MPFS: April Update Brings New Guidance

By Renee Dustman
Mar 10th, 2016

Some changes you’ll find in the April 2016 update actually went into effect the first of the year. They are:

  • HCPCS Level II code G0464 Colorectal cancer screening; stool-based dna and fecal occult hemoglobin (e.g., kras, ndrg4 and bmp3) is now assigned a procedure status of I Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. (Code not subject to a 90 day grace period.)
  • CPT 10030 is now assigned global period days of 000 Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.
  • CPT 77014 is now assigned a PC/TC indicator of 1 Diagnostic tests/radiology services. These codes generally have both a professional and technical component. Modifiers 26 and TC can be used with these codes.
  • CPT 80055 is now assigned a procedure status of X Statutory exclusion. These codes represent an item or service that is not in the statutory definition of “physician services” for fee schedule payment purposes. No RVUs or payment amounts are shown for these codes and no payment may be made under the physician fee schedule. (Examples are ambulances services and clinical diagnostic laboratory services.)

Medicare administrative contractors will not search their files to either retract payment for claims already paid or retroactively pay claims. It is the responsibility of the healthcare provider to correct claims for these codes.

Effective for services performed on or after April 1, 2016:

  • G9678 is assigned a procedure status of X
  • G9481 (Remote E/M new pt 10 mins) has a PE RVU = 0, all other MPFS indicators/values = 99201
  • G9482 (Remote E/M new pt 20 mins) has a PE RVU = 0, all other MPFS indicators/values = 99202
  • G9483 (Remote E/M new pt 30 mins) has a PE RVU = 0, all other MPFS indicators/values = 99203
  • G9484 (Remote E/M new pt 45 mins) has a PE RVU = 0, all other MPFS indicators/values = 99204
  • G9485 (Remote E/M new pt 60 mins) has a PE RVU = 0, all other MPFS indicators/values = 99205
  • G9486 (Remote E/M est. pt 10 mins) has a PE RVU = 0, all other MPFS indicators/values = 99212
  • G9487 (Remote E/M est. pt 15 mins) has a PE RVU = 0, all other MPFS indicators/values = 99213
  • G9488 (Remote E/M est. pt 25 mins) has a PE RVU = 0, all other MPFS indicators/values = 99214
  • G9489 (Remote E/M est. pt 40 mins) has a PE RVU = 0, all other MPFS indicators/values = 99215
  • G9490 (Joint replac mod home visit) with all MPFS indicators & RVUs = those of G9187.

Codes G9481-G9490 are new and are assigned Type of Service 1 Medical care.


Source: MLN Matters MM9531

Modifier CT: New Reporting Guidelines

By Renee Dustman
Mar 10th, 2016

Effective January 1, 2016, the definition for modifier CT has changed. The new definition may change the way you report claims for computed tomography (CT) scans.

New Definition

Modifier CT Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR-29-2013 standard

“Attributes” of this standard are:

  1. DICOM dose structured reporting
  2. Pediatric and adult reference protocols
  3. CT dose check
  4. Automatic exposure control

When to Report Modifier CT

Report modifier CT with the following CPT® radiology codes when the service is furnished on non-NEMA standard XR-20-2013-compliant equipment:

70450-70498, 71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-74178, 74261-74263, 75571-75574 (and any succeeding codes)

What Happens if You Don’t Comply

Providers that fail to attest to this standard beginning this year will be subjected to a 5 percent payment reduction for all CT-designated procedures for Medicare, as it applies to the technical component of the procedure. Beginning in 2017 and subsequent years, the penalty will be 15 percent. System attestation by providers will be verified through the periodic supplier accreditation process (e.g., Joint Commission, ACR, IAC, etc.).



Medicare Claims Processing Manual, Chapter 4, Section 20.6.12

MITA Smart Initiative

Comment on New Medicare Part B Prescription Drug Models

By Renee Dustman
Mar 9th, 2016

The Centers for Medicare & Medicaid Services (CMS) announced March 8 a proposed rule that, when finalized, would allow testing of new Medicare Part B prescription drug models. The federal agency is soliciting comments from stakeholders on six alternative payment models to help find one that would better align physician incentives to successful patient outcomes.

The Proposed Models

  1. Improving incentives for best clinical care. This model would change the add-on payment from 6 percent to a budget neutral 2.5 percent plus a flat fee payment of $16.80 per drug, per day.
  2. Discounting or eliminating patient cost-sharing. This model would decrease or eliminate cost sharing to improve beneficiaries’ access to the medication they need.
  3. Feedback on prescribing patterns and online decision support tools. This proposed model would create evidence-based clinical decision support tools for providers and suppliers to use to track best practices in prescribing and information on prescribing patterns relative to location and trends.
  4. Indications-based pricing. This model would test varying the payment for a drug based on its clinical effectiveness for different indications.
  5. Reference pricing. This proposed model would test the practice of setting a standard payment rate, or benchmark, for a group of therapeutically similar drug products.
  6. Risk-sharing agreements based on outcomes. This model would allow CMS to enter into voluntary agreements with drug manufacturers to link patient outcomes with price adjustments.

