Medtronic ENT Transnasal Endoscopic Procedures Coding Guide. Effective January 1, 2009

Transcription

1 Medtronic ENT Transnasal Endoscopic Procedures Coding Guide Transnasal Esophagoscopy Laryngeal Sensory Testing FEES FEEST Transnasal Fiberoptic Laryngoscopy Stroboscopy Disposable Sheaths Effective January 1, 2009 Please direct any questions to: Kim Brew Manager, Reimbursement and Therapy Access Medtronic ENT (904)

2 TO OUR PARTNERS IN HEALTH CARE This document provides general reimbursement information provided to assist in obtaining coverage and reimbursement for healthcare services. These coding suggestions do not replace seeking coding advice from the payer and/or your own coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for interpretation of the appropriate codes to use for specific procedures. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other third party payers as to the correct form of billing or the amount that will be paid to providers of service. All products should be used according to their labeling. Current Procedural Terminology (CPT) is copyright 2008 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. 2

3 Table of Contents Overview Physician Coding ICD-9 Diagnosis Coding CPT Coding and Payment HCPCS Coding and Payment for Disposable Sheaths Hospital Outpatient and ASC Sample Appeal Letters Sample Claim Form for Disposable Sheaths

4 Overview The following transnasal endoscopic procedures may be performed in an office, hospital outpatient department, or an ASC setting. Prior to each exam, the patient is usually given a topical anesthetic to numb the nasal passage through which the tube is passed. This topical anesthesia is delivered in a mist or spray. It can also be combined with another medication that shrinks the lining of the nose, making it easier to pass the flexible scope through the nasal passage. 2 Disposable sheaths are used over each of the flexible endoscopes to eliminate the need for sterilization or high-level disinfection of the equipment between procedures. Using and then disposing of a single-use sheath can shorten the time between procedures. Transnasal Esophagoscopy Transnasal Esophagoscopy (TNE) is an endoscopic exam of the upper digestive tract including, but not limited to the pharynx, hypopharynx, vocal folds, larynx, and esophagus. The physician inserts a rigid or flexible illuminated endoscope transnasally to visualize the structures of the upper airway and esophagus. Laryngeal Sensory Testing The provider passes a flexible endoscope into the oropharynx. The endoscope includes a sensory stimulator that allows for quantification of stimuli by delivering pulses of air at sequentially increased pressures to elicit the laryngeal adductor reflex. FEES (Fiberoptic Endoscopic Evaluation of Swallowing) Endoscopic evaluation of swallowing is performed using a fiberoptic laryngoscope passed transnasally to view the hypopharynx, larynx and surrounding structures. The provider views and assesses the anatomy, physiology and motor function of the pharyngeal stage of swallowing. The provider tests motor function through use of different food consistencies to assess oral transit time, laryngeal elevation, aspiration, pooling, laryngeal closure, reflux and inability to clear residue. FEESST (Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing) This procedure is a combination of the FEES testing with Sensory testing. Transnasal Flexible Laryngoscopy Transnasal Flexible Laryngoscopy (TFL) is an office-based diagnostic procedure which uses a thin flexible fiberoptic endoscope to examine the laryngeal structures and functions. 1 TFL may be used in evaluating people with vocal fold tumors or paralysis of the vocal cords. Since the individual is wide awake during TFL, assessment of the mobility of vocal cords can be readily performed during speech or singing. It is also used to examine the nasopharynx, the soft palate, the throat and the back of the tongue. Transnasal Flexible Laryngoscopy (TFL) with Stroboscopy This examination is a specialized viewing of vocal fold vibration. Laryngeal stroboscopy involves controlled high-speed flashes of light timed to the frequency of the patient's voice. Images acquired during these flashes provide a slow motion-like view of vocal fold vibration during sound production. 4

