2008 will not bring with it extensive changes in coding and billing rules and regulations as has been the case in recent years. However, it is still imperative that your business office staff has the most up to date coding and billing resources.
For Medicare patients we must follow all Medicare coding rules and regulations. Resources readily available on the CMS Website include:
Identifying Official Coding & Billing Resources
The Administrative Simplification Section of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 required the Department of Health and Human Services to name national standards for electronic transaction of health care information.
The HIPAA Final Rule names the Healthcare Common Procedure Coding System (HCPCS) as a national standard code set. HCPCS is divided into two principal subsystems, HCPCS Level I CPT® code set and the HCPCS Level II code set.
The CPT (Current Procedural Terminology) code set is developed and maintained by the American Medical Association (AMA). The CPT consists of descriptive terms and identifying numeric codes used for reporting medical services and procedures furnished by physicians and other health care professionals. The CPT codes are published and updated annually by the AMA with an effective date of January 1st of each year.
The AMA CPT codebook includes the CPT Level I and Level II (HCPCS) Modifiers, Place of Service (POS) codes and detailed clinical examples for Evaluation and Management services.
Prior to the beginning of each year review your electronic or paper charge sheets to verify that the codes and their descriptions accurately describe the services you are providing. Have staff members from the business office and clinical office compare the codes and descriptions in the 2008 CPT with those on your forms.
You can order CPT codebooks that are published by alternative publishers but in doing so you may lose some valuable information. The AMA CPT Professional codebook includes narrative developed by the CPT Editorial Panel and features references that indicate when additional instruction is available in the AMA’s CPT Changes: An Insider’s View or the AMA CPT Assistant monthly newsletter. All AMA coding resources are available on the AMA Website.
HCPCS Level II codes are alpha-numeric codes consisting of one alphabetical letter followed by four numeric digits. These codes are used primarily to identify those products, supplies, and services that are not included in the CPT codes, such as ambulance services, drugs, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
Under HIPAA the Centers for Medicare and Medicaid Services (CMS) has the authority to maintain and distribute HCPCS Level II Codes. HCPCS Level II codes are released on January 1st and July 1st of each year and are effective six months after the date of the release.
The HCPCS Level II Codes are available on the CMS Web site on the HCPCS Quarterly Update page. Monitor the HCPCS for deleted, revised and new HCPCS and update your practice management systems and charge forms to reflect the changes.
Other HIPAA designated standards include ICD-9-CM volume 1 and 2 for diagnosis codes, ICD-9-CM volume 3 for inpatient hospital services, CDT for dental services, and NDC codes for drugs. The National Center for Health Statistics (NCHS) and CMS are responsible for overseeing all changes and modifications to the ICD-9-CM.
The AMA CPT Changes: An Insider’s View is published annually by the AMA and includes the logic and rationale of CPT changes as well as clinical examples of the new or revised codes and coding guidelines. This publication is a reference guide to be used along with the most current CPT codebook.
The 2006 edition is particularly helpful when looking for detailed information and guidance on drug administration services. If you don’t already have this edition it is highly recommend that you order it. Be careful, when looking for coding guidance start with the most recent editions first and work your way backwards so that you aren’t following outdated information.
The CPT Assistant published monthly by the AMA provides clarification to confusing coding issues, coding commentaries, rationale behind the coding rules, clinical vignettes and coding FAQs.
On March 5, 2007 the AMA announced the establishment of a newly formed Editorial Advisory Board (EAB) for the CPT Assistant. The EAB members are:
Chair: William Thorwarth, MD
Secretary: Dan Reyes
J. Martin Tucker, MD
Peter A. Hollmann, MD
Albert Bothe, Jr., MD
Richard A. Molteni, MD
Helene M. Fearon, PT
Charles F. Koopman, Jr., MD
Kenneth B. Simon, MD, MBA
Richard W. Whitten, MD, MBA
Gerald E. Silverstein, MD
Claudia J. Bonnell, RN, MLS
What does this mean to you? The AMA acknowledges that the development of the new CPT Assistant Editorial Advisory Board (EAB) is an effort to increase its standing with public and private payers. The inclusion of public and private payers in the CPT Assistant EAB will lead to a greater acceptance of CPT coding guidelines.
