Health Hazards in China… Fun with ICD–10
Z77.110 — Contact with and (suspected) exposure to air pollutionnnZ77.128 — Contact with and (suspected) exposure to other hazards in the physical environmentnnK90.1 — Cochin-China diarrhea
R. Todd Welter Visits 5 Beijing Hospitals in 5 Days
Welter Healthcare Partners is thrilled to announce that our own R. Todd Welter recently revisited Beijing, China to work directly with healthcare professionals in providing insight to the American Healthcare System.nnCEO of Welter Healthcare Partners, R. Todd Welter went to visit 5 hospitals in 5 days in a whirlwind trip to Beijing, China (now a city of over 20 million people) to provide area medical professionals with insight to how the American Healthcare System works. Welter spoke on topics of medical coding and revenue cycles… and a bit about American politics.nnWelter visited China back in 2004 for a similar trip, and the hospital associates there were anxious to meet with the American medical billing and healthcare expert again. For insight into his trip, and a review of the 2004 venture, check out an article by Welter, below.n
Third-Party Payer Committee
nBy Todd WelternnBilling and Coding, Medical Records and Managing HealthcarennI am in Beijing China, a city of over 10 million. I was invited by a Swiss company to attend The Chinese Orthopedic Association’s National Congress. Over 2,500 Chinese physicians will attend to hear discussions on the latest surgical procedures, new products, and new ideas on patient care. I have traveled with my friend Dr. Michael Janssen, an internationally known and well-respected orthopedic spine surgeon. Dr. Janssen has an orthopedic spine surgery practice in Thornton, Colorado.nnIn addition to our official duties, the obvious tourist opportunities, and the many complex social events we are invited to, I am determined to learn as much as I can about the Chinese healthcare system, how it is financed, how records are kept, and how the physicians are compensated (who said healthcare business consulting is boring?)nn[vc_toggle title=”CLICK HERE TO READ MORE” size=”sm” el_id=””]The Chinese system for coding is not as specific as ours. Even though they perform essentially the same services and procedures, they record very basic, general service descriptions. They then have a fixed fee schedule for all services. The patient pays for medical care, many times in advance. If it is not paid for, it is simply not done.nnThe Chinese people, those living in the larger cities at least, have insurance. In China, employers pay for the insurance. Most of the time the insurance pays very minimally and the remainder is paid by the patient or their family or outright by their employer.nnI am visiting the Beijing General Military Hospital, a sprawling 1,100 bed facility in the heart of Beijing, a few minutes from Tiananmen Square. Our hosts tell me that this is the best hospital in all of Beijing. I find the facility to be very “1950’s Institutional.” Stark white tiled walls and floors. No patient amenities (televisions, bathrooms in the rooms, etc.). Other than that, the set up is very similar with one very notable exception. In China, the patient’s family is expected to play a big part in the patient’s care. The patient’s family does a lot of what we call nursing care (food, patient comfort, even moderate physical therapy). Every patient room I saw had at least one extra bed in it for a family member.nnI was very privileged to be able to discuss the Chinese systems of record keeping, coding, charges, and reimbursement with the hospital’s Vice President of Finance who is also a gastroenterologist. All the physicians at this hospital are employed by the hospital. Many have apartments on the grounds of the massive complex. Physicians are paid a salary and then receive bonus pay based on their productivity (number of cases, patients seen, etc.). Physicians are also able to receive additional compensation for a wide variety of other efforts, some officially frowned upon but openly accepted.nnThe hospital and physicians use a single electronic medical record. Computers throughout the facility are able to access a patient’s record, charges, physician notes, nursing notes, etc.nnOne area of great difference is the concept of outpatient surgery. The Chinese do not perform “outpatient surgery.” Part of our visit to the facility included a session with the Orthopedic Department to do case reviews. There was a kind of International Grand Rounds done with Dr. Janssen from Denver and a physician from Prague. The Chinese physicians discussed several cases and presented their x-ray results, including MRI. As it turns out, a procedure that could be done in Denver in 30 minutes with a 4-hour stay in an outpatient facility would result in at least a 2-day in-patient stay in China.nnThe Chinese system appeared to equal ours; in fact they perform the same complex procedures we perform (open heart surgery, complex spine and neurosurgery, transplants, etc.) in addition to all the more routine services. Their system was, however, remarkable for it being less efficient than ours. On the provider side, it appeared that their system is hospital-centered rather than physician-centered. They therefore, don’t seem to be as concerned about seeing as many patients as possible, turning around O.R. rooms quickly and getting the patients out of the hospital as soon as possible. I was struck by this difference.nnBased on this trip, other international visits, and even many domestic observations, I am starting to conclude that the American system of healthcare, with all its apparent blemishes, owes its efficiency to American physicians playing such an important role in it. The concept of system efficiency is lost to the Chinese, because it is a hospital-centered system. The lesson in this may be to protect and, in fact, strengthen the physician’s role in healthcare rather than allow it to continually erode. It appears, by observation, that when there is a system which does not allow the physician to initiate care, make decisions, order, admit and discharge while compensating him/her to do so in a way that values this expertise, the system suffers from inefficiencies, lack of creativity, and thus higher costs.nnBeing a coder at heart, I brought a 2004 CPT book with me and showed it to them. Its level of detail mesmerized them. We agreed to exchange pricing information and I was allowed to photograph much of the facility including patient rooms, patients, and even a medical record. (Something we could never do here.) The company who invited me to China is sending me a large package of information on the Chinese healthcare system for follow-up.nnThe President of the Beijing General Military Hospital presented us gifts. He gave Dr. Janssen the title of Honorary Chairman of the Orthopedic Department (a very high honor) and presented me with a traditional Chinese tea set (something we will cherish at my home). I plan to send him a copy of John Fielder’s book of Colorado photographs and, of course, a CPT book.nnThis article originally posted on CMGMA.com.[/vc_toggle]
