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Issue #107 - August 20, 2008 
ICD-10-CM Date Proposed by CMS
The Department of Health and Human Services (HHS) announced Friday a long-awaited proposed regulation that would replace the ICD-9-CM code set now used to report health care diagnoses and procedures with greatly expanded ICD-10-CM (diagnosis) and ICD-10-PCS (hospital procedure) code sets effective Oct. 1, 2011. In a separate proposed regulation, HHS has proposed adopting the updated X12 standard, Version 5010, and the National Council for Prescription Drug Programs standard, Version D.0, for electronic transactions, such as health care claims.  Version 5010 is essential to use of the ICD-10 codes.
View both regulations
The AAPC (AAPC) lobbied successfully to delay implementation beyond its initial 2010 proposed date. AAPC believes, however, that the 2011 date will still create undo hardships in the industry, as it falls too soon on the heels of other significant regulatory changes that have burdened providers in recent years.
If you feel the implementation date should be pushed to a later time, submit your comments to CMS.
Submit Comments Electronically (due by 5 p.m. eastern time on Oct. 21):

Submit Comments by Mail (due by 5 p.m. eastern time on Oct. 21):
Send one original and two copies to:
CMS-0013-P 3
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-0013-P,
P.O. Box 8016,
Baltimore, MD 21244-8016.
Note: Hand delivered or overnighted comments are also accepted. Instructions on these methods can be found at the Web site containing the proposal, listed above.

ICD-9-CM Final Rule Posted
The National Committee for Vital Health Statistics (NCVHS) has posted the final rule for 2009 on its Web site and in the Federal Register. Some codes discussed during the hearings but not included in the Preliminary Rule have been added and changed. The final rule also includes 367 additions (most of which appear in the August issue of Cutting Edge), 61 revisions and 25 deletions to ICD-9-CM codes.

Go to the Federal Register Web site for more information.

Comment »

FDA Approves Flu Vaccines
The 2008-2009 seasonal influenza vaccines, including new strains of the virus,  are approved by the Food and Drug Administration (FDA), AMA eVoice reports Aug. 14. Visit the FDA Web site for more information, including a list of vaccines and their manufacturers. You can also view FDA approval information for each vaccine.

If you report immunizations, be sure to review the influenza virus CPT® codes, 90665-90663, before the immunization season starts. Also, communicate with your payers about changes to reporting, adjudication, and payment.

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ASC 2009 Payment Rates Corrected
CMS published a correction on Aug. 11 to the July 18 version of the 2009 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System (E8-15539) proposed rule. You should replace Table 30 on pages 41504 through 41505 with the update published in the Aug. 11 Federal Register.

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AMA Offers EHR Guidance
Considering recent legislation (H.R. 6357) approved by the House Energy and Commerce Committee to promote faster adoption of electronic health records (EHRs), it's probably a good idea to seriously consider how your practice will implement an EHR system. If you're not sure where to begin, head over to the American Medical Association (AMA) Web site.

The AMA has created an educational resource "15 questions to ask before signing an electronic medical record or electronic health record agreement" to help you assess your practice's needs and determine which vendor best meets those needs.

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Pilot Lets Beneficiaries Maintain PHRs
CMS announced Aug. 11 a pilot program to test options for beneficiaries with Original Medicare to maintain their health records electronically, Medical News Today reports. Under this pilot program in Arizona and Utah, a beneficiary may choose one of the selected commercial personal health record (PHR) tools, and Medicare will transfer up to two years of the individual's claims data into the individual's PHR.

A PHR is a record of health information under the control of the consumer or patient, rather than the physician, as with EHRs. It may only contain data entered by the individual or their provider, but it can also include information from a health plan—as is the case in this pilot, where Medicare provides health information from its claims data base.

The program is scheduled to begin in January 2009. Medicare administrative contractor (MAC), Noridian Administrative Services (NAS), began solicitation to potential PHR vendors.

