FEBRUARY  2020.  ISSUE 2.  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.  

United Healthcare

Radiology Program Procedure Code Changes

Effective Jan. 1, 2020, UnitedHealthcare (UHC) has updated the procedure code list for the Radiology Notification and Prior Authorization programs based on code changes made by the American Medical Association (AMA). Claims with dates of service on or after Jan.1, 2020 are subject to these changes.

Codes added:

  • 78830
  • 78831
  • 78832

Codes deleted:

  • 78205 , 78206
  • 78320
  • 78607, 78647
  • 78710
  • 78805 – 78807

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UHC will update the Radiology notification and prior authorization procedure code list and add 76391 – Magnetic Resonance Elastography (MRE). This will be effective for claims with dates of services on or after March 1, 2020.

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Emergency Department (ED) Professional Evaluation and Management (E/M) Policy:

Effective Date: April 1, 2020

Focus: Professional Emergency Department (ED) claims that are submitted with level 5 E/M code 99285.

United Healthcare will begin using the Optum Evaluation and Management Professional (E/M Pro) tool, which determines appropriate E/M professional coding levels based on data such as patient’s age and conditions, for the Medical Decision Making key component.

The E/M Pro tool accounts for diagnosis codes submitted on the claim to determine the appropriate level of complexity that correlates with the E/M professional service reimbursement. Since medical decision making and problem complexity is the primary driver, the E/M Pro tool calculates the appropriate E/M level based on submitted diagnosis codes.

This will result in fair and appropriate reimbursement for ED services rendered.

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Allograft/Spinal Surgery – 20930

Back PainUnited Healthcare commercial plans will include CPT code 20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery) when used in spinal surgery to the notification & prior authorization requirements list for certain states. This will be effective from service date March 1, 2020 in all states except for the following:

The prior authorization requirement in California, Colorado, Connecticut, New Jersey, New York, Kansas, Kentucky and Ohio and Nebraska will be effective from service date April 1, 2020.

This change will take effect from service date June 1, 2020 in Iowa.

Sierra, UHC Oxford & UHC West plans are excluded from this requirement.

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UHC Medicare Advantage – Claims processing Update

Effective April 1, 2020, UHC requires that certain information showing a claim was submitted to the primary payer (automobile insurance carrier) is included with any claims that are submitted to United Healthcare. If UHC records show that there is a primary payer, UHC will ask for you to include this information in your claim. If UHC does not receive this information within 60 calendar days from the receipt of the original claim, UHC will deny your claim.

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United Healthcare Oxford Site of Service Expansion – Effective Date Postponed

UHC previously said that the expanded notification/prior authorization requirements and site of service medical necessity reviews for surgical codes would be effective for UHC Oxford plans as of Feb. 1, 2020. The effective date has been postponed to April 6, 2020 or later.

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Aetna

Experimental & Investigational lab tests

Most of Aetna’s plans will not cover laboratory tests that are considered experimental and/or investigational. Patients should be informed that they are responsible for the full cost of these non-covered services.

Most common non-covered tests are:

Lyme disease(CPB #0215)

Vitamin D Assay (CPB #0945)

Lipoprotein Cholesterol Test (CPB #0381)

Homocysteine Test (CPB #0381)

Aetna provides an online reference tool which lists conditionally covered laboratory tests that are considered experimental and investigational. Providers can access this list to verify coverage.

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Aetna expanding its Medicare Advantage plans:

Aetna is offering its MA plans in an additional 264 counties. Depending on the provider contract, they may be listed as participating provider on MA networks. (2020 Expansion counties..)

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Improving communication on updates

Beginning March 2020, Aetna will share monthly updates on clinical payments and coding policies.

ICD 10 Coding tips for Acute Myocardial Infarction (AMI) & Chronis Kidney Disease (CKD):

AMI:

  • Use codes from category I21 for AMI only if less than 4 weeks (28 days) of acute onset.
  • Use codes from I21 or I22 for subsequent AMI within 4 weeks (28 days) of initial AMI.
  • Use code from category I23 for certain complications within 4 weeks (28 days) of initial AMI.
  • If AMI onset is more than 28 days ago, use code I25.2, regardless of any ongoing treatment.
  • Always document each AMI occurrence by date in prior medical history.
  • Initially, write “acute myocardial infarction” followed by “AMI” in parentheses, and then use just “AMI” throughout the remainder of the note.

CKD

  • Document the specific stage, if known, and always use a code from category N18.
  • Document acute or chronic CKD.
  • Coding CKD with other conditions:

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New Preapproval requirements – AL, AR, ID,LA, MS & SD

Effective Jan 1, 2020, Aetna’s enhanced clinical review program with eviCore healthcare will require pre-authorization for certain procedures. This affects members in Aetna Medicare Advantage HMO/PPO Aetna in Alabama, Arkansas, Idaho, Louisiana, Mississippi and South Dakota.