CMS is accepting comments on this proposed rule through May 9, 2016. The proposed rule will be published March 11 in the Federal Register.

Share Your Expertise & Write for HBM

By Michelle Dick
Mar 9th, 2016

Writing for Healthcare Business Monthly can be a rewarding experience.

AAPC’s membership of healthcare business professionals thrives on sharing know-how through networking, presentations, webinars, and writing. Most of the content in Healthcare Business Monthly is submitted by AAPC members. We encourage you to send your original articles on subjects in which you excel for the purpose of educating fellow members.

Guidelines to Make It Easy

To make the editing process run smoothly, we ask all of our contributors* to follow a few guidelines:

Format – Articles should be submitted electronically as a Word Document. We cannot publish PowerPoint presentations, but we can help you turn them into articles.

Length – Articles should be between 500 to 2,000 words. If your article runs longer than 2,000 words, you may want to break it into two articles.

Citations or sources – Make sure you quote anything that is not in your own words. List the source separately after the article or attribute sources in the text. You may include website URLs in your article.

Codes – On the first use in your article, CPT®, ICD-10-CM, or HCPCS Level II codes must be accompanied with full code descriptions. Avoid confusing your readers by paraphrasing descriptions or using unofficial short descriptions.

Acronyms – Spell out acronyms and abbreviations on first use. Not everyone is familiar with the acronyms and abbreviations unique to your specialty.

About you – Include a 50-word or less biography at the end of the article and a digital photo for each author. Be warned that photos taken off the Web are usually low resolution and don’t print well, so send the original photo before it was adjusted for the Internet. Send the photo as a separate attachment from the Word Document.

For editorial consistency throughout our publications, AAPC uses the Associated Press Stylebook, Chicago Manual of Style, American Medical Association (AMA) Manual of Style, and AAPC Official Style Conventions as the final word on editorial style and grammar. (You don’t need to know these guidelines. That’s our editors’ job!*)

You may be eligible for continuing education units (CEUs) for writing. To be eligible, you must be credentialed, and the article must be a minimum of 500 words. Typically, we only offer CEUs for articles that provide clinical guidance for coding, billing, compliance, etc. If you are eligible to receive CEUs, you’ll receive them several weeks after your article is published and mailed to members.

Don’t Sweat the Small Stuff

Don’t let your inexperience in writing stop you from sharing your experience in the business of healthcare. Our editors will help you make your article look its best. If you’re unsure about where a comma should go, or if you should use “then” or “than,” don’t worry about it — we’ve got you covered.

Send your healthcare business-related articles to John Verhovshek, CPC, at or your member-related articles to Michelle Dick at

Don’t Overlook Obstetric Panel Alternative

By Rae Jimenez
Mar 9th, 2016

CPT® 2016 introduced a new obstetric panel code, 80081 Obstetric panel (includes HIV testing), which is identical to the long-standing obstetric panel 80055 Obstetric panel, with one exception: The newer code includes HIV testing.

Required components for both codes include:

  • Blood count, complete (CBC), and automated differential WBC count (85025 or 85027 and 85004)


  • Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009)
  • Hepatitis B surface antigen (HBsAg) (87340)
  • Antibody, rubella (86762)
  • Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592)
  • Antibody screen, RBC, each serum technique (86850)
  • Blood typing, ABO (86900)


  • Blood typing, Rh (D) (86901)

To these tests, 80081 adds HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result (87389). CPT® also specifically instructs, “When syphilis screening is performed using a treponemal antibody approach [86780], do not use 80081. Use the individual codes for the tests performed in the obstetric panel.”

Remember: When reporting a panel code, each test listed in the panel description must be performed. If any single test defined as part of a panel is not performed, seek out a different panel code (e.g., If an obstetric panel is performed without an HIV test and all other tests are performed, continue to report 80055). If no panel code properly describes the tests performed, report the code(s) to describe the individual tests performed, rather than the panel code.

You may not report two or more panel codes including the same tests (for instance, you would never report 80081 and 80055 together); however, you may report test(s) performed in addition to panel components. The American Medical Association’s (AMA) CPT® Changes 2016: An Insider’s Guide is careful to note, “The panel components are not intended to limit performance of other tests. If tests are performed in addition to the tests listed for a panel, the additional tests are reported separately in addition to the panel code.” This instruction is supported by guidelines within the CPT® codebook.


Raemarie Jimenez, CPC, CPB, CPMA, CPPM, CPC-I, CANPC, CRHC, CCS, is vice president, AAPC Member and Certification Development.

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About Has 5 Posts

Raemarie Jimenez, CPC, CPB, CPMA, CPPM, CPC-I, CANPC, CRHC, manages AAPC's member and certification solutions, is a coding liaison to the AMA CPT® Editorial Panel, and has more than 20 years of experience in the medical field. With AAPC, she has also served as the clinical development manager for the exams program, national externship director, and as an advertising coordinator. Prior to joining AAPC, she spent many years as an instructor for coding and medical assistant programs. Ms. Jimenez has also worked as a medical assistant, billing and coding manager, instructor, auditor for outpatient and physician services, and physician educator. She received her BA in psychology from Florida Atlantic University.
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