UHC No Longer Reimbursing for Consult Codes
Effective for claims with dates of service on or after Oct. 1, 2017, UnitedHealthcare will reimburse the appropriate evaluation and management (E/M) procedure code which describes the office visit, hospital care, nursing facility care, home service or domiciliary/rest home care reported in lieu of a consultation services procedure code. This notification will be the first of several communications to clarify this change in reimbursement strategy supporting our commitment to the Triple Aim of improving health care services, health outcomes and overall cost of care.nnUnitedHealthcare will align with the Centers for Medicare & Medicaid Services (CMS) and no longer reimburse consultation services represented by CPT codes 99241-99245 and 99251-99255. At the time of the original CMS decision to no longer recognize these consultation services procedure codes, UnitedHealthcare began pursuit of data analysis and trending to better understand the use of consultation services codes as reported in the treatment of our commercial members. Similar to CMS’s findings, our extensive data analysis has revealed misuse of consultation services codes for this population.nnThe current Relative Value Unit (RVU) assignments reflect numerous changes made during recent years to both E/M codes and other surgical services creating an overall budget neutral experience supporting this strategy as a more accurate reflection of services rendered.n
New Policy – Advanced Practice Health Care Professional Evaluation and Management Procedures Policy
nEffective for claims with dates of service on or after Sept. 1, 2017, UnitedHealthcare will require physicians reporting evaluation and management (E/M) services on behalf of their employed Advanced Practice Health Care Professionals to report the services with a modifier to denote the services were provided in collaboration with a physician. UnitedHealthcare will accept the modifier SA on claims for these services when provided by nurse practitioners, physician assistants and clinical nurse specialists.nnIn addition, the rendering care provider’s National Provider Identifier (NPI) must also be documented in field 24J on the CMS-1500 claim form or its electronic equivalent. Use of the modifier SA and documentation of the rendering care provider will assist UnitedHealthcare in maintaining accurate data with regard to the types of practitioners providing services to our members.nnFor more information, call 877.842.3210 or visit UnitedHealthcareOnline.com.
Welter Healthcare Partners is excited to present our monthly Code Spotlight! Each month, Welter Healthcare Partners will spotlight a unique CPT or ICD-10 code to profile and discuss practice applications of the code, as well as pertinent guideline reminders.nnM48.062 – Spinal Stenosis, lumbar region, with neurogenic claudicationnThe list of ICD-10 code updates is extensive and lumbar spinal stenosis got a makeover with this year’s revision. The previous code M48.06 – Spinal stenosis, lumbar region will no longer be valid as of October 1st. There are now two new code options to replace the old code. These options now include specificity for neurogenic claudication. Spine surgeons and coders will be excited to finally have a code to capture this level of specificity!nnIt is important for coders to understand the clinical definition of neurogenic claudication. “Neurogenic claudication is the medical term used to describe the symptom of pain induced by walking,” according to spinal-healthcare.com, which goes on to call the condition “a hallmark symptom of lumbar stenosis.” Clinical documentation should include indications of trouble walking in the operative notes. If there is no indication of ambulatory issues or other signs of neurogenic claudication, you’ll assign the code for lumbar stenosis without neurogenic claudication; if the note describes the patient as having ambulatory issues due to stenosis, this could indicate claudication, in which case you’ll need to assign M48.062.
As part of the new coding format for our newsletter, Welter Healthcare Partners is excited to offer you a new surgery coding series in which we want to help you! The 2nd week of every month we will highlight a complicated surgical case. This week we are highlighting a general surgery case. We want to hear from you! If you have a complicated surgery case and need help with coding, please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. Click Here To Submit Redacted Surgery Case Study. 
As a result of the many provisions of the Affordable Care Act (ACA), the CMS Innovation Center (CMMI) was created to promote quality healthcare, stronger health outcomes, and encourage fiscal responsibility. CMMI acts as the facilitator for designing the most efficient payment methodology for reimbursing healthcare providers based on value rather than volume. CMMI also provides a platform for doctors, stakeholders, and other health care partners to participate in a collaborative process for generating the ultimate pay-for-performance model.nnCMMI is responsible for the implementation and oversight of Quality Payment Program (QPP), which aligns all other incentive programs such as Meaningful Use, Value Based Payment Modifier, and PQRS. Practices will begin to see the financial impact of QPP starting in 2018. Upcoming CMMI initiatives include:n
Biomechanical Device Coding: Spine surgery has been one of the specialties hardest hit by recent CPT code bundling, NCCI edit updates, code revisions and additions, and RVU decreases. Most recently, biomechanical device coding changes were implemented, which impacts many spine surgery practice’s bottom lines. This change essentially states that all anterior instrumentation is now bundled with device anchoring. This will affect all operative anterior spinal procedures that involve instrumentation and caging. CMS has stated they will only allow use of modifiers to bypass these bundling edits if the surgeon performs additional anterior instrumentation unre¬lated to anchoring the device. However, clinical documentation must support the medical necessity and detail the procedure at great length. It is imperative that spine surgery practices understand the fundamentals of compliant coding and clinical documentation as it pertains to these changes.n