AMA & CMS
The code is effective March 13, 2020 as the industry standard for reporting novel coronavirus tests across the nation’s health care system. Click here…
- 87635 – Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
Click this CPT Assistant for coding guidelines and FAQs related to the newly developed CPT code.
Please note that, per the standard early release delivery process for CPT codes, hospitals/providers will need to manually upload this code descriptor into their EHR system. This CPT code will arrive as part of the complete CPT code set in the data file for 2021 later this year.
The Centers for Medicare & Medicaid Services has established two Healthcare Common Procedure Coding System codes for coronavirus testing. (News alert). The Medicare claims processing system will be able to accept this code on April 1, 2020 for dates of service on or after February 4, 2020.
- U0001 – 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel using CDC
- U0002 – 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19) using any technique, multiple types or subtypes (includes all targets)
CMS posted a fact sheet with pricing information for both CDC and non-CDC tests. Click here to review CMS’s complete coverage and payment related details for all types of treatment.
Physicians and health care organizations should check with local payers to determine their specific reporting guidelines for this new CPT code.
ICD 10 coding for COVID-19
Based on circumstances, either one of the below codes can be used:
- 2 – Coronavirus infection, unspecified
- 29 – Other coronavirus as the cause of diseases classified elsewhere
Examples:
- Patients with COVID-19 may also develop acute respiratory distress syndrome (ARDS), in which case you should choose J80 (acute respiratory distress syndrome) and B97.29 (other coronavirus as the cause of diseases classified elsewhere).
- If the patient has bronchitis due to COVID-19, use code J40 (bronchitis, not specified as acute or chronic) along with code B97.29 (other coronavirus as the cause of diseases classified elsewhere).
- Use Z20.828 (contact with and (suspected) exposure to other viral communicable diseases) to document an encounter with a patient infected with any form of the virus. If the patient may have been exposed to COVID-19 but the provider rules out that possibility after evaluation, use.
Z03.818 (encounter for observation for suspected exposure to other biological agents ruled out)
Coding tip: If the provider documents “suspected”, “possible” or “probable” COVID-19, do not assign code B97.29. Assign a code(s) explaining the reason for encounter (such as fever, or Z20.828).
Aetna
Effective July 1, 2020, Aetna requires precertification for the following:
- Functional endoscopic sinus surgery (FESS) – 31254, 31255
- Revision of shoulder arthroplasty – 23473, 23474
- Arthrodesis for spine deformity – 22800 – 22812, 22845 – 22847
- Kyphectomy – 22818, 22819
Update on Surgical Pathology Lab Policy
Effective June 1 2020, Aetna is adding procedure codes 88341 and 88344 to its existing in-office surgical pathology lab policy.
Aetna reimburses these services performed in the office when providers submit documentation of their CLIA certification. Click here…
Modifier KX for additional hemodialysis
Effective June 1 2020, Aetna will allow hemodialysis services in excess of three times per seven-day period to be billed with modifier KX. The excess hemodialysis treatment will only be paid when the modifier KX is used.
No referral or prescription needed for Mammogram:
Aetna wants providers to remind their 1199SEIU patients to get their annual preventive screenings. This includes mammograms for women between ages 40 and 80. Patients do not need a referral or prescription. All they need to do is provide their radiologist their name and the contact details of the PCP who will get the test results.
Opiod overdose risk screening
Aetna’s behavioral health clinicians screen members to identify patients at risk for an opiod overdose. Any patient receiving a diagnosis of opiod dependence may be at risk.
How providers can help?
You can tell patients, their families and support networks how to identify the signs of opium overdose and how to administer naloxone, which reverses the effects of overdose. Giving naloxone kits to laypeople reduces overdose deaths, is safe and cost effective.
Mailing address change:
The Aetna mailing address is changing for Texas, Oklahoma and New Mexico. Contract mailings should be submitted to the following address.
Aetna | South Central Network
Network Management
2777 N. Stemmons Frwy, #1450
Dallas, TX 75207
SBIRT – Screening, Brief intervention and referral to treatment
SBIRT is an evidence-based practice designed to support health care professionals. Overall, the practice aims to improve both the quality of care for patients with alcohol and substance use disorder conditions, as well as outcomes for patients, families and communities.
