Anthem Blue Cross selects solution to help genetic testing

Anthem Blue Cross has initiated a genetic testing solution aimed at encouraging suitable, safe, and affordable testing and counseling for patients.

The Anthem Blue Cross program is developed and administered by national specialty benefits management leader, AIM Specialty Health, which offers an automated system that guides the decision-making process.

Anthem’s Genetic Testing Solution promotes appropriate use and provides education that addresses the clinical and financial complexities of genetic testing. Through a combination of clinical review of testing requests and coordination with genetic testing laboratories, providers and members can draw upon verified resources to support clinical decision making.

Anthem’s program has been in place since the day of July 1 and is being first used with its completely insured and self-insured members; national account members will be added in the year of 2018.

“More than 70,000 genetic testing products are presently on the market, and an average of 10 new products is introduced every day,” says Razia Hashmi, MD, Anthem’s medical director for commercial business. “Stakeholders across the healthcare system are increasingly challenged to manage the pace of change.”

With an international market for such testing estimated at $10.3 billion market by the year of 2024, the healthcare insurance and the industry in general is being thrust into an ongoing debate about how to handle the increasing array of complicated and costly tests.

Anthem considers the testing solution will improve the efficiency of the healthcare system for laboratories, doctors’ offices and insurers by moving from a manual, labor-intensive and post-service process to a real-time automated system that can deliver prior authorizations to doctors as they are sitting with their patients. The company also considers it’ll decrease the likelihood of errors in filling out paperwork, which adds to labor and time.

For several tests, using the solution can cut down the average time for submitting and processing an insurance claim from days to minutes because the prior authorization review provides specific CPT code data to the insurer to facilitate the claim processing, Anthem Blue Cross and AIM Specialty say.

 

Sequin Dermatology Hit by ransomware attack

Sequin Dermatology, a solo practice in the region of Seguin, Texas, fell victim to a serious ransomware attack in the time period of mid-September after its server was encrypted.

A contractor was capable to eliminate the ransomware but a forensic examination discovered a high likelihood that protected health information was approached, Robert Magnon, MD, told sufferers in a notice sent initially this month. “Also, it couldn’t be ruled out that confidential data might have been removed from the server,” he further added. Sequin Dermatology was recently struck by ransomware attack

The server didn’t consist of medical records and financial data, but compromised data that involved patient name, address, and telephone number, date of birth, as well as insurance billing information and CPT codes.

An unrevealed number of sufferers also had their Social Security numbers compromised and as an outcome the practice is providing these patients identity and credit monitoring services from Equifax.

“To stop this from happening again, we’re performing a review of our physical and computer security, reassessing our policies of our office and procedures, and performing staff training,” Magnon told sufferers. “We sustain to monitor the case and will notify you as necessary.”

Magnon included a detailed seven-page notice of privacy practices in patient letters explaining their rights to access their electronic health records (EHRs), the capability of patients to share the data as they wish, the ability to ask Magnon to restrict the information he uses or shares, and to know with whom information is being shared. This kind of information normally is not included in notices to sufferers following a breach.

The practice didn’t respond to a request for extra information.

 

EHR Vendor Leader Observe Changes in the year 2016

John Squire, president and COO at ambulatory software vendor Amazing Charts, provides 4 Health IT predictions for the year 2016:

Issues will give new answers for EHRs. With certain notable exceptions, EHRs are mostly blamed for dissatisfaction and physician burnout. Now EHR vendors are discovering the issue-oriented medical record, a more intuitive access that works the similar way a doctor thinks. It arranges clinical records and practice workflows around particular patient issues, making it faster and more satisfying for physicians to utilize. Look for recent issue-based EHR networks to acquire market share in the year 2016.

Chronic Care Management (CCM) will grow rapidly. To promote effective care management of chronic sicknesses, CMS launched CPT code 99490 in 2015. This code compensates contributors for outreach between office visits, like telephone conversations, medication reconciliation, and coordination among caregivers. Latest levels of technology integration will drive the capability of clinicians to finish the CCM reporting of remote care from inside their EHR.

Healthcare charges will get more transparent. The Affordable Care Act (ACA) supported millions of persons to sign up for high-deductible policies, which means routine healthcare is paid for out of pocket. Various sufferers are demanding more price transparency from their physicians and insurers. As a result, nontraditional value-based payment models-like Medicare Advantage, Direct Primary Care (DPC) and on-jobsite/near-jobsite clinics-will sustain to progress in popularity.

EHR interoperability will sustain to be elusive. EHR interoperability survives within Accountable Care Organizations (ACO) and Health Information Exchange (HIE) groups. But, outside of these agencies the business case is weak and active involvement in sharing information is relatively low. Until the industry as a whole accepts the requirement for true interoperability and areas population health and seamless exchange of information ahead of corporate silos, the complete potential of interoperability will not be recognized.

AMA to Medicare: Begin Paying for Care Coordination in 2012

October 12, 2011 — An influential committee of the American Medical Association (AMA) has issued a challenge to Medicare: If you are serious about the patient-centered medical home, show us the money in 2012.

That group, the AMA/Specialty Society Relative Value Scale Update Committee (RUC), is asking the Centers for Medicare and Medicaid Services (CMS) to start paying separately for certain care coordination services for the chronically ill:

• telephone consults with patients;


• education and training for patient self-management performed by nonphysicians;


• medical team conferences, regardless of whether the patient is present; and


• anticoagulation management.

Right now, such services are generally considered rolled into, and reimbursed under, evaluation and management (E&M) services, epitomized by office visits with established patients. In addition, such services all involve care that does not hinge on a face-to-face encounter between physicians and patients. Organized medicine has long complained that although Medicare pays for the work that occurs in the exam room, it does not adequately compensate physicians for what they do once the patient walks out the door.

The new healthcare reform law aims to solve this payment problem through the medical home, which consists of clinician teams, usually lead by physicians, that will receive a monthly fee for care coordination on top of fee-for-service reimbursement. CMS is testing the medical home concept through pilot projects.