5 Physician Coding The medical necessity of the services must be documented. The documentation must include a formal, descriptive narrative. The procedural details and findings should be clearly stated. In instances that require serial or follow-up procedures, the documentation must show how repeat procedural findings influence the prescribed treatment plan. In general, Medicare does not cover screening tests. Transnasal Esophagoscopy There currently are no local medical policies directly addressing transnasal esophagoscopy, but most carriers have policies related to diagnostic evaluation of the upper digestive system including CPT code Laryngeal Sensory Testing, FEES, FEESST AMA CPT Codes and are used to report evaluation of oral and pharyngeal swallowing function without and with cine or video recording respectively. Cross-references instruct provider to use to report motion fluoroscopic evaluation of swallowing. A crossreference was also added following code directing the user to the appropriate radiological supervision and interpretation code. AMA CPT codes are used to report the services associated with swallowing and laryngeal sensory testing. Under Medicare Part B, these codes are reimbursable only to physicians. Services of speech pathologists may be billed by physicians only under the "incident to" guidelines. Therefore, specially trained and credentialed speech pathologists that perform these services must do so under the direct supervision of a physician in order for the physician to receive Medicare reimbursement. Direct supervision means the physician is in the office and available, but does not need to be in the exam room during testing. "Incident to" services cannot be billed in an inpatient hospital or outpatient hospital setting. Transnasal Flexible Laryngoscopy TFL performed in the absence of signs or symptoms is considered screening and is not covered. For non-screening Transnasal Flexible Laryngoscopy, be sure to use an ICD9-CM code for the specific sign, symptom or diagnosis which prompted the procedure. Transnasal Flexible Laryngoscopy (TFL) with Stroboscopy An otolaryngologist or speech-language pathologist typically performs laryngoscopy and/or stroboscopy. The examiner's training and background experience is critical in performing and evaluating laryngoscopy and stroboscopy findings. However, in certain situations, stroboscopy may be performed by a nurse practitioner or a physician assistant under the supervision of an otolaryngologist. Diagnostic laryngoscopy is integral to laryngoscopy with both biopsy and stroboscopy. Code should not be assigned and submitted separately with or

6 ICD-9-CM Diagnosis Coding ICD-9-CM diagnosis codes are used by physicians and hospitals. To comply with Medicare and third-party payer requirements, claim forms should indicate the ICD-9-CM code(s) that describe the principal diagnosis that supports the medical necessity of the tests for diagnostic evaluation of the specific anatomy or surrounding anatomic sites. Most Common ICD-9 Codes that Support Medical Necessity 1 Dozens of ICD-9 codes can be used to support the medical necessity of performing the following procedures. As an example, a few common ICD-9 codes are listed below: Transnasal Esophagoscopy ICD-9 Codes Description Esophagitis unspecified Reflux esophagitis Esophageal reflux/ gastroesophageal reflux Barrett's esophagus Malignant neoplasm of hypopharynx Benign neoplasm Hypopharynx Pharynx, unspecified Benign neoplasm Pharynx, unspecified Malignant neoplasm of esophagus Benign neoplasm Esophagus Malignant neoplasm of larynx Larynx Laryngeal Sensory Testing, FEES, FEESST ICD-9 Codes Description Dysphagia due to late effect of CVA, code first if applicable Dysphagia, unspecified Dysphagia, oral phase Dysphagia, oropharyngeal phase Dysphagia, pharyngeal phase Dysphagia, pharyngoesophageal phase Other dysphagia Neoplasm of uncertain behavior of digestive and respiratory systems, larynx Speech and language deficits; aphasia Dysphasia (impaired speech) Paralysis of vocal cords or larynx Edema of Larynx Pneumonitis due to inhalation of food or vomitus Feeding difficulties and mismanagement Foreign body in larynx Foreign body in trachea Foreign body in main bronchus 6

7 Transnasal Flexible Laryngoscopy ICD-9 Codes Description Malignant neoplasm of supraglottis Chronic laryngitis Paralysis of vocal cords or larynx Polyp of vocal cord or larynx Edema of larynx Laryngeal spasm Other voice disturbance - hoarseness Dysphagia Non-covered diagnosis per Medicare: Medicare will not consider the following diagnosis codes as supporting the medical necessity of these tests: Routine screening tests, V82.9, performed in the absence of clinical symptoms will result in denial. Claims reported with diagnosis codes V70.0 through V70.9 will be denied as not medically necessary. CPT Coding and Payment The following CPT codes may describe the procedure performed. The provider is instructed to report the CPT code that best describes the procedure performed. RVUs for calendar year 2009 are shown. Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Because GPCI varies by area, each physician's specific reimbursement will vary from the national average payment shown. Also note that any applicable coinsurance, deductible and other amounts which are patient obligations are included in the national average payment amount shown. Transnasal Esophagoscopy including biopsy Global Days RVU Non- RVU Non- Payment Payment CPT Description Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) $ $ Esophagoscopy, rigid or flexible; with biopsy, single or multiple $ $

