May 1- CMS Claim Edit

May 1, 2013 CMS Claim Edit

by Aisha Bailey

According to CMS publication; MLN Matters Number SE 1305, MLN Matters Effective May 1, 2013 CMS will  enforce the requirement that the referring provider listed on claims must be currently enrolled in Medicare. The referring provider must also be eligible to order or refer the service being billed.

Claim edits will enforce this 2010 requirement  for the following service providers; Home Health, Part B laboratories, imaging services and durable medical equipment providers.

Take a Closer Look at the Audit Process

By Jaci Johnson, CPC, CPC-H, CPMA, CPC-I, CEMC

AAPC offers a wide selection of specialty specific exams. These allow individuals to test their skills in one particular area where they feel they have a certain level of expertise. In addition to these specialty exams there is one that allows the individual to showcase their skills across multiple specialties. The Certified Professional Medical Auditor (CPMA®) exam tests one's ability to audit various specialties as well as understand how an audit is conducted from beginning to end. How do you know when you are ready to sit for this exam? What knowledge base is needed to understand the concepts? The easiest way to approach these questions is to consider how an audit is conducted in a medical practice. From the time someone in the practice decides to request an audit until the results are tabulated and presented, there are multiple steps in the process to consider. Let's take a closer look at the audit process. In essence, let's audit an audit. The first step is the decision to perform the audit. Is this audit being performed because there is a known compliance issue, did a provider request to have his records reviewed, or is it part of an annual compliance plan? Based on the answer to this question, the scope of the audit can be determined. The scope will outline the time frame for the selection of claims to be audited. The reason for the audit also will help in deciding how many claims should be reviewed. The number of claims will vary based on whether this is a focused review that is only concerned with a specific coding issue or a baseline audit that is conducted to determine if there are any potential risk issues. Often the request for the audit will require a statistically significant number of claims to be reviewed to ensure a measure of reliability in the results. The number for the statistical sample would be based on the total number of claims within a selected period of time. Once the scope is determined and the selection process has been completed, the actual review of the documentation can begin. In addition to the supporting documentation, auditors require the claims data to reflect what was actually billed. If the audit will include the review of Evaluation and Management (E/M) codes, then the auditor should have a sound knowledge of certain concepts and have certain tools available. The auditor should have a firm grasp of all the E/M guidelines in the CPT® manual and the Medicare Documentation Guidelines, both versions. The auditor also will require a thorough understanding of any modifiers associated with E/M codes. In addition to the fundamentals of auditing the documentation to ensure proper E/M code selection, the auditor should have knowledge of "incident to" guidelines, understand the guidelines associated with Physicians at Teaching Hospitals (PATH), and know how to identify in the documentation any misuse of the guidelines. If the audit will include reviewing any surgical services, the auditor is responsible for an even greater fund of knowledge. The auditor must be skilled in maneuvering through the National Correct Coding Initiative (NCCI) to determine any misuse of bundled codes. The auditor should also be aware of any Local Coverage Decisions (LCD) that may pertain to those procedures and National Coverage Issues as determined by the Centers for Medicare & Medicaid Services. As with any coding audit, an understanding of the CPT® manual coding rules for that service is mandatory. The auditor must also understand proper use of modifiers for various surgical coding scenarios and be able to determine if the documentation can support the need for that modifier. The PATH guidelines are often a part of a surgical audit as well, and it is important that the auditor be able to recognize who is performing the service. The medicine section of the CPT® manual presents the coder with a wide variety of procedures and services. From an audit perspective, this can pose a challenge. There are no set rules that cover all those services. The auditor needs to be as well-versed with infusions as with psychiatry services or physical therapy and all things in between. The NCCI and LCD can still be useful reference tools, along with any individual guidelines found within CPT®, and of course the use of modifiers. To complete an audit it is also necessary to assess the diagnosis codes that were billed to determine if the documentation can support their use. The documentation should be compared to the code billed for correct specificity. The Official Coding Guidelines found in the ICD-9 manual should be consulted for any questions concerning coding accuracy. In addition to all the coding guidelines and CMS requirements that have been noted above, the auditor should be familiar with signature requirements and also verify proper dates of service for all services reviewed. Once the audit has been completed, the results should reflect any variances in what codes and modifiers were billed versus what the auditor determined to be the codes and modifiers based on the documentation provided. The auditor should be able to provide the resources that were used in determining the findings of the audit. What is done with the audit and how the results or findings are communicated is often determined by management in the practice. Depending on the types and severity of the variances discovered in the audit process, a decision may be made to bring in legal counsel to help determine next steps. The auditor should be familiar with the information provided by the Office of Inspector General (OIG) concerning compliance and Corporate Integrity Agreements, even though the process may be handled by a lawyer. Sometimes the audit may begin at the request of a lawyer, and the whole process is considered under attorney client privilege. This concept should be clearly identified to the auditor so that the privacy of the audit can stay intact. Performing an audit can be quite a cumbersome endeavor and is a heavy responsibility. The steps outlined here are not a comprehensive list but provide an overview of some of the considerations during the audit process and should be used as a guide when deciding to sit for the CPMA® exam. Jaci Johnson is president of Practice Integrity, Richmond, Va. She has been working in the field of medical coding and auditing for 22 years and has been a CPC®since 1994. She teaches PMCC courses and manages a national client list, providing compliance monitoring for provider documentation. Johnson was recognized as Coder of the Year for the state of Virginia in 2006. She is the past president of her local AAPC chapter and currently serves on the AAPC National Advisory Board. She can be reached atjaci@practiceintegrity.com.