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Hospitals Have 2009 IPPS Final Rule
In the 2009 Inpatient Prospective Payment System (IPPS) final rule, released July 31 by CMS, you can expect payment updates and quality care incentives.

Provisions in the 2009 IPPS final rule include:

  • The final transition to 100 percent cost-based payment rates
  • A requirement for hospital cost reports to distinguish between high and low cost supplies and devices
  • A final transition to Medicare severity diagnosis-related groups (MS-DRGs), and "modest changes" to the program
  • IPPS 2009 rates update of 3.6 percent for inflation (1.6 percent for hospitals that don't submit quality data). CMS estimates Medicare spending to increase 1.8 percent in 2009, which will reduce the IPPS rate by 0.9 percent. This is in addition to the 0.6 percent reduction carried over from the 2008 IPPS final rule, according to HealthLeaders Media.
  • An objective analysis of how payments would change if the Medicare Payment Advisory Commission (MedPAC) wage index reform proposal is adapted
  • Twenty percent of the budget neutrality adjustment calculated on a state-by-state basis and 80 percent calculated on a national basis
  • The criteria for new geographic reclassification phased in
  • A higher-paying MS-DRG in cases using a total artificial heart, as well as new technology Add-On payments in approved clinical trial settings
  • New Emergency Medical Treatment and Labor Act (EMTALA) guidelines
  • The current Medicare Advantage regulation amended to allow collection of encounter-level data from MA organizations for services furnished to their enrollees
  • The capital IPPS teaching adjustment phased out
  • Capital Indirect Graduate Medical Education (IME) payments reduced to half of the amount provided under the current formula
  • Rebased payment rates for sole community hospitals (SCHs) based on 2006 hospital-specific rates, if doing so results in a higher payment rate than in 1982, 1987 or 1996

Due to length, CMS did not publish Tables 6G and 6H (additions to and deletions from the Complications and Comorbidity Exclusion List, respectively) in the final rule. They are available on the Acute Inpatient PPS section of the CMS Web site.

The final rule, effective for discharges on or after Oct. 1 through Sept. 30, 2009, is on the CMS Web site, and is scheduled to appear in the August 19 Federal Register.

Comment »

Medicare Facing Financial Challenges
The fuss over Medicare payments and funding continues. HHS secretary Mike Leavitt responded to a new measure (H Res 1368) by Congress in a July 24 press release, saying the pending legislation "... will do nothing to resolve the enormous financial challenges presented by Medicare in the near future."

On July 23, the House Rules Committee approved a measure that would delay consideration of President Bush's Medicare "trigger" bill. The House then approved the rule (H Res 1368) July 24 with a vote of 231-184, delaying consideration of the bill for the remainder of the 110th Congress. The resolution does not require Senate action, the AP/Arizona Daily Star reports.

For two years running, Medicare has pulled more than 45 percent of its funding from general government revenue, Medical News Today reports. As required by the "trigger" provision in the 2003 Medicare law, the Bush administration responded to the deficit by issuing a legislative proposal on Feb. 15. As savings measures, the bill recommends increasing Medicare prescription drug benefit premiums for higher-income beneficiaries, capping non-economic damages in medical malpractice lawsuits, and requiring providers to implement EHRs.

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MCR Neglect May Cost You
Providers who don't fill out their Medicare Cost Reports (MCRs) don't understand the impact the data has on their payments, according to CMS. By law, providers are required to submit cost reports annually. CMS says, however, that many are failing to do so.

CMS and the MedPAC use MCR data to evaluate PPS payments. If MCR data is incorrect or inadequate, CMS says PPS payments may not be adjusted accurately for factors such as inflation and the labor market.

CMS released Transmittal 362 and MLN Matters article MM6132, dated Aug. 1, to inform contractors they need to educate providers on MCR data usage.