RUC, however, wants quicker, broader action. In a letter to CMS last week, RUC Chair Barbara Levy, MD, asked the agency to begin reimbursing care coordination services for the chronically ill next year on a short-term, piecemeal basis until a more comprehensive approach, such as the medical home, is in place. By doing so, Dr. Levy says, CMS would demonstrate that it "is prepared to incentivize care coordination and foster delivery reform."

While boosting Medicare spending up front, separately reimbursed care coordination services will pay for themselves by eliminating unnecessary office visits, trips to the emergency department, hospitalizations, and prescriptions, she added.

CMS can ignore RUC's recommendations. However, the agency is in the habit of listening to them. It relies heavily on the AMA committee for input when, every 5 years, it updates the relative value units that make up the resource-based relative value scale, which is used by CMS to price physician services.

Codes Already Exist, but Go Unreimbursed

RUC's proposal to CMS is couched in the words and numbers of Current Procedural Terminology (CPT) codes, which are developed and maintained by the AMA for reporting services and procedures performed by physicians. CMS has officially adopted this code set as the means to bill Medicare and Medicaid for physician services.

However, just because the AMA creates a CPT code for a particular service does not guarantee that Medicare and Medicaid will necessarily reimburse it. Case in point are CPT codes 99363 and 99364 for anticoagulation management. The AMA's CPT editorial panel created them in 2007, using 99363 for the first 90 days of such therapy and 99364 for each subsequent 90-day period. In her letter to CMS, Dr. Levy noted that the agency had calculated the reimbursement for the 2 codes ($41 per month for 99363, and $14 per month for 99364), but never authorized paying for them, reasoning that managing someone's warfarin regimen was bundled into E&M reimbursement. RUC is asking CMS to begin paying for these codes on their own.

Other care coordination services listed in the RUC letter also come with codes already on the books:

• Education and training for patient self-management, CPT codes 98960 to 98962: These apply to sessions conducted by nonphysicians such as a registered nurse on a physician's staff.


• Telephone services, CPT codes 99441 to 99443 and 98966 to 98968: These codes are designed for telephone conversations initiated by an established patient that do not originate from a related E&M service within the previous 7 days or lead to an E&M service or procedure within the next 24 hours, or at the soonest available appointment. The first set of codes is for telephone conversations between patients and physicians. When another kind of clinician takes the call, the second set of codes applies.


• Medical team conferences, CPT codes 99366 to 99368: The 99366 code pertains to nonphysicians who confer together with the patient or family members; 99368 is for such nonphysician conferences when patient and family are absent. The 99367 code describes team meetings that include a physician, but not a patient or family members.

Someday, "One Big Code" for Care Coordination

The RUC recommendation to pay for care coordination on a piecemeal basis until the medical home model is in place drew nods of approval from domains of organized medicine beyond the AMA.

"These are short-term fixes, but they recognize the value of work done outside the face-to-face visit, which has not been properly paid for," Lori Heim, MD, who chairs the primary care payment valuation task force of the American Academy of Family Physicians, said in an interview with Medscape Medical News. "[The RUC proposal] could be a real game-changer."

Likewise, Shawn Martin, director of government relations for the American Osteopathic Association, called the RUC recommendations an interim step toward a "comprehensive payment model."

"We're pretty pleased," Martin told Medscape Medical News. "Compensation for services outside the face-to-face visit is a core element of the medical home. Ultimately, you will have one big code for an undefined set of services."

Do's & Don'ts For Imaging Center Claims Submission

Do	Make sure the beneficiary's name matches their ID card exactly.
Do	Use the right modifiers. Make sure you have used the appropriate modifier (-51 is the most problematic, carriers say).
Do	List the Medicare identification number (UPIN) for the provider.
Do	Check your codes against the CCI list to determine which CPT® codes can be billed together for Medicare. Some insurance carriers will follow  Medicare's determination of which CPT® codes can be billed together.
Do	Use the correct diagnosis code for the service. This is a common problem and frequent reason for denials. Check that you haven't submitted a  three-digit code when a fourth- or fifth-digit code exists (remember, you must code to the highest degree of specificity), or made any typographical  errors.
Do	List your Clinical Laboratory Improvement Amendments (CLIA) identification number for claims containing laboratory tests performed in your office.
Do	Properly list purchased diagnostic tests. Those diagnostic services with a professional and technical component are subject to the "purchased  diagnostic" provision of the Medicare program. Carriers may decide whether or not the physician performed both components (i.e., did not purchase  one of the components from an outside source). To signify whether the test was both performed and interpreted in the physician's office, some  carriers require the use of locally assigned codes. Check with your carrier for local guidelines.
Don't	Submit an operative report and a cover letter for claims filed with unlisted CPT codes or CPT codes with modifier 22, Unusual procedural service.  Wait until the carrier sends a request for documentation. When the request comes in, then send your documentation to include the operative report  and cover letter. Remember, the operative report is the documentation that describes the procedure performed for which there is no appropriate  CPT code or explains what was unusual about the service to warrant additional payment to support modifer 22. The cover letter should detail the  procedure performed, explain in layman's terms why the procedure was different, took a longer amount of time or why a higher skill level was  required, as the clerk who reviews your claim may not have extensive medical knowledge. This is a change due to the mandatory electronic claim  submission implemented by Medicare in July 2005.
Don't	Bill for a visit that is included in the global period for a surgery or procedure. This rule only applies to those codes with a global period. Remember,  you cannot bill for a visit that is used to perform a surgical procedure. Only if the decision to perform the surgery was made during the visit (and  modifier -57, Decision for Surgery, is used) can you bill for both the visit and the procedure.
Don't	Re-submit returned or rejected claim forms. If your claim is returned or rejected for any reason, re-submit a completely new claim. Do not resend  the old one and mark it "corrected." This will only result in a second rejection.
Don't	Bill for an unrelated visit during the postoperative period without modifier -24, Unrelated E&M Service by the Same Physician During a Postoperative  Period. A visit during the postoperative period must be unrelated to the surgery to be billed and must include modifier -24. The diagnosis code for  this visit should be for something completely unrelated.
Don't	Automatically resubmit a claim. Remember, it takes roughly 13 days to process an electronic claim and 27 days to process a paper claim. Check  the filing date on your original claim before resubmitting.
Don't	Bill Medicare for routine physical exams and related services. Medicare does not pay for these services. These charges should be collected from  the patient. A signed waiver is not required.
Don't	Write "signature on file" for Item 31 (Signature of Physician or Supplier) of the CMS form 1500 for paper claims. It is appropriate to use "signature on  file" and/or a computer-generated signature for electronic claims.

