DECEMBER 2019. ISSUE 1. This newsletter is published by Currence Physician Solutions, a full-service RCM company dedicated to optimizing your financial performance. Each issue summarizes recent changes in federal rules, regulations, and coding practices that improve your ability to effectively bill and collect.
2020 CPT Changes
It’s time again to get ready for the CPT changes. Let’s see the major CPT updates for 2020. There are 394 code changes in the code set for 2020:
- New codes – 248
- Revisions – 75
- Deletions – 71
Among this year’s important additions to CPT are new medical services sparked by novel digital communication tools, such as patient portals, that allow healthcare professionals to more efficiently connect with patients at home and exchange information.
The CPT Panel has responded by adding six new codes to report online digital evaluation services or e-visits. These codes describe patient-initiated digital communications provided by a physician or other qualified healthcare professional (99421, 99422, 99423) or a non-physician healthcare professional (98970, 98971, 98972).
To better support home blood pressure monitoring, the CPT Panel added codes (99473, 99474) to report self-measured blood pressure monitoring.
For more accurate reporting, the CPT Panel replaced six old codes with new ones (96156, 96158, 96164, 96167, 96170) and add-on codes (96159, 96165, 96168, 96171) for health and behavior assessments and intervention services.
Changes to E/M Office Visit Revisions
As previously proposed, CMS is not going to implement the single payment option for the office visit codes.
On Feb 9, 2019 the AMA convened CPT editorial panel addressed the same with approved revisions to the CPT E/M office or other outpatient visit reporting guidelines and code descriptors.
The scope of the AMA proposal is solely focused on revisions to the E/M office or other outpatient visits (CPT codes 99201-99215). The code set revisions will be effective Jan. 1, 2021.
Summary of Revisions:
- Eliminate history and physical as elements for code selection
- Allow physicians to choose whether their documentation is based on Medical Decision Making (MDM) or Total Time
- Modifications to the criteria for MDM
- Deletion of CPT code 99201
- Creation of a shorter prolonged services code.
2020 CDT changes
As CPT, we also have the dental code changes every year. Below are the CDT changes for 2020.
- New codes – 37
- Revisions – 5
- Deletions – 6
The CDT sections Preventive, Implant services and Orthodontics have many new codes.
NEW CODES (scroll left on phone)
Section & Code Range # of New Codes New Codes Diagnostic -- D0100 - D0999 1 D0419 Preventive -- D1000 - D1999 6 D1551 - D1553 D1556 - D1558 Restorative -- D2000 - D2999 1 D2753 Prosthodontics, removable -- D5000 - D5899 2 D5284, D5286 Implant Services -- D6000 - D6199 14 D6082 - D6084 D6086 - D6088 D6097 - D6099 D6120 - D6123 D6195 Prosthodontics, fixed -- D6200 - D6999 3 D6243, D6753, D6784 Oral and Maxillofacial Surgery -- D7000 - D7999 1 D7922 Orthodontics -- D8000 - D8999 8 D8696 - D8699 D8701 - D8704 Adjunctive General Services -- D9000 - D9999 1 D9997
Sections that do not have any new codes added are:
- Endodontics – D3000-D3999
- Periodontics – D4000-D4999
- Maxillofacial Prosthetics – D5900-D5999
Beckers \ CMS.gov
Changes to IPO & ASC CPL
In 2020, CMS is adding a few more procedure codes to the ASC covered procedure list (CPL) and finalizing changes to the Inpatient only (IPO) list. These include:
- Total Knee Arthroplasty (TKA)
- Knee Mosaicplasty
- Six additional coronary intervention procedures, and
- Twelve procedures with new CPT codes are added to ASC CPL.
Changes to IPO List
This rule finalizes changes to the IPO list including removal of total hip arthroplasty, six spinal surgical procedures and certain anesthesia services from the list, making these procedures Medicare eligible in both hospital inpatient and outpatient settings.
5 Anesthesia Codes Removed from the IPO List
CMS removed five anesthesia CPT codes from the IPO list for 2020: 00670, 00802, 00865, 00944 and 01214.
These codes are related to procedures that have already been removed from the inpatient only list.
3 Changes in Medicare 2020 Final Rule Affecting GI Practices
Effective January 1 2020, CMS will implement three rule changes recommended by the American Society for Gastrointestinal Endoscopy (ASGE):
- Colorectal cancer “surprise billing”
- Removal of screening colonoscopy adenoma detection rate payment system
- Collapsing payments for office and outpatient visits.
Imaging Rules in 2020 – Things to Know
Effective Jan 1 2020, CMS will implement the new Appropriate Use Criteria (ACU) for advanced diagnostic imaging services provided in ASCs, physician offices, and other applicable settings.