In conversation on October 27, 2007 Dr. Richard Whitten, Contractor Medical Director, Medicare Part B for Alaska, Hawaii and Washington and CPT Assistant EAB member, stated that there will be substantial support for coding guidance found in the CPT Assistant subsequent to the establishment of the EAB.
With the formation of the EAB and their process of consensus agreement the AMA says that the focus of the newsletter will subtly shift to responding to “real world” coding issues.
The AMA states that formal input from key stakeholders will:
With the formation of the new EAB and the AMA’s stated goals for the publication every practice will need to have a subscription to the CPT Assistant if they want to be up to date on coding guidance. This publication is well worth the subscription price and is available in both print and electronic format.
Practical Tips for the Oncology Practice (previously titled Practical Tips for the Practicing Oncologist), is a comprehensive reference guide containing frequently asked questions about coding, reimbursement, coverage, and regulatory policies specific to the oncology practice. Practical Tips for the Oncology Practice also contains an extensive appendix of important resource information including sample forms, contact information for CMS local and regional offices, and supporting documentation from Medicare manuals and the Federal Register specific to oncology.
In addition to the information available in Practical Tips ASCO staff will also answer your coding and reimbursement questions by email at firstname.lastname@example.org.
Summary of New/Deleted 2008 CPT Codes
Deleted Effective 12/31/2007:
New Effective 1/1/2008
New Modifiers Effective 1/1/2008
*Modifiers ED & EE apply only to ESRD patients receiving dialysis in renal dialysis facilities
References: CR 5700 www.cms.hhs.gov/Transmittals/downloads/R1307CP.pdf
The codes and descriptions listed above are provided as a summary only. For a complete listing of coding changes & descriptions refer to the AMA CPT® 2008. www.ama-assn.org
Important Note: Not all codes will be accepted by Medicare, verify all coding changes & rules with your Medicare Contractor and other payers!
CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2007 American Medical Association. All Rights Reserved No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein The AMA CPT is available on the AMA website at: www.ama-assn.org
Medicare Premiums Increase in 2008
The Medicare Modernization Act of 2003 (MMA) requires that beginning in 2007 higher income beneficiaries be responsible for a higher percentage of the coverage cost of Medicare Part B, reducing the cost to the federal government.
The Part B Premiums are based on annual income and by the end of the 3-year transition period in 2010 higher income beneficiaries will pay a monthly premium equal to 35%, 50%, 65%, or 80% of the total cost, depending on their income level.
In the second year of the transition, the 2008 Part B monthly premium rates for all Medicare beneficiaries have increased again.
The table below shows the 2008 monthly premium rates to be paid by beneficiaries who file an individual tax return (including those who are single, head of household, qualifying widow(er) with dependent child, or married filing separately who lived apart from their spouse for the entire taxable year), or joint tax return.
Source: CMS Fact Sheet
The table below shows the 2008 monthly premium rates to be paid by beneficiaries who are married, but file a separate return from their spouse and lived with their spouse at some time during the taxable year are:
Source: CMS Fact Sheet
CMS Delays Required Use of Tamper-Resistant Prescription Pads
On May 25, 2007 Section 7002(b) of the U.S. Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007 was signed into law. This section mandates the use of tamper-resistant prescription pads for all written, non-electronic Medicaid prescriptions.
On August 17, 2007, CMS issued a letter to State Medicaid Directors with guidance on implementing the new requirement. CMS outlined three baseline characteristics of tamper-resistant prescription pads stating:
To be considered tamper resistant on April 1, 2008, a prescription pad must have at least one of the following three characteristics:
No later than October 1, 2008, to be considered tamper resistant, States will require that the prescription pad have all three characteristics.
CMS says they will leave it to each State to define the specific features it will require to meet those characteristics in order to be considered tamper resistant.
The new tamper-resistant requirement does not apply in the following situations:
On September 29, 2007, President Bush signed the “Extenders Law”, which delays the implementation date of this requirement to April 1, 2008.
CMS Releases 2008 Medicare Physician Fee Schedule Final Rule
On Thursday November 1, 2007 CMS issued the 2008 Medicare Physician Fee Schedule Final Rule, Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, and Other Part B Payment Policies for CY 2008; Revisions to the Payment Policies of Ambulance Services Under the Ambulance Fee Schedule for CY 2008; and the Amendment of the E-Prescribing Exemption for Computer-Generated Facsimile Transmissions.
