Webinar On Cardiology Coding Update 2018

1. Cardiology C o d i n g U p d ates for2018 O N L I N E A U D I O T R A I N I N G T erry Fletcher Consulting,Inc. By : T erry Fletcher C P C , C C C , C M C , C M S C S , C M C S , C C S-P , C C S , C E M C , A C S - C A ,S C P - C A www.onlineaudiotraining.com 1

2. ICD-10-CM GUIDELINES RELEASED!! Just released on Thursday, Aug. 10 are the Official ICD-10-CM/PCS Coding and Reporting Guidelines for the 2018 fiscal year, totaling 117 pages. The National Center for Health Statistics, via the CDC (Centers for Disease Control and Prevention), has posted the guidelines on its websitehere:https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf. Readersshouldnotethatthetime frameto whichtheseguidelinesapplyto is Oct.1,2017to Sept.30,2018. Whenyoureviewtheguidelines for thiscomingfiscalyear, pleasetakenote thefollowing: Narrative changes appear in boldtext Itemsunderlinedhavebeenmovedwithintheguidelinessincethe FY 2017version Italics are used to indicate revisions toheading changes     TheconventionsforICD-10-CMarethe general rulesforuseofthe classification,independentof theguidelines,andthere remain19 of these conventions, as in the FY 2017 guidelines. Convention No. 15, “with,” does have some revised narrative, so every coding professionalshouldreadthisovercarefully.Here’saportion of thisrevision,highlightedin bluefont: Theword “with” or “in” shouldbeinterpreted to mean“associatedwith” or“dueto” whenit appearsin acodetitle, the Alphabetic Index,oraninstructionalnotein theTabularList. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentationclearly statestheconditionsareunrelatedorwhenanotherguideline existsthatspecificallyrequiresadocumented linkagebetweentwoconditions(e.g.,sepsisguideline for “acuteorgandysfunctionthatisnotclearly associated with the sepsis”). 2

3. ACUTE MYOCARDIAL INFARCTION(AMI) Definition Change When documenting an AMI, keep the following inmind: 1. Timeframe: AnAMI isnow considered“acute” for 4weeksfrom the time of the incident, arevised time frame from the ICD-9period of 8weeks. Episode of care ICD-10-CM does not capture episode of care (e.g. initial, subsequent, sequelae). SubsequentAMI ICD-10 allows coding of anewMI that occurs during the 4week “acute period” of the originalAMI. Type 1 andType2 AcuteMyocardialInfarctionDiagnosesto better descript when Ischemicheart disease is involved. (2018Update) 2. 3. 4. ICD-10-CM Code Examples: I21.- I21.- I21.02 I21.4 I21.A1 I21.A9 I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall (no changes to subsequent) Acute Myocardial Infarction (2018 revision to the definition) (Type 1) Acute Myocardial Infarction (2018 revision to the definition) (Type1) ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery Non-ST elevation (NSTEMI) myocardial infarction Myocardial infarction (New 2018) (Type2) Other myocardial infarctiontype ICD-10-CM 2018 will add the new code I21.9 (acute myocardial infarction, unspecified). This could be helpful when a patient is seeninthe ERandit isnot clearwhat stageofAMI the patient isin. 3

4. Six New Hypertension Codes2018 ICD-10-CM 2018 brings us 6 new codes for pulmonary hypertension, which effects the arteries of the lungs and the heart. New codes are as follows:  I27.20 (Pulmonary hypertension, unspecified)  I27.21 (Secondary pulmonary arterial hypertension)  I27.22 (Pulmonary hypertension due to left heart disease)  I27.23 (Pulmonary hypertension due to lung diseases and hypoxia)  I27.24 (Chronic thromboembolic pulmonary hypertension)  I27.29 (Other secondary pulmonary hypertension) You may see these codes more often with Right Heart Cath coding and possible valve replacement coding. 4

5. Brand-New Category for Heart Failure Section I50-“Heartfailure”will addanew category(I50.8-,Otherheartfailure). TheICD-10-manualwilloffernewcodestospecifywhenpatients havea conditions thatfall underthiscategorysuchas right ventricular failure or BiV heart failure. These additions include thefollowing: I50.81-(Right heartfailure)  I50.810 (Right heart failure,unsp)  I50.811 (Acute right heartfailure)  I50.812 (Chronic right heartfailure)  I50.813 (Acute on chronic right heartfailure)  I50.814(Rightheartfailuredueto leftheartfailure) >>I50.82 (Biventricular heartfailure) >>I50.83 (High output heartfailure) >>I50.84 (End Stage heartfailure) >>I50.89 (Other heartfailure) There has been an increase, within patient medical records documentation, of biventricular heart failure (new code ICD-10-CM I50.82). This will make coding a bit more specific when ordering tests, labs, visits, etc. Medical Necessity will be easier to support. 5

6. New Specialty Taxotomy Codes Added for2017 Billing: CMSadds3specialtydesignationsstartingOctober1st,2017and2018 Preparefor theadditionof threenewspecialties thatwill appear under theproviderenrollmentchain and ownershipsystem (PECOS)andthatmayopenupbillingopportunitiesfor your providerstaff. These specialty codes, pertaining to cardiology, medical toxicology and cell transplantation providers, go into effect Oct.1:  C7-Advanced heart failure and transplantcardiology  C8-Medicaltoxicology  C9-Hematorpoietic cell transplantation and cellulartherapy Some specialty groups are saying this is a big win for medical billing staff and some of the denials that have come from the local Medicare carriers for duplicate billing. When a cardiologist, for example, and (heart failure) specialist from the same practice have billed for E/M services on the samedate,denialsaregoingto happen.Hopefully with thesenewdesignations,CMSwill allowfor separate services when appropriate. 6

