2017 Hospital Coding and Payment Guide

Transcription

1 Reimbursement Men s Health 2017 Hospital Coding and Payment Guide This coding reference guide is intended to illustrate the common coding and payment groups for male prosthetic urology procedures and related procedures. This guide is limited to male prosthetic urology procedures performed in the hospital outpatient and hospital inpatient site-of-service. Companion guides for physicians or ambulatory surgery centers (ASCs) are also available. Hospital Outpatient Coding and Payment Effective January 1, 2017 CPT APC Medicare Urinary Sling Procedures Sling operation for correction of male urinary incontinence (e.g., fascia or synthetic) 5376 $7, Removal or revision of sling for male incontinence (e.g., fascia or synthetic) 5375 $3, Penile Procedures Excision of penile plaque (Peyronie disease); 5375 $3, Excision of penile plaque (Peyronie disease); with graft to 5 cm in length 5375 $3, Excision of penile plaque (Peyronie disease); with graft > 5 cm in length 5376 $7, Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine) 5371 $ Plastic operation on penis to correct angulation 5374 $2, Insertion of penile prosthesis; non-inflatable (semi-rigid) Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis 5374 $2, Repair of component(s) of a multi-component, inflatable penile prosthesis 5375 $3, Removal and replacement of all component(s) of a multi component, inflatable penile prosthesis at the same operative session Removal and replacement of all components of a multi-component penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session Removal and replacement of non-inflatable (semi-rigid) or inflatable (self contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Testicular Procedures Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach 5374 $2, $2, Orchiectomy, partial 5374 $2, Orchiectomy, radical, for tumor; inguinal approach 5341 $2, Insertion of testicular prosthesis (separate procedure) 5375 $3, Laparoscopy, surgical; orchiectomy 5361 $4, Scrotoplasty; simple 5374 $2, Scrotoplasty; complicated 5375 $3, HCPCS s C1762 C1763 C1771 C1813 C2622 C2631 L8699 Connective tissue, human (includes fascia lata) Connective tissue, non-human (includes synthetic) Repair device, urinary, incontinence, with sling graft Prosthesis, penile, inflatable Prosthesis, penile, non-inflatable Repair device, urinary, incontinence, without sling graft Prosthetic Implant, not otherwise specified Medicare reimbursement for devices are packaged with APC reimbursement. For other insurance, please follow payer claims reporting instructions.

2 2017 Hospital Coding and Payment Guide / Men s Health ICD-10 PCS codes require 7 characters. Not all codes below contain the number of characters required and may not represent a fulldescription please see ICD-10 PCS coding reference for complete codes and descriptions based on the operation performed. The list is not intended to include all possible codes but a representative list of potential codes and partial codes as examples. Hospital Inpatient ICD-10 PCS Coding Procedure Procedure 0TSB_,_,_ Reposition Bladder 0TPD8JZ Removal of Synthetic Substitute from Urethra, via Natural or Artificial Opening Endoscopic 0TSC_,_,_ Reposition Bladder Neck 0TPD8KZ via Natural or Artificial Opening Endoscopic 0TSD_,_,_ Reposition Urethra, 0VB9_,_,_ Excision of Right Testis 0TQB_,_,_ Repair Bladder 0VBB_,_,_ Excision of Left Testis 0TQC_,_,_ Repair Bladder Neck 0VBC0ZX Excision of Bilateral Testes 0TQD_,_,_ Repair Urethra 0VQS_,_,_ Repair Penis 0TPB8JZ Removal of Synthetic Substitute from Bladder, Via Natural or Artificial Opening Endoscopic 0VR90JZ Replacement of Right Testis with Synthetic Substitute, 0TPB_,_,_ Removal of Nonautologous Tissue Substitute from Bladder 0VRB0JZ Replacement of Left Testis with Synthetic Substitute, 0TPD0JZ 0TPD0KZ 0TPD37Z 0TPD3JZ 0TPD3KZ 0TPD47Z 0TPD4JZ 0TPD4KZ 0TPD77Z 0TPD7JZ 0TPD7KZ 0TPD87Z Removal of Synthetic Substitute from Urethra, Open Approach Removal of Autologous Tissue Substitute from Urethra, Percutaneous Approach Removal of Synthetic Substitute from Urethra, Percutaneous Approach Percutaneous Approach Removal of Autologous Tissue Substitute from Urethra, Percutaneous Endoscopic Approach Removal of Synthetic Substitute from Urethra, Percutaneous Endoscopic Approach Percutaneous Endoscopic Approach Removal of Autologous Tissue Substitute from Urethra, Via Natural or Artificial Opening Removal of Synthetic Substitute from Urethra, via Natural or Artificial Opening Via Natural or Artificial Opening Removal of Autologous Tissue Substitute from Urethra, via Natural or Artificial Opening Endoscopic 0VRC0JZ 0VT9_,_,_ 0VTB_,_,_ 0VTC_,_,_ 0VU90JZ 0VUB0JZ 0VUC0JZ 0VUS_,_,_ 0VWD_,_,_ 0VWDXJZ 0VWS_,_,_ Replacement of Bilateral Testes with Synthetic Substitute, Resection of Right Testis Resection of Left Testis Resection of Bilateral Testes Supplement Right Testis with Synthetic Substitute, Supplement Left Testis with Synthetic Substitute, Supplement Bilateral Testes with Synthetic Substitute, Supplement Penis with Synthetic Substitute Revision of Synthetic Substitute in Testis Revision of Synthetic Substitute in Testis, External Approach Revision of Synthetic Substitute in Penis

