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Table of Contents:
April 2015
Ask the Coder
Pathology Spotlight
Build your Business
Countdown to ICD-10
NewsFlash
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Ask the Coder
2015 Changes to Medicare PQRS Measure
#249 - Barrett’s Esophagus
Clinical Info/Hx: 70 y/o Medicare patient with GERD
Date of Service: 1-1-15
Gross Description: Received in formalin, labeled
esophageal biopsy, are three fragments of tan tissue
measuring 0.2 to 0.6 cm in diameter. Submitted in toto
-1 cassette.
Final Microscopic Diagnosis: Glandular mucosa
with Barrett’s esophagus - low grade dysplasia. No
malignancy.
What are the appropriate CPT, CPT II, ICD-9, and
ICD-10 codes for this scenario?
Specimen
CPT
CPT II
Codes
Esophageal
Biopsy
88305
3126F
ICD9-CM
ICD10-CM
530.85 –
Barrett’s
Esophagus
K22.710 –
Barrett’s
esophagus with
dysplasia – low
grade
CPT / CPTII:
Esophageal biopsy is a listed specimen in Current
®
Procedural Terminology (CPT ) as 88305.
Since the CPT and diagnosis coding combination of
88305 and 530.85 meet the requirements for PQRS
measure #249, the report should be reviewed to
determine if the requisite documentation regarding
dysplasia is included in order to assign the appropriate
PQRS/CPT II code. The 3126F should be assigned
due to the documentation of Barrett’s esophagus with
a statement regarding dysplasia defined as low-grade.
2015 CPT II Code Definition for 3126F:
Esophageal biopsy reports with the histological finding
of Barrett’s mucosa that contains a statement about
dysplasia (present, absent or indefinite, and if
present, contains appropriate grading).
Important PQRS Reminders:
• Providers must report on a minimum of nine
measures. If less than nine measures apply,
report on ALL measures that do apply.
• Effective Jan. 1, 2015, CPT II codes 3125F,
3125F-1P and 3125F-8P are no longer
accepted by Medicare. The new codes are
3126F, 3126F-1P, and 3126F-8P.
ICD-9 CM:
Barrett’s esophagus with low-grade dysplasia.
2015 ICD-9 Manual Alphabetic Index: Barrett’s
esophagus 530.85
ICD-10 CM:
Barrett’s esophagus with low-grade dysplasia.
2015 Draft ICD-10 Manual Alphabetic Index: Barrett’s
esophagus – with dysplasia – low grade K22.710
• K22.7 is the primary description of Barrett’s
esophagus
th
• 5 digit of 1 defines that dysplasia is present
th
• 6 digit of 0 defines the dysplasia as low
grade
References:
2015 CPT Professional Edition Manual, American Medical
Association (AMA), page 539.
2014 ICD-9-CM Professional Manual (AMA), pages 131, 818.
2015 Draft ICD 10-CM Manual (AMA), pages 35, 617.
Beth McDevitt, CPC
Compliance – pathology and laboratory
McKesson Business Performance Services
This commentary does not supplant the American Medical
Association’s (AMA) current listing of Current Procedural
Terminology (CPT®) codes, its documentation in the annual CPT
Changes publications, and other related publications from the AMA,
which are the authoritative source for information about CPT
codes. Please refer to your 2015 CPT Code Book, annual CPT
Changes publication, HCPCS Book and Payer Bulletins for
additional information, including additions, deletions, changes, and
interpretations that may not be reflected in this document.
CPT is a registered trademark of the AMA. The AMA is the owner of
all copyright, trademark, and other rights to CPT and its updates.
MLN Matters® is a registered trademark of the U.S. Department of
Health and Human Services.
Pathology Spotlight
Pathology Coding Contingent on
Documentation The Golden Rule: `Not
documented, not done’
Strong documentation is the key to effective coding.
Without accurate clinical notes, compliance risks
increase and reimbursements are reduced.
ReveNews recently spoke with McKesson certified
coders about common documentation errors in
pathology.
Pathologists are costing themselves money each time
they fail to include a key word or words in their
pathology reports, according to Jerri Lea Key, SCC,
CPC, director of pathology coding for McKesson
Business Performance Services (McKesson).