Spirometry Billing (A Reimbursement Guide)

Who should have Spirometry Testing? In earlier times there was no any real concept that how to get reimbursement against the spirometry. Afterwards, in 1994, the American Thoracic Society published an official statement of “Standardization of Spirometry.” In this statement there was seen a potential indications for Spirometry, some of which may not be covered by Medicare or other payors:

• To assess therapeutic interventions (e.g., bronchodilator therapy, steroid treatment, management of CHF, etc.)


• To assess preoperative risk


• To screen individuals at risk of having pulmonary diseases (e.g., smokers, occupational exposures)*


• To assess health status before enrollment in strenuous physical activity programs*


• To assess patients as part of a rehabilitation program*


• To assess risks as part of an insurance evaluation*


• To assess individuals for legal reasons (e.g., Social Security. personal injury lawsuits)*

*These Indications are generally not covered by Medicare. What Codes describe spirometry procedures? What are the associated payment rates? The current Procedural Terminology (CPT) codes defined below are the most common codes used to describe spirometry procedures performed. The simplicity Spirometer does not perform a respiratory flow volume loop (CPT code 94375). Note: According to the Centers for Medicare and Medicaid Service (CMS) Correct Coding Initiative, none of the procedures described by the CPT codes listed below may be billed together on the same date of service. Please consult the latest version of the National Correct Coding Policy Manual to identify rebundling combinations. Edits may be reviewed at www.cms.hhs.gov/physicians/cciedits/default.asp

CPT Code **	Description	Unadjusted 2005 Medicare Allowable***
94010 (may not be billed with 94060 or 94375 on same DOS)	Breathing capacity test	$33
94060 (may not be billed with 94010 or 94375 on same DOS)	Evaluation of wheezing (pre-and post-bronchodilator)	$55
94375 (may not be billed with 94060 or 94375 on same DOS)	Respiratory flow volume loop	$36

** Most commonly used CPT codes for spirometry. Additional codes may be found in the Current Procedural Terminology (CPT) Manual published by the American Medical Association. All spirometers may not perform all procedures identified by CPT codes. The existence of CPT codes does not guarantee coverage of payment for any device by any insurance carrier of Medicare. Medical necessity must be established by the patient’s physician in accordance with specific coverage policy guidelines. *** Medicare allowable amounts vary by geographic region. What documentation is needed to support payment for spirometry procedures? Many Medicare Part B carriers have published Local Medical Review Policies (LMRP) that describe specific coverage guidelines for spirometry procedures. For example Upstate Medicare in New York offers the following list of ICD-9 codes, which may help support the medical necessity for spirometry testing. These codes may not be applicable in other regions of the country. For definitive coverage and payment information contact your local Part B carrier. What are general coverage guidelines for spirometry under the Medicare Program? · Local Medical Review Policies have been written by many Part B carriers, and copies may be requested through customer’s local Medicare Part B Carrier. · The appropriate combination of tests may be coded if proper clinical indication exists. Consult local medical necessity policy for Correct Coding guidelines and unbundling information. · The Medicare Program specifically excludes coverage for screening tests, including;

• Spirometric assessment of an asymptomatic patient, with or without high risk of lung disease;


• Studies as part of a routine examination; and


• Studies as part of an epidemiologic survey.

Reference:

1. American Thoracic Society (1995). Standardization of spirometry, 1994 update. Am J Respir Crit Care Med. 1995;152:1107-1136.


2. American Medical Association. Current Procedural Terminology. Professional Edition.


3. Physician fee Schedule: payment policies and relative units. Federal Register Vol. 69, No. 219, November 15, 2004.


4. Local Medical Review Policy. Pulmonary Function Testing. 2003. Update Medicare Division, New York.


5. American Medical Association. International Classification of Diseases, ICD-9-CM.

Pain Management post operative Anesthesia billing codes

Pain Management Consultation

Evaluation and management services for postoperative pain control on the day of surgery are considered part of the usual anesthetic services and are not separately reportable. When medically necessary and requested by the attending physician, hospital visits or consultative services are reportable by the anesthesiologist during the postoperative period. However, normal
postoperative pain management, including management of intravenous patient controlled analgesia, is considered part of the surgical global package and should not be separately reported.

Postoperative Pain Control Procedures

When provided principally for postoperative pain control, peripheral nerve injections and neuraxial (spinal, epidural) injections can be separately reported on the day of surgery using the appropriate CPT procedure with modifier -59 (Distinct Procedural Service) and 1 unit of service.

Examples of such procedures include:

62310-62319 Epidural or subarchnoid injections
64415-64416 Brachial plexus injection, single or continuous
64445-64448 Sciatic or femoral injections, single or continuous
64449 Lumbar plexus injections, continuous

These services should not be reported on the day of surgery if they constitute the surgical anesthetic technique.

NOTE: Modifier 59 requires that the medical record substantiate that the procedure or service was a distinct or separate services performed on the same day.

Daily Management of Continuous Pain Control Techniques

Daily hospital management of continuous epidural or subarachnoid drug administration is reported using CPT code 01996 (1 unit of service daily). This code may be reported on the first and subsequent postoperative days as medically necessary.

When continuous block codes 64416, 64446, 64448, or 64449 are reported on the day of surgery, no additional reporting of daily management is permitted during the following ten days (10 day global period). When these injections procedures constitute the main surgical anesthetic and are therefore not separately reported on the day of surgery, subsequent days’ hospital management is reported using the appropriate hospital visit code (99231-99233).