8 Comments: CPT codes 43200/43202 have no global days assigned, thus the physician may report E&M services related to the care of the patient beginning the day after the procedure and the E&M will not require any modifiers on the E&M if only an esophagoscopy was performed. If the physician examines the patient and decides to perform the diagnostic evaluation on the same day, the physician will append a modifier 25 (significant, separately, identifiable E&M on the same day as another service or procedure) on the E&M service. The physician s documentation must support the E&M category and level of service reported. If the physician schedules the transnasal esophagoscopy for a return visit, report the procedure only on the return visit, unless the physician evaluates an unrelated problem. CPT code is designated as a separate procedure. As such, if a biopsy or dilatation or more extensive procedure on the esophagus is performed during the same session, the (diagnostic esophagoscopy) will not be separately reportable. Medicare Correct Coding Initiative identifies CPT code (diagnostic esophagoscopy) as comprehensive to CPT code (flexible fiberoptic laryngoscopy). A zero modifier is appended to 31575, which means that Medicare will not recognize this code combination as reimbursable when reported together. This edit became effective July 1, Medicare will reimburse the esophagoscopy and will deny the as bundled. Laryngeal Sensory Testing, FEES, FEESST CPT Description RVU Non- RVU Non- Payment Payment FEES (Swallowing Test) Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording $ $ Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording; physician interpretation and report only $37.87 $37.87 Laryngeal Sensory Testing Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording; $ $ Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording; physician interpretation and report only $33.90 $33.90 FEESST (Swallowing Test and Sensory Test) Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording; $ $ Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording; physician interpretation and report only $41.48 $41.48 Unlisted Procedure Unlisted otorhinolaryngological service or procedure Carrier priced

9 Comments: These procedures have no global days. Report 92700, Unlisted otorhinolaryngological services or procedures, if the provider performs a flexible fiberoptic or endoscopic evaluation of swallowing without cine or video recording. Medicare s Correct Coding Initiative identifies CPT code as being Comprehensive to CPT code (Laryngeal function studies). Do not report CPT code (flexible fiberoptic laryngoscopy) during the same session as CPT codes Transnasal Flexible Laryngoscopy including biopsy and stroboscopy CPT Description RVU Non- RVU Non- Payment Payment Laryngoscopy, flexible fiberoptic; diagnostic $ $72.13 Laryngoscopy, flexible fiberoptic; with biopsy $ $ Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy $ $ Comments: Laryngoscopy is often part of a larger ENT examination performed in the physician office. Usually, indirect visualization is performed using a mirror to examine the larynx and other structures. Many payers consider the mirror visualization to be part of the overall examination and do not reimburse it separately. TFL, however, is more invasive than the mirror examination. According to an AAO-HNS Policy Statement, flexible laryngoscopy should not be considered to be a routine part of the initial patient visit. When performing a TFL for a specific diagnostic reason, e.g. to evaluate hoarseness, the laryngoscopy should be documented in a separate operative note. It is important to show that the E/M visit and the TFL are separately billable events. An accompanying E/M visit may be billed separately, using a -25 modifier, when the documentation shows that the physician performed a history, examination and medical decision making of another condition or for the underlying condition, apart from that associated with the TFL. However, if a physician performs a TFL routinely as part of a complete ENT exam, it shouldn t be billed for separately. 3 Diagnostic laryngoscopy is integral to laryngoscopy with both biopsy and stroboscopy. Code should not be assigned and submitted separately with or

10 HCPCS Coding and Payment for Disposable Sheaths Disposable sheaths fall under HCPCS II codes. The HCPCS II code available is: A4270 Disposable endoscope sheath, each Note that this code is used per sheath, regardless of how it may come packaged. Also, since just a single code is available, A4270 may be used for the different types of sheaths and endoscopies such as diagnostic transnasal esophagoscopy, esophagoscopy with biopsy, and basic. In the office, both the endoscopic procedure and supply of the disposable sheath are coded. Medicare typically includes the cost of the sheath in the total reimbursement for the procedures and does not reimburse for them separately. Additional payment for A4270 is at the carrier discretion. Some commercial payers may pay the physician an additional amount for the sheath and others will not make separate payment because they continue to consider it an incidental surgical supply. For commercial payers, additional payment to the physician for code A4270 varies according to individual policy. You should contact your local payers to verify coverage and reimbursement. Comments: Whenever a sheath is used Code A4270 should be listed as a separate item on the CMS 1500 form, regardless of whether or not it is separately reimbursable. Every few years CMS reviews the utilization of billed codes to develop future reimbursement rates and/or policies. Listing the code on the claim form will assist CMS in determining the utilization of the sheaths. It is also important to display a charge consistent with mark-ups for other similar supplies. This enables consistent data analysis for rate-setting. Under Medicare, if the code is not billed clearly, the Practice Expense RVUs for the endoscopies may not accurately incorporate the cost of the sheath. For other payors, breaking out A4270 allows for separate reimbursement when this is available and, when separate payment is not made, ensures that costs are appropriately captured for future rate-setting analysis. For an example of a claim displaying an office endoscopy and the disposable sheath, see the attached sample CMS