“The golden rule in coding is `not documented, not
done’,” Key said. “As coders, we’re only as good as
the documentation that is provided to us.”
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ReveNews Pathology
Experience has shown that merely adding one key
word can significantly reduce a practice’s
variance/error rate, Key said. Pathologists should
incorporate language and key words found in the CPT
descriptors when dictating their final pathology report,
she added.
Physicians should keep in mind that auditors also
follow the “not documented, not done” rule. And
because most auditors are not specialty trained, they
typically will reject any service provided – however
routine it may be -- that isn’t clearly spelled out in the
clinical notes. Doctors therefore can better withstand a
coding audit and improve their changes of avoiding
refunds to the payer if they use CPT common
procedural language in all cases.
Common Mistakes
Here’s an example of what can happen when the
correct language is omitted: Both the pathologist and
coder know that the decalcification process was
performed in connection with a bone marrow case.
However, because the word "decal" was not included
in the final pathology report, the coder is prevented
from applying CPT code 88311 for the service. This, in
turn, results in lost revenue.
Another area where seemingly insignificant omissions
can lead to lost revenue involves breast specimens. If
the pathologist states that he or she reviewed the
surgical margins, the CPT code applied should be
88307. But failing to mention the margin review means
the coder must apply the lower CPT code 88305.
Similarly, physicians should always include the
methodology utilized for cytological specimens. Not
mentioning the fact that the specimen was performed
using a liquid-based methodology would likely mean
the coder would have to apply a lower valued CPT
code.
Key said that when McKesson coders are asked to
evaluate documentation and coding for potential
clients, the most common error seen involves applying
codes for services that were not documented in the
physician’s report. Ironically, the second most frequent
error is just the opposite: Not billing for services that
were clearly documented.
ICD-10 Coming
“The pathology report is the roadmap coders must
follow to code and file a claim,” Key said. “If that map
is incomplete or inaccurate, it basically means the
physician won’t get paid for all the services provided. It
is therefore critical that pathologists invest the time to
make their documentation as accurate, consistent and
complete as possible.”
include not just ICD-10-related training but any
other educational opportunity that allows coders to
keep pace with the almost non-stop changes in
the coding field.
She added: “The key to a healthy practice is to start
with good, clear documentation. This leads to clean
claims and hopefully, a quick turnaround with accurate
reimbursement.”
And as important as accuracy is in today’s
environment, detailed and precise clinical notes will
become even more essential once the ICD-10 code
sets take effect in October of this year, Key said. ICD10 documentation requires considerably more clinical
and anatomical specificity than the current ICD-9
system.
“There obviously is some risk associated with
providing training opportunities, since you’re
making your people more marketable and some
may jump ship,” Gullotti said. “But it’s a risk worth
taking. Not only are you helping them improve the
quality of their work, but you’re also demonstrating
a commitment to their professional development.”
•
Recognition and Accolades – Simple though it
may sound, providing formal recognition for a job
well done can go a long way toward cementing
coder loyalty. This recognition, based on a coder’s
demonstrated superior quality and/or production
skills, can be conveyed via a certificate, group
email, one-on-one meeting with a manager,
departmental meeting or some combination
thereof. The process should occur at least on a
quarterly basis.
•
Workplace Flexibility –Coders also should be
given a range of options regarding scheduling.
McKesson, for example, which employs more than
650 certified coders to support its billing and
accounts receivable management outsourcing
customers, allows coders to choose from 8-to-4, 9to-5 or 7-to-3 shifts, depending on the
requirements of their personal life.
•
Reasonable Job Duties and Expectations –
Burnout is a problem in coding, so it is important
that employers take steps to make tasks
manageable and predictable. As nearly as
possible, schedules should be kept to 40 hours
per week. Overtime – particularly on weekends –
should be avoided.
Build your Business
Are Your Coders Happy? Retention
Strategies Key to ICD-10 Success
For hospitals and physician practices, a successful
ICD-10 transition in the fall will largely depend on the
skills and training of the coders they employ. That’s
why avoiding coder turnover will be essential for all
providers in the weeks and months ahead.