Coding Pain Management

Transforaminal epidural injection: 64479-64484
Transforaminal epidural injection is given at the nerve root in to the spidural space(64479-64484). The injection is passed through the foramen to reach the nerve root. These are unilateral codes and require 50 modifier for bilateral injections. The physician injects at the nerve root like L4 or between the vertebral interspaces like L4-L5.

Interlaminar injections: 62310-62311
Interlaminar injections are given in to epidiral or subarahnoid space through lamina without passing through the foramin. The injection goes directly into the lamina unlike previous one which has to go through foramen and then lamina. These are nonneurolytic injections for dianostic or therapeutic purposes inlcuding anesthetic, steroid, opoid or other substances. These injections also includes contrast if given.

Facet jont injections: 64422-64427
Code Range 64470-64472 is for injection of steroid and/or an anesthetic.
If any other type of substance is injected may be nondistructive or pulsed radiofrequency use 64999. Facet joint injection codes are unilateral and modifier 50 should be used for bilateral procedures. If a Neurolytic is injected for destruction, code range is 62280-62284.

Trigger point injection: 20550-20553
CPT codes 20552-20553 are reported only once per session. CPT code 20551 should be reported one time for multiple or single injections to a single tendon origin or tendon insertion performed. Injections to multiple tendon origins or tendon insertions are reported one time for each injection. For dry needling technique use unlisted procedure code 20999. Imaging guidance is reported sepertely like 77002 for fluoroscopic, 76942 for ultrasound, and 77021 for MR.

Coding for Sleep Medicine Testing and Treatment

Sleep medicine is a new field, and some important aspect of sleep medicine coding changes almost every year. This review will focus on policies of the Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration or HCFA. CMS pays for only 10-20% of a typical sleep center's studies, but CMS policy decisions influence other third-party payers.

Physicians can bill for services in diagnostic sleep testing in one of three ways. First, physicians providing services in their offices or freestanding sleep centers bill for the global service - both the professional work (interpretation) and the technical component - using the appropriate CPT code, such as 95810, without a modifier. Physicians interpreting diagnostic tests in hospital-based sleep centers or in some freestanding centers, will bill using CPT 95810-26; the -26 modifier means the bill is for the professional work only. Owners of some freestanding centers will bill for their technical fee as 95810-TC; the -TC modifier indicates that the bill is for the technical component of service only. Although freestanding centers and independent physicians may bill CMS for their separate component fees, most third party payers insist on getting a single bill, for the global fee.

Current CPT codes are listed in the following table. Codes 95806 and 95807, which do not require sleep staging, are termed "Sleep study." Codes 95808, 95810 and 95811, termed "Polysomnography," require sleep staging including electroencephalography (EEG) (1-4 leads), electro-oculography (EOG), and electromyography (EMG). In addition to sleep staging, code 95808 records 1-3 additional parameters of sleep, code 95810 records 4 or more additional parameters of sleep, and code 95811 records 4 or more additional parameters of sleep and CPAP use. New 2002 CMS policies for CPAP payment require that the sleep apnea diagnosis "must be based on a minimum of 2 hours of sleep recorded by polysomnography" (italics added), so the distinction between sleep studies and polysomnography is important to patient care.

Code 95806 describes an unattended sleep study, but all other codes require a technologist to be in attendance. (A home sleep study remotely monitored by an offsite technologist is not an attended study.) All codes require recording for 6 hours or more. The modifier, -52, may be used to code a limited service. For example, when a patient is intolerant to CPAP and stops a titration polysomnogram before 6 hours of recording has been completed, the procedure should be coded 95811-52. Tests performed to screen for a diagnosis, such as sleep apnea, must be coded with a "V" code - but CMS rarely pays for screening tests, even if a significant pathologic diagnosis is made.

Sleep Testing Codes, CPT 2002
CPT Code	Description
95805	"Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness."
95806	"Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist."
95807	"Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist."
95808	"Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist."
95810	"Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist."
95811	"Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist."

 

Some "Additional physiologic parameters" are listed in below. While CPT codes require that a certain number of parameters these parameters be recorded, the codes are not specific about the method of recording. For example, technologist observations of snoring intensity and body position may be adequate as two physiologic parameters of sleep for a polysomnogram.

ADDITIONAL PHYSIOLOGIC PARAMETERS, FOR POLYSOMNOGRAPHY
EKG	Extended EEG
Airflow	Penile tumescence
Respiratory effort	GE Reflux
Gas Exchange by	Continuous BP monitoring
Oximetry Transcutaneous monitors End-tidal gas analysis	Body Position Other
Limb muscle activity	ÂÂ

Based on a 2002 conversion factor of $36.20, the following table summarizes CPT requirements and CMS payment scale for diagnostic sleep studies and polysomnography.

Hospitals bill for the technical component of outpatient sleep studies under the relatively new system of Ambulatory Patient Classification (APC) Groups. To simplify coding and reimbursement for hospital outpatients, CMS grouped the CPT codes, numbering about 7500, into 451 APC codes. Each APC contains two to fifty (2-50) procedures. CMS established a national payment rate for each APC, adjusted geographically for the wage index. The payment includes costs for supplies, drugs, and room charges, but not professional fees, clinical lab fees, durable medical equipment, or rehabilitation services. The hospital is paid for each procedure based on the 1996 median hospital cost of all the services in the APC. One result is that book-keeping is simplified: hospitals bill for, and CMS pays for, only 451 separate fees rather than 7500 separate fees. Under the previous payment system, Medicare hospital outpatients were to pay 20% of hospital charges, but now benefit coinsurance will be gradually adjusted to 20% of the APC rate. Since charges often greatly exceeded hospital costs, hospital outpatients usually will pay lower fees under the new system.

For 2002, the technical charges for most sleep studies are in APC Group 0209 - Extended EEG Studies and Sleep Studies, Level II. The following sleep diagnostic tests are in this APC Group: 95805-TC, 95807-TC, 95808-TC, 95810-TC, 95811-TC. Among the prominent sleep testing codes, only the unattended sleep study is excluded. All-night sleep EEG, 24 hour EEG with video monitoring, and 24-hour EEG with computer analysis, are the only other codes in this group. The 2002 APC rate for the technical component of any service in this group is $537.

