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MEDICARE PHYSICIANCHANGES

EFFECTIVE JANUARY 1, 2017 (CY 2017)

CRHF Economics & Health PolicyDecember 1, 2016

DISCLAIMER

This presentation is intended only for educational use. Any duplication is prohibited without written consent of the authors. This information does not replace seeking coding advice from the payer and/or your coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for their 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.

CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not contained herein.

Note: CPT® code descriptions may be abbreviated and not listed in their entirety in all cases in this presentation. For full descriptions, please refer to your 2017 CPT code book.

2 CRHF ECONOMICS & HEALTH POLICY

CONTINUING EDUCATION UNITS

This program has prior approval of the American Academy ofProfessional Coders (AAPC) for one continuing education hour. Granting of this prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.

The AAPC requires attendees to participate in the entire Web-Ex presentation in order to qualify for the CEU certificate.

This program has prior approval of the American Health Information Management Association (AHIMA) for one continuing education unit. Granting of this prior approval in no way constitutes endorsement by AHIMA of the program content or the program sponsor.

Registered attendees that qualify will receive an email that includes the AAPC and the AHIMA CEU certificates within a couple of weeks.


AGENDA FY 2017 MEDICARE PHYSICIAN FEE SCHEDULE (MPFS)

2017 Medicare Updates – CY 2017 MPFS Payment calculation

– Coding Updates

Medicare National Payment Rates for CRHF Therapies

CY2017 MPFS Regulations– Site Neutral Payment: Provider-Based Designation

– Global Surgical Package

– MPFS Location changes

Common Coding Scenarios for CRHF

Medicare Coverage

Device Monitoring

Quality Programs

Appendix

Q &A


MPFS CONVERSION FACTORCY 2017 VERSUS CY 2016

The Physician Medicare service conversion factor for CY 2017 is $35.8887 in comparison to $35.8043 for CY 2016 (+.24%)

Conversion factor in effect for CY 2016 35.8043Update Factor ........................................................ 0.50 % (1.0050).CY 2017 RVU Budget Neutrality Adjustment .... -0.013 % (0.99987).CY 2017 Target Recapture Amount ................... -0.18 % (0.9982).CY 2017 Imaging MPPR Adjustment ................... -0.07 % (0.9993).

CY 2017 Conversion Factor 35.8887

RVU: Relative Value Unit

MPPR: Multiple Procedure Payment Reduction

Source: CY 2017 MPFS: Page 80543 of Federal Register dated November 5, 2016. Link in Appendix.


Coding Updates for CY 2017


WHAT’S NEW IN 2017?THE BREAKDOWN

Sections Added Revised Deleted

E/M 0 0 1

Anesthesia 0 0 0

Surgery 51 360 29

Radiology 4 7 11

Path/Lab 11 6 8

Medicine 26 109 14

Category II 0 1 0

Category III 59 15 8

Appendix (modifiers) 1 0 0

Totals 149 498 81

Source: AMA


NON FACE-TO-FACE PROLONGED SERVICE CODESNEW COVERAGE AND RULES

In keeping with the focus on Primary Care and care management, CMS approved payment for CPT codes 99358 and 99359:– 99358 (Prolonged evaluation and management service before and/or after direct patient

care; first hour)

– 99359 (Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes [List separately in addition to code for prolonged service]).

These services were previously bundled into a face-to-face (E/M) visit, but are now allowed to be billed separately, on the same day, or a different day than the face to face visit. CPT 99358 and CPT 99359 may not be reported:

– During the same month as Complex Chronic Care Management (CCM) services (99487and 99489) and Transitional Care Management (TCM) services (99495 and 99496).

– During the TCM 30-day service period by the same practitioner who is reporting the TCM.

The prolonged services codes require detailed documentation and providers need to understand how they may be specifically applicable to their Practice. Time does not include separately reportable services

CY 2017 MPFS: Pages 80226-80230 of Federal Register dated November 15, 2016. Link in Appendix.


CPT®1 CODING REVISIONS FOR CY 2017MODERATE SEDATION

CPT Code Description99151Work RVU: 0.50

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient younger than 5 years.

99152Work RVU: 0.25

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient 5 years or older.

99153Work RVU: 0.00

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; each additional 15 minutes of intraservice time (List separately in addition to code for primary service)

99155Work RVU: 1.90

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial15 minutes of intraservice time, patient younger than 5 years of age

99156Work RVU: 1.65

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15minutes of intraservice time, patient 5 years or older

99157Work RVU: 1.25

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes of intraservice time (List separately in addition to code for primary service)

1 AMA 2017 CPT code book; 2 CY 2017 MPFS: Pages 80339-80349 of Federal Register dated November 15, 2016. Link in Appendix.