Voluntary participation in the AUC program, which began in July 2018, will become mandatory on Jan 1 2020 when a new testing period begins.
The AUC will require professionals to consult a Clinical Decision Support Mechanism (CDSM) before ordering Part B advanced diagnostic imaging services. Providers should enter a G-Code on a separate claim line to report that a qualified CDSM was consulted.
Claims won’t be denied during the 2020 testing period if the claim line does not contain the G code, however starting Jan 1 2021, the claims must include information regarding consultation with CDSM.
Precertification Requirement for Certain Gastroenterology Procedures
Effective Jan 1 2020, most customers with Cigna Connect individual and family plans will require precertification for the following gastroenterology procedures:
- Esophagoscopy/Esophagogastroduo-denoscopy (EGD), and
- Most capsule endoscopies.
Click here to view the list of CPT codes associated with these procedures.
When the word “Connect” appears in the upper right-hand corner of a patient’s Cigna Card, the patient requires precertification.
Cigna Shares Commitment to Whole Person Health
When patients suffer from stress, depression, and/or substance use, providers often discuss the mind-body connection and how it may affect physical health. This conversation can lead to better informed treatment options including referrals to mental health specialists.
Cigna provides primary care physicians with the following support:
- Screening tools to identify patients who may be affected by emotional and/or mental health issues
- Resources to facilitate patient conversations about mental health and addiction
- Information on how to get reimbursed for these conversations.
Click here for links to nationally published tools that can be used to screen patients for common emotional health issues like depression, substance use, and loneliness.
United Healthcare’s (UHC) medical policy bulletins share important up-to-date information on medical policies, benefit drug policies, coverage determination guidelines, utilization review guidelines, and quality care guidelines.
UHC enters a health service (e.g., test, drug, device or procedure) in these bulletins when it is adopting a new policy and/or updating, revising, replacing, or retiring an existing policy. It does mean, however, that it necessarily provides coverage for the named service.
The following definitions apply:
New: New clinical coverage criteria or documentation review requirements have been adopted for a health service (e.g, test, drug, device or procedure).
Updated: Changes have not been made to the clinical coverage criteria or documentation review requirements, but items such as clinical evidence, FDA information, and/or lists(s) of applicable codes may have been updated after reviewing an existing policy.
Revised: An existing policy has been reviewed and revisions have been made to the clinical coverage criteria and/or documentation review requirements.
Replaced: An existing policy has been replaced with a new or different policy.
Retired: The health service(s) addressed in the policy are no longer managed or considered proven and/or medically necessary, and therefore are now considered unproven and/or not medically necessary, unless coverage guidelines or criteria are documented elsewhere in another policy.
Medical Policy Update
UHC added a documentation requirement section for CT colonography codes (74261 – 74263), effective Jan 1, 2020.
When referring radiology services, providers should call the UHC number on the patient’s ID card and document the following:
- Recent history & physical
- Co-morbid medical conditions
- Medical necessity.
Genetic Testing for Hereditary Cancer
Effective December 1 2019, United Healthcare revised the coverage criteria for “genetic testing for BRCA1 & BRCA2 for individuals without a personal history of related cancer” from at least two to at least one close blood relative with a BRCA related cancer.
Coverage Determination Guideline
United Healthcare has made some changes to the coverage determination guide (CDG) for several surgeries and services.
1. Breast Reduction Surgery
Effective November 1 2019, UHC updated the documentation requirement for reduction mammoplasty to include:
- The evaluation and management note for the date of service
- The note for the day the decision to perform the surgery was made.
2. Preventive Hearing Care
Effective December 1 2019, UHC revised the preventive care benefit instructions / age limit guidelines for hearing tests:
- Ages 0 – 90 days. There is not a diagnosis code requirement for the preventive benefit to apply.
- Ages 91 days – 21 years (ending on 22nd birthday). Requires diagnosis code Z00.00 OR Z00.01.
Aetna now requires precertification for maternity and newborn stays that exceed the standard length of stay (LOS), which are:
- 3 days or fewer for vaginal delivery
- 5 days or fewer for Caesarean section.
Other procedures, drugs, and special programs that require precertification can be found here.
Things to remember:
- Requests for precertification can be submitted electronically through Aetna’s secure website or the EMR portal.
- Aetna encourages providers to submit precertification requests at least two weeks before scheduled services.
Expanded Claim Edits
Effective December 1 2019, Aetna introduced new claim edits, which is part of its third party claim and code review program. You can view these edits on the Aetna website using the perspective claims editing disclosure tool.