3 2017 Hospital Coding and Payment Guide / Men s Health The Centers for Medicare and Medicaid Services (CMS) utilizes the Medicare Severity DRG (MS-DRG) classification system (Version 27 Grouper) to differentiate severity of illness among patients. The MS-DRG system subdivides MS-DRG sets based on the presence or absence of Major Complications or Comorbid conditions (MCCs) and Complications or Comorbid conditions (CCs). Coding patients to the highest level of specificity is critical to appropriate MS-DRG assignment Hospital Inpatient Payment Effective Jan 1, 2017 MS-DRG Minor bladder procedures w/mcc $17, Minor bladder procedures w/cc $8, Minor bladder procedures w/o CC/MCC $7, Penis procedures w/ CC/MCC $12, Penis procedures w/o CC/MCC $8, Testis procedures w/ CC/MCC $12, Testis procedures w/o CC/MCC $6, For reimbursement and health insurance information: coloplastreimbursement@argentaadvisors.com Hotline / Fax DISCLAIMER: This document is for informational use only, is general in nature, and does not cover all payers rules or policies. This information was obtained from third party sources and is subject to change without notice as a result of changes in reimbursement regulations and payer policies. This document represents no promise or guarantee by Coloplast regarding coverage or payment for products or procedures by CMS or other payers. Providers are responsible for reporting the codes that most accurately describe the patient s medical condition, procedures performed and products used. Providers should check Medicare bulletins, manuals, program memoranda, and Medicare guidelines to ensure compliance with Medicare requirements. Inquiries should be directed to the appropriate other payer for non-medicare coverage situations. The information in this document is intended for informational purposes only. The final decision for coding and billing is the responsibility of the provider. The existence of codes does not guarantee coverage or payment. Coloplast Corp. makes no warranties or guarantees, expressed or implied, concerning the accuracy or appropriateness of this information for any particular use and this information is not intended to provide coding direction or advice SOURCES Current Procedural Terminology (CPT) Copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Centers for Medicare & Medicaid Services CY2017 Hospital OPPS Final Rule: Addendum B Centers for Medicare & Medicaid Services CY2017 Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System MS-DRG ICD-10-PCS Coloplast Corp. Customer Service: The Coloplast logo is a registered trademark of Coloplast A/S All rights reserved. Coloplast Corp., Minneapolis, MN USA. M1788N 1.17

4 Men s Health 2017 Ambulatory Surgery Center Coding and Payment Guide This coding reference guide is intended to illustrate the common coding and payment groups for male prosthetic urology procedures and related procedures. This guide is limited to coding and payment for male prosthetic urology procedures performed in the ambulatory surgery center (ASC) site-of-service. Companion guides for hospitals and physicians are also available. Ambulatory Surgery Center Coding and Payment Effective January 1, 2017 CPT ASC Medicare Urinary Sling Procedures Sling operation for correction of male urinary incontinence (e.g., fascia or synthetic) $6, Removal or revision of sling for male incontinence (e.g., fascia or synthetic) $1, Penile Procedures Excision of penile plaque (Peyronie disease); $1, Excision of penile plaque (Peyronie disease); with graft to 5 cm in length $1, Excision of penile plaque (Peyronie disease); with graft > 5 cm in length $4, Injection of corpora cavernosa with pharmacologic agent(s) (e.g., papaverine, phentolamine) $ Plastic operation on penis to correct angulation $1, Insertion of penile prosthesis; non-inflatable (semi-rigid) $12, Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir $12, Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis $1, Repair of component(s) of a multi-component, inflatable