Knowledge Base Category -

A recent television commercial shows an older gentleman with whom all the older ladies want to dance. He attributes his popularity with the ladies to his beautiful smile and perfect dentition. Unfortunately, older Americans will not be getting that perfect smile paid for by Medicare. Medicare does not cover dental services except in rare circumstances. That is a shame, because good dental health affects much more than just a person’s popularity. Poor dental hygiene also contributes to an increased risk for heart disease, stroke, dementia, respiratory problems, and diabetic complications.

Per the Social Security Act, Medicare does not cover items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth (e.g., preparation of the mouth for dentures). Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed. Medicare only covers dental services if they are incident to and an integral part of a procedure or service that is covered by Medicare. For example, tooth extractions performed in preparation for radiation treatment for jaw cancer would be covered, but tooth extractions because of tooth decay are not.

The Office of Inspector General (OIG) has identified improper payments for non-covered dental services as a topic in their annual Work Plan since 2012. This March, the OIG released their report summarizing the results of audits of dental services’ payments for six Medicare Administrative Contractors (MACs). Those MACs are CGS, First Coast, NGS, Noridian, Novitas, and WPS. The audit report also includes recommendations CMS could implement to help ensure that future claims for hospital outpatient dental services meet Medicare coverage requirements.

The OIG selected a sample of 600 claims from a total of 15,690 hospital outpatient dental services for the six contractors, totaling $10,874,814 paid to providers during the period January 1, 2011, through December 31, 2014.  They did not include dental services associated with a diagnosis related to cancer or physical trauma because those services are generally eligible for Medicare payment. On the basis of their results, the OIG estimated that the six contractors improperly paid providers an estimated $9,783,023 for hospital outpatient dental services that did not comply with Medicare requirements. This is approximately 90% of the total dental service payments considered. The types of dental services performed and paid that are not covered by Medicare included:

• tooth socket repairs, generally performed in preparation for dentures,
• routine oral evaluations, x rays, and tooth extractions,
• excisions and gum repair (performed when removing inflamed gums and when reshaping healthy gums for a cosmetic or functional purpose), and
• periodontal osseous surgery (performed when treating gum disease).

The OIG recommended the implementation of national edits for hospital outpatient dental claims, but CMS did not concur with this recommendation since dental coverage is based on the specific clinical needs of the beneficiary. CMS does agree to work with its contractors to develop and strengthen local edits to help ensure that payments made to providers for dental services comply with Medicare requirements.

It pays to take care of your teeth when you are young, because once you reach Medicare age, you are on your own.

Q:

What is the appropriate diagnosis code for Pleural Effusion when there is documentation of Pleural Effusion with CHF and the Pleural Effusion requires a Thoracentesis?

A:

Assign J91.8, Pleural Effusion in Other Conditions Classified Elsewhere, when the Pleural Effusion with CHF requires treatment, such as a Thoracentesis or diagnostic testing. Typically, Pleural Effusion with CHF would not be reported because it is minimal and does not require specific treatment. Previously, in ICD-9-CM, we used 511.9, Unspecified Pleural Effusion. Resource: Coding Clinic, Second Quarter 2015, page 15

Q:

Can debridement be reported separately in addition to shoulder arthroscopy procedures?

A:

The answer is it depends. Although the shoulder has three “areas” or “regions”: the glenohumeral joint, the acromioclavicular joint and the subacromial bursal space, CMS generally considers the shoulder to be a single anatomic structure. Arthroscopic treatment of a shoulder injury in adjoining areas of the same (ipsilateral) shoulder constitutes treatment of a single anatomic site. National Correct Coding Initiative (NCCI) procedure-to-procedure edits should not be bypassed with the addition of a modifier for arthroscopic shoulder procedures unless performed on the opposite (contralateral) shoulder.Limited debridement (e.g. CPT code 29822) and usually extensive debridement (e.g. CPT code 29823) are included in shoulder arthroscopy procedures even if the limited debridement is performed in a different area of the same shoulder than the other procedure. According to the American Association of Orthopaedic Surgeons Coding, Coverage and Reimbursement Committee, “Code 29822 covers limited debridement of soft or hard tissue and should be used for limited labral debridement, cuff debridement or the removal of degenerative cartilage and osteophytes. Code 29823 should be used only for extensive debridement of soft or hard tissue. It includes a chondroplasty of the humeral head or glenoid and associated osteophytes or multiple soft tissue structures that are debrided such as labrum, subscapularis and supraspinatus.” (see April 2006 AAOS Bulletin)

