July 01, 2018
Area(s) of Interest: Practice Management
CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.
Each year, the Centers for Medicare and Medicaid Services (CMS) releases an updated version of the National Correct Coding Initiative (NCCI) Policy Manual. The annual updates reflect changes to the CPT® and HCPCS code sets, as well as new and revised coding guidelines. This month, we’ll discuss the most significant, recent updates to chapters 1-7 of the Policy Manual that affect coding, compliance and reimbursement for providers. Next month, we’ll do the same for the remaining chapters of the Policy Manual, 8-13.
Chapter I: General Correct Coding Policies
To reduce the paid claims error rate, CMS has instituted Medically Unlikely Edits (MUE), which define the maximum units of service that a provider may report, under most circumstances, for a single beneficiary, on a single date of service, for a specific HCPCS/CPT® code. As part of the 2018 update, the Policy Manual includes additional examples to demonstrate how the edits are applied, as follows:
- The MUE for a knee brace is “2” because there are two knees and Medicare policy does not cover back-up equipment.
- The MUE value for a lumbar spine procedure reported per lumbar vertebra or per lumbar interspace cannot exceed “5,” since there are only five lumbar vertebrae or interspaces.
- The MUE value for a procedure reported per lung lobe cannot exceed “5,” since there are only five lung lobes (three in right lung and two in left lung).
- If a code descriptor uses the plural form of the procedure, it must not be reported with multiple units of service. For example, if the code descriptor states “biopsies,” the code is reported with “1” unit of service regardless of the number of biopsies performed.
- The MUE value for a procedure with “per day,” “per week” or “per month” in its code descriptor is “1” because MUEs are based on number of services per day of service.
- The MUE value of a code for a procedure described as “unilateral” is “1” if there is a different code for the procedure described as “bilateral.”
- The MUE value for CPT code 86021 (Antibody identification; leukocyte antibodies) is “1” because the code descriptor is plural including testing for any and all leukocyte antibodies. On a single date of service only one specimen from a patient would be tested for leukocyte antibodies.
The new examples do not change policy, but clarify guidelines already in place.
Chapter II: Anesthesia Services CPT Codes 00000-09999
New language stresses that collection of blood specimen is reported only in addition to lab services, or if blood collection is the only service provided:
CPT code 36591 describes “collection of blood specimen from a completely implantable venous access device.” CPT code 36592 describes “collection of blood specimen using an established central or peripheral venous catheter, not otherwise specified.” These codes shall not be reported with any service other than a laboratory service. That is, these codes may be reported if the only non-laboratory service performed is the collection of a blood specimen by one of these methods.
Similarly, irrigation of implanted venous access device for drug delivery may be reported only if it is the sole service provided:
CPT code 96523 describes “irrigation of implanted venous access device for drug delivery system.” This code may be reported only if no other service is reported for the patient encounter.
Chapter III: Integumentary System CPT Codes 10000-19999
The above guidelines regarding blood collection (36591, 36592) and irrigation of venous access device (96523) are repeated in this chapter, and several times throughout the Policy Manual.
Chapter IV: Musculoskeletal System CPT Codes 20000-29999
New text clarifies that you may not separately report integral anterior instrumentation (e.g., 22845-22847) with either 22853 or 22854, which describe insertion of interbody biomechanical device(s) into intervertebral disc space(s), if the purpose of the anterior instrumentation is to anchor the interbody biomechanical device(s) to the intervertebral disc space. The guidelines do allow, however, that “additional anterior instrumentation (i.e., plate, rod) unrelated to anchoring the device may be reported separately appending an NCCI-associated modifier such as modifier 59.”
Chapter V: Respiratory, Cardiovascular, Hemic And Lymphatic Systems CPT Codes 30000-39999
New guidelines stipulate, “Flexible laryngoscopy and direct laryngoscopy shall not be reported for the same patient encounter.” No exceptions to this rule are allowed, per the Policy.
Added text now instructs, “Thrombectomy of thrombus in the vascular territory of a diseased artery is inherent in the work of an atherectomy procedure.” As such, you may not report 37186 Secondary percutaneous transluminal thrombectomy for the removal of such a thrombus. “For example, if a physician performs a lower extremity endovascular revascularization atherectomy, removal of any thrombus from the vascular territory of the vessel treated with atherectomy is not separately reportable.”
Collection of venous blood by venipuncture is to be reported with a single unit of 36415, per episode of care, regardless of how many times venipuncture is performed. Per the Policy, “An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.”
Bone marrow aspiration and biopsy codes received updates in CPT® 2018. Existing codes 38220 Diagnostic bone marrow; aspiration(s) and 38221 Diagnostic bone marrow; biopsy(ies) were revised, and 38222 Diagnostic bone marrow; biopsy(ies) and aspiration(s) was added to report aspiration and biopsy performed during the same encounter.
CPT® guidelines tell us not to report 38222 with 38220 or 38221 (because both biopsy and aspiration are included in 38222). Additionally, you should never report 28220 and 38221 together to report biopsy and aspiration at the same location; in such a case, 38222 is appropriate.
The NCCI Policy Manual clarifies that you may report 28220 and 28221 together if the aspiration and biopsy occur at different locations:
The column one/column two code edit with column one CPT code 38221 (Diagnostic bone marrow biopsy) and column two CPT code 38220 (Diagnostic bone marrow, aspiration) includes two distinct procedures when performed at separate anatomic sites (e.g., contralateral iliac bones) or separate patient encounters. In these circumstances, it would be acceptable to use modifier 59. However, if both 38221 and 38220 are performed on the same iliac bone at the same patient encounter which is the usual practice, modifier 59 shall NOT be used. Although CMS does not allow separate payment for CPT code 38220 with CPT code 38221 when bone marrow aspiration and biopsy are performed on the same iliac bone at a single patient encounter, a physician may report CPT code 38222 (Diagnostic bone marrow; biopsy(ies) and aspiration(s)).
Chapter VI: Digestive System CPT Codes 40000 - 49999
New text bundles the use of mesh or other prosthesis during hernia repair, unless specific instruction in the CPT codebook advises otherwise:
Most CPT codes that describe a procedure that includes a hernia repair include insertion of mesh or other prosthesis. CPT codes describing implantation of mesh or other prosthesis (e.g., 15777, 49568, 57267, 0437T) shall not be reported with a procedure including a hernia repair unless there is a CPT Manual instruction specifically stating that the implantation of mesh or other prosthesis CPT code may be reported with that procedure.
In addition, arterial anastomosis of the hepatic artery and anastomosis of the extrahepatic biliary ducts (e.g., 47760, 47780, 47800) are new specifically included as a part of (not separately reported with) liver allotransplantation (e.g., 47135).
Chapter VII: Urinary, Male Genital, Female Genital, Maternity Care And Delivery Systems CPT Codes 50000 – 59999
The Policy Manual now defines radiofrequency ablation of uterine fibroid(s) (e.g., 58674, 0404T) and myomectomy of leiomyoma(ta) (e.g., 58140-58146, 58545, 58546, 58561) as mutually exclusive procedures for the same leiomyoma:
For example if a physician initiates a laparoscopic radiofrequency ablation of a uterine fibroid but must complete the procedure by laparoscopic myomectomy, only the completed procedure, laparoscopic myomectomy, may be reported. In the unusual circumstance where a physician performs radiofrequency ablation on one or more leiomyoma(ta) and it is medically reasonable and necessary to perform a myomectomy on a different leiomyoma, the physician may report both procedures.