CTS Thanks to the EMR! — Fun with ICD-10
G56.01 — Carpal tunnel syndrome, right upper limbnnG56.02 — Carpal tunnel syndrome, left upper limbnnZ57.8 — Occupational exposure to other risk factorsnnZ56.6 — Other physical and mental strain related to worknnY92.531 — Health care provider office as the place of occurrence of the external cause
CMS Release — Medicare Reporting and Returning of Self-Identified Overpayments
The Centers for Medicare & Medicaid Services (CMS) has published a final rule that requires Medicare Parts A and B health care providers and suppliers to report and return overpayments by the later of the date that is 60 days after the date an overpayment was identified, or the due date of any corresponding cost report, if applicable. A separate final rule was published in the May 23, 2014 Federal Register (79 FR 29844) that addresses Medicare Parts C and D overpayments.nnSummarynThe requirements in this rule are meant to support compliance with applicable statutes, promote the furnishing of high quality care, and to protect the Medicare Trust Funds against improper payments, including fraudulent payment. This rule clarifies requirements for the reporting and returning of self identified overpayments. Health care providers and suppliers have been and will remain subject to the statutory requirements found in section 1128J(d) of the Social Security Act (the Act) and could face potential False Claims Act (FCA) liability, Civil Monetary Penalties Law (CMPL) liability, and exclusion from federal health care programs for failure to report and return an overpayment. Health care providers and suppliers will also continue to be required to comply with current CMS procedures when we, or our contractors, determine an overpayment exists and issue a demand letter.nnBackgroundnSection 6402(a) of the Affordable Care Act established a new section 1128J(d) of the Act. Section 1128J(d)(1) of the Act requires a person who has received an overpayment to report and return the overpayment to the Secretary, the state, an intermediary, a carrier, or a contractor, as appropriate, at the correct address, and to notify the Secretary, state, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment. Section 1128J(d)(2) of the Act requires that an overpayment be reported and returned by the later of: (A) the date which is 60 days after the date on which the overpayment was identified; or (B) the date any corresponding cost report is due, if applicable. Section 1128J(d)(3) of the Act specifies that any overpayment retained by a person after the deadline for reporting and returning an overpayment is an obligation (as defined in 31 U.S.C. 3729(b)(3)) for purposes of 31 U.S.C. 3729. In the February 16, 2012 Federal Register (77 FR 9179),nnCMS published a proposed rule to implement the provisions of section 1128J(d) of the Act for Medicare Parts A and B providers and suppliers.nnMajor ProvisionsnThe major provisions of this final rule include clarifications around: the meaning of overpayment identification; the required lookback period for overpayment identification; and the methods available for reporting and returning identified overpayments to CMS.n
Medicare Meaningful Use Hardship Exception Application Process Changes Released by CMS
On Jan. 22, 2016, CMS issued a new application and sweeping changes to the Medicare Electronic Health Records (EHR) Incentive Program hardship exception application process. The changes are intended to temporarily ease the burden on providers seeking exemption from the 2017 Medicare meaningful use payment adjustments.nnHighlights of CMS’ guidance include:n
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- CMS may accept Medicare Meaningful Use Hardship Exception Applications for the 2015 EHR Reporting Period from EPs thru March 15, and from qualifying hospitals thru April 1, 2016.
- While CMS has not stated it will issue blanket exemptions to EPs and hospitals who failed to attest to meaningful use in 2015, the language in Section 2.2.d. of the revised Hardship Exception Application leaves open the possibility that CMS will categorically grant exemptions to those applicants asserting Section 2.2.d as the reason for their failure to timely attest to meaningful use for the 2015 EHR Reporting Period.
- Multiple providers may apply for a Hardship Exception as a group by submitting a single electronic application to CMS that includes each providers’ NPI and CCN.
- CMS’ revised Hardship Exception Application requires less information from the applicant than the old application, permitting easier filing and processing.
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nThe revised application and instructions, which are both accessible here, implement the Patient Access and Medicare Protection Act, Pub. L. No. 114-115 (Dec. 28, 2015) (PAMPA). PAMPA was passed in the last days of 2015 in the wake of provider frustration created by repeated revisions to the meaningful use criteria and CMS’ delayed release of the Stage 2 Meaningful Use Program Final Rule1 (Final Rule). CMS did not release the Final Rule until early October 2015. Consequently, eligible professionals (physicians and others subject to meaningful use as eligible professionals (EPs)) and qualifying hospitals were left with less than 90 days before year’s end to digest, implement, and attest to meeting the revised program’s criteria; yet, the Final Rule called for a 90 day data reporting period. Many EPs and hospitals also had trouble locating certified EHR technology updated for the new requirements in time to report data for the entire designated 2015 reporting period.n
nThis article originally posted on Polsinelli.com.