11 Hospital Outpatient and ASC Coding and Payment Medicare assigns Ambulatory Payment Classification (APC) codes to be used for hospital outpatient procedures. Medicare s payment methodology for ASCs mirrors the hospital outpatient reimbursement system. This generally includes using the same procedure code weights as those used for hospital outpatient. However, the conversion factor is lower for ASCs, resulting in ASC payment at about 65% of the hospital outpatient rates. Status Indicators show how a code is handled for payment purposes: T = significant procedure, multiple reduction applies. In other words, payment for each code is made at 100% of the rate when it is the only significant procedure billed. When billed with another status T procedure with higher weight, payment is reduced to 50% of the rate. A2 = Surgical procedure on ASC list in CY 2009; payment based on OPPS (hospital outpatient) relative payment weight. P3 = Office-based surgical procedure with MPFS (Medicare physician fee schedule) nonfacility PE (practice expense) RVUs; payment based on MPFS non-facility PE RVUs. The following tables cross-reference the CPT codes to the appropriate Medicare Ambulatory Payment Classification and ASC procedure payment: Transnasal Esophagoscopy including biopsy CPT APC Description Hospital Outpatient Status Indicator Relative Weight 2009 Payment Level I Upper GI Procedures T $ Level I Upper GI Procedures T $ CPT ASC Description Status Indicator Relative Weight 2009 Payment Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) A $ Esophagoscopy, rigid or flexible; with biopsy, single or multiple A $

12 Laryngeal Sensory Testing, FEES, FEESST Medicare has not assigned any of the codes to either an ASC or an Ambulatory Payment Classification (APC). Transnasal Flexible Laryngoscopy including biopsy and stroboscopy CPT Code APC APC Description Hospital Outpatient Status Indicator Relative Weight 2009 Payment Level II Endoscopy Upper Airway T $ Level V Endoscopy Upper Airway T $1, Level III Endoscopy Upper Airway T T $ Transnasal Flexible Laryngoscopy including biopsy and stroboscopy CPT Code Description ASC Status Indicator Relative Weight 2009 Payment Laryngoscopy, flexible fiberoptic; diagnostic P $62.76 Laryngoscopy, flexible fiberoptic; with biopsy A $ Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy P $ Check your commercial payer contract for ASC reimbursement specific to the codes listed above. Status Indicator Key Status Indicator and shows how a code is handled for payment purposes: T = significant procedure, multiple reduction applies. In other words, payment for each code is made at 100% of the rate when it is the only significant procedure billed. When billed with another status T procedure with higher weight, payment is reduced to 50% of the rate. A2 = Surgical procedure on ASC list in CY 2009; payment based on OPPS (hospital outpatient) relative payment weight. P3 = Office-based surgical procedure with MPFS (Medicare physician fee schedule) nonfacility PE (practice expense) RVUs; payment based on MPFS non-facility PE RVUs. Sample Appeal Letters 12

13 Disposable Sheaths Name of Insurance Company Address Re: Patient name and policy number Date: Dear (address to a specific person): Please consider this a formal appeal for reversal of a denied claim on your insured, list patient name here. The disposable endoscopic sheath CPT code A4270 was used in conjunction with (list appropriate procedure and CPT code here). Disposable endoscopic sheaths are used over flexible endoscopes to aid in the prevention of disease transmittal. Disposable sheaths are used in hospital-based procedures, ambulatory surgery centers, and also in procedures performed in the physician office. In the office, some of the most commonly performed endoscopies include: laryngoscopy, transnasal esophagoscopy (TNE), and laryngeal sensory testing. The disposable sheath was a supply purchased specifically for this patient. Therefore, we are requesting the disposable endoscopic sheath CPT A4270 to be a separately reimbursable item. I look forward to receiving your payment for the attached claim. I am sending the original HCFA 1500 claim form, the EOB with the denial, and the procedure note for the date of service. Sincerely, Signed by physician appealing denied services cc: patient 13

14 Sensory Testing, FEES, FEESST Name of Insurance Company Address Re: Patient name and policy number Date: Dear (address to a specific person): Please consider this a formal appeal for reversal of a denied claim on your insured, list patient name here. The endoscopic swallowing evaluation and/or laryngeal sensory testing was performed alone or in conjunction with (list appropriate or denied CPT code here). Endoscopic evaluation of swallowing and/or swallowing with sensory testing involves placement of a special endoscope to view the hypopharynx and laryngeal structures during the oral transition phase of swallowing. Patients at high risk of aspiration are evaluated using a flexible endoscope with special equipment to monitor patient response to sensory stimuli and motor function. This patient is a candidate for this procedure due to their high risk of aspiration related to the following medical conditions: I look forward to receiving your payment for the attached claim. I am sending the original HCFA 1500 claim form, the EOB with the denial, and the operative note for the date of service. Please inform me if your payment policies require submission of office notes for consideration of payment. I will submit the required documentation with the original claim in the future if this is your policy. Sincerely, Signed by physician appealing denied services cc: patient 14

15 Sample Claim Form For Disposable Sheath Billing 15