Aetna® will reimburse you when you screen your patients for alcohol and substance use, provide brief intervention, and refer them to treatment.
NY – New Law and CPT code for maternal depression
New York has a new law that requires carriers to reimburse for maternal depression screening and cover the service under a newborn’s plan if the mother does not have insurance. We were advised that this service will be paid if billed with CPT code 96161.
NC – Multiple imaging procedures
Effective June1 2020, Aetna will apply its existing policy on multiple procedures which includes MRIs, CT scans and ultrasounds to NC providers. Reductions apply to each subsequent scan performed for the same member, on the same day, by the same provider.
Medicare Advantage – Annual wellness visits
Medicare advantage members can now get their annual wellness visits once per calendar year instead of once every 366 days. This means that patients who had their annual visit late in the calendar year can be scheduled early in the next year.
United Healthcare
The following enhancements have been made to United Healthcare’s Prior Authorization and Notification Tool (PAAN).
- Outpatient facility case requests are changing from a single date of service to an automatic 90-day service period. This means you no longer have to call to change the date as long as it falls within the 90-day service period.
- Enhanced functionality supports adding attachments
- For standard medical prior authorizations, UHC enabled an Integrated screen experience which addresses any pop-up blocker issues.
Click here… (page #5)
New requirements for Percutaneous PFO closure
Effective May 1 2020, UHC is introducing a required notification/prior authorization process for Percutaneous Patent Foramen Ovale (PFO) closure for UHC Commercial members. In IOWA, this change will be effective Aug 1 2020.
- 93580: Percutaneous transcatheter closure of congenital interatrial communication (i.e., fontan fenestration, atrial septal defect) with implant.
If a notification/prior authorization isn’t completed before performing the procedure, the claim will be denied. Members can’t be billed for services denied due to lack of prior authorization.
Click here… (page #12)
Prior Authorization and Site of Service Reviews for Surgical Codes
United Healthcare removed all CPT codes included in CODE Group 4 from the list of surgical codes that are subject to site of service medical necessity review.
Click here…(page #13)
Hospital Lab Reference Protocol
For claims paid on or after May 1 2020, hospitals acting as a Reference Laboratory or conducting diagnostic testing for non-patients cannot bill such tests under their hospital’s Facility Participating Agreement.
Hospitals wishing to participate in United Healthcare‘s commercial network as a Reference Laboratory may apply with United Healthcare to be credentialed and contracted as a Reference Laboratory.
Click here… (page #16)
Reimbursement Policy Updates
Intraoperative Neuromonitoring Policy, Professional:
Effective with dates of service May 1, 2020, the study codes reported with IONM services 95940, 95941 & G0453 will be denied if billed under the below criteria:
- The technical component (modifier TC) or the professional component (modifier 26) of the study codes reported with IONM services in a non-facility POS on the same DOS.
- Study codes without a TC or 26 modifiers, reported with IONM services in any POS on the same DOS.
- The technical component (modifier TC) of study codes reported with IONM services in POS 24 on the same DOS.
- Per UHC’s replacement codes policy, IONM code 95941 is not reimbursable.
Outpatient Hospital CCI Editing Policy, Facility:
Effective May 1 2020, UHC will align the CMS National Correct Coding Initiative (NCCI) to Procedure to Procedue (PTP) edits for outpatient claims submitted on the CMS UB04 claim form or its electronic equivalent.
Click here… (page #17)
Enhancements to Procedure to Modifier Policy
Consistent with the Centers for Medicare & Medicaid Services (CMS), UHC is enhancing the Procedure to Modifier policy for Medicare Advantage plans to include modifiers CT, FX and FY.
Modifier CT:
- CAT scans furnished on non-NEMA Standard XR-29-2013-compliant equipment
- Payment reduction of 15% will be applied to the technical component (TC) payment portion
Modifier FX:
- Imaging services that are X-rays taken using film
- Payment reduction of 20% will be applied to the TC payment portion
Modifier FY:
- Imaging services that involve cassette-based imaging which utilizes an imaging plate to create the image
- Payment reduction of 7% will be applied to the TC payment portion
Effective for claims with dates of service on or after April 1, 2020, UHC will implement reductions to the TC payment (and the TC portion of the global fee) portion of radiological services when appended with the CT, FX or FY modifiers
Click here… (page #25)
Cigna
Cigna’s Response to COVID-19. Click here for interim billing guidance.