It’s That Time of Year Again… Stick with those New Year’s Resolutions — Fun with ICD-10
E66.01 — Other obesity due to excess caloriesnnZ68.38 — Body mass index (BMI) 38.0-38.9, adultnnZ72.3 — Lack of physical exercisennZ72.4 — Inappropriate diet and eating habitsnn
Meaningful Use to End in 2016 Per CMS
The Centers for Medicare and Medicaid Services (CMS) announced this week that it will be ending the “meaningful use” EHR Incentive Program in 2016.nnThe announcement—delivered by CMS Acting Administrator Andy Slavitt in a speech at a J.P. Morgan Healthcare Conference on Tuesday—follows months of requests from physician and other health stakeholder groups to slow the program down and loosen its requirements.nnCMS had announced stage 3 meaningful use guidelines in October which followed a series of proposed changes to the program, including payment adjustments and the creation of hardship exemptions.nnIn remarks at the J.P. Morgan conference and on Twitter, Slavitt said further specifics on exactly what will replace meaningful use will be forthcoming, though it will be tied to the implementation of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and include streamlining various quality reporting programs.nn“The meaningful use program as it has existed will now be effectively over and replaced with something better,” Slavitt said, according to a transcript of his speech. “Since late last year we have been working side by side with physician organizations across many communities—including with great advocacy from the AMA—and have listened to the needs and concerns of many. We will be putting out the details on this next stage over the next few months, but I will give you themes guiding our implementation.”nn
One of those themes focuses on shifting away from rewarding providers for the use of technology and instead centers on achieving better outcomes. He said CMS wants to offer providers the ability to customize “their goals so tech companies can build around the individual practice needs, not the needs of the government,” Slavitt said.nnAccording to Aaron Albright, director of media relations at CMS, Slavitt’s announcement is consistent with what CMS announced in the stage 3 final rule in October.nnAt that time, CMS stated that: “This rule moves us beyond the staged approach of ‘meaningful use’ by 2018 and helps us collectively move forward to a system based on the quality of care delivered, as opposed to quantity. We will use this feedback to inform future policy developments for the EHR Incentive Programs, as well as consider it during rulemaking to implement MACRA, which we expect to release in the spring of 2016 and other rulemaking as appropriate.”nnWhat remains to be seen, however, is whether CMS will still penalize eligible providers for not meeting stage 1 meaningful use requirements, or whether eligible providers should even bother continuing to track their progress on the meaningful use measures for reporting this year. Albright declined to respond to those questions at press time.nnThis article originally posted on AHIMA.org.
Value Based Contracting
We have been saying it for years. Value Based Contracting is coming and in many markets it is here…and it is here to stay! nnIt is not a bad thing as long as it is transparent! Follow the money, if you cannot you should not sign the agreement! As in all economic transactions, both sides (all sides) need to be able to see and understand very clearly how it works. There are two messages here: 1) Value Based Contracting is a Market Solution – it is not and cannot be a ‘one-off’ solution where one practice or small group has a great idea and wants to keep it even semi-exclusive. Think BIG and solve BIG problems! 2) Physicians need to work together! That collaboration gene was beaten out of many docs through the battle to get into and out of medical school, getting the best residency and fellowship. We need it back! There is nothing more powerful and exciting than docs working together to solve the problems we have in health care. The smartest guys in the room have to work together and they need to take back their natural position as Leaders!nn
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About R. Todd Welter • MS, CPCnFounder and President of Welter Healthcare Partners
nMr. Welter has over 25 years of healthcare industry experience assisting physicians and other providers, hospitals and other facilities with the business side of medicine. Through strategic planning and analysis, Mr. Welter’s main focus is to strategically increase revenues and profitability in this radically changing health care environment. Mr. Welter has a Masters Degree in Organizational Leadership from Regis University in Denver where he has had an appointment as affiliate faculty in the School for Professional Studies for over ten years. In addition, Mr. Welter holds a faculty appointment at the University of Denver’s University College. In the Health Care Leadership program he teaches Macro Economics in Health Care and Innovative Strategies and Change in Health Care to graduate students.
Pain in the Bum!
S30.876A – Insect bite (nonvenomous) of anus, initial encounternnY93.K1 – Activity, walking an animalnnY92.480 – Sidewalk as the place of occurrence of the external causenn
ICD-10 PUSH Training for Physicians and Hospitals from Welter Healthcare Partners#038; Associates
The PUSH program:
nICD-10 Performance Measures: Ensure Success!nThe ICD-10 PUSH program was designed to evaluate provider performance with the ICD-10-CM code set. This program will assist in identifying utilization and accuracy as well as areas for improvement related to ICD-10.nnPost ICD-10 Implementation Evaluation:n
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- ICD-10-CM documentation evaluation of 20 encounters selected by the provider to get them invested in the evaluation process. The evaluation will focus on appropriate clinical documentation as well as accurate code selection with the ICD-10-CM code set.
- WHP will provide appropriate feedback based on the results of the ICD-10-CM documentation evaluation and an accuracy percentage based on ICD-10-CM code utilization.
- The ICD-10 evaluation can be completed by provider or by practice if desired. We can accommodate whatever works for your practice!
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nICD-10 Education and Training:n
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- Delivery of the ICD-10-CM documentation evaluation results and training can be in a group setting or individualized, depending on the needs of the providers/practice.
- Education/Delivery can be offered live or via web-based training.
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nICD-10 Reinforcement Services (when needed):n
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- Provider shadowing to evaluate work–flows and system utilization.
- EHR template consultation with an ICD-10 expert.
- One-on-one EHR consultation.
- Assistance with coding backlogs for both outpatient/inpatient services.
- Rent an WHPelter Coder.
- HCFA claims review for the encounters evaluated to determine if the encounters were billed appropriately and revenue maximized.
- Technical assistance for coding support.