Yet holding onto coders may prove difficult. The
coding industry has long been understaffed, and
demand will only increase as providers scramble to
meet the October 1 go-live date. Competition for
certified coders and resulting higher wages will likely
cause many to consider moving on.
Todd Gullotti, vice president of Shared Services for
McKesson Business Performance Services
(McKesson), said developing strategies to retain
coding staff is critical for two reasons: Staff stability will
help ease the transition next October, and it will also
protect the investment providers already have made in
training coders for the ICD-10 code set.
Employers also should guard against “scope
creep,” or the tendency to load coders up with
ancillary tasks that aren’t central to their jobs.
These can include searching for medical elements
that aren’t included in the documentation, or being
asked to complete other kinds of clerical work not
connected to coding. Put simply, it is the duty of
the employer to make daily workflows consistent,
reasonable and simple.
Keeping salary and benefit packages competitive is
arguably the most important step practices can take to
reduce turnover, Gullotti said. But providers should
also look beyond money to consider other techniques
that can improve the odds that coders will stay put.
Consider:
•
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Training and Education – Gullotti said
organizations should be willing to provide a wide
range of training and education opportunities to
coders at no cost to the individual. These can
ReveNews Pathology
•
Professional Respect – It is human nature for
those in positions of power to sometimes take for
granted the contributions others make. Highly
educated physicians consequently may need to be
reminded that coders have a high level of
competency and are trained in a complex and
difficult discipline.
“I’m not an accountant, so I go to one to do my taxes,”
Gullotti said. “And I’m not a mechanic, so I go to one to
get my oil changed. Medical coding is the same kind of
thing. You rely on coders because they have the
expertise to do the job correctly.”
Countdown to ICD-10:
CMS Completes Successful End-to-End
Testing
Held January 26 through February 3, the testing
involved 661 entities and about 1,400 National
Provider Identifiers (NPIs) submitting nearly 1,500
claims either directly to CMS or through
clearinghouses and Medicare Administrative
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Contractors (MACs.)
19% Error Rate
End-to-end testing simulates real-world claims
submission to determine if payers can accurately
recognize, adjudicate and pay an ICD-10-coded claim.
Of the 14,929 claims submitted during the recent test
period, 81% were accepted, CMS reported.
•
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2
3
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3% were rejected for invalid submission of
ICD-9 diagnosis or procedure code.
3% were rejected for invalid submission of
ICD-10 diagnosis or procedure code.
End-to-End Testing Fact Sheet, Centers for Medicare & Medicaid
Services, February 2015,
http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2015Jan-End-to-End-Testing.pdf
Ibid.
Ibid.
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ReveNews Pathology
Cindy Slocum, project manager, ICD-10
implementation for McKesson Business Performance
Services (McKesson), said the company submitted
claims to four MACs during the testing period. The
claims were for a variety of specialties, including
radiology, pathology, E&M services, and emergency
medicine.
A valid sample?
Although the Medicare testing results were positive,
Slocum cautioned that only a small number of claims
were processed.
“Overall, participants in the January 26 to February 3
testing were able to successfully submit ICD-10 claims
and have them processed through our billing systems,”
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CMS said in a prepared statement.
•
13% were rejected for non-ICD-10 related
errors, including issues setting up the test
claims (e.g., incorrect NPIs, health insurance
claim numbers, submitter IDs, dates of service
outside the range for valid testing, invalid
HCPCS codes, and invalid place of service).
Overall, the majority of McKesson claims were
successfully processed, with an error rate well below
the 19% error rate experienced across the entire endto-end simulation. Slocum attributed the lower
McKesson error rate to the company’s decision in late
2013 to begin transitioning McKesson coders to the
ICD-10 codes via an early adoption program.
Cautious optimism about Medicare’s ability to handle
claims once the new ICD-10 code sets take effect
emerged in the wake of limited, invitation-only end-toend testing by the Centers for Medicare & Medicaid
Services (CMS).
Causes of disallowed claims were, according to CMS:
•
“When the testing is so limited in scope, it is difficult to
say with any degree of certainty that the systems are
going to be able to process the millions of ICD-10
claims that are going to be coming in starting next fall,”
she said. “I think everyone would feel better if the
testing could be significantly expanded.”