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DMEPOS Fraud Out of Control
Weakness in the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) enrollment and inspection process have allowed sham companies to fraudulently bill Medicare for unnecessary or nonexistent supplies, according to a U.S. Government Accountability Office (GAO) summary report (GAO-08-955).

CMS in the past year approved Medicare billing privileges for two fictitious medical equipment suppliers that the GAO established to test the ability of the agency to prevent fraud, Medical News Today reported (Aug. 5).

According to the report, CMS officials said they agreed with the results of the report, but added that the agency recently implemented new standards requiring medical equipment suppliers to obtain certification before they can receive billing privileges. CMS began requiring suppliers to retain documents from physicians and restrict the use of cell phones and pagers as primary business numbers for suppliers. A competitive bidding program was also established, but is delayed due to the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 (H.R. 6331).

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Imaging Coverage Denials on the Rise
Health insurance coverage denials for medical imaging procedures recommended by physicians judged to be unnecessary are increasing, according to an America's Health Insurance Plans (AHIP) report. The AHIP says imaging procedures account for nearly $100 billion in U.S. health care spending, but about half of scans for some conditions fail to improve patient's diagnoses or treatments (Medical News Today July 30 report).

One way insurers are cutting down on unnecessary imaging procedures is with the use of radiology benefit managers. Read Wall Street Journal's July 28 "Health Blog" for a discussion on what other programs health insurers are using to limit spending on medical imaging procedures.

A GAO report recommends Medicare follow suit and adopt prior authorization in an attempt to curb the rapid increase in Medicare imaging costs, says the Medical News Today report.

Comment »

Coding Tips
New Requirement for ASC X-ray Services
Once upon a time (in the 2008 OPPS/ASC final rule) several radiology codes were added to the list of payable ASC procedures effective Jan. 1, 2008; and now CMS is stressing compliance. Beginning Jan. 1, 2009, you must include the ordering/referring physician's name and national provider identifier (NPI) for ASC claims with the TC modifier Technical component. For guidance, read Transmittal 1572 or MLN Matters article MM6129 on the CMS Web site.

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Streamline UHC Billing
Submit your UnitedHealthcare (UHC) claims online for immediate return of a fully-adjudicated claim value for most claims, the plan's responsibility, and the patient's responsibility based on contracted discounts and plan benefits. UHC says it only takes five easy steps after login to submit a claim to

  1. Go to Claims & Payments and select Claim Submission
  2. Select Patient
  3. Select Physician/Provider
  4. Enter Claim Information
  5. View Claim Summary and Confirmation

Can you submit secondary claims electronically to UHC? UHC does not require secondary claims (both Medicare and commercial professional secondary [COB]) to be submitted manually on paper. You can submit most secondary claims electronically via EDI channels or through UnitedHealthcare Online. For additional tips to help you with electronic claims submission, visit > Claims and Payments > Electronic Claim Submission. There are other EDI tools and resources including a Quick Reference Guide, benefits of EDI, tips for physicians and facilities, and more.

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4-Step Process to Compliance
HCPro recommends incorporating each of the following steps into your compliance planning process.

  1. Focus on building a "top-down" structure for the compliance program.
  2. Develop a code of conduct.
  3. Establish an employee compliance hotline.
  4. Communicate the compliance program to employees.

Read the full article on HCPro's Web site, which explains these steps in greater detail.

Comment »

Suture Removal All Sewn Up
If you're perplexed about coding suture removals, you're not alone. According to Bill Dacey, CPC, MBA, MHA, there aren't any specific CPT® codes. "The CPT® manual implies that removal of sutures is not a separately reportable event," Dacey says in a recent article on the Physicians Practice Web site.

According to Dacey, follow-up visits for sutures are "E&M-like in nature," and are usually coded using CPT® code 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family—possibly 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family if the patient needs further treatment for the wound to heal properly. Go online to read Dacey's article, Coding for Suture Removal.