A copy of the Final Rule is available now. However, the Final Rule is not expected to be published in the Federal Register until November 27, 2007. The document published in the Federal Register will be the official CMS approved document and may vary slightly from this published copy. Once published in the Federal Register a 60 day comment period will commence.
The Final Rule at 1481 pages will take some time to read and study the details; an in-depth analysis of the Final Rule will follow in the next Oplinc Best Practices Review Newsletter. Below is a summary of some of the provisions:
The table below illustrates the changes in the drug administration services due to the PE revisions transitioned in at 50% in 2008 and the negative 10.1% update bringing the Conversion Factor (CF) to $34.0682. Figures below are based on information provided in the 2008 Final Rule and are subject to change if Congress acts to stop the negative 10.1% update.
Make Your Voice Heard!
The Sustainable Growth Rate (SGR) formula is specified by statute as the method through which the Medicare Physician Fee Schedule (MPFS) is updated. See Volume 3 Issue 4 of the Oplinc Best Practices Review Newsletter for details on the SGR formula.
The only method through which CMS can intervene with the SGR formula and the MPFS update is to buy down the negative update with the The Physician Assistance and Quality Initiative (PAQI) fund.
As mentioned earlier in this newsletter, CMS declined to use the PAQI fund to buy down the estimated negative 10.1 percent update to the Medicare Physician Fee Schedule (MPFS) for 2008 choosing instead to use the $1.35 billion to fund the 2008 PQRI program. Therefore, unless Congress intervenes CMS will reduce physician payments 10.1% beginning January 1, 2008.
The American Medical Association (AMA) and other national provider organizations are leading an effort to stop the impending cut to Medicare physician payments. The AMA suggests that providers and patients contact their legislators and ask them to stop the pending Medicare physician payment cuts. Information for patients is available on the AMA Patient’s Action Network Web page.
New legislation addressing the Medicare payment package is expected to be introduced shortly. The AMA is asking providers to contact their senators and ask them to speak to Senators Max Baucus, D-Montana, and Charles Grassley, R-Iowa, the chair and ranking member of the Senate Finance Committee, respectively, and urge them to include positive Medicare physician updates in the Medicare bill. To contact your legislators call the AMA's toll-free Grassroots Hotline at 1-800-833-6354.
The American Society of Hematology (ASH) reports that the Senate Finance Committee is putting together a Medicare package that would halt the 10.1 percent reduction in physician fees scheduled to take effect on January 1, 2008.
ASH reports that the committee is focusing on a reduction in reimbursements to private fee-for-service Medicare Advantage (MA) plans to offset the cost of the Medicare package. Also under consideration are reductions in Medicare reimbursements for medical imaging and home oxygen services.
According to ASH Senator Baucus proposed a $30 billion Medicare package that would suspend the scheduled 10.1 percent reduction for two years, stop a scheduled reduction in rehabilitation therapy reimbursements and increase payments to providers in rural areas. Senator Grassley’s proposal includes a one-year suspension of the scheduled reduction in Medicare physician fees, thus requiring a smaller decrease in payments to MA plans.
ASH is urging physicians to contact their Congressional members asking them to pass legislation to stop the scheduled cuts to physician reimbursement. You can contact your Congressmen through the ASH Advocacy Center on the ASH Web site.
Medicare Administrative Contractors
As part of the Medicare Contracting Reform mandated in section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) CMS is replacing 43 Medicare Part A and Part B Contractors with fifteen A/B Medicare Administrative Contactors (MACs) who will process and pay both Part A and Part B claims.
The new MACs are awarded the A/B MAC contract in a competitive bidding process. Issues of concern with the new MACs include the uncertainty of how the new MACs will interact with the state Carrier Advisory Committee (CACs) and the number of Contractor Medical Directors (CMDs) the MAC will have.
Many State Medical Oncology Societies have begun to form regional groups or a task force consisting of representatives from each of the State Medical Oncology Societies in their MAC Jurisdiction.
As of November 12, 2007 CMS has awarded five of the fifteen A/B MAC contracts. The J2 A/B MAC – Alaska, Idaho, Oregon and Washington is expected to be announced any day.
A/B MACs Awarded:
July 31, 2006
August 2, 2007
September 5, 2007
October 24, 2007
October 25, 2007
ABOUT THE EDITOR
CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.