2016 CPT® Coding and Key Reimbursement Changes For Pain Management and Anesthesia
We begin this new year with a list of the key changes to CPT coding and Medicare payment policies.
The 2016 CPT edition had more than 300 changes, including 140 new codes, 132 revised codes and 91 deleted codes. It is important to understand the changes and what should be documented to support the new or revised codes.
The majority of changes for 2016 appear in the Pathology/Laboratory section of CPT. Radiology also had major CPT changes, including several for bundling along with “written report” guidelines. There have been gastrointestinal changes made in both 2014 (upper) and 2015 (lower) and in 2016 there were several additional changes.
The Office of the Inspector General (OIG) has included non-covered services under Anesthesia Services to the 2016 Work Plan, stating: “We will review Medicare Part B claims for anesthesia services to determine whether they were supported in accordance with Medicare requirements. Specifically, we will review anesthesia services to determine whether the beneficiary had a related Medicare service. Medicare will not pay for items or services that are not ‘reasonable and necessary.’”
Medicare will continue to cover 100 percent of the allowable amount for screening colonoscopies as it has done since January 1, 2015. Patients will still be responsible for co-payments and deductibles for diagnostic and therapeutic colonoscopies, as well as co-payments for screening colonoscopies that end up with a biopsy or polyp removal. CMS finalized modified regulations relating to the 2015 policy change, confirming that the beneficiary deductible will be waived for anesthesia services furnished in conjunction with a colorectal cancer screening test even when a polyp or other tissue is removed during a colonoscopy. Specific modifiers must be reported in conjunction with the anesthesia code 00810. The modifiers are 33, screening colonoscopy and PT, screening colonoscopy converted to a therapeutic colonoscopy. Documentation should be clear on the reason for the procedure and the outcome of the procedure to code the modifiers appropriately. The following chart shows the use of the modifiers for code 00810, anesthesia for lower intestinal endoscopic procedures.
Again, there were no changes made to the anesthesia CPT codes, but there were additions and revisions to the ASA 2016 CROSSWALK. Anesthesia providers should ensure that they understand the impact of potential revenue or compensation changes due to additions or revisions to the ASA 2016 CROSSWALK (Please refer to Appendix A - Summary of Additions and Revisions in the 2016 ASA CROSSWALK for a complete list of the additions or revisions). These changes include CPT to ASA cross changes and alternative ASA code changes, and due to these changes the base unit values have been increased or decreased based on the change itself. For example, anesthesia for certain catheter placement services (36221-36226) was valued at 6-10 base units, depending on which of three different ASA codes (01924-01926) applied, and they have all been changed to cross to one ASA code, 01916, for 5 base units.
Pain management providers should take note of a few changes in the 2016 CPT code set. These include new paravertebral block/catheter codes along with additional bundling of imaging guidance with base CPT codes. Additional parenthetical guidelines have been added for destruction codes (64633-64636) due to common misconceptions. P - Revised indicates that only the parenthetical guidelines were revised, + denotes an add-on code.
In 2015 two new Evaluation and Management (E/M) codes were introduced that may have an impact on some anesthesiologists and the services they provide. CMS did not reimburse for these codes in the calendar year 2015; effective January 1, 2016, however, they have been assigned an active rate of reimbursement.
In 2015, Medicare made significant and substantial adjustments in the relative values that resulted in reimbursement changes. One of particular interest to pain medicine was the revision to the epidural steroid injections (62310, 62311, 62318, & 62319). In 2014 the reimbursement was drastically reduced and in 2015 Medicare realized that the services were potentially misvalued in 2014, therefore the RVUs for these services were adjusted in 2015 to include the fluoroscopic guidance. Due to this decision, Medicare prohibited separate billing of image guidance in conjunction with these services. An interesting point was the CPT 2015 Codebook does permit the separate reporting of fluoroscopic guidance, if used, with codes 62310, 62311, 62318, and 62319. However, the second quarter of 2015 NCCI edits included the bundling of these combinations for those carriers that have adopted NCCI edits. Even more interesting is that CPT 2016 Codebook still permits the separate reporting of fluoroscopic guidance with the four steroid injections. Rumor has it this may change in the near future with an errata notification.
A Few Reminders Regarding Your Clinical Documentation
Moderate (Conscious) Sedation is billed based on the intra-service time which starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation. Since moderate sedation is a time-based code the intra-service time must be documented in the medical record. In order to bill for the first 30 minutes of intra-service time using code 99144, at least 16 minutes must be documented. An additional level, 99145, can be billed if 38 minutes of time are documented (each additional 15 minutes needs a minimum of 8 minutes).
Radiology was a subject of change for 2016 with several code changes. The biggest change for anesthesia and pain management is the use of imaging guidance. The following statement has been added to the Introduction, Surgery and Medicine sections in the CPT 2016 Codebook: “When imaging guidance or imaging supervision and interpretation is included in a procedure, guidelines for image documentation and report, included in the guidelines for radiology (including nuclear medicine and diagnostic ultrasound) will apply.” The radiology section also includes a new statement for “written reports,” i.e., “A written report (e.g., handwritten or electronic) signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation. “Images” refer to those acquired in either an analog (i.e., film) or digital (i.e., electronic) manner.” The image interpretation and report should include the details of what the imaging was used for, the outcome of the use of the imaging, along with the medical necessity and documentation that the image is on file/stored/saved, etc. (the word “image” has replaced “film” in the radiology section.)
It is important to include documentation of the patient’s physical status and any co-morbidities on all anesthesia records. Often this information helps to support the medical necessity of the need for anesthesia and in some cases it may result in additional revenue.
ICD10 finally went into effect on October 1, 2015. ABC prepared for this implementation well in advance which has turned out to be a wise decision as the transition has been smooth. Remember to be as specific as possible in the diagnosis description when documenting and to include the condition, site/laterality, cause (how the injury/health condition happened, placed, activity, etc.), and qualifier (reason for or due to along with special details such as with/without bleeding/hemorrhage/obstruction, etc.) as applicable for each service performed. ABC clients may use our ICD10 hotline telephone number (1-800-544-6647 #1) as well as an e-mail address (ICD10.HelpDesk@Anesthesiallc.com) to assist with any ICD10 related questions.
We hope that all of our readers will have a happy, healthy and successful New Year.