Comment »

Medical News
Prostate Screening Unnecessary for Men 75 and Up
If CMS gives credence to a recommendation and accompanying evidence summary appearing in the Aug. 5 issue of the Annals of Internal Medicine, Medicare may soon limit its coverage for prostate cancer screening. According to a recent recommendation from the U.S. Preventive Services Task Force, men age 75 and older should not be screened for prostate cancer and younger men should discuss the benefits and harms of the prostate-specific antigen (PSA) test with their clinicians before being tested, Health Imaging News reports.

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Pharmacogenomic Testing for Warfarin Response
CMS opened a National Coverage Analysis (NCA) Aug. 4 to determine if the use of pharmacogenomic testing for warfarin is reasonable and necessary under the Medicare program.

Pharmacogenomics is the study of how an individual's genetic makeup, or genotype, affects the body's response to drugs. According to CMS, a patient's initial response to warfarin therapy may be influenced by a multitude of factors other than genetics  and questions whether it is reasonable to base the effect on overall health outcomes attributed to treatment strategies that include pharmacogenomic testing in dosage determination.

CMS requests public comments on the effectiveness of pharmacogenomic testing for warfarin metabolism in the Medicare beneficiary population. The initial 30-day public comment period runs Aug. 4 – Sept. 3. Instructions on submitting public comments are found at the CMS Web site.

To read the full tracking sheet (CAG-00400N), go to the What's New Report page.

Comment »

A Clue to a Cure for Endometriosis
Have scientists identified a possible cause of endometriosis? According to a BBC News report, scientists at the University of Liverpool believe over-production of telomerase, an enzyme that plays a role in cell division, may be responsible. With this finding, it is hoped the Human Reproduction study may lead to new ways to diagnose and treat endometriosis—a condition that can cause severe pain, heavy periods, and infertility in women.

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Wireless MR Infusion System Gets FDA OK
Medrad, Inc. announced Aug. 12 that the wireless version of its Continuum MR Infusion System has received FDA 510(k) clearance. According to a Medical News Today report, the new Continuum Wireless MR Infusion System enables the clinician to control a patient's medication infusion during a magnetic resonance procedure from both inside and outside the scan room. The powerful magnet and sensitive radio coils used in the technology continue to push facilities to explore new methods of performing the tests.

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KYNAPID™ Atrial Fibrillation Injection Approvable
Cardiome Pharma Corp. and its co-development partner Astellas Pharma US, Inc. ("Astellas") announced they have received an approvable action letter from the FDA for KYNAPID™ (vernakalant hydrochloride) Injection for the treatment of atrial fibrillation (AF), Medical News Today reports. Atrial Fibrillation is a potentially life-threatening condition occurring when electrical signals in the heart malfunction.

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FDA Says OK to Improved Cardiovascular Products
Cook Medical announced approval from the FDA to market its improved Zenith Abdominal Aortic Aneurysm (AAA) Iliac Flex Legs and Z-Trak Introduction System, made for use with the Zenith Flex AAA Endovascular Graft, Medical News Today reports. The products are designed specifically to provide increased flexibility and improved conformability in the aorta and iliac artery, a tortuous section of patient anatomy, for patients undergoing endovascular aneurysm repair (EVAR).

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New Prostate Cancer Test Ready for General Use
Health Discovery Corporation (HDC) announced Aug. 11 that its new gene-based molecular diagnostic test for prostate cancer has now successfully completed its phase III double-blind clinical trial. According to a Medical News Today report, the test is now ready for commercialization to be used by physicians on their patients at risk of having prostate cancer.

Comment »

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Featured Items
ICD-10-CM Date
FDA Approves Flu Vaccines
ASC 2009 Payment Rates
AMA Offers EHR Guidance
Beneficiaries PHRs
2009 IPPS Final Rule
Medicare Challenges
MCR Neglect
Imaging Coverage Denials
Coding Tips
Medical News
Coding Job Links
Test Yourself Online

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