Practice Management Alerts from the AMA

Practice Management Alerts

May 1: Important Medicare enrollment date  The Centers for Medicare and Medicaid Services (CMS) announced that, starting May 1, physicians who refer or order services for Medicare patients will be required to be enrolled in Medicare. Claims submitted on or after May 1 that include the name and National Provider Identifier (NPI) of a physician who referred or ordered services for a Medicare patient but who is not enrolled in Medicare will be denied. CMS had originally planned to implement this requirement in 2010, but the AMA succeeded in getting it delayed for several years, during which CMS has worked to ensure that physicians are enrolled. Physicians who have a valid opt-out affidavit on file are not required to enroll in Medicare. CMS also has a special, shorter enrollment form for use by physicians and other health professionals who just refer and order services but do not bill Medicare directly, known as the 855-0. More information on the new edits can be found in this CMS article as well as its website. For more information on Medicare enrollment in general, please visit the AMA’s Medicare enrollment website. Was this alert helpful? Forward it to a friend, and invite them to sign up for the AMA Practice Management Alerts to receive future alerts like this one. Be an AMA member. Join the AMA today at ama-assn.org/go/membership or call (800) 262-3211 to be part of the efforts to help shape a better health care future.

You need a check up!

We check our tires, our oil, our lights, check our credit report and bank account for updates all day. We check many things all day, because we know that checking and double checking is an essential part of being prepared.


But how do you prepare for increased reimbursement or changes in payer contracts. If your not checking , You need a check up!

In addition to medical billing services we also perform comprehensive claim review and auditing which result in increased revenue and can help you streamline your practice workflow.

Give us a call to see how a check up can help you make more money.

Reimbursements, Get off at the next EXIT!

 Most small practices operate with the help of a small staff.
And most of the staff members have dual responsibilities.

Do you have a medical biller/medical assistant/receptionist/ office manager/appointment scheduler/ authorization specialist/coder/ medical records clerk/ appointment confirmer/copay collector/claims submitter..... in your office?

If you do- I have some questions for you? Who is dedicated to collecting payments from the insurance company? and more importantly who is keeping a watchful eye over the reimbursement trends to increase your revenue cycle?

There is no fault in hiring a rock star multi-tasker, but even the best needs the right tools to do their job.  And that tool is TIME.

Consider the time it takes to perform all those other important office functions vs. the time it takes to perform the most important administrative job in the practice; securing reimbursement.

By using a billing company you will be able to save your company from spending more money on paying one or more salaries, vacations, sick pay, health insurance and all the other overhead associated with hiring an in-house biller. Your existing support staff will be able to perform the best of their expertise without compromising reimbursement.

Because our billers are assigned specifically to your practice, you will have 24/7 access through our web based integrated billing/ practice management software. This will give you access to have your accounts/billing information just like the one on one transparency you would have with an in-house medical biller. And most importantly, give you TIME to focus on what's important.

We have over 25 years experience in medical billing and practice management. Along with our experience we are equipped with knowledge and access to tremendous software tools that cater to all the nuances of medical billing.

Interested?  Call or email me for a Free Billing Consultation.

abailey@mkbilling.com      www.mkbilling.com     914-226-8642

For more information please contact me directly, and I will be happy to answer any of your questions. 

Common Coding Mistakes in Ambulatory Surgery Centers: Orthopedic & Pain Management (Part 1 of 3)

Procedural coding errors can lead to lost revenue or unintentional upcoding at ambulatory surgery centers. 