Also for 2002, CPT code 95806-TC, the technical component of the unattended sleep study, is in APC Group 0213 - Extended EEG Studies and sleep Studies, Level I. Five other EEG codes complete this group. The 2002 APC rate for the technical component of any service in this group is $135. CMS does not approve payment for CPT code 85806 when charged separately by a freestanding sleep center, but hospitals may be paid for performing this service on outpatients by billing the APC code.

Charges for pulse oximetry performed in the physician office should not be billed separately, but rather should be included as part of services during an office visit. An exception to this rule is CPT code 94762: "Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure)." The value of our organized lobbying was demonstrated when CMS restored separate reimbursement for overnight oximetry in response to comments by the Academy of Sleep Medicine - and when CMS decided to pay about $6.90 for it in 2002.

CPT code 99508 is "Home visit for polysomnography and sleep studies," conducted by a nonphysician. The CPT editorial panel in 2001 recommended that it be deleted.
A small but increasing number of physicians provide durable medical equipment through their office practice or freestanding sleep centers. Coding for PAP supplies is complex. To code for oral appliance therapy, including fitting, use CPT Code E1399: "Durable medical equipment, miscellaneous," or HCPCS Code S8620 "Oral orthodontic for the treatment of obstructive sleep apnea." CMS does not allow payment for oral appliances, but local insurers may approve reimbursement using one of these codes.

Clinicians and manufacturers for actigraphy, oral appliance therapy, pharyngometry, and other services have requested new CPT codes. Since the expansion of CMS funding is limited, it appears likely that payment for any approved new services will come from the sleep medicine "bucket," reducing payments for existing services.

To be eligible for Medicare payment a sleep study must be performed at a "sleep disorders clinic." The term is defined by CMS as a facility in a hospital or under the control of a medical director. CMS also requires that polysomnography and sleep studies be performed under the "general supervision" of a physician, meaning that the physician is responsible for the direction and control of the procedure, but the physician's presence is not required during the test.

In 1999 CMS published its policy for services performed in a facility independent of a physician's office or hospital, in a newly defined "Independent Diagnostic Testing Facility" (IDTF). For sleep testing to be performed in an IDTF, CMS requires that the physician supervisor be certified by boards in psychiatry and neurology, internal medicine with pulmonary subspecialty, or in sleep medicine. CMS also requires that IDTF technologists must be certified in electroneurodiagnostic testing or registered in polysomnography.

To pay for CPAP, CMS previously required that a patient have "30 apneas" per 6 hours of recording. Under a new 2002 policy, CPAP will be approved for patients with an apnea/hypopnea index (AHI) of 15 or more, and for patients with an AHI of 5-14 "with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of stroke. The AHI is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of 2 hours of sleep recorded by polysomnography using actual recorded hours of sleep (i.e. the AHI may not be extrapolated or projected). Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thorocoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. The polysomnography must be performed in a facility-based sleep study laboratory, and not in the home or in a mobile facility."

This revised CPAP payment policy tasks referring physicians to order polysomnography, not sleep studies, to diagnose sleep apnea. If CMS interprets this policy literally, any diagnosis made using data from a 4-channel cardiorespiratory "sleep study" or from home "polysomnography" must be confirmed by an attended polysomnogram in the laboratory, possibly in a split-night protocol. The policy puts new burdens on testing facilities to revise their scoring rules to comply with CMS definitions, and to ensure that split night studies include a baseline of 2 hours of sleep. Since it is unlikely that facilities will use separate scoring rules only for Medicare patients, most facilities now must standardize their definition of hypopnea. To reduce difficulty for the patient, DME provider and prescribing physician, each report should clearly state the facility scoring conventions, the technical description of the recording, the patient's symptoms, the number of apneas, and the AHI.

Not only must the interpreting physician code the study correctly - effective January 1, 2002, "a new [CMS] national policy states that a doctor who interprets it should bill using the ICD-9 code for the final, related diagnosis - not the reason for the test... symptoms that prompted the ordering of the test may be reported as additional diagnoses." Releasing this policy, CMS has reinforced the primacy of ICD-9-CM for diagnostic coding and has reinforced the injunction to code to the highest level of accuracy and specificity. The same policy also requires that a testing facility must document the testing order from the referring physician.

Sleep specialists are faced with two sets of diagnostic coding. The ICSD - International classification of sleep disorders: Diagnostic and coding manual, edited by Thorpy, was published by the American Sleep Disorders Association, now the AASM, in 1990. A revised edition was published in 1997, and an update process has begun. The ICSD has been very helpful for sleep specialists and for sleep research, but most medical specialties and insurers rely on the International Classification of Diseases, 9th revision, Clinical Modification - the ICD-9-CM. The tenth revision of ICD is due in 2002. Most clinicians use ICD-9-CM coding for clinical purposes, since insurers rely on it to match services with diagnoses, and since Medicare requires the ICD-9-CM code. Note, however, that the AASM may require accredited centers to use the ICSD diagnostic codes. The following table lists some common sleep disorders and their codes. Some notes on coding:

• There is no separate ICD-9-CM diagnostic code for central sleep apnea. Code for obstructive or central sleep apnea depending on whether the patient has insomnia or hypersomnolence.


• There is no specific ICD-9-CM code for primary snoring without significant sleep apnea. The suggested code is a nonspecific code under "Symptoms involving respiratory system and other chest symptoms."


• The suggested ICD-9-CM code for restless legs syndrome is a nonspecific code under "Other extrapyramidal disease and abnormal movement disorders,"" but the definition of the nonspecific codes mentions the condition: "333.99, Other, Restless legs." This may also be the best code for periodic limb movement disorder, a movement disorder occurring during sleep, which is not specifically listed in ICD-9-CM.


• There is no specific ICD-9-CM code for idiopathic insomnia as defined in the ICSD. Specific codes for transient or persistent insomnia are listed in ICD-9-CM "307.4 Specific disorders of sleep of nonorganic origin."