However, CMS does make three exceptions related to separate reporting of extensive debridement in Section E, Chapter 4 of the NCCI policy manual. If extensive debridement (CPT 29823) is performed in a different area of the same shoulder with one of the following arthroscopic shoulder procedures, it may be reported separately:

• CPT 29824 – Arthroscopic claviculectomy including distal articular surface
• CPT 29827 – Arthroscopic rotator cuff repair
• CPT 29828 – Biceps tenodesis

Remember, the separate reporting of extensive debridement only applies to the three CPT codes listed above. Extensive debridement is included in other shoulder arthroscopy procedures, for example CPT codes 29806, 29807, and 29821. Section I. of Chapter 4 of the NCCI policy manual states, “With limited exceptions open or arthroscopic procedures performed on a joint include debridement (open or arthroscopic) if performed. A debridement code may be reported with a joint procedure code only if the debridement is performed on a different joint or at a site unrelated to the joint. See Section E (Arthroscopy) for discussion of exceptions.”

Reference: National Correct Coding Initiative (NCCI) Policy Manual, 2017, Chapter 4. 

Q:

Do the same guidelines in ICD-10-CM apply to chronic pain and chronic pain syndrome as they did in ICD-9? In ICD-9 coders were instructed not to code chronic pain (338.29) if a definitive diagnosis was documented but chronic pain syndrome (338.4) could be reported with a definitive diagnosis.

A:

No, the guidelines in ICD-10 are different than that in ICD-9.

Section I.C.6.a.1 of the (ICD-9) Official Coding Guidelines state “A code from subcategories 338.1 and 338.2 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control/management and not management of the underlying condition.

As you can see the code 338.4 was not included in with that particular guideline so it was therefore assumed that it could be assigned with a documented definitive diagnosis.

The codes in ICD-10 are chronic pain G89.29 and chronic pain syndrome (G89.4).

Section I.C.6.b.1 of the (ICD-10-CM) Official Coding Guidelines state “A code from category G89 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control/management and not management of the underlying condition.

Given that both conditions begin with the category G89, the guideline would include both diagnoses and chronic pain syndrome should not be reported when there is a known definitive diagnosis documented.

Q:

What is required if a hospital wants to outsource its Medicare appeals?

A:

The hospital will need to follow the instructions in Section 270, Chapter 29, Medicare Claims Processing Manual.
Some key points from these instructions include:

• A specific individual must be named as the representative. An organization or entity may not be named as a representative, but rather a specific member of that organization or entity must be named. This ensures that confidential beneficiary information is released only to the individual so named.
• A written appointment of the representative must be submitted: the hospital can use Form CMS-1696 or a written instrument which must contain:
• A statement appointing the representative to act on behalf of the hospital, and authorizing the adjudicator to release identifiable health   information to the appointed representative;
• A written explanation of the purpose and scope of the representation;
• Dated, handwritten ink signatures of both the hospital signee and the individual accepting the appointment (both must sign the request within 30 days of each other);
• The name, phone number and address of both the hospital and the representative;
• The representative’s professional status and relationship to the appointing party; and
• The hospital’s NPI number.
• Appointed representatives are responsible for submitting a valid appointment instrument to the contractor with each new appeal request.
• A photocopy of the original may be submitted as long as the original is available upon request.
• Resubmission of the instrument at subsequent levels of appeal for the item(s)/service(s)/claims(s) at issue is encouraged though not required.
• The hospital may appoint a representative to assist with filing an appeal at any time during the course of an appeal.

“If an individual is attempting to act as a representative of a party that is not the beneficiary (such as a hospital) and fails to include an appointment instrument with the appeal request, the individual lacks the authority to act on behalf of the party, and is not entitled to obtain or receive any information related to the appeal. The MAC shall notify the   individual that no redetermination will be performed until a valid request is received from the party or a valid appointment instrument is resubmitted with the redetermination request.”

Q:I am confused about how to charge and bill for inhalation treatments, CPT code 94640. I heard the Correct Coding Initiative (CCI) information changed, but I notice the MUE limit is still 2. Could you please explain what the rule is and how hospitals should handle this? 