Services that require pre-approval:

  • PET ScanHigh-tech outpatient diagnostic imaging procedures such as MRI/MRA, nuclear cardiology, and PET scan and CT scan, including CTA
  • Non-emergent outpatient stress echocardiography
  • Non-emergent outpatient diagnostic left and right heart catheterization
  • Insertion, removal and upgrade of elective implantable cardioverter defibrillator, cardiac resynchronization therapy defibrillator and implantable pacemaker
  • Polysomnography (attended sleep studies)
  • Interventional pain management
  • Musculoskeletal large joint (hip and knee) arthroplasty procedures
  • Radiation therapy services

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Third Party Claim and Code review program

Effective March 1, 2020, Aetna is introducing new claim edits on the provider website.

You can access and review applicable claims  under My health plans>Aetna>claims>Policy information>Expanded claim edits.

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Coding Corner 

Know how to use modifier 58 & 78:

Modifier 58: Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional during the Postoperative Period

Example 1: A surgeon performs a complete mastectomy and a sentinel lymph node excision of a deep axillary node. If the pathology report indicates metastasis to the sentinel lymph node, the surgeon intends to schedule the patient for a lymph node dissection. Two weeks later, the surgeon performs the axillary lymphadenectomy based on positive sentinel lymph node results.

Code it:

For the initial procedures, report

19303 (Mastectomy, simple, complete)

38525 (Biopsy or excision of lymph node(s); open, deep axillary node(s))

For the axillary lymph node resection two weeks later, report 38745 with modifier 58, (Axillary lymphadenectomy; complete) because the second procedure was planned prospectively based on the outcome of the original procedure that has a 90-day global period.

Example 2: The surgeon excises a 1.5 cm squamous cell carcinoma of the cheek. The surgeon chooses to perform an adjacent tissue transfer to minimize scarring, but decides to wait for the pathology report to ensure clear margins before proceeding with the repair. Three days later, the surgeon performs the adjacent tissue transfer.

Code it:

Report the initial excision as 11642 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm). Three days later, report the tissue transfer as 14040 with modifier 58 (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less) .

Key: The excision has a 10-days global period, and the tissue transfer occurs during that time. Typically, the tissue transfer code includes the lesion excision. But because this is a staged procedure correctly identified with modifier 58, you should get paid for both procedures.

Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period

Example 1: A patient visited the physician with colovesical fistula, surgeon performed closure of the fistula with partial resection of sigmoid colon through laparotomy. After two weeks patient returns to the physician with severe pain and swelling of the incision site. Physician identified infection of the surgery incision site. Patient taken to the operative room and incision and drainage performed for the infected wound.

Code it:

Report the initial procedure as 44661 (Closure of enterovesical fistula; with intestine and/or bladder resection).

Two weeks later, report the I&D as 10180 with modifier 78 (Incision and drainage, complex, postoperative wound infection) .

Key: Closure of enterovesical fistula has a 90-days global period, and I&D occurs during that time due to a complication following surgery which requires an additional trip to the operating room (OR) identified with modifier 78.

Example 2: A patient reported with an abscess in left arm, surgeon performed an incision and drainage. After six days patient returns to the physician with pain and serous drainage from I&D site. Physician removed the dressing and performed an extensive debridement of non-viable devitalized tissues from the wound surrounding with scalpel and packed the abscess cavity with Iodofoam gauze and applied new dressing. All procedures including debridement & dressing change performed at the patient’s bed side without any difficulties.

Code it:

Report the initial procedure as 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single).

Six days later, report the subsequent visit as 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure).

 Key: Though the physician performed extensive debridement and wound packing as per the guidelines of global surgical package, all additional medical or surgical services required a surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room (OR) are inclusive with the global surgical package.

Coding Cataract Surgeries:

Cataract SurgeryThe two CPT codes which are used frequently for cataract surgeries are

  • 66982: Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation
  • 66984: Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation

Endoscopic CycloPhotocoagulation

  • Endoscopic CycloPhotocoagulation or ECP has proven to be an effective way to reduce intra-ocular pressure, is most often performed at the same time as cataract surgery, after the cataract has been removed from the eye.
  • No additional incisions are required. The ECP probe uses tiny, optical fibers to illuminate, view and treat the ciliary body with laser energy. Approximately 20 to 40 laser applications will be administered.