Medicare National Payment Rates for CRHF Therapies and Services


National Medicare Physician Payment Rates forSignificant Medtronic Therapies

Therapy/CPT® Code CY 2013

CY2014

CY2015*

CY2016**

CY2017

% Change

CY 13-17

Pacemaker

(DC system 33208)$526 $545 $554 $554 $543 3.2%

ICDs (33249) $909 $946 $964 $963 $955 5.1%

CRT-Ds(33249 and +33225)

$1,365 $1,424 $1,452 $1,450 $1,446 5.9%

ILR Implant 33282 $323 $243 $248 $247 $234 (-27.6%)

PVI Ablation 93656 $1,098 $1,153 $1,180 $1,175 $1,174 6.9%

MPFS PAYMENTS TO PHYSICIANS 2013-2017

* Effective 7/01/2015

** Effective 7/01/2016

Source: RVU Tables – Multiplying Total Facility RVU by Conversion Factor. See Appendix for RVU Table links.


Payments do not include the 2% sequestration adjustment

MPFS 2017 VS. 2016 NATIONAL PAYMENT CRHF EXAMPLES

CPT Brief Description 2017 2016 Change

Pacemaker and CRT-P Insertion

33206 Insertion/replacement of permanent pacemaker with transvenous atrial electrode (Single Chamber System) $469 $479 ($10)

33207 Insertion/replacement of permanent pacemaker with transvenous ventricular electrode (Single Chamber System) $501 $511 ($10)

33208Insertion/replacement of permanent pacemaker with transvenous electrodes(s); atrial and ventricular (Dual Chamber System)

$543 $554 ($11)

CRT-P Insert cardiac resynchronization therapy system (33208 + 33225) $1,035 $1,041 ($6)

0387T * Transcatheter insertion Leadless PacemakerContractor

PricedContractor

Priced

Pacemaker (PM) Generator Removal and Replacement

33227 Removal of PM generator w/replacement of PM generator; single lead system $351 $364 ($13)

33228 Removal of PM generator w/replacement of PM generator; dual lead system $368 $380 ($12)

33229 Removal of PM generator w/replacement of PM generator; multiple lead system $389 $400 ($11)


* Will be effective once coverage is granted by CMSMPFS Relative Value Files for 2017 and 2016 are available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html



ICD and CRT-D System Insertion

33249 Transvenous insertion single/dual ICD generator and lead(s) $955 $963 ($8)

CRT-D Insert cardiac resynchronization therapy system ( 33249 + 33225) $1,446 $1,450 ($4)

ICD Generator Removal and Replacement

33262 Remove ICD generator and replace ICD generator.; single lead system $388 $400 ($12)

33263 Remove ICD generator and replace ICD gen.; dual lead system $404 $416 ($12)

33264 Remove ICD and replace ICD gen.; multiple lead system $421 $433 ($12)

Implantable Cardiac Event Recorder Insertion/Removal

33282 Implant patient-activated cardiac event recorder $234 $247 ($13)

33284 Removal of an implantable, patient-activated cardiac event recorder $206 $219 ($13)


MPFS Relative Value Files for 2017 and 2016 are available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html




Catheter Ablation

93650 AV node ablation $ 618 $627 ($9)

93653 SVT ablation and EP evaluation $874 $882 ($6)

93654 VT ablation and EP evaluation $1,170 $1,174 ($4)

93656 Ablation of AF by PVI with transseptal puncture and EP evaluation $1,174 $1,175 ($1)

+93655 Additional ablation of discrete arrhythmia, SVT or VT (Use 93655 in conjunction with 93653-4, 93656) $445 $441 $4

+93657 Additional linear focal lesion for AF (Use 93657 in conjunction with 93656) $444 $441 $3


MPFS Relative Value Files for 2017 and 2016 are available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html



MPFS Regulations


GLOBAL SURGICAL PACKAGETHREE – PRONG DATA COLLECTION TO BEGIN IN 2017

1. The claims-based data collection:

For procedures furnished on or after July 1, 2017, practitioners in practices that include 10 or more practitioners in nine selected states will be required to report claims data on post-operative visits furnished during the global period of a specified procedure.

– CPT code 99024 (Post-operative follow-up visit, normally included in the surgical package, to indicate that an E&M service was performed during a postoperative period for a reason(s) related to the original procedure) will be submitted for the procedures specified by CMS.

– The specified procedures are those that are furnished by more than 100 practitioners and either are nationally furnished more than 10,000 times annually or have more than $10 million in annual allowed charges. The final list of codes subject to required reporting will be available on the CMS website in the future.

The selected states are:

– Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island.

Source: CY2017 MPFS: Pages 80209-80225 of Federal Register dated November 15, 2016. Link in Appendix.