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nICD-10 implementation date was October 1, 2015. ICD-10 will bring monumental changes to all physicians, practices, hospitals and healthcare vendors and entities. Organizations that fail to properly prepare for this transition will see claims denials, decrease in revenues, decreased coder productivity and significant cash flow issues!nnDo not delay, get started now! Our ICD-10 training and workshops are presented by an AHIMA-Approved ICD-10-CM/PCS Trainers and will help you start preparation efforts and put your organization on the right track for a successful implementation.n
Club Fed!
R41.0 — DeliriumnS06.0X2D – Concussion with loss of consciousness of 31 minutes to 59 minutes, subsequent encounternW16.032D – Fall into swimming pool striking wall causing other injury, subsequent encounternY92.146 – Swimming pool of prison as the place of occurrence of the external causenn
Celebrate Independent Physicians
They say Private Practice is dying! They say the independent physician is a dinosaur!nnI say private practice is changing, becoming more efficient, more flexible and much more capable! I think the dinosaur in the room (apologies to the elephant) is the ‘everything for everyone 24/7 huge hospital’ which is constantly scrambling to fill beds!nnWe are currently living in a time of short term solutions (seriously, go outside and look around!). In order to fill the beds and feed the dinosaur (not meant to be disparaging, I love hospitals and hospital people!) the hospitals have engaged an old strategy: Employ the docs and funnel the patients! It will work and work well in some markets. It will unwind itself in most, just as it did 10 or so years ago because at the end of the day the math does not work! (We in health care seem to have a ten year idea cycle.)nnThe longer term solution to A) the Cost Curve of health care, B) the Health of the Population and C) the Vitality of Physicians is to have and support Independent physicians who understand and control cost, smaller hospitals which have a specific specialty focus with much less bed days.nn
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About R. Todd Welter • MS, CPCnFounder and President of Welter Healthcare Partners
nMr. Welter has over 25 years of healthcare industry experience assisting physicians and other providers, hospitals and other facilities with the business side of medicine. Through strategic planning and analysis, Mr. Welter’s main focus is to strategically increase revenues and profitability in this radically changing health care environment. Mr. Welter has a Masters Degree in Organizational Leadership from Regis University in Denver where he has had an appointment as affiliate faculty in the School for Professional Studies for over ten years. In addition, Mr. Welter holds a faculty appointment at the University of Denver’s University College. In the Health Care Leadership program he teaches Macro Economics in Health Care and Innovative Strategies and Change in Health Care to graduate students.
2016 CPT Changes and Updates!
By Toni Woods, CCS, CPC, AHIMA-Approved ICD-10-CM/PCS TrainernnThe new CPT changes take effect January 1st. Understanding the new codes is crucial to obtaining the proper reimbursement for your services while also staying compliant with current coding and billing requirements. The changes for 2016 address a number of interrelated issues. Clinical practice has evolved and several issues required CPT clarification. CPT 2016 offers most changes in digestive procedures, diagnostic and interventional radiology as well as significant changes in prolonged services.n
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- 140 New CPT Codes
- 134 Revised CPT Codes
- 91 Deleted CPT Codes
- 365 Total CPT Edits
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n*Please note, this article is not an all-inclusive list; review your 2016 CPT book for complete descriptions of all changes. Appendix B of 2016 CPT provides a summary of additions, deletions, and revisions.n
Highlights of the changes:
n[toggle title_open=”Evaluation and Management (E/M) Chapter of CPT” title_closed=”Evaluation and Management (E/M) Chapter of CPT” hide=”no” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]Add-on codes for outpatient prolonged services +99354 and +99355 now apply to prolonged face-to-face outpatient psychotherapy as well as to prolonged face-to-face E/M codes. Use a primary E/M or psychotherapy code, one 99354 (30-74 minutes in addition to the time spent on the initial/primary service) per day and as many units of 99355 as needed to match the time spent in prolonged service.nnThere are two new add-on outpatient prolonged services codes:nn+99415 and +99416 are to be used to report prolonged face-to-face clinical staff service with physician, NP OR PA supervision. Same rules apply as above. Please note, documentation must reflect what you did and how long you did it.nn*These add-on codes can never appear on a claim by itself.[/toggle]nn[toggle title_open=”Integumentary System Chapter of CPT” title_closed=”Integumentary System Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]Two new codes have been added for soft tissue-marker placement with imaging guidance.n
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- 10035 – Placement of soft tissue localization device (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion
- 10036 – Placement of soft tissue localization device (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; each additional lesion[/toggle]
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n[toggle title_open=”Respiratory System Chapter of CPT” title_closed=”Respiratory System Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]A few new codes have been added for bronchoscopy procedures. These codes now include moderate sedation in the procedural reimbursement. There were also some notable revisions to transbronchial lung biopsies.n
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- 31652 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtrachael and/or transbronchial sampling (eg aspiration[s]/biopsy[ies], one or two mediastinal and/or hilar lymph node stations or structures.
- 31653 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtrachael and/or transbronchial sampling (eg aspiration[s]/biopsy[ies], 3 or more mediastinal and/or hilar lymph node stations or structures
- 31654 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) for peripheral lesions (list separately in addition to code for primary procedure(s)[/toggle]
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n[toggle title_open=”Cardiovascular System Chapter of CPT” title_closed=”Cardiovascular System Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]A few new codes have been added for cardiovascular procedures. Of note, there is a new code to replace the Category III code (0262T) for TPVIs (transcatheter pulmonary valve implantation), which includes all cardiac catheterizations, balloon angioplasty, valvuloplasty, stent deployment, intraprocedural contrast injections, angiography, radiological S&I.nnThere were also notable revisions to the language of thrombectomy codes. Fluoroscopy is now included in all of these procedures.n
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- 33477 Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed.