penile prosthesis $1, Removal and replacement of all component(s) of a multi component, inflatable penile prosthesis at the same operative session $12, Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis $1, Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session $12, Testicular Procedures Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach $1, Orchiectomy, partial $1, Orchiectomy, radical, for tumor; inguinal approach $1, Insertion of testicular prosthesis (separate procedure) $1, Laparoscopy, surgical; orchiectomy $2, Scrotoplasty; simple $1, Scrotoplasty; complicated $1, HCPCS s C1762 Connective tissue, human (includes fascia lata) C1763 Connective tissue, non-human (includes synthetic) Medicare reimbursement for devices C1771 Repair device, urinary, incontinence, with sling graft are packaged with APC reimbursement. C1813 Prosthesis, penile, inflatable For other insurance, please follow payer claims reporting instructions. C2622 Prosthesis, penile, non-inflatable C2631 Repair device, urinary, incontinence, without sling graft L8699 Prosthetic Implant, not otherwise specified

5 2017 Ambulatory Surgery Center Coding and Payment Guide / Men s Health ICD-10-CM s commonly associated with male prosthetic urology procedures* N39.45 Continuous leakage N52.1 Erectile dysfunction due to diseases classified elsewhere C61 Malignant neoplasm of prostate N52.2 Drug-induced erectile dysfunction C62.00-C62.92 Malignant neoplasm of other and unspecified testis N52.3 Post-surgical erectile dysfunction E10.40-E10.49 Type 1 diabetes mellitus with neurological complications N52.31 Erectile dysfunction following radical prostatectomy E10.51-E10-59 Type 1 diabetes mellitus with circulatory complications N52.32 Erectile dysfunction following radical cystectomy E10.61-E10.69 Type 1 diabetes mellitus with other specified complications N52.33 Erectile dysfunction following urethral surgery E11.40-E11.49 Type 2 diabetes mellitus with neurological complications N52.34 Erectile dysfunction following simple prostatectomy E11.51-E11.59 Type 2 diabetes mellitus with circulatory complications N52.39 Other post-surgical erectile dysfunction E11.61-E11.69 Type 2 diabetes mellitus with other specified complications N52.8 Other male erectile dysfunction E13.41-E13.49 Other specified diabetes mellitus with neurological complications N52.9 Male erectile dysfunction, unspecified E13.51-E13.59 Other specified diabetes mellitus with circulatory complications Q55.9 Congenital malformation of male genital organ, unspecified E13.61-E13.69 Other specified diabetes mellitus with other specified complications R32 Urinary incontinence, unspecified E29.1 Essential hypertension; unspecified S14.0XXS Concussion and edema of cervical spinal cord, sequela I73.9 Peripheral vascular disease, unspecified S14.101S- S14.109S Unspecified injury of cervical spinal cord N36.42 Intrinsic (urethral) sphincter deficiency (ISD) S24.0XXS Concussion and edema of thoracic spinal cord, sequela N36.43 Combined hypermobility of urethra and intrinsic sphincter deficiency S24.101S- S24.109S Unspecified injury of thoracic spinal cord N39.3 Stress incontinence, (Female)(Male) S34.01XS Concussion and edema of lumbar spinal cord, sequela N44.00-N44.04 Torsion of the testis S34.02XS Concussion and edema of sacral spinal cord, sequela N48.6 Induration penis plastica (Peyronie s Disease) S34.101S- S34.139S Other and unspecified injury of lumbar and sacral spinal cord N48.81-N48.9 Other specified disorders of the penis T36-T50 Poisoning by, adverse effects of and underdosing of drugs, medicaments and biological substances N50.1 Vascular disorders of male genital organs T83.010A- T83.498A N50.81-N50.89 Other specified disorder of male genital organs T83.51XA- T83.6XXA Mechanical complication of genitourinary device, implant, and graft Infection and inflammatory reaction due to prosthetic device, implant and graft in genital tract N52.01 Erectile dysfunction due to arterial insufficiency Z85.46 Personal history of malignant neoplasm of prostate N52.02 Corporo-venous occlusive erectile dysfunction Z85.47 Personal history of malignant neoplasm of testis N52.03 Combined arterial insufficiency and corporo-venous occlusive erectile dysfunction * For a full listing of available codes, please consult an ICD-10-CM reference. Guidelines require coding to the highest level of specificity. For reimbursement and health insurance information: coloplastreimbursement@argentaadvisors.com Hotline / Fax DISCLAIMER: This document is for informational use only, is general in nature, and does not cover all payers rules or policies. This