Clinical Diagnosis	ICSD Code	ICD-9-CM Code
Obstructive sleep apnea syndrome	780.53-0	780.51 Insomnia with sleep apnea 780.53 Hypersomnia with sleep apnea 780.57 Other and unspecified sleep apnea
Central sleep apnea syndrome	780.51-1	780.57 Other and unspecified sleep apnea
Primary snoring	780.53-1	786.09 Other Excludes respiratory distress and failure
Narcolepsy	347	347 Narcolepsy
Restless legs syndrome	780.52-5	333.99 Other Restless legs
Periodic limb movement disorder	780.52-4	333.99 Other Restless legs
Idiopathic insomnia	780.52-7	780.52 Other insomnia Insomnia NOS

Private insurers often develop proprietary coverage policies about sleep medicine, and they often do not disclose them freely. Aetna/US Healthcare, to its credit, has posted its "Coverage Policy Bulletin" on its website. Local professional relationships are important to the sleep center and to the insurers; with persistence and good will, we can help the insurer medical directors to develop policies helpful to our patients. Please help to influence national sleep medicine policies: join the American Medical Association and register as a specialist in sleep medicine, join the AASM, and contribute to the AASM's Political Action Committee.

References

1. Raphaelson, M. Sleep Center Management. AASM 1998. 2nd ed 2000.


2. Inglehart, J. The Centers for Medicare and Medicaid Services. NEJM 345: 1920-1924, 2001.


3. Tunis, S. et al. Continuous Positive Airway Pressure (CPAP) Therapy Used in the Treatment of Obstructive Sleep Apnea: Coverage Decision Memorandum for CPAP, 2001. http://www.hcfa.gov/coverage/download/8b3-bbb1.rtf 


4. ICSD - International classification of sleep disorders: Diagnostic and coding manual. Diagnostic Classification Steering Committee, Thorpy MJ, Chairman. Rochester, Minnesota: American Sleep Disorders Association, 1990.


5. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) 6th Edition (2001 Update. Department of Health and Human Services, National Center for Health Statistics (NCHS). October 1, 2001.


6. Medicare Part B News.15:pages 1 and 7, October 1, 2001. Policy B-01-61 is available through: http://www.partbnews.com 


7. Shepard, John. President's Perspective. AASM Bulletin, 4-5, Winter 2002. (Discusses the 2002 CMS CPAP payment rules.)

Attribution

Marc Raphaelson, MD is medical director for Greater Washington Sleep Disorders Centers in Metropolitan Washington, DC. He is a member of the AASM's Health Policy Committee.

Marc Raphaelson, MD
Greater Washington Sleep Disorders
Washington, D.C.

Glossary of Insurance and Medical Billing Terms

Following are some of the most common terms you may hear that are associated with your insurance plans and medical billing.

Ambulatory Surgery	Surgery done in the doctor’s office or at a surgical center, and not requiring an overnight stay.
Ancillary Providers	Services over and above physician services, including laboratory, radiology, home health and skilled nursing facilities.
Authorization	Approval of care required before a service is provided. Pre-authorization may be necessary before hospital admission, or before care is given by non-HMO providers.
Balance Billing	Billing a patient for charges not paid by their insurance plan because the charges are above the Usual and Customary Rate or because the insurer considered a procedure medically unnecessary.
Carve-out Policy	A contracted agreement between an insurance company and another company which provides special services to its members, such as prescription drugs or cancer treatment.
Case manager	A case manager is a trained insurance professional, primarily in the areas of long-term medical care, life insurance and annuities, which presides over a patient or client’s account. Case managers are prevalent in the healthcare industry.
Claim	A record of medical services provided to a patient and submitted by the provider to the insurance company for payment.
Claims Review	The method by which a patient’s health care service claims are reviewed before reimbursement is made. This is done to validate the appropriateness of services given and that the cost is not excessive.
Coinsurance	A provision which limits the amount of the coverage paid by an insurance plan to a certain percentage, with the remaining costs paid by the member.
Co-pay	Co-pay is the amount that a patient is responsible for at the time they visit a physician or hospital, or have a prescription filled. The patient is responsible for this up-front fee, while the insurance provider covers the remaining cost of a medical service or prescription.
CPT-4	A 5-digit code that applies to medical services delivered.
COBRA (Consolidated Omnibus Budget Reconciliation Act)	The COBRA Act allows for employees and their dependents to continue to receive insurance coverage after the loss of a job or reduction in hours. COBRA insurance is more expensive than group insurance, but is still usually less expensive than individual coverage.
Deductible	An insurance deductible is the amount that a policyholder is responsible for on a claim. Whether it is on an auto, homeowner’s or renter’s policy, the deductible must be paid before the insurer will cover any of the other expenses.
EOB (Explanation of Benefits)	A statement describing medical benefits and account activity, including explanation of why certain claims may or may not have been paid.
Exclusion	Services or supplies not covered under a health plan.
Fee Schedule	A listing of the maximum fee which a health plan will pay for services based on CPT billing codes.
Family and Medical Leave Act (FMLA)	The FMLA provides up to 12 weeks of unpaid leave per year for employees with medical issues, for those who are caring for family members, or for births and adoptions. All public agencies, elementary and middle schools, and businesses with more than 50 employees are subject to the FMLA guidelines.
Health Insurance Portability and Accountability Act (HIPAA)	This act, which was passed in 1996, helps ensure that privacy is maintained in regards to patients’ medical records. It also created a set of standards to which all electronic medical records must adhere.
ICD-9	A 3 to 5-digit number code describing a diagnosis or medical procedure.
Inpatient	A patient who is admitted to a hospital and receives medical services from a physician during at least a 24-hour period.
Insurance cap	An insurance cap is the total lifetime dollar amount that a provider will pay on a particular policy. Many insurance companies have a lifetime cap of $1 million, which can be easily attained in cases of prolonged medical treatment and care.
In-Network Provider	Physicians and other service providers who are contracted with a managed care plan.
Out-of-Network Provider	Physicians who are not contracted with a managed care plan.
Outpatient	A patient who receives health care services, but is not admitted to a hospital during a 24-hour period.
Patient Navigator	Patient Navigator is an organization that assists families with medical treatment options and with the explanation of insurance coverage and acts as a liaison with medical personnel.
Primary Care Physician	A physician, usually a general, family practitioner or internist, who delivers general health care, and is most often the first doctor a patient sees. This physician treats the patient directly, refers them to a specialist (or secondary care physician) or admits them to the hospital.
Provider	A physician, hospital, laboratory, pharmacy or other organization that provides health care, goods or services.
Pre-Certification	Also known as pre-admission certification, is the process of obtaining authorization from the health care plan for routine inpatient and outpatient admissions. Failure to obtain pre-certification may result in penalty to the provider or the subscriber.
Premium Pre-certification	Premium pre-certification occurs when a person requesting insurance coverage fills out additional paperwork to determine whether they meet the requirements for policy coverage. This occurs primarily in mental health insurance cases.
Referral Authorization	Approval for a member to see a physician or access services outside of the participating medical group.
Referral Physician	A physician who sees a patient after another doctor has sent them for specialty care or services.
Referring Physician	A physician who sends a patient to another doctor for specialty care or services.
Subscriber	A person who enrolls in a health care plan and agrees to pay for premiums, co-payments and deductibles that are part of the plan.
Treating Physician	A physician who provides care to the patient while in the hospital, and usually works at the hospital or comes in as a specialist.