A:
You are correct that the CCI information changed for 2017. In the 2017 CCI Policy Manual, the wording for how often CPT code 94640 can be reported changed from “once during a single patient encounter” to “once during an episode of care” regardless of the number of separate inhalation treatments that are administered. The manual further clarifies exactly what is meant by an episode of care.“An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.

If a patient receives inhalation treatment during an episode of care and returns to the facility for a second episode of care that also includes inhalation treatment on the same date of service, the inhalation treatment during the second episode of care may be reported with modifier 76 appended to CPT code 94640.

If inhalation drugs are administered in a continuous treatment or a series of “back-to-back” treatments exceeding one hour, CPT codes 94644 (continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour) and 94645 (...; each additional hour) should be reported instead of CPT code 94640.”

Based on this information, the MUE limit of 2 would be appropriate to accommodate those patients that return to the facility for a second episode of care.

Now let’s address “charging” versus “billing:”

This is a “billing” rule for Medicare, and it is specific to outpatient “billing”. The hospital may “charge” for one treatment for each face-to-face encounter with the patient, but when the bill drops for outpatient Medicare, the hospital would have to apply a “billing” rule of reporting a quantity of 1 for each episode of care.

If a hospital does not charge for each treatment, their gross revenue will be affected; it is important to report charges for all services to Medicare so total cost is accurately reflected regardless of the number of units reported in accordance with Medicare requirements. Other payers may not have quantity limits for 94640 in which case billing more than one would be appropriate. Your hospital should check with each payer to determine their requirements.

Also remember, that under Medicare outpatient payment (OPPS), CPT code 94640 is conditionally packaged with a Status Indicator of “Q1.” These means Medicare does not provide separate payment if the code is on a claim with other outpatient services with status indicators of S (significant procedures), T (mostly surgical procedures), or V (visit codes including ED visits). 

It is hard to believe it is 2017. Time flies when you are having fun and when you are not. It is also hard to believe it has been over three years since Medicare changed the definition of what supports an inpatient admission to the two-midnight rule. This occurred in October, 2013 because CMS was concerned about the number of inappropriate inpatient admissions being denied by review contractors, by the large number of extended outpatient/observation stays that had potential financial impacts for the Medicare beneficiary (co-pays and liability for skilled nursing home stays), and the inconsistent practices between hospitals for inpatient and outpatient status. The policy establishes that inpatient payment is generally appropriate if physicians expect patients’ care to last at least 2 midnights; otherwise, outpatient payment would generally be appropriate.

Unfortunately, the two-midnight policy was not the magic bullet Medicare thought it would be and a recent report by the Office of Inspector General (OIG) finds that there are still inconsistencies and issues with the application of the rule. So let’s examine what might be “right” and what might be “wrong” related to the two-midnight rule. Here I must apologize ahead of time – determining and getting a patient in the correct status is not as simple and straight-forward as this discussion may make it sound. I have the utmost respect and admiration for the physicians and utilization review staff that work very hard daily to interpret and apply Medicare’s guidelines.

Applying the rule

One thing hospital staff has struggled with since implementation of the two-midnight rule is where does admission criteria (such as InterQual and Milliman) fit in this model? The first question that has to be asked related to patients presenting to the hospital is whether they need extended care (such as beyond an ER visit) in a hospital setting and this is a good place to utilize commercial criteria. These criteria can help determine if care in a hospital setting is appropriate.

Once it is determined that care in a hospital setting is necessary, the next task is to determine if the physician believes the patient will need such care beyond a second midnight. If yes, then an inpatient admission is appropriate; if no or if unsure, outpatient with observation is likely the correct status. For inpatient admissions, the medical record should reflect that care beyond a second midnight is expected – for example, the admission orders and plan of care should support that the patient will be receiving tests and/or treatments beyond a second midnight.

And, as a hospital, if you want to be paid for your services and avoid a technical denial, make sure there is an inpatient admission order signed by a practitioner with admitting privileges prior to the patient’s discharge.