- 37252 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (list separately in addition to code for primary procedure)
- 37253 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (list separately in addition to code for primary procedure)[/toggle]
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n[toggle title_open=”Mediastinum and Diaphragm System Chapter of CPT” title_closed=”Mediastinum and Diaphragm System Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]Two new codes have been added for mediastinoscopy with biopsy.n
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- 39401 Mediastinoscopy; including biopsy(ies) of mediastinal mass (eg lymphoma), when performed
- 39402 Mediastinoscopy; with lymph node biopsy(ies) (eg lung cancer staging)[/toggle]
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n[toggle title_open=”Digestive System Chapter of CPT” title_closed=”Digestive System Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]The digestive chapter had the most code expansion in this year’s CPT changes. There are new codes to report biliary stent placements, biliary catheters, conversions, balloon dilation, etc. There were also significant changes to the guidelines for anal surgery.n
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- 43210 Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, including duodenoscopy when performed.
- 47531 Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (eg ultrasound and/or fluoroscopy) and all associated radiological S&I; existing access
- 47532 Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (eg ultrasound and/or fluoroscopy) and all associated radiological S&I; new access (eg percutaneous transhepatic cholangiogram)
- 47533 Placement of biliary drainage catheter, percutaneous, including diagnostic, cholangiography when performed, imaging guidance (eg ultrasound and/or fluoroscopy), and all associated radiological S&I; external
- 47534 Placement of biliary drainage catheter, percutaneous, including diagnostic, cholangiography when performed, imaging guidance (eg ultrasound and/or fluoroscopy), and all associated radiological S&I; external-internal
- 47535 Conversion of external biliary drainage catheter to internal-external biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg fluoroscopy), and all associated radiologic S&I
- 47536 exchange of biliary drainage catheter (eg external, internal-external, or conversion of internal-external to external only) percutaneous, including diagnostic cholangiography when performed, inaging guidance (eg fluoroscopy), and all associated radiological S&I
- 47537 Removal of biliary drainage catheter, percutaneous, requiring fluoroscopic guidance (eg with concurrent indwelling biliary stents), including diagnostic cholangiography when performed, imaging guidance (eg fluoroscopy) and all associated radiological S&I
- 47538 Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed and all associated radiological S&I; existing access
- 47539 Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed and all associated radiological S&I; new access, without placement of separate biliary drainage catheter.
- 47540 Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed and all associated radiological S&I; new access, with placement of separate biliary drainage catheter (eg external, or internal-external)
- 47541 Placement of access through the biliary tree and into small bowel to assist with an endoscopic biliary procedure (eg rendezvous procedure), percutaneous, including diagnostic cholangiography when performed, imaging guidance (ultrasound and/or fluoroscopy), and all associated radiological S&I, new access
- 47542 Balloon dilation of biliary duct(s) or of ampulla (sphincteroplasty), percutaneous, including imaging guidance (eg fluoroscopy), and all associated radiological S&I, each duct (list separately in addition to code for primary procedure)
- 47543 Endoluminal biopsy(ies) of biliary tree, percutaneous, any method(s) (eg brush, forcepts, and/or needle), including imaging guidance (eg fluoroscopy), and all associated radiological S&I, single or multiple (list separately in addition to code for primary procedure)
- 47544 Removal of calculi/debris from biliary duct(s) and/or gallbladder, percutaneous, including destruction of calculi by any method (eg mechanical, electrohydraulic, lithotripsy) when performed, imaging guidance (eg fluoroscopy) and all associated radiological S&I, single or multiple (list separately in addition to code for primary procedure)
- 49185 Sclerotherapy of a fluid collection (eg lymphocele, cyst or seroma), percutaneous, including contrast injection(s), diagnostic study, imaging guidance (eg ultrasound, fluoroscopy) and radiological S&I when performed[/toggle]
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n[toggle title_open=”Urinary System Chapter of CPT” title_closed=”Urinary System Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]Many new codes have been added for urinary procedures. Kidney procedures had the most expansion of this chapter, with new codes added for injections, catheter placements, conversions, and exchanges.n
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- 50430 Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg ultrasound and fluoroscopy) and all radiological S&I; new access
- 50431 Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg ultrasound and fluoroscopy) and all radiological S&I; existing access
- 50432 Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg ultrasound and/or fluoroscopy) and all associated radiological S&I
- 50433 Placement of nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg ultrasound, and/or fluoroscopy) and all associated radiological S&I, new access
- 50434 Convert nephrostomy catheter to nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg ultrasound and/or fluoroscopy) and all associated radiological S&I, via per-existing nephrostomy tract.