Stephanie Ellis, RN, CPC, is the president and owner of Brentwood, Tenn.-based Ellis Medical Consulting, and Lolita M. Jones, RHIA, CSS, is an independent coding and billing consultant.

Here Ms. Jones and Ms. Ellis elaborate on seven trouble areas for coding orthopedic and pain management procedures.

1. Fracture debridement. Coders frequently do not recognize debridement of an open fracture, since it may be only a couple of words in the operative report. They should pay close attention to fracture care in case debridement is mentioned. If it's noted by the surgeon at all, it must be coded in addition to the fracture treatment, Ms. Jones says. The correct code to use is 11010, 11011 or 11012.

2. Tendon grafts with ACL reconstruction. The 20924 code for the harvest of a patellar or hamstring tendon graft is billable only when the graft is obtained from the opposite knee or from either ankle, Ms. Ellis says. 

The current procedural guidelines state the graft must be "from a distance" when billed with the 29888 ACL repair code, which means the tendon graft cannot come from a separate incision in the same knee. Coders should be aware of where the graft came from.

"[This does] not constitute a far enough distance to bill for it separately, according to CPT guidelines, even though it is not unbundled in the CCI material and it is performed through a separate incision," she says.

3. External fixation. Most fracture treatment codes have been revised so external fixation has to be coded separately, Ms. Jones says. Coders often follow rules from years past, when external fixation was included and inadvertently lose revenue.

4. Sacroiliac joint injections. Sacroiliac joint injections can be confusing because of there are several variations used depending on the procedure and the payor. Coders should use 27096 — which documents the injection procedure for a sacroiliac joint, arthrography and/or anesthetic or steroid — when billing commercial payors or billing the physician's surgical service, Ms. Ellis says.

When billing Medicare for the same procedure, coders should use the CPT G0260, which documents the injection procedure for a sacroiliac joint. Imaging is included in both of these codes and should not be billed separately.    

However, if the joint injection is performed without fluoroscopic guidance or arthrography, coders should use 20610, injection into a major joint. The 20610 code does not include imaging and would be used by both the physician and the ASC facility for billing to all payors, she says.

5. Hardware or implant removals. Deep pin removals done in an ASC require the code 20680. The physician will have to make an incision to visualize the implant, but the code is only to be billed once per fracture or previously operative site, regardless of the amount of hardware removed or the number of incisions made, Ms. Ellis says. The code can only be billed twice if the surgeon removes an implant or hardware from a completely different surgical or anatomical area. 

6. Nerve branch destruction. For pain management treatments, rather than reporting the destruction of each nerve branch separately, coders should be reporting based on each intervertebral joint destroyed, Ms. Jones says. Each joint is supplied by two nerve branches, so coding separately would double the cost of the bill. Physicians may balk if they used a separate needle for each nerve branch, but that does not change the coding. 

CMS To Terminate Common Working File for Eligibility

The Common Working File (CWF) is a single data source for Fiscal Intermediaries and Carriers to verify beneficiary eligibility and conduct prepayment review and approval of claims from a national perspective. It is the only place in the fee for service (FFS) claims processing system where full individual beneficiary information is housed. CWF has four quarterly releases that control, implement, and update software changes due to legislative mandates. Software changes for the claims processing operations are managed in quarterly releases developed through a change control process that begins with the Medicare Change Control Board (MCCB) review and prioritization of pending requests. The FFS Operations Board approves the quarterly releases with oversight by the FFS Governance Council and manages/integrates day-to-day operations of the FFS program across CMS. The FFS claims processing environment is distributed across four (4) claims processing modules and one (1) integrated testing module. This investment directly supports the PMA Improve Financial Performance, as it is an essential component ensuring that accurate payments are made for medically necessary services and are provided to eligible beneficiaries by qualified providers of care. The impact of not funding CWF would be detrimental to Medicare, introducing system errors, causing harmful delays in claims processing and payment, and reducing the access, availability, and provision of health care services to Medicare beneficiaries. Error-free releases that implement legislative mandates with minimal interruption to processing ensure that beneficiaries receive the correct service and providers receive the correct payment. Current Common Working File submitters must seek alternative solution Effective April 1, 2013, the Centers for Medicare and Medicaid Services (CMS) is required to eliminate the Common Working File provider query for eligibility.  What does this mean for you? If you currently use Common Working File queries to verify Medicare eligibility, you must implement an alternative solution by April 1, 2013.

