Effective Jan. 1, 2011, new CPT codes and, inevitably, new Correct Coding Initiative (CCI) physician edits are there for physicians. For version 17.0, “19,822 new edit pairs have been added to the database while 9,778 have been terminated, for a net gain of 10,044 new edit pairs,” according to Frank Cohen, MPA, MBB, of the Frank Cohen Group, in his Dec. 14, 2010, “NCCI Version 17.0 Change Analysis” announcement.

The main edits you want to be sure to watch for are those related to new code 96446 (Chemotherapy administration to the peritoneal cavity via indwelling port or catheter).

The 96446 non-mutually exclusive (NME) edits are largely what you would expect based on other chemotherapy code edits — bundles with E/M, anesthesia, venipuncture and other vascular procedures, for example. You want to be sure to watch which is the column 1 code and which is the column 2 code for these bundles.

CCI places E/M codes 99217-99239 in the column 1 position and 96446 in the column 2 position. On the other hand, CCI places 96446 in the column 1 position and E/M codes 99201-99215 in the column 2 position, as shown below:

Remember that if you report both codes in an NME edit pair without a modifier, Medicare (and payers who adopt these edits) will deny the column 2 code and pay you only for the column 1 code. The edits in the table above all have a modifier indicator of 1, meaning that you may override the edits with a modifier when appropriate, such as in the case of distinct,...

Remember to check for updated or revised guidelines when preparing to use your new code books for 2011, not just code descriptors. CPT 2011 includes new details for coding some common injection procedures, as pointed out at the AMA’s CPT and RBRVS 2011 Annual Symposium in Chicago. Read on for a few pointers to help stay on the right track.

The introduction of new codes for paravertebral facet joint injections in 2010 (64490-64495) meant changes to how you reported related codes. During the CPT and RBRVS Symposium, Douglas G. Merrill, MD, MBA, of the American Society of Anesthesiologists, pointed out two revised guidelines dealing with paravertebral facet (spinal) joint procedures.

Instructions in CPT 2010 directed you to report 64999 (Unlisted procedure, nervous system) if the provider used ultrasound guidance during paravertebral facet joint injections. The AMA released a correction later in 2010, and the CPT 2011 clarifies the situation. If your provider used ultrasound guidance when administering paravertebral facet joint injections, report the appropriate code(s) from 0213T-0218T (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with ultrasound guidance …).

T12-L1 change: CPT 2010 guidelines mandated that you report 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [for nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) for an injection to the T12-L1 joint, or nerves innervating that joint. New 2011 guidelines direct you to submit 64490 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [for nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; single) instead.

In addition, the 2011 guidelines direct providers to report paravertebral facet joint injections performed without image guidance with the appropriate trigger point injection code. Submit either 20552 or 20553 (Injection[s]; single or multiple trigger...

The Affordable Care Act (ACA) extended preventive coverage to more than 88 million patients covered by health insurance, and Medicare has codified that benefit in the form of an annual wellness visit. Medicare valued the new annual wellness codes based on a level 4, problem-oriented new and established E/M service. The two new codes are:

• G0438 – Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit
• G0439 – Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit.

Tip 1: Apply G0438 to Second Year of Coverage

Be wary of applying these codes to new Medicare patients coming in to your physician’s practice in 2011.

The reason is that Medicare will only reimburse the initial visit (G0438) during the second year the patient is eligible for Medicare Part B. In other words, during the first year of the patient’s coverage, Medicare will only cover the Initial Preventive Physical Exam (IPPE), also known as the Welcome to Medicare exam.

Tip 2: CMS Limits G0438 to One Physician

If your FP sees the patient for the initial visit (G0438) and the patient sees a different physician for the next annual wellness visit, that second physician will only receive reimbursement for the subsequent visit (G0439), despite having never seen the patient before.

CMS has indicated that when a patient returns to the same or new physician in a third year, they might only pay for the subsequent visit, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. “It is therefore important that you convey this information to any new physician the patient sees.”

Tip 3: Add Preventive Service Codes, If Performed

You can bill the new annual visit codes in addition to any other preventive service, such as G0102 (Prostate cancer...

CMS has offered Part B practices a late holiday gift with the news that MACs won’t institute ordering/referring PECOS edits until July, thanks to a new transmittal on the topic.

Currently, if you submit claims for services or items ordered/referred and the ordering or referring physician’s information is not in the MAC’s claims system or in PECOS, your practice will get an informational message letting you know that the practitioner’s information is missing from the system. It was previously announced that MACs would start denying these claims on Jan. 3, but CMS announced on Dec. 16 that claim denials won’t begin until July 5.

In Part B, MACs will take two steps before denying your claims. First, the carrier will check whether the ordering/referring physician is in PECOS. If not, the MAC will try to find the provider in the Claims Processing System Master Provider File. If the physician is in neither system, the claim will be rejected starting this July.

Even though CMS won’t reject your claims this month, you should still take this time to ensure that you and your ordering/referring providers are in PECOS as soon as possible, just in case the MAC edits become a reality, said National Government Services’ Andrea Freibauer during a Nov. 9 webinar on ordered and referred services.

To read the updated CMS transmittal, visit http://www.cms.gov/transmittals/downloads/R825OTN.pdf.

Hospices benefited from a separate holiday gift that CMS delivered just before Christmas – a delay of the enforcement date for the new face to face encounter requirement.

For weeks, hospices, home care providers, and their representatives had been giving CMS the full court press about the burdensome new physician visit requirement. In a Dec. 15 letter to CMS Administrator Donald Berwick, more than 25 senior and long-term care organizations joined the National...