Cigna implemented several updates in the first quarter of 2020. Click here…
| Policy | Update | Effective Date | Coverage Policy Reference |
|---|---|---|---|
| Incontinence Supplies | Cigna will deny payment for all incontinence supplies if billed with HCPCS codes that begin with “T or A”. Incontinence supplies are used to meet daily needs and are not considered as medical benefit. | Jan 1, 2020 | No coverage affected |
| Allergy testing and Non-Pharmacologic Treatment | Coverage limitations for certain allergy tests in a 12 months period. Codes affected are 86003 - 80 units,95004 - 80 units,95024 - 40 units | Feb 17, 2020 | Feb 17, 2020 |
| Anesthesia for Interventional Pain Management Procedures in an Adult | New medical coverage policy will be implemented to allow sedation coverage for certain diagnosis specified in the policy | Feb 17, 2020 | 0551 |
| E/M Services | • Require documentation to review proper use of E/M service when billed with codes for joint injection or aspiration. E/M code reimbursement may be denied. | Mar 16, 2020 - Claims processed on or after this date | R30 |
| • Reimbursement for E/M services when billed with 99211 with modifier 25 will be denied if billed alone or with another procedure code on the same date of service. |
Cigna added 66 new CPT codes and 15 new HCPCS codes to the precertification master list. Six existing codes were removed from the list. Click here to review the complete list.
Health Engagement Incentives
Patients who are enrolled in a Cigna health plan through their employer may be eligible to earn financial rewards if the plan includes a health engagement incentive program. The program is offered at no cost to patients and helps supplement the physician’s treatment plan. This is especially important for patients who have chronic conditions.
Physicians should consider asking their patients if their plan offers incentive programs and suggest that they take advantage of them.
The programs help patients improve health and lower medical costs.
- They lowered overall costs an average of 10%
- For customers with two or more chronic conditions such as heart disease and diabetes, they lowered overall costs and average of 13%.
Hi-Tech Radiology Site of Care Review
For members with fully insured plans, Cigna’s precertification requirement for CT and MRI will include a medical necessity review for the site of care. Beginning April 15 2020, requests will be reviewed to ensure that the customers receive coverage for an appropriate site of care such as a free-standing facility rather than an outpatient hospital setting.
There will be no change in the pre-certification request process.
Coding Corner
An “assistant at surgery” is a physician who actively assists the physician in charge of a case in performing a surgical procedure. The “assistant at surgery” provides more than just ancillary services.
When billing these services, submit two claims. One for the primary surgeon as you do regularly and the other for the assistant surgeon using the most appropriate modifier from the list below. (Use these modifiers only with the surgery codes._
Modifier 80 – Assistant Surgeon:
- When the assistant at surgery service was provided by a medical doctor (MD).
- Provides full assistance to the primary surgeon
- Capable of taking over the surgery should the primary surgeon become incapacitated
- Reimbursement will be approximately 16% of the provider’s applicable Fee Schedule allowed amount for the primary surgery
Modifier 81 – Minimum Assistant Surgeon:
- An assistant who does not participate in the entire procedure but provides minimal assistance to the primary surgeon
- Reimbursement will be approximately 16% of the provider’s applicable Fee Schedule allowed amount for the primary surgery
Modifier 82 – Assistant Surgeon (When Qualified Resident Surgeon is not Available):
- Used primarily in teaching hospitals to indicate that a qualified resident surgeon is unavailable
- Reimbursement will be approximately 16% of the provider’s applicable Fee Schedule allowed amount for the primary surgery
Modifier AS – Non-physician Assisting at Surgery:
- Used to report Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) services for assistant-at-surgery
- Reimbursement allowed will be 85% of the 16% for the assistant at surgery services.
Documentation requirements: Just mentioning the name of the assistant surgeon in the Operative Report is not sufficient to code the assistant surgeon modifier and submit their claims. Primary surgeon should document the need for the assistant and their role during the entire procedure.
Sample documentation notes on the assistant surgeon requirement:
- Assistant Surgeon required during this case for retraction, dissection and surgical decision making to minimize anaesthesia time and maximize patient safety.
- Doe, John MD served as first assistant due to his certification and training in robotic surgery. Surgical residents are not robotic surgery certified or trained.