- 50435 Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg ultrasound and/or fluoroscopy) and all associated radiological S&I
- 50606 Endoluminal biopsy of ureter and/or renal pelvis, non-endoscopic, including imaging guidance (eg ultrasound and/or fluoroscopy) and all associated radiological S&I (list separately in addition to code for primary procedure)
- 50693 Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg ultrasound and/or fluoroscopy) and all associated radiological S&I; pre-existing nephrostomy tract
- 50694 Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg ultrasound and/or fluoroscopy) and all associated radiological S&I; new access, without separate nephrostomy catheter
- 50695 Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg ultrasound and/or fluoroscopy) and all associated radiological S&I; new access, with separate nephrostomy catheter
- 50705 Ureteral embolization or occlusion, including imaging guidance (eg ultrasound and/or fluoroscopy) and all associated radiological S&I (list separately in addition to code for primary procedure)
- 50706 Balloon dilation, ureteral structure, including imaging guidance (eg ultrasound and/or fluoroscopy) and all associated radiological S&I (list separately in addition to code for primary procedure)[/toggle]
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n[toggle title_open=”Male Genital System Chapter of CPT” title_closed=”Male Genital System Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]Only two new codes have been added for male GU procedures.n
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- 54437 Repair of traumatic corporeal tear(s)
- 54438 Replantation, penis, complete amputation including urethral repair[/toggle]
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n[toggle title_open=”Nervous System Chapter of CPT” title_closed=”Nervous System Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]A few new codes have been added for nervous system procedures. There are now three codes to identify paravertebral block injections at single of multiple levels.n
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- 61645 Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s)
- 61650 Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory
- 61651 Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; each additional vascular territory (list separately in addition to code for primary procedure)
- 64461 Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance when performed)
- 64462 Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance when performed) (list separately in addition to code for primary procedure)
- 64463 Paravertebral block (PVB) (paraspinous block), thoracic; continuous infusion by catheter (includes imaging and guidance when performed)
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n[/toggle][toggle title_open=”Eye and Ocular Adnexa Chapter of CPT” title_closed=”Eye and Ocular Adnexa Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]One new procedure was added to report services for corneal ring implants. There were many revisions to trabeculoplasty procedures and retinal detachments.n
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- 65785 Implantation of intrastromal corneal ring segmentsn
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n[/toggle][toggle title_open=”Auditory System Chapter of CPT” title_closed=”Auditory System Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]One new procedure was added to report services for removal of impacted cerumen that does not require instrumentation, but irrigation and/or lavage is achieved. This new code should never be reported with the instrumentation code for removal of impacted cerumen (69210).n
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- 69209 Removal impacted cerumen using irrigation/lavage, unilateral
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n[/toggle][toggle title_open=”Radiology Chapter of CPT” title_closed=”Radiology Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]A few areas of the radiology chapter expanded in this year’s CPT updates. There are new codes for fetal MRIs and nuclear medicine. There were also some notable code bundling changes for diagnostic radiology and brachytherapy. The subsection with the highest number of changes is lower extremities.nnThe term “film” has been replaced by the word “image” for radiation oncology codes. Also, in my cases, the dosimetry calculations are now included in the radiation therapy procedures.n
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- 74712 Magnetic resonance (eg proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single of first gestation
- 74713 Magnetic resonance (eg proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (list separately in addition to code for primary procedure)
- 77767 Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes base dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel
- 77768 Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes base dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions.
- 77770 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel
- 77771 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry when performed; 2-12 channels
- 77772 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry when performed: over 12 channels
- 78265 Gastric emptying imaging study (eg solid, liquid, or both); with small bowel transit
- 78266 Gastric emptying imaging study (eg solid, liquid, or both); with small bowel and colon transit, multiple days
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n[/toggle][toggle title_open=”Laboratory/Pathology Chapter of CPT” title_closed=”Laboratory/Pathology Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]Many new codes were added to the lab and path chapter of CPT. Most changes related to surgical pathology and genetic testing. Gene names have been updated using the Human Genome Organization (HUGO) approved names. Six codes that were a Tier 2 molecular pathology code have moved to Tier 1, as the procedures were performed with frequencies consistent with their intended clinical use. Tier 2 procedures were revised to include the addition of analytes, revised analyte names, and deleted analytes. HIV testing has been added to the standard OB panel.n
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- 80081 Obstetric Panel (includes HIV testing) same as 80055 with HIV-1 antigen(s), with HIV-1 & HIV-2 antibodies, single result (87389)
- 81170 ABL1 (ABL proto-oncogene, 1, non-receptor tyrosine kinase)(eg acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain.
- 81162 BRCA1, BRCA2 (breast cancer 1 and 2) (eg hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis.
- 81218 CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg acute myeloid leukemia), gene analysis, full gene sequence
- 81219 CALR (calreticulin) (eg myeloprofilerative disorders), gene analysis, common variants in exon 9
- 81272 KIT (k-vit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma) gene analysis, targeted sequence analysis (eg exons 8, 11, 13, 17, 18)
- 81273 KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg mastocytosis), gene analysis D816 variant(s)
- 81276 KRAS (Kristen rat sarcoma viral oncogene homolog) (eg carcinoma) gene analysis; additional variant(s) (eg codon 61, codon 146)
- 81311 (NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg colorectal carcinoma), gene analysis varienta in exon 2 (eg codons 12 and 13) and exon 3 (eg codon 61)
- 81314 PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg gastrointestinal stromal tumor (GIST), gene analysis, targeted sequence analysis (eg exons, 12, 18)
- 81412 Ashkenazi Jewish associated disorders (eg Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia Group C, Gaucher disease, Tay-Says disease_ genomic sequence analysis panel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC,GBA, HEXA, IKBAP, MCOLN1, & SMPD1
- 81432 Hereditary breast cancer-related disorders (eg hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 14 genes, including ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2, MSH6, NBN, PALB2, PTEN, RAD51C, STK11, TP53
- 81433 Hereditary breast cancer-related disorders (eg hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2 and STK11
- 81434 Hereditary retinal disorders (eg retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes including ABCA4, CNGA1, CRB1, EYS, PDE6A, PRPF31, PRPH2, RDH12, RHO, RPI, RP2, RPE65, RPGR, and USH2A
- 81437 Hereditary neuroendocrine tumor disorders (medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma, or paraganglioma; genomic sequencing analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL.
- 81438 Hereditary neuroendocrine tumor disorders (medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma, or paraganglioma; duplication/deletion analysis panel, must include analyses for SDHB, SDHC, SDHD and VHL.
- 81442 Noonan spectrum disorders (eg Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence of at least 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1.