Creating A Successful Billing Team

Working as medical biller for some of the largest medical groups and hospitals in the Westchester area has given me a great deal of experience and knowledge of the inner workings that make up a billing department. A billing team can consist of one or two great billers for a small practice, a multitasking front desk/ biller or a large team of billers and collectors. This depends heavily on the type of practice, the size and demand on the practice. Here are some tips that I have found to be very useful when building a medical billing team. Team Work Only -No exceptions

 
A medical biller usually has to wear many hats during the day. Having one biller send out all the claims, send the patient bills, post all the money, answer the patient phone calls and work on the A/R may work for single and small practices. However multiple provider practices should have a team of multiple billers. A medical biller should be a great multi-tasker. This is a very important aspect of the job. But even the best biller can become over extended by having to work on too many tasks. Make sure that your practice has the support staff needed so that the biller can focus on the very important task of collecting the money. Outsourcing your billing is also a great way to secure a team of people that are only focusing on collecting. A billing company is not in your office answering phones, filing charts and making appointments- they should have 100% of their time dedicated to bringing in money for your practice. Diversify the Tasks

Once you have a team of billers that meets the demands of your practice you will find that creating a system of checks and balances is key. I have consulted for practices and saw a large amount of over 120 day unpaid claims that have never been worked on. No phone calls, no EOB information- this should never happen. Some may say that a claim can fall through the cracks. I believe that if a billing team diversifies their tasks, this can be prevented. The team should be set up with some billers working on sending claims out. One biller should make phone calls while another biller posts money. This way everyone can have a hand in every account. Working on the A/R can be split also. If there are three billers in your practice, have one work on the 30-60 day bucket, another work on the 90-120 and the other work the EOB's. This will ensure that all parts of the A/R are always worked on and that each person has a second set of eyes looking over their work. Monitor your team and give tasks based on areas of strength. Some people are great with accuracy let that biller post charges and payments. For the biller that loves to investigate assign EOB's and appeals to be worked on. Diversify your tasks and watch your team flourish. Communicate, Share and Evaluate

Keep an open forum for learning, sharing information and growth. A meeting should not always consist of numbers and analytics only. Your billing team has a lot to share. They are on the front lines, talking to the patients and the insurance companies. Maintain an environment for communication between departments, billers and the practice. I once worked in a billing department that did not allow the payment posting department to meet with, speak directly to or share information with the collections department. Needless to say, this was not a great policy. It caused confusion, division and prevented work from being done. Keep all lines of communication open and you will have a team of informed billers.


The best words a biller wants to hear are thank you. Remember to encourage your team for their hard work they will appreciate it.

Insert your name here.....

Why are you wasting time and money trying to do your own medical billing?  Hire a Medical Billing Company and you could spend your extra time and money here!

Billing Made Easy: Electronic Claim Status

Did you know that it costs significantly more to manually check claims status as opposed to checking claims status electronically?

Claim Status- Is the act of contacting the insurance company, payer to obtain payment appeal or denial information.

Needless to say , checking claim status should be the primary function of your medical billing company. However checking claims status manually can be time consuming and can also prevent you from performing other revenue enhancing activities. Medical billers spend significant time on the phone on hold, waiting for call backs and leaving messages for claim status information. Therefore, every effort should be made by an experienced biller and billing service to determine claim status using electronic means.

According to the AMA ( American Medical Association) the cost analysis to determine claim status manually vs. electronically is :

Cost to determine claim status manually: $3.70 x 620 = $2,294
Cost to determine claim status electronically: $0.37 x 620 = $229
Average annual savings per physician from automating claim status: $2,065*
* Based on an annual average of 6,200 claims submitted for a single physician. Source: Milliman, Inc., “Electronic Transaction Savings Opportunities for Physician Practices.” Technology and Operations Solutions. Revised: Jan. 2006

Most insurance companies have a website available, where one-click claim status can be obtained. This may also be obtained from a clearinghouse, or electronic claims functions within your billing system. At MK Professional Billing Services we seize every opportunity to efficiently build revenue. We work harder and smarter for our clients. Even when electronic claim status capabilities are not available you can try to obtain emails for claims adjusters from Workers Compensation providers or smaller local plans. Faxes and automated systems also help get the claim status ball rolling as well.

By removing these parts of the manual processes in an office’s routine, physicians can free their practice staff to perform many other operations to speed up the revenue cycle.

 

Handling a denial for Intraoperative Monitoring Services

Sending medical claims to insurance carriers is the simplest aspect of medical billing. The most challenging part of medical billing is dealing with denials.

Here are some tips that I have acquired for dealing with denials.