Cardiology Billing

Cardiology Billing
If you are not aware and prepared for the 2009 cardiology billing and coding changes you may be leaving a lot of money uncollected. The 2009 coding and billing changes are the most significant for cardiology that have been seen since the mid 1990s.
While the average physician will see slightly over a 1% increase in Medicare fees, Cardiologists will see a 2% reduction in fees. This is mainly the result of lower payments for office-based imaging. Cardiologist that have a higher than average use of imaging services will see decreases in their Medicare fees far in excess of 2%, while other cardiologists may be able to achieve an increase in Medicare fees.
Here are examples of some of the upcoming changes:
• All of the codes previously used to submit charges for implanted device follow-up have been deleted and replaced with new codes. Not only have the old codes been replaced, but they have been replaced with a more updated code set that provides codes for checks of devices with leads in 3 chambers, codes specific to a remote (internet) device check, codes for following ICM devices, codes for per procedural checks, etc.
• Global periods related to device follow-up now include global periods of 30 or 90 days. The new codes are now service specific (i.e., either an interrogation evaluation of a programming evaluation).
• Wearable cardiac telemetry devices (for instance Cardio net type service) now have specific codes. You no longer bill with an unlisted code. These new codes include the complication of global periods.
• Codes that bundle multiple echo services under a single code have been introduced. Examples include a single CPT for bundling an echo with both a Doppler and color flow and a stress echo CPT that bundles both the stress test and stress echo.
As the examples above demonstrate, the magnitudes of this year’s cardiology billing changes are more significant that has been seen in recent years. Without proper education, training, software upgrades and billing resources cardiology practices may see marked reductions in collections and increases in AR.
Importance of Cardiology Billing
Medical billing is a crucial health care service that supports physicians by submitting and collecting the payments from insurance companies and patients. One needs to be an expert to ensure that the bills are collected fully and in a timely fashion. It is quite common for over 20% of a practice's potential revenue to remain unclaimed because of improper coding and weak collection strategies. Outsourcing medical billing is growing in popularity as an approach for addressing this tremendous loss of practice income. The range of outsourcing options runs from extremely large organizations to individual freelancers who work from home to provide medical billing services.
Medical billing is a highly complex area and it requires experience-based knowledge and expertise to contend with insurance companies. When it comes to cardiovascular billing, the situation gets even more complex. Such complexity can be handled only by a company that is staffed with well trained cardiology billing professionals. The medical billing specialist must be familiar with the specific codes and rules that make up the world of cardiac billing. Cardiovascular coding and cardiac billing cannot be done by everyone, it is a highly specialized field and it is not possible to be successful in collecting the bills fully from the insurance companies without the proper skills and training.
As the cost of providing cardiology related healthcare services continues to rise, medical institutions and cardiology practices cannot afford to leave revenue uncollected by billing companies or freelancers that are not knowledgeable in cardio billing. It is also important to keep in mind some companies may promote themselves as large cardiac billing service providers but in reality they sub-contract the cardiovascular billing to freelancers who work from home. Hiring such companies will lead to lost revenue because of the lack of proper process, controls, and training.
One of the major drawbacks of hiring a company that does not specialize in cardiology billing is their lack of familiarity with the procedures and the terminologies used. Even if the medical billing company serves one or two cardiologists, they will lack the depth and breadth of expertise required for successful cardiology billing. Moreover if the hired company does not specialize in cardiovascular billing, then they will not have the expertise to effectively appeal denied claims or answer questions raised by the insurance companies. A company that does not encompass a wide range of cardiology billing experience will find it difficult to track underpayments since multiple procedure rules, nuclear camera rules and cardiology procedures have significantly more complicated contractual adjustment rules than a typical family doctor or internist's claims. In addition, the billing software and system design of a generalist billing company will often be insufficient for the more complicated requirements of reporting and insurance follow-up required in cardiology billing.
These billing complications extend to the patient collections arena as well. The patient collection process for specialists like cardiologists is more complicated because of the large patient balances often owed, the complexity of the procedures/EOBs that must be explained to patients that do not understand their bills and the typically older population cardiologists serve. A medical billing service with expertise in cardiology billing knows how to deal with these situations. Billing services without such experience will increase the risk of both lower patient collections and upset patients confused about their bill.
To avoid all these billing related pitfalls cardiologists need to utilize specialized cardiology billing services. It is not advisable for an internist to perform cardiac surgery, similarly someone without training in cardiovascular coding and cardiology billing is not qualified to offer reliable billing services for cardiovascular practices.
2009 Challenges in Cardiology Billing
If you are not aware and prepared for the 2009 cardiology billing and coding changes you may be leaving a lot of money uncollected. Not since the mid 90’s have cardiology seen such significant coding and billing changes as have been put in place in 2009. Across the board the average Medicare fee increased just 1.1 percent. Cardiology in general fared worse than average, experiencing an average decrease of 2% due primarily to decreases in payments for in-office imaging. Keep in mind the 2% reduction is an average number. Some practices will be well above this (especially heavy users of echo services) and others will actually see fee increases.
Here are examples of some of the upcoming changes:
- Sweeping changes in the codes for following up on implanted devices (sweeping as in all of the old codes are gone and the new ones have significant differences). The new codes include such things as specific codes or internet (remote) device checks, codes for devices with leads in 3 chambers, ICM device follow-up codes, and codes for per procedural checks.
- 30 and 90 day global periods are now in place for follow-up for some devices. Also, the new codes are specific to either an interrogation evaluation or a programming evaluation. The codes are no longer dependent on whether reprogramming occurred.
- Wearable cardiac telemetry devices (for instance Cardio net type service) now have specific codes. You no longer bill with an unlisted code. These new codes include the complication of global periods.
- Codes that bundle multiple echo services under a single code have been introduced. Examples include a single CPT for bundling an echo with both a Doppler and color flow and a stress echo CPT that bundles both the stress test and stress echo.
As the examples above demonstrate, the magnitude of this year’s cardiology billing changes is more significant that has been seen in recent years. Without proper education, cardiology billing training, software upgrades and billing resources cardiology practices may see marked reductions in collections and increases in AR.
Staffing
Based on the experience of Cardiology Billing Partners there are four key elements to creating a world-class billing staff:
Recruit, train and retain the best billing staff:
The leading billing organizations recruit best staff. A dedicated, specialized HR team evaluates applicants—applicants must pass a proprietary billing testing process assessing both skill and will. This process shouldn’t be different from the recruiting process of a Fortune 500 organization. The leading billing organizations train to develop desired quality. Junior staff members must pass demanding training programs—junior team members are developed into billers, capable of following the measured and monitored billing process. In addition, staff is trained throughout the year in latest payer rules, follow-up techniques and compliance guidelines. A dedicated Compliance Officer is responsible for all additional HIPAA and OIG training. Best staff is retained; weak staff released. The billing organizations staff is evaluated every year to assure proper development and progress. Evaluations are based on tangible, measurable targets and quality indicators. Best performers are properly rewarded and lowest 10% of performers are asked to leave. This should be done methodically in an effort to continuously improve the quality of billing staff.
Specialization of the billing team: The top billing organizations’ billing team is composed of dedicated specialists in demographic data entry, charge posting, follow up, and patient collections. Each position is designed to excel in its role and is properly supervised and incentivized. Provide the staff with solid analytics support; Besides providing the clients with continuous practice analytics focused on clients’ practice improvements (coding, contracting, profitability, marketing, etc) , the leading billing organizations’ Analytics Group should offer strong analytics support to the billing staff. The Analytics Group should trend and measure payers response times, rejection trends, payment rates ,etc in order to properly focus the billing staff. They should also measure various elements of the internal billing process for continuous improvements. Incentives for billing staff: All positions in billing process are monitored and incentivized to perform optimally for your account. The incentive system while highly motivating for the staff, falls within the parameters established by the OIG for an acceptable incentive system in a medical billing environment. The best performers should be rewarded accordingly.