- 81490 Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score.
- 81493 Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score.
- 81525 Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score.
- 81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result.
- 81535 Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; 1st single drug or drug combination.
- 81536 Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; each additional single drug or drug combination (List separately in addition to code for primary procedur)
- 81538 Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival.
- 81540 Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype.
- 81545 Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg benign or suspicious)
- 81595 Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score.
- 88350 Immunofluorescence, per specimen; each additional single antibody stain procedure (list separately in addition to code for primary procedure)
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n[/toggle][toggle title_open=”Medicine Chapter of CPT” title_closed=”Medicine Chapter of CPT” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]A few areas of the medicine chapter expanded in this year’s CPT updates. There were changes to vaccines, otolaryngology, cardiography, neurology, reflectance confocal microscopy, and ocular screening.[/toggle][toggle title_open=”Vaccines/Toxoids (4)” title_closed=”Vaccines/Toxoids (4)” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]n
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- 90697 FDA approval pending Diptheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use
- 90625 FDA approval pending Cholera vaccine, live, adult dosage, 1 dose schedule for oral use
- 90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB), 2 dose schedule, for intramuscular use
- 90621 Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB), 3 dose schedule, for intramuscular use
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- 92537 Caloric vestibular test with recording, bilateral; bithermal (ie 1 warm and 1 cool irrigation in each ear for a total of 4 irrigations)
- 92538 Caloric vestibular test with recording, bilateral; monothermal (1 irrigation in each ear for a total of 2 irrigations)[/toggle]
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- 93050 Arterial pressure waveform analysis for assessment of central arterial pressures, includes obtaining waveform(s), digitization and application of nonlinear mathematical transformations to determine central arterial pressures and augmentation index, with interpretation and report, upper extremity artery, non-invasive.
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- 96931 Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, 1st lesion
- 96932 Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, 1st lesion
- 96933 Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation & report only 1st lesion
- 96934 Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition & interpretation & report, each additional lesion (list separately in addition to code for primary procedure) (use with 99631)
- 96935 Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (list separately in addition to code for primary procedure) (use with 96932)
- 96936 Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation & report only, each additional lesion (list separately in addition to code for primary procedure) (use with 96933)
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- 99177 Instrument-based ocular screening (eg photoscreening, automated-refraction), bilateral; with on-site analysis
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Too Much Spiked Eggnog! — Fun with ICD-10
R46.2 – Strange and inexplicable behaviornR46.1 – Bizarre personal appearancenF10.921 – Alcohol use, with intoxication deliriumnW22.02XA – Walked into lamppost, initial encounternY90.7 – Blood alcohol level of 200-239 mg/100 ml or morenn
Holidays with the In-Laws — Fun with ICD-10
R51 – HeadachenR46.6 – Undue concern and preoccupation with stressful eventsnZ63.1 – Problems in relationship with in-lawsnn
Third Party Payer Update – COLORADO
The Triple Aim:n
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- Improving the patient experience
- Improving the health of populations
- Reducing per-capita cost
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nThe Triple Aim is on all the payer’s minds these days. These three tenants are now being woven into many of the decisions being made about cost, quality, reimbursements, network size, etc. Using these three items in your contracting strategy will help your success. Measuring and being able to report your ability to positively affect these three goals will make your practice more valuable to the health plans.nnThe payers are continuing to engage in the soft-narrowing of their various networks, using the direction of member volume to leverage rates. The “Value Based” PCP relationship appears to be the primary mechanism of this process. Therefore a member is not a member until you have their benefits carefully verified.nnThese days your referral people need to take a couple of extra steps:n
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- Are we on the PCP and Members list?
- What benefits are available for this plan type, product type, etc?
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PAYER UPDATES:
nAetna is in the process of buying Humana.nnAetna is sub dividing its Medicare Advantage product into sub-groups – watch for proper referrals and authorizations!nnAnthem is buying CIGNA. This is a huge merger and will require FTC approval. It will likely take a year or more to happen. The interesting thing about this merger is CIGNA is almost 100% self-funded (ASO) business. Anthem is currently about 50/50 self-insured and fully insured. They are capturing an enormous amount of the ASO business with this merger, an interesting reaction to the Affordable Care Act.nnJuly 1 Anthem updated its RBRBS year to 2014 – The more recent RBRVS years tend to favor the E&M codes at the expense of some surgical procedural codes – watch your reimbursement!nnMergers – Is There Opportunity for Your Practice? Usually during merger activity the health plans want a stable network. There may be a time for each of these (four different major health plans) to take a look at better rates! They all react to these things differently, so we will all need to keep our ears to the ground and look for opportunity.nnColorado HealthOP – They have had an incredible increase in members this year as a partial result of very favorable rate filings with the state. It will be interesting to see their rate fillings and growth as the New Year approaches.nnUnited Healthcare is updating their RBRVS year! They are also increasing their focus on the use of Out-Of-Network (OON) providers. If you are in-network but routinely refer to OON providers it is nearly impossible to increase your in-network rates. United appears to be following Anthem’s recent program to locate and weed out the use of OON providers.nnMedicare and Orthopedics: Medicare has initiated an Orthopedics bundled program called Comprehensive Care for Joint Replacement (CCJR). This program requires 800 pre-selected hospitals in 75 areas of the country to participate. They call it a Bundled Program but really it is a form of Pay-for-Performance in which the hospital gets the money and makes the decisions. More to come on this!nnICD-10 – so far so good? We haven’t seen any wholesale issues just yet. If you are experiencing any trouble please let us know!