Inappropriate inpatient short stays

The OIG reported that overall inpatient admissions have decreased since the implementation of the two-midnight rule by 2.8% and short inpatient stays have decreased by 9.9%. Although this is good news, the OIG also reported that 39% of short inpatient stays “were potentially inappropriate for payment under the 2-midnight policy because the claims did not appear to meet any of CMS’s criteria for an appropriate short inpatient stay.” These accounted for $2.9 billion in payments. We must consider however that the OIG estimated the number of inappropriate inpatient short stays based on claims’ data without actually reviewing the medical records. This assessment was based on inpatient stays with inpatient-only procedures; mechanical ventilation; an unforeseen circumstance such as the beneficiary’s death, transfer to another hospital, or departure against medical advice; or a duration of 2 midnights or longer in the hospital when outpatient time prior to admission is added to inpatient time. Using only claims data, the OIG would be unable to identify appropriate inpatient admissions where the patient experienced clinical improvement after the physician documented an expectation of a 2-midnight stay. This could explain some of the volume of potentially inappropriate short inpatient stays but I understand the OIG’s concern.

Also of concern are the most common reasons for short inpatient stays cited by the OIG report: coronary stent insertion, fainting, digestive disorders, and chest pain. Again the decision to admit is complex and the admitting physician must consider several clinical factors including the beneficiary’s medical history, the severity of the beneficiary’s symptoms, and the expected care. There are patients that will require longer stays, say for coronary stent insertion, due to co-morbidities and overall risk, but most Medicare patients are able to have this procedure and be discharged after one midnight.

This is where it is critical to apply the rule correctly – at the time of admission, did the physician expect the patient to require hospital care beyond a second midnight? Does the patient’s condition and the expected treatments as evidenced in the admission orders and plan of care in the medical record support that expectation? If it is a condition or procedure that can usually be treated in less than two-midnights, does the medical record explain what is different for this patient or for this case?

Inappropriate long outpatient stays

The OIG report did find a slight decrease in the number of long outpatient stays (2.8%) but there were still almost 750,000 long outpatient stays. At MMP, Inc., we also notice that some of our clients continue to have long observation stays going beyond a second midnight. If a Medicare outpatient needs medically necessary care beyond a second midnight, then it is appropriate to admit the patient as an inpatient. This means that as an outpatient receiving observation services is approaching a second midnight, it is time to get an inpatient order or evaluate the need for continued medically necessary care (see the next section for valid reasons for long outpatient stays). These patients do not have to meet any commercial inpatient criteria to be admitted – they only have to continue to need medically necessary care in a hospital setting beyond that second midnight.

Valid reasons for long outpatient stays

But what if after evaluation it is determined that the patient doesn’t continue to need medically necessary care in a hospital setting? What if there are other reasons the patient cannot be sent home at this time that have to do with the convenience of the patient, physician or facility? This is much more common than one might think – certain diagnostic testing is not offered on weekends; testing is not completed until late in the day and the physician will not round until the next morning to discharge the patient; the patient has to wait until the next day to get a ride home from the hospital; etc. In these cases, it is acceptable to keep the patient in the hospital one more midnight as an outpatient.

However, observation services are likely not medically necessary in these cases anymore than inpatient services would be. If continued medically necessary care was appropriate past a second midnight, an inpatient admission would be correct. Therefore, there may be valid reasons for a long outpatient stay, but not really for observation services beyond a second midnight. When medically necessary care in a hospital setting is no longer needed and the patient remains due to convenience factors, the hospital should no longer report covered observation hours on the claim. At this point, observation hours should not be charged or should be reported on the claim as not medically necessary with a GZ modifier. If the hospital is ready for the patient to be discharged, but the patient refuses to leave or the patient’s physician refuses to discharge the patient, it is acceptable to issue an advanced beneficiary notice (ABN) to the patient making them financially responsible for the continued hospital care.

The last things of concern to the OIG are the continued variation in use of inpatient and outpatient status among hospitals and ultimately the financial impact on Medicare and Medicare beneficiaries. Short inpatient stays ranged from around 1% to above 5% and long outpatient stays were from 2% to above 11% between different hospitals. It is not surprising that all hospitals are not applying the rules the same, as Medicare reviewers have even struggled to get it right. This is evidenced by the starts, stops, delays, and transitions of short-stay reviews within Medicare.

Good luck to all the utilization reviewers out there. Maybe a crystal ball or Ouija board would help…

TRANSMITTALS

Update to Medicare Deductible, Coinsurance and Premium Rates for 2017

• MLN Matters® Number: MM9902
• Related Change Request (CR) #: CR 9902
• Related CR Release Date: December 2, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R103GI
• Implementation Date: January 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9902.pdf
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs and Durable Medical Equipment MACs, for services provided to Medicare beneficiaries.

