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Medicare along with AMA CPT finalized a number of significant changes to the coding for services for the Gastroenterology Specialty. Now that these changes have gone into effect, healthcare organizations should be monitoring and be auditing their existing records to make sure they are capturing services and maximizing their reimbursements. This presentation will address coding along with billing and payments for said services.\n\nWhy should you attend?\n• Capturing the New Patient vs established patient visits\n• Coding for an E/M and an endoscopy test on the same date.\n• Coding for endoscopy services in the office and facility setting.\n• The Telemedicine \"star\" symbol for 2018 and the impact it will have for Gastroenterology Telemedicine\n• The role of NPP\'s in the office and hospital for E/M services\n• Screening Colonoscopies and the billing and reimbursement process\n• Modifiers as it relates to Endoscopic services for GI practices\n• Moderate Sedation services and documentation for code capture in 2017-2018.\n\n\n\n\n\nWhat tools and benefits will your session provide to the attendees?\nHow to Tips for physicians, and easy to understand guidelines for E/M, and language examples to make sure physicians are compliant with their documentation when trying to capture new services in 2018. New Medicare Update such as the 2018 New Patient Modifiers will be discussed.\n\nWho should attend?\n• Coders\n• Billers\n• Administrators\n• Collectors\n• physicians\n• back office\n• mid-levels\n\n\n\nonline audio training is an online audio training provider
O N L I N E A U D I O T R A I N I N G
By : T erry Fletcher
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.
Readers should note that the time frame to which these guidelines apply to is Oct. 1, 2017 to Sept. 30, 2018.
When you review the guidelines for this coming fiscal year, please take note the following:
Narrative changes appear in boldtext
Items underlined have been moved within the guidelines since the FY 2017 version
Italics are used to indicate revisions to headingchanges
The conventions for ICD-10-CM are the general rules for use of the classification, independent of the guidelines, and there remain 19
of these conventions, as in the FY 2017 guidelines. Convention No. 15, “with,” does have some revised narrative, so every coding
professional should read this over carefully. Here’s a portion of this revision, highlighted in bluefont:
The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic
Index, or an instructional note in the TabularList.
These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the
documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented
linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”).
Changes proposed to diverticulitis with perforation for ICD-10 coding to better clarify the severity
of the patient’s problem and whether generalized peritonitis occurred
Distinctions between cholecystitis without gangrene or perforation, cholecystitis
with gangrene without perforation, and cholecystitis with perforation are proposed
new codes to more accurately characterize the severity of cholecystitis
A finding indicating the presence of multiple pouches, usually in the colonic or gastric wall.
Diverticular disease of intestine
Diverticulitis of small intestine with perforation and abscess
K57.00…… without bleeding
K57.01…… with bleeding
Diverticular disease of small intestine without perforation or abscess
K57.10Diverticulosis of small intestine without perforation or abscess without bleeding
K57.11Diverticulosis of small intestine without perforation or abscess with bleeding
K57.12Diverticulitis of small intestine without perforation or abscess without bleeding
K57.13Diverticulitis of small intestine without perforation or abscess with bleeding
Diverticulitis of large intestine with perforation and abscess
K57.20…… without bleeding
K57.21…… with bleeding
Diverticular disease of large intestine without perforation or abscess
K57.30Diverticulosis of large intestine without perforation or abscess without bleeding
K57.31Diverticulosis of large intestine without perforation or abscess with bleeding
K57.32Diverticulitis of large intestine without perforation or abscess without bleeding
K57.33Diverticulitis of large intestine without perforation or abscess with bleeding
Diverticulitis of both small and large intestine with perforation and abscess
K57.40…… without bleeding
K57.41…… with bleeding
Diverticular disease of intestine, part unspecified, without perforation or abscess
K57.90Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding
K57.91Diverticulosis of intestine, part unspecified, without perforation or abscess with bleeding
K57.92Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding
K57.93Diverticulitis of intestine, part unspecified, without perforation or abscess with bleeding
For example: A 64-year-old male is seen for follow-up of diverticulitis. Without documentation of location or complications,
the correct code is K57.92.
ICD-10-CM 2018 brings us 6 new codes for pulmonary hypertension, which effects the arteries of the
lungs and theheart.
New codes are asfollows:
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
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
Reporting Telehealth Services with the appropriate modifiers-Only ½ the story
Submit your Medicare and Medicaid claims for telehealth services using the appropriate CPT® or HCPCS 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 “hands on” visit per
month to examine the vascular accesssite.
For Federal telemedicine demonstration programs in Alaska or Hawaii, your submitted claims with the
appropriate CPT® or HCPCS code for the professional service along with the GQ modifier, to certify a
asynchronous telecommunications system was used.
! 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 modifiers are not included, the
service will be denied by Medicare.
Make sure you attend one of our Telemedicine Webinars in 2018 to become even more informed on this topic.
*Terry Fletcher is a member of the American Telemedicine Association 2017
E/M Codes with modifier -25 may face drastic pay reductions for some
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 impact reimbursement for many practices around the country. I fear this could have
physicians bringing patients back on a different day to get paid for both services at 100%.
We strongly urge providers who are participating with this plan to fight it with the
provider relations department of that payer. There is no basis for this.
Next year CMS plans to give physicians and some non-physician
practitioners the opportunity to test drive modifiers that indicate the
relationship between provider and patient.
CMS was required to create codes that will be appended to Medicare claims to “facilitate the attribution of
patients and episodes to one or more clinicians” ~ byMACRA
Here are the proposed modifiers for the 2018 physician feeschedule:
*X1- (Continuous/broad services) Principal care no plannedendpoint
*X2- (Continuous/focused services) Clinicians whose expertise is needed for ongoingmanagement
*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, radiationetc..
*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 voluntarily reported on Medicare
claims, and will not effect payment”. They should not be used with quality measures.
Medicare continues to performing mo r e frequent pre and post-payment audits and sharing
these results with secondaryproviders.
B e proactive and spot checkyour practice. If y ou get a letter from your M A C carrier saying they
found a 5 0 % or higher error rate on E / M or y ou are frequently being asked for records to support
services, perform an internal audit (or use an external auditor) to give y ou an assessment of your
practice so y ou can be prepared for any refund requests from both Medicare and the secondary
(Contact us at T erryFletcherCPC@aol.comfor internal/external auditing options or1-800-805-8056)
Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA
This coding reference manual, or parts thereof, may not be reproduced, stored in a retrieval system or transmitted in any form by any
means, without written permission from the author and/or publisher. Terry Fletcher Consulting,Inc.©
All reference to the AMA© CPT-4 codes are copyrighted by AMA.