Outsourcing
One of the key advantages of billing outsourcing is the clear alignment of incentives between the practice and the billing company. The billing company only gets paid when the practice gets paid while the practice’s staff gets paid irrespective of results. There is also an incentive for the billing company to perform better—the better it performs the more it collects for the practice and in turn the more it earns (and vice versa). This is not true for in-house staff whose wages are fixed irrespective of performance and quality of work. This issue, however, is often not fully understood or appreciated by many providers. These providers frequently say: “the staff works directly for me in my office-- they are more loyal and will do a better job and I can see what they are doing”. From our experience, this is simply not true. I recently spoke with a partner at a busy cardiology practice. While one of the billers was out sick, some paperwork was required and the supervisor went out looking for it. When the supervisor opened the missing biller’s desk, a stack of unfiled, old claims was also discovered. It turned out about $40,000 of them were past timely filling deadlines. They were lost. I repeat—the practice lost $40,000! When the biller returned from her leave, she was “sternly” reprimanded. Let me say it one more time—she was reprimanded. No: not fired, but reprimanded. Either way, the practice lost $40,000 in just this one instance alone. When I asked the doctor why a more severe action was not taken, he explained to me that "we already have staffing problems and did not want to alienate the billing staff any further.” The guilty biller was apparently moved to the front-desk role and is now responsible for gathering demographic information and money. I also asked how it was possible that the billing supervisor missed that $40,000. Did they not reconcile charges and payments and track charges, payments and write-offs? To this the doctor replied that “their system did not provide this level of reporting and no such reports were ever given to him”. Since, the practice was using a new release of a major billing software, I know this system has such capabilities—it is just that either (1) no one knows how to use the system—that’s bad or (2) they just don’t want to bother—that’s’ worse! Just imagine how much money is probably lost there annually. At Cardiology Billing Partners we deal with these issues methodically and comprehensively: All the charges, payments and write-offs are visible to you. We track everything so no charges (batches, days or places of service, etc) can be missed.
If we have your charges and do not submit them properly--- Cardiology Billing Partners will reimburse your practice for what you would have been paid by the payers based on your allowable. What this means is that you never suffer financially if we drop the ball. Try to have your billers reimburse you if they drop the ball. Cardiology Billing Partners also provide clients with access to our system so that they can see real time status of their account. We will give you client portal access to reports and dashboard functionality 24/7. At any time, you or your practice manager can go in and check status of claims, payments, patient balances, etc. No more excuses that “the system cannot do this”! We often hear from the physicians how hard and long they work for ever decreasing reimbursements. All this is true. However, too often we also see practices (through various reasons) hurt themselves financially—over and over again. No—your staff will not work harder for you just because you employ them; and no- the biller who lost you $40,000 will not do any better job collecting money and gathering information from patients. You will probably need to “sternly” reprimand them again. A high performing cardiology medical billing company with complete transparency and full alignment of incentives is the surest path to medical billing excellence and strong financial performance for your cardiology practice.