CPT Coding
FESS – Functional Endoscopic Sinus Surgery
Functional endoscopic sinus surgery (FESS) is a minimally invasive surgical treatment which uses nasal endoscope to enlarge the nasal drainage pathways of the para-nasal sinuses to improve sinus ventilation.
This procedure is generally used to treat inflammatory and infectious sinus diseases, including chronic rhino-sinusitis (CRS) that doesn’t respond to drugs, nasal polyps and some cancers. The four paranasal sinuses are: Maxillary, Frontal, Ethmoid & Sphenoid.
The FESS CPT Codes range is 31253 – 31288. In 2018, new FESS combo codes were introduced as below:
- 31253 – Nasal/sinus endoscopy + Total ethmoidectomy + Frontal Sinus exploration with tissue removal from frontal sinus when performed
- 31257 – Nasal/sinus endoscopy + Total ethmoidectomy + Sphenoidotomy
- 31259 – Nasal/sinus endoscopy + Total ethmoidectomy + Sphenoidotomy with tissue removal from sphenoid sinus
No combo code for maxillary sinus and they are always coded separately in addition to any one of the combo codes above when performed.
- 31256 – Nasal/sinus endoscopy + Maxillary antrostomy
- 31267 – Nasal/sinus endoscopy + Maxillary antrostomy with tissue removal from maxillary sinus
| Nasal/SInus Endoscopy | With Ethmoldectomy, Total | With Ethmoldectomy, Partial | |
|---|---|---|---|
| Nasal/ sinus endoscopy, surgical; | 31237 | 31255 | 31254 |
| with sphenoidotomy | 31287 | 31257 | NA |
| with sphenoidotomy, & removal of tissue | 31288 | 31259 | NA |
| with frontal sinus exploration without tissue removal | 31276 | 31253 | NA |
| with frontal sinus exploration & removal of tissue | 31276 | 31253 | NA |
| with maxillary antrostomy | 31256 | NA | NA |
| with maxillary antrostomy & removal of tissue | 31267 | NA | NA |
- Combo 1: Code ethmoid/frontal as a combination code and code sphenoid separately
- Combo 2: Code ethmoid/sphenoid together and code frontal separately.
| RVU COMPARISON | |||
| COMBO 1 | COMBO 2 | ||
| 31253 | 14.40 | 31259 | 13.57 |
| 31288 | 6.71 | 31276 | 10.86 |
| 31267 | 7.61 | 31267 | 7.61 |
| TOTAL | 28.72 | TOTAL | 32.04 |
Let’s Learn ICD 10 coding
Post-operative Complication During an Intra-operative Session:
Scenario: A surgeon treated an elderly woman’s right eye age-related cortical cataract at a day surgery center. After the procedure was completed, the patient suffered a post-operative hemorrhage of the eye, which the surgeon addressed.
ICD 10 codes – H25.011, H59.311, Y92.530
Rationale: Complication codes in ICD-10 CM are differentiated between intra-operative and post-operative. In this case, the primary diagnosis is the cataract and the post-operative complication is listed as a secondary diagnosis.
A place of occurrence code can be added to indicate the procedure occurred in a day surgery center. This code includes an outpatient surgery center connected with a hospital. As the complication code has the external cause included, as per coding guideline 1.C.19.g.4, an external cause of injury code is not required here.
Otitis Media
Scenario: A five-year old female child is seen for acute ear pain. Examination reveals left acute serous otitis media. Further examination revealed a total perforated tympanic membrane of the right ear due to chronic otitis media.
Coding: H65.02, H66.91, H72.821
Rationale: Otitis media has an expansion of codes in ICD-10-CM to classify these conditions. Laterality is also part of the classification in ICD-10-CM. In category H65, distinction is made between recurrent infections. A note is present stating that an additional code for any associated perforated tympanic membrane should be coded.
In this case, acute serous otitis media for left ear is coded as primary and perforated tympanic membrane is coded by assigning the correct code for the right side associated with the chronic otitis media. Otitis media refers to inflammation of the middle ear (area between ear drum and inner ear including the eustachian tube). Serous otitis involves a collection of fluid that occurs in the middle ear space caused by altered eustachial tube function. This is also referred to as secretory or with effusion.
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