via an interactive telecommunication system;
- The service must be furnished by an authorized practitioner;
- The patient must be in a telehealth originating site; and
- The patient must be an eligible telehealth patient.
Payment. Medicare pays both a facility fee to the originating site and a physician fee to the practitioner furnishing the service.
Telephones and Emails. Telephone, fax, and stand-alone email are not interactive telecommunication systems.
New Critical Care G Codes. New codes G0508 and G0509 are designed for critical care rendered via telehealth, and are effective January 1, 2017.
Medicare can now recoup overpayments against a provider who shares a TIN with an “obligated provider” who owes Medicare money, regardless of whether that provider is assigned a different Medicare billing number or NPI from the obligated provider.
New Code for Assessment of Cognitive Impairment
Medicare adopts a new G-code for the assessment of cognitive impairment, such as Alzheimer’s or dementia. The AMA, via CPT, has indicated it will adopt a similar code in 2018. Code G0505 cannot be billed on the same DOS as new patient and established patient E/M codes (99201-99215), or certain psych codes.
Placement/Replacement of Stimulator/Leads for Sleep Apnea – T Codes
Placement, revision, removal, and other related codes pertaining to a generator and stimulator leads for sleep apnea are contained in the temporary codes (a/k/a emerging technology codes) 0424T-0436T.
New Anti-Discrimination Requirement – Translation Services
Final Rule. Earlier this year, the Dept. of Health & Human Services (DHHS) released a rule that requires specified notices to be published by certain healthcare providers. This rule acts to implement Section 1557 of the Affordable Care Act (ACA).
Requirements. The Final Rule will require groups receiving federal financial assistance (defined to include the acceptance of Medicaid) to do the following:
- Post a notice of non-discrimination in a conspicuous area where the group deals with the public, stating that the group does not discriminate, and offers free language assistance services;
- Post that same notice on the group’s website, with a link on the home page to the anti-discrimination notice;
- Post “tag lines” in the top 15 non-English languages in each group’s state, stating that if the patient needs language assistance services, they are provided free of charge, with a telephone number to call to arrange for those services;
- Develop a language assistance plan to provide free language assistance services to the disabled and those with LEP (Limited English Proficiency);
- If you have 15 or more employees, appoint a compliance coordinator to assure compliance with these rules;
- If you employ 15 or more employees, develop grievance procedures so the patient can file a grievance with your compliance coordinator; and
- Submit a signed Assurance of Compliance form to DHHS.
Defining Financial Assistance. This rule applies to any entities or physician groups who accept financial assistance from the federal government; accepting Medicaid is considered as financial assistance. So, if you accept Medicaid, you are required to follow this rule.
Government Published Forms. The government has done most of the heavy lifting for you. First, the government has published the anti-discrimination notice that must be posted. Second, the government has a website where the top 15 languages in each state are listed, so you know which taglines, in which languages, you must include in your notice. Third, the government’s website contains a document listing what the top 15 tag lines must say in each of 64 possible languages. Fourth, the government has created the Assurance of Compliance Form which must be signed and mailed to DHHS (Form HHS 690). (See www.hhs.gov/civil-rights/for-individuals/section-1557/translated-resources/index.html for taglines.)
Anesthesia and Pain Groups. For anesthesia groups, it is possible that the facility may post the notice for you, and may even provide the language assistance services (you need to verify both of these items), but if you have a website, you must still post the notice on the website and submit the Assurance of Compliance form. For pain groups, the burden falls on you to post the notice and taglines, which would typically be posted in the waiting room and on your website.
DHHS Website. Most of the forms you need are on the DHHS website. You will know you are in the right place if you have reached a page entitled, “Translated Resources for Covered Entities.” You will have to “google” “HHS Form 690” which will get you to the Assurance of Compliance form that must be signed and filed with DHHS.
OIG 2017 Work Plan
The OIG has announced that it is going to target for investigation the following areas with regard to chronic pain.
- Orthotics. Review the reasonableness of pricing on back and knee braces.
- Orthotics. Review orthotic claims for compliance with LCDs.
- Transitional Care Management. Review the accuracy of billing for transitions from inpatient to LTAC, rehab, nursing home or home.
- Chronic Care Management. Review the billing where non-face-to-face care is billed for patients with 2 or more significant chronic conditions that place the patient at risk of death and which are expected to last 12 months or until death.
- DME. Must be enrolled in Medicare to order durable medical equipment.
- Prolonged Services. Review medical necessity of these claims.
- Drug Wastage in Single Use Vials. Determine whether requiring manufacturers to lower the volume in single use vials can reduce cost.
I wish to thank Baton Rouge healthcare attorney David Vaughn for providing the bulk of the above information.
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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.