Thoroughly review the denial This may seem like an obvious step however many medical billers miss the importance of this. It is not enough to simply review a denial from the insurance company, look at an explanation of the denial and accept it as fact. Investigation is a necessary part of medical billing, especially IONM billing. Call the insurance company and ask as many questions about the denial as you need. Don't be afraid to ask and ask again. You'd be surprised to know that most insurance phone representatives don't understand the billing process, coding and your specific denials. If you don't get an understanding about your denial call again, sometimes getting a different representative on the phone can change the entire outcome of the claim.

Research
After you receive a denial that you understand it's time to research. Track other denials you received that are similar. How were they handled before? Was your denial paid before on another claim? If it was paid before, this may be an indicator of an incorrect denial, or a series of errors from the insurance carrier.
Research the coverage determinations for the carrier that denied the claim. Don't forget to reference the Local Coverage Determination from Medicare also.

Most carriers use Medicare's policy to determine coverage of IONM coding.

Appeal
Once you've determined an approach for your appeal. Obtain your intraoperative notes supporting the codes that you billed. Review the records.

Don't blindly send an appeal letter with a claim without reviewing the intraoperative notes.
When you create an appeal letter, obtain your supporting documents, past appeals, explanations of benefits, LCD's; have someone else review this. A second glance at your appeal from another set of eyes is always a good idea.
Copy or scan all of your documents and send them to the appeals address. Sending them to the regular claims address may cause the appeal to be rejected. Many insurance companies have a time limit for appeals. This is why it is important to work all your Explanation of Benefits within a week of receiving them. You can avoid issues by getting your appeal out on time.

Know the rules for the carrier you are appealing. Some insurance companies want appeals in a certain format, others are more lenient. Make sure you know what is expected of your appeal.
Also- remember to keep some form of proof that the appeal was sent. A certified mail receipt is a good form of proof. If for any reason your appeal does not meet it's destination you can use this to prove the submission.

Follow Up

In order to make sure your appeal is reviewed and your claim is reprocessed you need to have a strategic follow up method. Make sure your appeal was received. Many times after an appeal is sent, billers just wait for a response. Don’t assume you will get one. Call at least 14 days after the appeal  is sent. Obtain an appeal document number or claim number. Make sure all your appeal documents were received. Know the number of pages in your appeal packet and make sure the rep can confirm that all pages were reviewed or scanned. Also make sure the document has been forwarded or is being worked on by the correct department.

Once you have all the information needed, set up a reasonable follow up time to call back and see if the appeal has been reviewed.

Lastly, don’t give up. Keep on fighting for payment. If you have followed the rules for appeal and you have all of your  supporting documentation don’t take no for an answer. Continue to track your denials and document  your entire follow up process.  Any claims that you get paid after the appeal can be used as leverage for new denials.

Outsourcing: What you Should Know

Outsourcing: What you Should Know

 

Imagine having the accessibility, transparency and convenience of an in house billing department without having to pay for salaries, vacation, personal sick time, health insurance and other technology costs associated with managing an in house staff. These are some of the reasons that practices and individual providers want to outsource their billing. Not only are you reducing costs for your practice, but you are freeing your time to focus on patient care and the growth of your practice.  By using a billing service providers have access to a team of expert billers working towards claim follow up all the time. Billing and collecting is one of the most important aspects of the practice aside from patient care. Every practice should have access to unlimited growth potential and by outsourcing an expert billing service your practice can tap into that growth

Medical Billing Can Be Frustrating

Look at her face? Is that how you look after a long day of working on medical billing, claims, appeals and denials? Medical Billing can be frustrating! Give us a call, we can take the frustation out of Medical Billing for you. 914-226-8642

Capitol Hill Report: $6 Million Win, NCS/EMG Update, VP Biden Mentions AAN

By Mike Amery, Legislative Counsel, Federal Affairs, (202) 506–7468, mamery@aan.com

AAN Wins Funding for Epilepsy Centers of Excellence

In an exciting victory for AAN advocacy, the Department of Veteran’s Affairs has agreed to continue funding of the Epilepsy Centers of Excellence (ECoE) for FY 2014 for $6 million.
When the ECoE were created by Congress in 2008 the legislation contained a “sunset” provision that would end authorization of the centers after five years unless Congress acted or the VA continued funding.
In October of last year, we received signals that the ECoE may not be funded, even though data clearly show the centers are improving care for veterans while also saving the VA money since patients no longer have to be referred to outside specialists.
We took our concern to the original author of the legislation, Rep. Ed Perlmutter (D-CO), to ask him to lead a letter to the VA requesting that the ECoE be fully funded. The AAN was joined in this effort by the Epilepsy Foundation of America (EFA). Both the AAN and EFA activated a grassroots lobbying campaign that resulted in 43 members of Congress signing Rep. Perlmutter’s letter.
The AAN is pleased that the VA indicated that the ECoE would be included in their FY 2014 budget. In a city dominated by dysfunction, the ECoE are at least one success story of how things can get done in Washington. We thank all AAN members who took the time to send a message to Congress that led to this success.