CMS plans two more end-to-end testing sessions
before the implementation deadline:
• April 27 through May 1, for volunteers that
have already been selected;
• July 20 through July 24, for volunteers
applying after March 13.
Avoiding a repeat of 5010
Given that the majority of claim rejections in the recent
test stemmed from protocol and process issues,
Slocum said she was concerned about a possible
repeat of the 2012 transition to the Version 5010
standard for electronic transactions.
The standard, which was mandated by the Health
Insurance Portability and Accountability Act (HIPAA),
was designed to improve the security of medical
claims. However, Slocum said many payers, including
a number of MACs, were not technically ready to
accept the standard on the Jan. 1, 2012 deadline.
As a result, physician payments were delayed and
some organizations experienced acute cash flow
problems. “It was a nightmare for the industry, and no
one wants to see a repeat of that with ICD-10,” Slocum
said.
Commercial carriers prepare
While the recent CMS tests focused on Medicare
claims, commercial payers also have been engaged in
end-to-end testing, Slocum stated. Although some are
further along than others, Slocum said that “for the
most part, everybody knows what they need to do and
are setting up systems to complete end-to-end
testing.”
home and hospital care, the Centers for Medicare &
Medicaid Services (CMS) is now paying primary care
physicians a monthly stipend to manage patient care
even if they do not see the patient in person. CMS will
pay a primary care physician $40 per month to
develop and maintain a patient care plan and
coordinate care with other physicians including
medication management and 24-hour availability to
their health care team for after-hours issues.
With a majority of Medicare patients having two or
more chronic conditions, including heart disease,
kidney disease or diabetes, coordination of care is
essential to avoid multiple treatments for the same
illness, duplicate tests and medication interactions.
She said McKesson is monitoring 125 commercial
payers to track their ICD-10 readiness levels.
The new CMS policy shift hopes to provide physicians
an incentive to spend more time addressing patient
needs and preventative care without an office visit
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being necessary.
“It’s important that practices identify who their major
carriers are and communicate with them about their
ICD-10 implementation plans,” she added.
Federal Fraud and Abuse Laws Apply to
Medicare Advantage, Too
Data feeds to smooth transition
As part of their preparation work, Slocum said it is
imperative that practices also assess the readiness of
their clinical partners to provide outbound data feeds
for demographic and charge information. If hospitals
aren’t ready or are slow in establishing the necessary
system interfaces, physician practices could take a
significant financial hit.
Of particular importance are hospital IT conversions
underway or planned for the second half of 2015.
Without ample lead time, she said, it will be difficult for
any billing entity to complete the necessary interfaces
and ensure uninterrupted data feeds.
To head off these problems, Slocum advised practices
that bill in-house as well as those that outsource to
reach out to their facilities to learn more about the
facility’s ICD-10 plans. In the case of McKesson
clients, groups should also work to facilitate direct
communication between the hospital and the
McKesson client manager.
In February, a doctor in Florida was charged with
healthcare fraud by a federal grand jury. The
physician’s clinic was included in Humana’s health
maintenance organization (HMO) network of primary
care physicians (PCPs) as part of Humana’s HMO
Medicare Advantage Plan. These programs are
funded with Medicare dollars and therefore fall under
the federal healthcare fraud and abuse statutes.
The physician’s practice in question allegedly
submitted fraudulent diagnoses to Humana that
resulted in higher Medicare Advantage capitated
payments to Humana, allowing the physician to
receive higher monthly payments from Humana.
Physicians submitting claims under the Medicaid
Advantage program must be aware of the laws
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governing such federally funded programs.
Massachusetts Blues Has an Offer
Doctors Might Refuse
Blue Cross and Blue Shield of Massachusetts plans to
introduce global budgets in its preferred provider
NewsFlash
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Medicare Starts Paying Doctors to
Coordinate Chronic Care
5
To promote better health for vulnerable Medicare
patients between physician visits and to avoid nursing
5
ReveNews Pathology
”Medicare starts paying doctors to coordinate chronic care”, The
Daily Briefing, The Advisory Board, Jan. 13, 2015. (last accessed
March 20, 2015)
Rodriguez, Todd, “Federal fraud and abuse laws apply to
Medicare Advantage too”, Physician Law, March 16, 2015. (last
accessed March 20, 2015)
organization (PPO) health plans and is approaching
medical groups in the state with a proposal similar to
Medicare’s accountable care contracts.