Summary: The new Calendar Year (CY) 2017 Medicare deductible, coinsurance, and premium rates.

Implementing Provider File Updates and PECOS to FISS Interface Via Extract File Updates to Accommodate Section 603 Bipartisan Budget Act of 2015

• MLN Matters® Number: MM9613
• Related Change Request (CR) #: CR 9613
• Related CR Release Date: August 5, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R1704OTN
• Implementation Date: January 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9613.pdf
• Affects hospitals with off-campus outpatient departments submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: All off-campus outpatient departments of a hospital provider are required to be correctly identified.

HCPCS Code Update for Preventive Services

• MLN Matters® Number: MM9888
• Related Change Request (CR) #: CR 9888
• Related CR Release Date: December 2, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3669CP
• Implementation Date: January 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9888.pdf
• Affects physicians and providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Effective for dates of service on and after January 1, 2017, CPT code 76706 replaces HCPCS code G0389. MACs will apply all editing that was applied to HCPCS code G0389 to CPT code 76706, including the waiver of deductible and coinsurance.

Update to Editing of Therapy Services to Reflect Coding Changes

• MLN Matters® Number: MM9698
• Related Change Request (CR) #: CR 9698
• Related CR Release Date: December 1, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3670CP
• Implementation Date: April 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9698.pdf
• Affects providers submitting claims to Medicare Administrative Contractors (MACs) for physical and occupational therapy services provided to Medicare beneficiaries.

Summary: Instructs the MACs to apply certain coding edits to the new Current Procedural Terminology (CPT) codes that are used to report physical and occupational therapy evaluations and re-evaluations, effective January 1, 2017.

New Revenue Code 0815 for Allogeneic Stem Cell Acquisition Services

• MLN Matters® Number: MM9674
• Related Change Request (CR) #: CR 9674
• Related CR Release Date: July 29, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3571CP
• Implementation Date: January 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9674.pdf
• Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for stem cell transplant services provided to Medicare beneficiaries.

Summary: Medicare systems will accept revenue code 0815 (Allogeneic Stem Cell Acquisition/Donor Services), recently created by the National Uniform Billing Committee (NUBC), effective January 1, 2017, when submitted on hospital claims (Types of Bill (TOB) 011x, 012x, 013x, or 085x)

Comprehensive Care for Joint Replacement (CJR) Model: Skilled Nursing Facility (SNF) 3-Day Rule Waiver

• MLN Matters® Number: SE1626
• Article Release Date: December 9, 2016
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1626.pdf
• Affects Skilled Nursing Facilities (SNFs) submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries in the Comprehensive Care for Joint Replacement (CRJ) model. Although this article applies to SNFs, hospitals participating in the CRJ model may be interested in this information.

Summary: This article informs SNFs of the policies surrounding use of the 3-day stay waiver available for use under the CJR Model and to provide instructions on using the demonstration code 75 on applicable CJR claims submitted on or after January 1, 2017.

January 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.0

• MLN Matters® Number: MM9892
• Related Change Request (CR) #: CR 9892
• Related CR Release Date: December 9, 2016
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3674CP
• Implementation Date: January 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9892.pdf
• Affects providers who submit institutional claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH+H) MACs, for services provided to Medicare beneficiaries.

Summary: Provides instructions and specifications for the Integrated Outpatient Code Editor (I/OCE) used for Outpatient Prospective Payment System (OPPS) and non-OPPS claims.

OTHER MEDICARE ANNOUNCEMENTS

FY 2015 Medicare FFS RAC Report to Congress

On December 7, CMS posted the Fiscal Year 2015 Recovery Audit Program Report to Congress. CMS has also published the related FY 2015 Recovery Audit Program Appendices.

Final Medicare Outpatient Observation Notice (MOON) (CMS-10611) Available

On December 8, CMS published a Fact Sheet regarding the release the final OMB-approved Medicare Outpatient Observation Notice (MOON) along with instructions for the form. Hospitals and critical access hospitals (CAH) must begin using the MOON no later than March 8, 2017. The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals and CAHS to provide notification to individuals receiving observation services as outpatients for more than 24 hours explaining the status of the individual as an outpatient, not an inpatient, and the implications of that status.

Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements

On December 7, the OIG published a final rule in the Federal Register, amending the safe harbors to the anti-kickback statute by adding new safe harbors that protect certain payment practices and business arrangements from sanctions under the anti-kickback statute. This rule updates the existing safe harbor regulations and enhances flexibility for providers and others to engage in business arrangements to improve efficiency and access to quality care while protecting programs and patients from fraud and abuse.

Effective date: January 6, 2017

Revisions to the Office of Inspector General's Civil Monetary Penalty (CMP) Rules

On December 7, the OIG published a final rule in the Federal Register, amending its CMP rules to incorporate new CMP authorities, clarify existing authorities, and reorganize regulations on civil money penalties, assessments, and exclusions to improve readability and clarity.

Effective date: January 6, 2017

Policy Statement Regarding Gifts of Nominal Value To Medicare and Medicaid Beneficiaries

On December 7, the OIG published a Policy Statement on what it considers to be a gift of nominal value. The OIG is adjusting the previous amounts, now interpreting “nominal value” as having a retail value of no more than $15 per item or $75 in the aggregate per patient on an annual basis. As with its previous interpretation, the items may not be cash or cash equivalents.

Q:

If a patient is admitted and documented with a condition in which laterality can be distinguished such as bilateral osteoarthritis of the knees, and only one side is being treated, would you report a diagnosis code only for the side receiving treatment?

A:

No.
You would assign the “bilateral” code.

• When a patient has a bilateral condition and the condition still exists on both sides, then a bilateral code is reported.
• Once one side has been treated and that condition no longer exists on that particular side then the appropriate “unilateral” code would be assigned.
• If treatment does not completely resolve the condition for the first side treated, then the “bilateral” code would continue to be reported.

Example #1: Patient is documented with bilateral osteoarthritis of the knees (stage IV of the right and stage III of the left) and is admitted for total knee replacement of the right knee.

ICD-10-CM code assignment would be:

M17.0 for Bilateral Primary OA of Knee

Example #2: H&P states patient with history of bilateral senile nuclear sclerosis cataract. Patient had great success with cataract surgery for the left eye 3 months prior and is now admitted for surgery on the right eye.

ICD-10-CM code assignment would be:

H25.11 for Age-related Nuclear Cataract, Right Eye

Example #3: Documentation shows patient with history of bilateral osteoarthritis of the hip. Total hip arthroplasty was performed on the left side 9 months prior successfully eliminating all pain and symptoms on that side. Patient is admitted now with continued pain on the right side which has been interfering with her daily activities.

ICD-10-CM codes assigned would be:

M16.11 for Unilateral Primary OA, Right Hip and
Z96.642 for Presence of Left Artificial Hip Joint

Q:

What is new for outpatient rehabilitative therapy services for 2017?

A:

Answer: CPT is deleting the existing rehabilitative therapy evaluation codes 97001-97004 and replacing them with eight new codes, CPTs 97161-97168. The new codes include complexity levels of low, moderate, and high for the evaluation codes for physical therapy (PT) and occupational therapy (OT) respectively and one re-evaluation code for each. Below are the new codes with their short descriptors, but the long descriptors can be found in the table at the end of MLN Matters Article MM9782 which also adds the new codes as “always therapy” codes to the therapy code list.

• CPT 97161 – PT Evaluation, Low Complexity, 20 minutes
• CPT 97162 – PT Evaluation, Moderate Complexity, 30 minutes
• CPT 97163 – PT Evaluation, High Complexity, 45 minutes
• CPT 97164 – PT Revaluation of Established Plan of Care

• CPT 97165 – OT Evaluation, Low Complexity, 30 minutes
• CPT 97166 – OT Evaluation, Moderate Complexity, 45 minutes
• CPT 97167 – OT Evaluation, High Complexity, 60 minutes
• CPT 97168 – OT Revaluation of Established Plan of Care

Medicare has also released the Therapy Cap Values for 2017 in MLN Matters Article MM9865. For physical therapy and speech-language pathology combined, the 2017 therapy cap will be $1,980. For occupational therapy, the cap for 2017 will be $1,980. As a reminder, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended the therapy caps exceptions process through December 31, 2017 and also extended the application of the therapy caps, and related provisions, to outpatient hospitals until January 1, 2018. The exceptions process allows billing of therapy services exceeding the limit with the KX modifier if the services are medically necessary.