NCS/EMG Update

For the last two months, much of the Capitol Hill Report has been devoted to AAN efforts to curb the dramatic cuts to nerve conduction and EMG studies proposed by CMS on November 1, 2012. If you do these studies you no doubt know that the cut went into effect on January 1.
Your AAN leadership, including President Bruce Sigsbee, MD, FAAN; Elaine C. Jones, MD, FAAN; and AMA RUC Committee member Marc Raphaelson, MD, worked tirelessly along with AAN staff to try to overturn this uninformed, arbitrary decision.
We have received a number of complaints from AAN members asking why we “allowed this to happen” or “why didn’t you do anything to stop this?” Regular readers of Capitol Hill Report know that we did everything we could before the cut went into effect, so I have a favor to ask. If you encounter AAN members with similar complaints, please let them know that our response to this situation was a swift, vigorous defense of physicians who conduct these studies and the patients who rely on them. 
CMS is an unelected, unaccountable government agency that ignored the recommendation of the RUC and acted (unfairly but legally) outside the normal process of government, which typically offers advance notice and an opportunity to comment, especially on reductions as significant as those affecting nerve conduction and EMG studies.

In the short time we were given, the AAN:

• Created a coalition of interested patient and provider groups
• Generated a letter from the US House objecting to the change that was signed by more than 40 members of Congress (at the height of the fiscal cliff crisis)
• Generated a similar bipartisan letter from the US Senate
• Met twice with CMS, including a high-level meeting attended by the AAN president, AAN's Government Relations chair, and the AAN’s RUC representative
• Prompted 1,368 letters from AAN members to members of Congress
• Encouraged more than 150 personal letters from AAN members to CMS
• Generated upwards of 5,000 congressional contacts, including coalition member contacts

We also learned that neurology is not the only physician specialty to have fallen victim to this process recently. Several groups, including cardiology and ophthalmology, have experienced similar situations. That is little consolation but at least we know we aren’t being targeted.
Going forward, CMS has asked for information on patient access to care problems caused by this cut. When treatment is adversely impacted arise, as it surely will be, the AAN will be asking you to share your stories. The cuts have gone into effect, but the end of this story has yet to be written.

AAN Mentioned by Vice President Biden

The AAN was mentioned by Vice President Joe Biden in this CNN news clip regarding medical organizations his task force met with on gun control. He calls the AAN a “leading organization,” along with the American Academy of Pediatrics and others. AAN President Bruce Sigsbee, MD, FAAN, represented the AAN at the meeting in Washington, DC.
I talked with Dr. Sigsbee after the meeting and he said that although there was no consensus on how to reduce gun violence, it was clear that everyone has an interest on improving mental health services. Sigsbee also said it served as a great opportunity to increase communication between the AAN and the administration on this and other issues.

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New Remote Monitoring Codes

The IOMN community is preparing for many new changes in reimbursement and coding for the remote monitoring code.
Add on code +95920, has been deleted and two new codes (+95940 and +95941) have been created to describe neurophysiology monitoring performed inside or outside the operating room.


The new code 95940 is reported per 15 minutes of service and requires reporting only the portion of time the monitoring professional was physically present in the operating room providing one–on–one patient monitoring, and no other cases may be monitored at the same time.

+●95940

Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure)

▶(Use 95940 in conjunction with the study performed, 92585, 95822, 95860, 95870, 95907–95913, 95925, 95939◀
The new code 95941 is reported for all cases in which there was no physical presence by the monitoring professional in the operating room during the monitoring time or when monitoring more than one case while in an operating room. This should be used exclusively for remote monitoring and when reported it does allow for:

+●95941

Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure)

The majority of the IOMN industry would use 95941, as most monitoring is performed remotely. However, Medicare does NOT allow simultaneous monitiring of more than one case. Therefore a G code was created by CMS to be used when reporting continuous remote monitoring for more than one patient.

