MPFS: April Update Brings New Guidance
Modifier CT: New Reporting Guidelines
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.
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:
- DICOM dose structured reporting
- Pediatric and adult reference protocols
- CT dose check
- 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.).
Comment on New Medicare Part B Prescription Drug Models
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
- 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.
- Discounting or eliminating patient cost-sharing. This model would decrease or eliminate cost sharing to improve beneficiaries’ access to the medication they need.
- 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.
- Indications-based pricing. This model would test varying the payment for a drug based on its clinical effectiveness for different indications.
- 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.
- 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.
Share Your Expertise & Write for HBM
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 email@example.com or your member-related articles to Michelle Dick at firstname.lastname@example.org.
Don’t Overlook Obstetric Panel Alternative
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 , 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.