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Issue #22 — April 25, 2012

AAPC BillingInsider e-Newsletter

F R O M   T H E   F I E L D

Be Ready for 5010 July 1 and ICD-10 Oct. 1, 2014

Two delays announced recently by the Centers for Medicare & Medicaid Services (CMS) give you a little extra time to bring your billing operation to compliance. But don't veer off course: Be ready for implementation.

Originally expected to be implemented at the beginning of 2012, compliance was extended to April 1. An extension of the penalty-free phase of the 5010 standards to July 1 was then made to accommodate providers and payers that had not successfully tested and implemented the claim guidelines.

CMS and payers caution providers not to put off compliance with 5010 standards, however, saying the sooner compliance can be attained, the better. June 30 most likely will be the last day before penalties for not correctly using 5010 are imposed.

The same is advised for ICD-10 implementation. Last week, CMS proposed a one-year extension of implementation to Oct. 1 in the Federal Register. Experts advise billers to take advantage of the extra year to learn how ICD-10 will affect their operations, plan for the transition, and begin making changes. This includes working with payers, electronic health record (EHR) vendors, providers, and coders to coordinate activities and develop new processes so revenue flow is uninterrupted. This also may require educating others (especially providers) what billers will need to assure reimbursement under the code set.

The 30-day comment period for this rule is open now, and is an important way to offer your opinion about the proposed ICD-10 compliance date change. You can submit comments in the following ways:

  • Electronically, by following the ''Submit a comment'' instructions on the website
  • Send a letter to:
    Centers for Medicare & Medicaid Services
    Department of Health & Human Services
    Attention: CMS–0040–P
    P.O. Box 8013
    Baltimore, MD 21244–8013

More information about the proposed rule can be found in the One-Year Delay of ICD-10 Compliance Date fact sheet, which outlines the background of the ICD-10 compliance date, and highlights provisions of the proposed rule and 5010 standards compliance date.

Even though both dates seem a long way off, AAPC and others encourage you to stay the course and be ready when implementation of 5010 and ICD-10 happen.

G O O D   T I P S

Qualitative vs. Quantitative Drug Testing

Sometimes billing for drug testing can become pretty confusing. Here are some basics:

Drug testing codes in the Pathology and Laboratory chapter of the CPT® code book are defined as either qualitative or quantitative. A qualitative test tells you if a particular substance (analyte) is present in the specimen. A quantitative test tells you how much (the quantity) of an analyte is present.

After the presence of an analyte has been established (which may involve a second, confirmatory test), the amount of the analyte present in the sample then may be measured. For example, you could test for the presence of alcohol in the blood (qualitative), and/or may test for the actual blood alcohol level (quantitative).

CPT® lists the drugs/drug classes that may be assayed under the "Drug Testing" subhead. These include alcohols, amphetamines, barbiturates, methadones, opiates, and others. As described above, if the presence of a drug/drug class is confirmed by qualitative screening, a quantitative screen may follow.

The most common mechanism by which drug screens are performed is known as chromatography, which involves passing a mixture that's dissolved in a mobile phase through to a stationary phase. This process isolates different molecules by type, after which each type can identified and measured.

When chromatography is used to identify multiple drug classes simultaneously, the appropriate code is 80100 Drug screen, qualitative; multiple drug classes chromatographic method, each procedure. Per CPT® instructions, count each combination of stationary and mobile phase as one procedure. "For example," CPT® guidelines continue, "if the detection of three drugs by chromatography requires one stationary phase with three mobile phases, use 80100 three times [once for each of the mobile phases]. However, if multiple drugs can be detected using a single analysis (e.g., one stationary phase with one mobile phase), use 80100 only once."

Codes for quantitative testing are more specific to the type of drug being measured. For example, quantitative testing for amphetamines is reported 82145 Amphetamine or methamphetamine, while the same testing for phencyclidine is reported 83992 Phencyclidine (PCP). You can find a quick and easy reference guide for drug testing codes—both quantitative and qualitative—by drug type, in the Pathology and Laboratory chapter Table of Contents.

F E A T U R E D   S T O R Y

The Real Deal About Appeals, Part 1
By Nancy Clark, CPC, CPC-I

Even though it seems at times that claims processing is as easy as "pushing a button", many claims are denied. How do you resubmit your claims with the best chance of success?

Carefully examine the denied claim for potential errors. Verify there are no mistakes in the original submission. You can save time if the error is identified and accurately revised by submitting a corrected claim instead of going through the entire appeals process.

If no errors are found, proceed to the appeals process. Understand why the claim is being denied. The denial code may be linked to an ambiguous message, such as "this service is not covered." You may have to call the insurance carrier.

Prepare your list of inquiries in advance:

  • Clarify the reason for the denial. For example, is the service not covered because it is deemed medically unnecessary? Is this procedure specifically excluded from the patient's benefits contract? Did the insurance carrier not recognize a modifier or modifiers on the claim?
  • When the cause of denial has been clearly identified, ask what documentation you need to appeal the claim. For example, they may request operative notes and pathology reports.
  • Confirm the insurance carrier's formal appeal process. This may require using a form provided by the company or it may require a written appeal on the practice's letterhead. Some commercial carriers and Medicare Administrative Contractors (MACs) have a standardized form available on their websites, while some carriers may prefer the use of a form from the state's department of banking and insurance.
  • Obtain the specific address to which the claim should be mailed. Include the name of the department or person to whose attention it should be addressed. If possible, get a fax number. This may yield faster results.
  • Document the phone call, the representative's name, and the date of the conversation. Keep this information in the appeal file.

Next month, we will look at strategies for writing an appeal letter that works.

FROM THE FIELD is thoughts and experiences from you the reader. If you have any tips, ideas, case studies, or just anecdotes please submit them to us for future editions.

In This Issue
Be Ready: 5010 & ICD-10
Drug Testing
The Real Deal: Appeals

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