Medicare Note: 95941 may not be used for Medicare beneficiaries because it allows a provider to remotely monitor several patients at the same time. Because the CMS allows a provider to monitor only one patient at a time, it created G0453, which covers continuous remote (outside the operating room) monitoring for one patient.

See link for more details:

American Academy of Neurology- AAN

http://www.aan.com/news/?event=read&article_id=10826

American Speech Language- Hearing Association- ASHA

http://www.asha.org/practice/reimbursement/coding/new_codes_aud.htm

Also see : http://www.capwiz.com/aset/issues/alert/?alertid=62168816&PROCESS=Read+More

Table 67—Neurology and Neuromuscular Procedures: Intraoperative Neurophysiology HCPCS code Short descriptor CY 2012 work RVU AMA RUC/HCPAC recommended work RVU CY 2013 interim/interim final work RVU Agree/disagree with AMA RUC/HCPAC recommended work RVU CMS refinement to AMA/HCPAC recommended time 95940 Ionm in operatng room 15 min New 0.60 0.60 Agree No. 95941 Ionm remote/>1 pt or per hr New 2.00 Invalid N/A N/A. G0453 Cont intraop neuro monitor New N/A 0.50 N/A N/A. [Page 69069]      Effective January 1, 2013, the CPT Editorial Panel is deleting CPT code 95920 (Intraoperative neurophysiology testing, per hour (List separately in addition to code for primary procedure)), and is replacing it with CPT codes 95940 (Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes) and CPT code 95941 (Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour). Currently remote monitoring is billed under the PFS using CPT code 95920, though the code does not specify whether the physician is present in the same room with a patient or monitoring from a remote location, nor does the code descriptor indicate whether the code may be billed for the monitoring of one patient or more than one simultaneously. Some carriers have established local coverage determinations (LCDs) to address these issues and more tightly define the circumstances under which CPT code 95920 may be billed.      The CPT prefatory language for CPT code 95941 states: “*          *          *          One or more simultaneous cases may be reported *          *          *          Report 95941 for all remote or non-one on one monitoring time connected to each case regardless of overlap with other cases.” Given this language, we are concerned that CPT code 95941 allows a practitioner to bill individual beneficiaries for monitoring more than one beneficiary for the same work during the same time interval. To resolve this concern, we have created HCPCS code G0453 (Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)), effective January 1, 2013. HCPCS code G0453 may be billed only for undivided attention by the monitoring physician to a single beneficiary, not for simultaneous attention by the monitoring physician to more than one patient. HCPCS code G0453 may be billed in multiple units to account for the cumulative time spent monitoring, that is, 15 minutes of continuous attendance followed by another 15 minutes later in the procedure would constitute one half hour of monitoring, and CPT code G0453 would be billed with a unit of 2. HCPCS code G0453 will replace CPT code 95941, which will have a PFS procedure status indicator of I (Not valid for Medicare purposes. Medicare uses another code for the reporting of and the payment for these services) for CY 2013. CPT code 95940, which describes continuous intraoperative neurophysiology monitoring in the operating room for one patient at a time, will be payable on the PFS for CY 2013, with a PFS procedure status indicator of A (Active).      After reviewing CPT code 95940, we agree with the AMA RUC that a work RVU of 0.60 accurately accounts for the work involved in furnishing this procedure. We are assigning a work RVU of 0.60 to CPT code 95940 on an interim final basis for CY 2013. Also, we agree with the AMA RUC that a work RVU of 2.00 accurately accounts for the work for involved in furnishing 60 minutes of continuous intraoperative neurophysiology monitoring from outside the operating room. Accordingly, we are assigning a work RVU of 0.50 to HCPCS code G0453, which describes 15 minutes of monitoring from outside the operating room, on an interim final basis for CY 2013. [Page 69072] iii. Common and Code-Specific Refinements      While Table KK7 details the CY 2013 refinements of the AMA RUC’s direct PE recommendations at the code-specific level, we discuss the general nature of some common refinements and the reasons for particular refinements in the following section. (l) Neurology and Neuromuscular Procedures: Intraoperative Neurophysiology (CPT Codes 95940, 95941 and HCPCS Code G0453)      Effective January 1, 2013, the CPT Editorial Panel is deleting CPT code 95920 (Intraoperative neurophysiology testing, per hour (List separately in addition to code for primary procedure)), and is replacing it with CPT codes 95940 (Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes) and CPT code 95941 (Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour).      As we note in section III.M.3.a. of this final rule with comment period, we have created HCPCS code G0453 (Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)), effective January 1, 2013 to replace CPT code 95941 for Medicare purposes. CPT code 95941 will have a PFS procedure status indicator of I (Not valid for Medicare purposes. Medicare uses another code for the reporting of and the payment for these services) for CY 2013. CPT code 95940, which describes continuous intraoperative neurophysiology monitoring in the operating room for one patient at a time, will be payable on the PFS for CY 2013. [Page 69076]      The AMA RUC provided direct PE input recommendations for CPT codes 95940 and 95941. However, we do not believe that these services are furnished to patients outside of facility settings. Medicare makes payment for technical inputs (labor, supplies, equipment, capital, and overhead) to the facility when services are performed in a facility setting. For these services, the patient would receive this service in the ASC or hospital setting and payment for any technical services, including those for remote monitoring, should be included in the facility payment. We do not believe it would be appropriate to incorporate nonfacility direct PE inputs or develop nonfacility PE RVUs for CPT code 95940 and newly created HCPCS code G0453 for CY 2013. We do not believe that these services incur PFS direct practice expense costs when furnished to patients in the facility setting. Therefore, we are developing facility PE RVUs for this service based on no direct PE inputs. (m) Neurology and Neuromuscular Procedures: Sleep Medicine Testing CPT Codes 95782, 95783)      The AMA RUC submitted direct PE input recommendations for new CPT codes describing pediatric polysomonography: 95782 (Polysomnography, younger than 6 years, 4 or more) and 95783 (Polysomnography, younger than 6 years, w/cpap). We note that in addition to refining minutes assigned to certain labor tasks based on CMS clinical judgment, we have not accepted the AMA RUC’s recommendation to create a new equipment item ‘crib’ for use in these services. We do not believe that a crib would typically be used in this service, and we have incorporated the bedroom furniture including a hospital bed and a reclining chair as typical equipment for this service.