7. 2018 E / M servicesupdate Physician practices should note several changes to E/M codes, which includes a new “star” symbol added to CPT to designate possible “Synchronous Telemedicine Health” code inclusions, and several revised code descriptor sections. Pay close attention to modifier -95 and-GT PlushCare VIPCare Telehealth eVisit • • • • 7

8. Coding for TelehealthServices-preview Reporting Telehealth Services with the appropriate modifiers- Only ½ thestory Submit your Medicare and Medicaid claims for telehealth services using the appropriate CPT® orHCPCS code for the telehealth service along with the modifier GT (via interactive audio and video telecommunications systems)-for example,99202-GT. By coding and billing the GT modifier with a covered telehealth procedure code, you are certifying that the beneficiary was present at an eligible originating site when your physician or qualified approved practitioner furnishes the telehealth service. By coding and billing the GT modifier with the covered ESRD-related service telehealth code, you are certifying that your provider furnishes one“handson” visitper monthto examinethe vascularaccesssite. For Federal telemedicine demonstration programs in Alaskaor Hawaii, your submitted claims with the appropriate CPT®or HCPCScodefor the professionalservicealong with the GQmodifier, to certify aasynchronoustelecommunicationssystemwasused. ! Reminder: CMS states that POS 02 is effective January 1st, 2017. A CMS transmittal (R3586CP) mentions that any time claims for telehealth services are reported that include modifier GT or GQ on either the CPT® or HCPCS code, but do not include new POS 02, they will be denied. It also mentions that if the new POS 02 is used and the modifiersare not included, the service will bedenied by Medicare. Makesure youattend one of our TelemedicineWebinars in 2018 to become even more informed on this topic. *Terry Fletcher is a member of the American Telemedicine Association2017 8

9. E/M New vs. Established patient clarification-AVOID denials-Cardiology Specialty in 2018 3 questions to avoid overpayments anddenials Was the patient seenby:?    A provider of the samesub-specialty? Keep in mind that under the E/M documentation guidelines, if the patient is new to your practice with an officevisit,but was seen in the E/Ror in the hospitalwithin in the past3-years, they arestill considered an establishedpatient. The sameprovider? A provider of the samespecialty? If, for example, a patient sees a general cardiologist 6-1-2017 in the office for follow up coronary artery disease but during that encounter an arrhythmia is detected (an abnormality of the computer of the heart) and the patient needs to be referred to an EP (electrophysiology physician), within the practice.On a different date, the patient would be considered a NP for that EP doctor. It helps that EP is a separate taxotomy code to differentiate a general cardiologist from an EP as asubspecialty. However, what if the physician referral was to a Peripheral Vascular physician in the same practice, no separate T ax ID? That is where the debate begins. OIG will be closely monitoring these claims. They have already settled a $700,000 claim from 2 medical centers in MASS for “up-coding” incorrectly from established patient visitto anew patient visitwhen it wasnot supported. 9

10. Modifier 25Alert!-2018 E/M Codes with modifier -25 may face drastic pay reductions forsome practices. Watch your E/M Claims where you append the modifier 25 (Significant, separately identifiable E/M service) if your patients have insurance with a Medicare Advantage carrier that operates in 25 states. This started on August 1st, when Independence Health Group, which covers almost 9 million people under private health insurance and Medicare Advantage plans, announced via their website and provider emails, it would apply a “payment reduction of 50%” to an E/M service when it is billed/reported with a modifier 25 on the same date as a minor procedure. The company also said it would cut payment at the same 50% rate for E/M services billed with modifier 25 when a preventative code is also billed. The policy document lists 17 preventative service codes that apply, including 99381-99387, 99391-99397, G0438 and G0349 the AWV. This revised payment policy will significantly impactreimbursement for many practicesaround the country. I fear this could have physicians bringing patients backon adifferentday to getpaid for both services at 100%. Westronglyurgeproviderswho are participating with this plan to fight it with the provider relationsdepartment of that payer.Thereis nobasisfor this. 10

11. New Patient relationship Modifiersfor 2018-per CMS Next year CMS plans to give physicians and some non-physician practitionersthe opportunityto testdrivemodifiersthatindicate the relationship between provider andpatient. CMSwasrequiredto createcodesthatwill beappendedto Medicareclaims to “facilitatethe attributionofpatients andepisodes to oneor moreclinicians” ~byMACRA Herearetheproposed modifiersfor the2018physicianfeeschedule: *X1- (Continuous/broad services) Principal care no plannedendpoint *X2- (Continuous/focused services) Clinicians whose expertise is needed for ongoing management *X3- (Episodic/broad services) Clinicians who have broad responsibility for comprehensive needs, i.e. hospitalist *X4- (Episodic/focused services) Specialty clinicians who provide time-limited care, i.e surgery, radiation etc.. *X5- (Only as ordered by another clinician) Example a radiologist or cardiologist who interprets a diagnostic test These modifiers are intended for use by physicians and applicable NPP’s. The Jan 1st, 2018 rollout of the codes is required by law. However the use of the modifiers will not be mandatory in 2018. The modifiers “may be voluntarilyreported on Medicare claims, and willnot effect payment”. They should not be usedwith quality measures. 11