It is unclear how many providers will be interested in
the alternative contracts. The PPO plans represent
615,000 beneficiaries and one-third of the network
6
contracts have until the end of 2015 to be renewed.
If they keep medical costs below budget, medical
groups choosing the model would be rewarded. Most
Mass Blues HMO network providers already have
global budgets and the carrier hopes to provide
incentives to doctors to further manage costs by
expanding them to its PPOs.
Because the ability to control costs is weaker under
PPO plans, physicians would lose money if spending
exceeds the budget. A provider that is not willing to
take the risk has the option of continuing to participate
under fee-for-service contracts that pay for each office
visit, test and procedure.
While HMOs have saved doctors 6.8% to 8.8% in
Massachusetts global budget HMOs, PPOs give
patients more freedom, allowing for out of network
care with no primary-care doctor required.
Massachusetts providers are questioning the risk of
PPO global budgets due to lack of influence over
patient choices and uncertainty of patient population
7
attributed to their performance.
Four More States Needed to Trigger
Streamlined Interstate Doc Licensing
Utah is the third state, following Wyoming and South
Dakota, to join the Federation of State Medical Board’s
(FSMB’s) interstate compact regarding the physician
licensing process. The model legislation created by the
federation designates patient location, not doctor
location, as the place where medical practice occurs.
The system, to go into effect, needs four more states
to join the effort to facilitate telemedicine growth.
The FSMB legislation model will centralize
credentialing requirements making it easier for
physicians licensed in one state to be quickly licensed
in another. The move will promote greater participation
in telemedicine care allowing states to attract more
physicians.
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7
6
Evans, Melanie, “Mass. Blues has an offer doctors might refuse”,
Modern Healthcare, March 12, 2015. (last accessed March 27,
2015)
Ibid.
ReveNews Pathology
Comparable physician licensing bills are awaiting
governor signatures in Idaho, Montana and West
Virginia. Similar bills have been introduced in
Alabama, Illinois, Iowa, Maryland, Minnesota,
Nebraska, Nevada, Oklahoma, Rhode Island, Texas
8
and Vermont.
New RARC Alerts Providers about
Upcoming Transition to ICD-10
“By mid-April, providers will begin seeing a new
Remittance Advice Remark Code (RARC) N742 on
their Remittance Advices (RAs), “Alert: This claim was
processed based on one or more ICD-9 codes. The
transition to ICD-10 is required by October 1, 2015, for
health care providers, health plans, and
clearinghouses. More information can be found at
http://www.cms.gov/Medicare/Coding/ICD10/Provider
Resources.html.” Medicare Administrative Contractors
will start using the new RARC in April. Since RARCs
are an industry standard, the new RARC has been
available for other health plans to use since March 1,
2015.
This is another example of the unprecedented level of
outreach by CMS to prepare the health care
community for ICD-10. CMS has a very mature and
rigorous testing program for its Medicare Fee-ForService claims processing systems and has completed
extensive testing in preparation for ICD-10. CMS is
ready for ICD-10 and encourages medical practices
and hospitals that bill Medicare to complete their
preparations for the October 1, 2015, implementation
9
date.”
If you have questions about information contained in this issue of
Pathology ReveNews, or would like more information about
McKesson’s Business Performance Services please contact your
account manager or contact us at 800.722.5219, e-mail
pathologyinfo@mckesson.com or visit
www.mckesson.com/bps/pathology
Copyright © 2015 McKesson Corporation and/or one of its
subsidiaries. All rights reserved. All other product or company
names mentioned may be trademarks, service marks or registered
trademarks of their respective companies. This publication is not
intended to constitute legal, accounting, financial, investment or
other professional advice. Any business decisions should be made
in consultation with your legal, professional and accounting advisors.
5995 Windward Parkway, Alpharetta, GA 30005
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9
Robeznieks, Andis, “Four more states needed to trigger
streamlined interstate doc licensing”, Modern Healthcare, March
23, 2015. (last accessed March 27, 2015)
MLN Connect. Provider ENews. March 26, 2015. CMS.gov