Practical Coding Advice on EMG/NCS

In response to numerous member questions on EMG/NCS, the AAN's Medical Economics & Management Committee provides this advice to members facing new codes and reimbursement cuts.
See Link Below from AAN.

http://www.aan.com/news/?event=read&article_id=11042

Five Things NOT to Do	Five Things TO DO  instead
1. Do not bill 2012 CPT codes for nerve studies or H-reflex (95900, 95903, 95904, 95934, 95936), because these codes have been deleted for 2013.	1. Use new nerve study codes 95907–95913 for all payers in 2013.
2. Do not perform EMG and NCSs on upper and lower studies on different days to receive increased payments.	2. Always perform testing in the best interest of patients.
3. Do not perform unnecessary nerve studies to achieve higher payment.	3.  Keep in mind that performing NCSs is still an efficient means to generate income.
4. Do not bill an E/M with EMG/NCS unless you are performing a separate justifiable service – specifically a full office visit or hospital visit separate from the EMG/NCS.	4. It is acceptable to bill E/M services with EMG/NCS when there is the medical necessity to support the office or hospital visit (this may require a -25 modifier).
5. Do not abruptly decide to discontinue NCS service to patients with Medicare until you have carefully determined the financial and commitment repercussions to your patients.	5. Review and negotiate payment rates for all of your payers, and determine which contracts make the best economic sense for your practice.
Do not expect someone else to advocate for neurology. Get involved. Complete RUC surveys. Respond to AAN Action Alerts. Have your practice manager join BRAINS to receive updates

Five Things NOT to Do	Five Things TO DO  instead
1. Do not bill 2012 CPT codes for nerve studies or H-reflex (95900, 95903, 95904, 95934, 95936), because these codes have been deleted for 2013.	1. Use new nerve study codes 95907–95913 for all payers in 2013.
2. Do not perform EMG and NCSs on upper and lower studies on different days to receive increased payments.	2. Always perform testing in the best interest of patients.
3. Do not perform unnecessary nerve studies to achieve higher payment.	3.  Keep in mind that performing NCSs is still an efficient means to generate income.
4. Do not bill an E/M with EMG/NCS unless you are performing a separate justifiable service – specifically a full office visit or hospital visit separate from the EMG/NCS.	4. It is acceptable to bill E/M services with EMG/NCS when there is the medical necessity to support the office or hospital visit (this may require a -25 modifier).
5. Do not abruptly decide to discontinue NCS service to patients with Medicare until you have carefully determined the financial and commitment repercussions to your patients.	5. Review and negotiate payment rates for all of your payers, and determine which contracts make the best economic sense for your practice.
Do not expect someone else to advocate for neurology. Get involved. Complete RUC surveys. Respond to AAN Action Alerts. Have your practice manager join BRAINS to receive updates