Final Colorado Workers' Compensation Medical Fee Schedule Issued
The Colorado Division of Workers’ Compensation (DOWC) recently issued final utilization standards and the final Colorado Workers’ Compensation Medical Fee Schedule that affect all workers’ compensation billing, and will go into effect January 1, 2016. Among several significant changes are that these rules and regulations require payers to adopt Medicare’s Resource-Based Relative Value Scale (RBRVS) method of payment. You should be aware of regulatory changes that will affect your billing, coding and processes, and make any necessary business adjustments now to ensure a smooth transition.nnThe DOWC set out to ensure that the transition to the new fee schedule and payment system would be budget-neutral overall; however, providers should examine the rules closely and analyze specifically how fee schedule changes may impact their payments for certain specialties.
Colorado Providers – New Credentialing Standards for Pinnacol Assurance!
As part of the ongoing effort to educate providers about the most effective treatment protocols for workers’ compensation, Pinnacol Assurance is amending their SelectNet network credentialing standards for nurse practitioners and physician assistants practicing in the following urban counties: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, El Paso, Elbert, Garfield, Jefferson, Larimer, Mesa, Pueblo, and Weld. Mid-level providers in these counties will be required to complete Division of Workers’ Compensation (DOWC) Level 1 training.nnEffective January 1, 2016, Pinnacol’s mid-level provider credentialing requirement for your SelectNet Agreement (Exhibit B, SelectNet Credentialing Policy) is amended/updated to include the following participation requirement: “Evidence that Mid-Level provider successfully audited a Division of Workers’ Compensation Level I course (or compliance within 12 months)”nnFor your convenience, a revised Exhibit B has been created and is available by clicking here. Please print this updated version and use it to replace the current Exhibit B of your SelectNet Agreement. In the next week, impacted mid-level providers will be notified of this new requirement. Registration information for an upcoming DOWC Level 1 training on December 3, 2015, the last training in 2015, is available here and here. You may register for additional Level I seminars in 2016 through the DoWC website. Pinnacol will reimburse a limited number of SelectNet mid-level providers for the cost of this course. Email LevelOne@pinnacol.com to request information about this reimbursement program.nnIf you have questions regarding this notification, please contact Pinnacol’s provider network management department at 303.361.4945 and speak with the provider relations specialist assigned to your contract.
Colorado Medicaid Begins Provider Credentialing Revalidations!
Colorado Medicaid and CHP+ Provider Revalidation & Enrollment Begins September 15, 2015
nNew federal regulations established by the Centers for Medicare and Medicaid Services (CMS) require enhanced screening and revalidation for all Medicare, Medicaid, and CHP+ providers.nnBeginning September 15, 2015, all Colorado providers who want to continue, or begin, providing services to Medicaid and CHP+ members after March 31, 2016, will be required to be validated and enrolled under new federal enrollment screening criteria. To meet these new requirements, as well as to ensure enrollment in the new claims processing system, Colorado providers must revalidate using the new Online Provider Enrollment (OPE) tool. Although the new OPE tool will launch in September 2015, Colorado Medicaid asks that provides complete your revalidation during your assigned revalidation and enrollment wave.nnBased on the CMS provider type and risk designation, the revalidation process may include a criminal background check, fingerprinting, and unannounced site visits – including pre-enrollment site visits for some providers. Visit our provider resources page for information specific to your provider type and information specific to the Home and Community-Based Services (HCBS) provided (if applicable). Providers who fail to revalidate and enroll by March 31, 2016 may have their claims suspended or denied.n
Revalidation & Enrollment Training Announcement
nEnrollment Application Training AvailablenOnline self-paced training for the new Colorado Online Provider Enrollment (OPE) tool is now available.n
Who: All interested providers
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When: Modules available online anytime beginning September 4, 2015
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Where: Online via eLearning modules
nPlease visit the Provider Resources page to register!nn
CLICK TO ENLARGE
Medical Reval FAQ
nWhy am I required to go through the revalidation/screening process?nnNew federal regulations established by the Centers for Medicare and Medicaid Services (CMS) require enhanced screening and revalidation for all existing (and newly enrolling). These regulations are designed to increase compliance and quality of care. The final regulations are being implemented at a federal level and were published in the federal register in February 2011.nnWhat is the difference between revalidation and screening?nnRevalidating is an enrollment process required every 5 years. Screening is verifying the provider is qualified for the risk level assigned.nnAre non-medical service providers subject to revalidation/screening?nnYes, all providers who are enrolled with and bill Medicaid for services under the state plan or a waiver must be screened under this rule.nnWill we be notified when we need to revalidate?nnWe are sending a revalidation notice letter to all currently enrolled providers. This letter will mailed 1-2 weeks prior to your enrollment wave, as a reminder.nnI didn’t receive a Revalidation Notice letter, does this mean I don’t have to revalidate?nnNo, all providers need to revalidate regardless of whether you receive the Revalidation Notice letter. Please visit Colorado.gov/HCPF/Provider-Resources to see your assigned revalidation wave.nnWhat is an enrollment wave window?nnYour wave window is a suggested time frame in which we would like you to complete your revalidation. These waves are just recommendations; if you need to begin sooner or later you can. The most important date to remember is March 31, 2016. Providers not enrolled and revalidated by this date, may have their claims suspended or denied.nnWhat should we do if our agency is spread out across multiple revalidation waves?nnGo ahead and choose between the waves that you are assigned to, you do not need to notify us of this change.
Please, Do Not Feed the Wildlife…
S61.451A — Open bite of right hand, initial encounternW55.81XA — Bitten by mountain lionnY93.01 — Activity, hikingnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to contact us for all of your training and education needs!