Now in 2020, two new codes are added for Cataract surgery with ECP

  • 66982 + ECP = 66987: Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with endoscopic cyclophotocoagulation
  • 66984 + ECP = 66988: Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with endoscopic cyclophotocoagulation

Let’s Learn ICD 10 coding

Retained Ear Tube Removals

Case 1: A child is taken to the operating room (OR) for the removal of a retained ear tube.

Coding:-

  • If the encounter is simply to remove the patient’s myringotomy tube, you will report Z45.82 (Encounter for adjustment or removal of myringotomy device (stent) (tube)).
  • If there are complications with the implanted tube, then you should report a complication code in addition to Z45.82.

 Note: This encounter requires further context in order to definitively answer. That’s because your diagnostic coding options will change depending on whether the patient is experiencing complications from the retained tube.

Case 2: A child is taken to the OR for the removal of a retained ear tube due to complaints of pain for past two weeks. The surgeon notes an infection at the site of the tube placement.

 Here, you’ve got to consider three diagnostic components: the tube removal, the infection, and the pain.

Coding:-

  • As per the Chapter 19 guidelines, you will first report the infection as a complication using code T85.79XA (Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter).
  • Next, you’ll report acute postprocedural pain code G89.18 (Other acute postprocedural pain) along with Z45.82 (removal of myringotomy tube).

Note: The ICD-10-CM guidelines specifically address how to report diagnoses involving pain from devices, implants, or grafts left in a surgical site: “Pain associated with devices, implants or grafts left in a surgical site (for example painful hip prosthesis) is assigned to the appropriate code(s) found in Chapter 19, Injury, poisoning, and certain other consequences of external causes. Specific codes for pain due to medical devices are found in the T code section of the ICD-10-CM. Use additional code(s) from category G89 to identify acute or chronic pain due to presence of the device, implant or graft (G89.18 or G89.28).”

This guideline offers the framework of how to report two of your three diagnoses. While the pain is clearly a symptom of the infection, the ICD-10-CM guidelines state that you should report pain using the appropriate G code when it’s the results of a surgical complication.

Parapharyngeal Mass Depending on Pathology Results

Case 1: A patient presents for an office visit complaining of swelling in her neck. Using a flexible laryngoscope, the physician identifies a mass in the parapharyngeal space.

For the sake of diagnosis coding purposes, the only information you currently have to code is a parapharyngeal mass. In a future encounter, the patient may have a biopsy performed (with or without excision), which would allow you to report the mass as either benign or malignant depending on the pathology results.

Coding:-

  • In this example, you will report J39.9 (Disease of upper respiratory tract, unspecified).

You should not consider J39.8 (Other specified diseases of upper respiratory tract), since a “mass” is nonspecific, by nature.

MIPS Measures For Ophthalmology:  View in Detail

(Scroll to left on phone & tablet)

Measure # Measure Description MIPS code High priority/Outcome
12 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation 2027F No
14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination G9974/G9975, G9892/G9893 No
19 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care 5010F Yes
117 Diabetes: Eye Exam 2022F,2024F,2026F,3072F No
130 Documentation of Current Medications in the Medical Record G8427,G8428 Yes
141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care 3284F,3285F & 0517F Yes
191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery 4175F Yes
192 Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures G8627 , G8628 Yes
226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention G9902 – G9905 ,                        G9906 – G9908 ,                                       4004F / 1036F/ G9909 No
303 Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery G0913,G0914 & G0915 Yes
374 Closing the Referral Loop: Receipt of Specialist Report G9969, G9970 Yes
384 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery G9515, G9514 Yes
385 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery G9516, G9517 Yes
388 Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) G9389, G9390 Yes
389 Cataract Surgery: Difference Between Planned and Final Refraction G9519, G9520 Yes
Measure #Measure DescriptionMIPS CodeHigh Priority/Outcome
12Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation2027FNo
14Age-Related Macular Degeneration (AMD): Dilated Macular ExaminationG9974/G9975, G9892/G9893No
19Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care5010FYe
117Diabetes: Eye Exam2022F,2024F,2026F,3072FNo
130Documentation of Current Medications in the Medical RecordG8427,G8428Yes
141Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care3284F,3285F & 0517FYes
191Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery4175FYes
192Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical ProceduresG8627 , G8628Yes
226Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionG9902 - G9905 , G9906 - G9908 , 4004F / 1036F/ G9909No
303Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract SurgeryG0913,G0914 & G0915Yes
374Closing the Referral Loop: Receipt of Specialist ReportG9969, G9970Yes
384Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of SurgeryG9515, G9514Yes
385Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of SurgeryG9516, G9517Yes
388Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)G9389, G9390Yes
389Cataract Surgery: Difference Between Planned and Final RefractionG9519, G9520Yes

Coding Corner Questions

Do you have any coding questions?  Ask us.  We’ll help you find the answers.
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