information was obtained from third party sources and is subject to change without notice as a result of changes in reimbursement regulations and payer policies. This document represents no promise or guarantee by Coloplast regarding coverage or payment for products or procedures by CMS or other payers. Providers are responsible for reporting the codes that most accurately describe the patient s medical condition, procedures performed and products used. Providers should check Medicare bulletins, manuals, program memoranda, and Medicare guidelines to ensure compliance with Medicare requirements. Inquiries should be directed to the appropriate other payer for non-medicare coverage situations. The information in this document is intended for informational purposes only. The final decision for coding and billing is the responsibility of the provider. The existence of codes does not guarantee coverage or payment. Coloplast Corp. makes no warranties or guarantees, expressed or implied, concerning the accuracy or appropriateness of this information for any particular use and this information is not intended to provide coding direction or advice SOURCES Current Procedural Terminology (CPT) Copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association 2017 ICD-10-CM Centers for Medicare & Medicaid Services CY2017 ASC Final Rule: Addendum AA Coloplast Corp. Customer Service: The Coloplast logo is a registered trademark of Coloplast A/S All rights reserved. Coloplast Corp., Minneapolis, MN USA. M1795N 1.17

6 Men s Health 2017 Physician Coding and Payment Guide This coding reference guide is intended to illustrate the common coding and payment groups for male prosthetic urology procedures and related procedures. This guide is limited to coding and payment for male prosthetic urology procedures performed by physicians. The table below provides the 2017 Medicare National Average physician payment rates. Companion guides for hospitals and ambulatory surgery centers (ASCs) are also available. Physician Coding and Payment Effective January 1, 2017 CPT Medicare Urinary Sling Procedures Sling operation for correction of male urinary incontinence (e.g., fascia or synthetic) $ Removal or revision of sling for male incontinence (e.g., fascia or synthetic) $ Penile Procedures Excision of penile plaque (Peyronie disease) $ Excision of penile plaque (Peyronie disease); with graft to 5 cm in length $ Excision of penile plaque (Peyronie disease); with graft > 5 cm in length $ Injection of corpora cavernosa with pharmacologic agent(s) (e.g., papaverine, phentolamine) $76.08 (facility) $92.95 (non-facility) Plastic operation on penis to correct angulation $ Insertion of penile prosthesis; non-inflatable (semi-rigid) $ Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir $ Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis $ Repair of component(s) of a multi-component, inflatable penile prosthesis $ Removal and replacement of all component(s) of a multi component, inflatable penile prosthesis at the same operative session $ Removal and replacement of all components of a multi-component penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue $1, Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis $ Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session Removal and replacement of non-inflatable (semi-rigid) or inflatable (self contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Testicular Procedures Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach $ Orchiectomy, partial $ Orchiectomy, radical, for tumor; inguinal approach $ Insertion of testicular prosthesis (separate procedure) $ Laparoscopy, surgical; orchiectomy $ Scrotoplasty; simple $ Scrotoplasty; complicated $ HCPCS s C1762 Connective tissue, human (includes fascia lata) C1763 Connective tissue, non-human (includes synthetic) Medicare reimbursement for devices C1771 Repair device, urinary, incontinence, with sling graft are packaged with APC reimbursement. C1813 Prosthesis, penile, inflatable For other insurance, please follow payer claims reporting instructions. C2622 Prosthesis, penile, non-inflatable C2631 Repair device, urinary, incontinence, without sling graft L8699 Prosthetic Implant, not otherwise specified $ $931.67

7 2017 Physician Coding and Payment Guide / Men s Health ICD-10-CM 3 s commonly associated with male prosthetic urology procedures* N39.45 Continuous leakage N52.1 Erectile dysfunction due to diseases classified elsewhere C61 Malignant neoplasm of prostate N52.2 Drug-induced erectile dysfunction C62.00-C62.92 Malignant neoplasm of other and unspecified testis N52.3 Post-surgical erectile dysfunction E10.40-E10.49 Type 1 diabetes mellitus with neurological complications N52.31 Erectile dysfunction following radical prostatectomy E10.51-E10-59 Type 1 diabetes mellitus with circulatory complications N52.32 Erectile dysfunction following radical cystectomy E10.61-E10.69 Type 1 diabetes mellitus with other specified complications N52.33 Erectile dysfunction following urethral surgery E11.40-E11.49 Type 2 diabetes mellitus with neurological complications N52.34 Erectile dysfunction following simple prostatectomy E11.51-E11.59 Type 2 diabetes mellitus with circulatory complications N52.39 Other post-surgical erectile dysfunction E11.61-E11.69 Type 2 diabetes mellitus with other specified complications N52.8 Other male erectile dysfunction E13.51-E13.59 Other specified diabetes mellitus with circulatory complications N52.9 Male erectile dysfunction, unspecified E13.61-E13.69 Other specified diabetes mellitus with other specified complications Q55.9 Congenital malformation of male genital organ, unspecified E29.1 Essential hypertension; unspecified R32 Urinary incontinence, unspecified I73.9 Peripheral vascular disease, unspecified S14.0XXS Concussion and edema of cervical spinal cord, sequela N36.42 Intrinsic (urethral) sphincter deficiency (ISD) S14.101S- S14.109S Unspecified injury of cervical spinal cord N36.43 Combined hypermobility of urethra and intrinsic sphincter deficiency S24.0XXS Concussion and edema of thoracic spinal cord, sequela N39.3 Stress incontinence, (Female)(Male) S24.101S- S24.109S Unspecified injury of thoracic spinal cord N44.00-N44.04 Torsion of the testis S34.01XS Concussion and edema of lumbar spinal cord, sequela N48.6 Induration penis plastic (Peyronie s Disease) S34.02XS Concussion and edema of sacral spinal cord, sequela N48.81-N48.9 Other specified disorders of the penis S34.101S- S34.139S Other and unspecified injury of lumbar and sacral spinal cord N50.1 Vascular disorders of male genital organs T36-T50 Poisoning by, adverse effects of and underdosing of drugs, medicaments and biological substances N50.81-N50.89 Other specified disorder of male genital organs T83.010A- T83.498A N52.01 Erectile dysfunction due to arterial insufficiency T83.81XA- T83.9XXA Mechanical complication of genitourinary device, implant, and graft Complications of genitourinary prosthetic devices, implants and graft N52.02 Corporo-venous occlusive erectile dysfunction Z85.46 Personal history of malignant neoplasm of prostate N52.03 Combined arterial insufficiency and corporo-venous occlusive erectile dysfunction Z85.47 Personal history of malignant neoplasm of testis * For a full listing of available codes, please consult an ICD-10-CM reference. Guidelines require coding to the highest level of specificity. For reimbursement and health insurance information: coloplastreimbursement@argentaadvisors.com Hotline / Fax DISCLAIMER: This document is for informational use only, is general in nature, and does not cover all payers rules or policies. This information was obtained from third party sources and is subject to change without notice as a result of changes in reimbursement regulations and payer policies. This document represents no promise or guarantee by Coloplast regarding coverage or payment for products or procedures by CMS or other payers. Providers are responsible for reporting the codes that most accurately describe the patient s medical condition, procedures performed and products used. Providers should check Medicare bulletins, manuals, program memoranda, and Medicare guidelines to ensure compliance with Medicare requirements. Inquiries should be directed to the appropriate other payer for non-medicare coverage situations. The information in this document is intended for informational purposes only. The final decision for coding and billing is the responsibility of the provider. The existence of codes does not guarantee coverage or payment. Coloplast Corp. makes no warranties or guarantees, expressed or implied, concerning the accuracy or appropriateness of this information for any particular use and this information is not intended to provide coding direction or advice SOURCES 1 Current Procedural Terminology (CPT) Copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 2 Centers for Medicare & Medicaid Services CY2017 Physician Fee Schedule Final Rule: Addendum A; National Average Medicare payment rates calculated using a conversion factor of $ ICD-10-CM Coloplast Corp. Customer Service: The Coloplast logo is a registered trademark of Coloplast A/S All rights reserved. Coloplast Corp., Minneapolis, MN USA. M2373N 12.16