GLOBAL SURGICAL PACKAGE - CONTINUED

2. Provider surveys– A representative sample of practitioners will be selected and surveyed to assess

pre and post-operative services.

3. Direct Observation– A more in-depth study, including direct observation of the pre and post- operative

care delivered in a small number of sites, including some ACOs.

The surveys and observation studies are being designed and are expected to begin mid-2017.

ALL providers are encouraged to participate in the claims-based data collection by submitted specified procedures with CPT 99024.

Providers are also encouraged to begin the claims processing data submission on January 1, 2017.

Beginning in 2019, CMS will use the data collected and other pertinent data to value surgical services.

Source: CY 2017 MPFS: Pages 80209-80225 of Federal Register dated November 15, 2016. Link in Appendix.


UPDATED DATA AFFECTING THE MPFSNEW GEOGRAPHIC PRACTICE COST INDICATORS (GPCIS)

Existing regulations require the use of new locality definitions based on a combination of MSAs and the current locality structure.

California is the only state affected. For California, this results in increase from 9 current Medicare fee schedule

localities to 27.

The inclusion of necessary “all other” designations will result in California having 32 Medicare fee schedule localities.

The provision is not budget neutral, and will increase payments to many physicians in urban parts of California without causing reductions in other areas; however there will be reductions based on the data in some areas.

Changes to Medicare Physician fee schedule payment rates in these areas will be phased in over six years beginning January 1, 2017.

Source: CY 2017 MPFS: Pages 80261-80266 of Federal Register dated November 15, 2016. Link in Appendix.


Site Neutral PaymentProvider-Based Designation


SITE NEUTRAL PAYMENTBACKGROUND

Medicare Regulation:– Section 603 of the Bipartisan Budget Act of 2015: Off-campus Provider-based departments that began

furnishing services on or after November 2, 2015 are not eligible to be paid under OPPS for services provided effective January 1, 2017. This also includes Provider-based departments that relocated after November 2, 2015.

Medicare classifies these Off-campus Provider-based services as “Non-Excepted.”– An Off-campus Provider-based department remains considered a department of the hospital and will

be included in the Hospital’s Medicare cost report.

CMS determined that the Medicare payment source for “Non-Excepted” Off-campus departments should be based on the Medicare Physician Fee Schedule; however, it is impossible to create a payment structure and claims processing rules in time for CY 2017.– The CY 2017 final rule provided an “interim rule” with a comment period that ends on December 31,

2016. CMS plans to review these comments and publish a final determination as to how procedures and services will be paid.

Source: CY 2017 OPPS: Page 79699-79718 of the Federal Register dated November 14, 2016. See Appendix for the link.


PLACE OF SERVICE (POS) PROVIDER-BASED DEPARTMENT OF A HOSPITAL

A Practice designated as office-based reports POS 11 Office on the professional claim form, and is paid based on the Medicare Physician Fee Schedule (MPFS).

Provider-Based: Off-Campus or On-Campus POS for claim submission1 :

POS 19: Off-Campus Outpatient Hospital

POS 22: On-Campus Outpatient Hospital In 2017 POS 19 sites will be paid differently:

– Off-Campus Provider-Based Departments (PBD) existing as of November 2, 2015 will receive payment for the hospital portion of the facility claim based on OPPS and the payment for the physician portion (professional claim) payment will based on the MPFS.

– Off-campus PBDs certified after November 2, 2015, or existing PBDs who had a change in location after that date, will be subject to an alternative payment mechanism, as defined in an interim rule in the CY 2017 OPPS Final Rule.

1 Pub 100-04 Medicare Claims Processing, Transmittal 3315 dated August 6, 2015 and effective on January 1, 2016 is available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3315CP.pdfProvider Based CMS Transmittal A-03-030 dated 4.18.2003:https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/a03030.pdfPub 100-02 Medicare Benefit Policy Manual Chapter 6 Hospital Services Covered Under Part Bhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c06.pdfFY 2017 OPPS: Page 79699-79718 of the Federal Register dated November 14, 2016. See Appendix for the link.


PROVIDER BASED DEPARTMENT BILLING2017 PAYMENTS

PB prior to11/02/2015CY 2017 Payments

Use modifier PO for off campus

PB on or after 11/02/2015CY 2017 Payments

Use Modifier PN for off campus

Claims Split-billed: Place of service OP Hospital

for professional claim (POS 22) on campus; POS 19 for off-campus (1/1/16)

Outpatient hospital claim for technical fee

Split-billed: Place of service off campus OP

Hospital for professional claim (POS 19)

Outpatient hospital claim for technical fee

Payment Technical fee: APC Pro fee: Physician fee

schedule at facility rate

Technical fee: APC at approx. 50% rate

Pro fee: Physician fee schedule at facility rate

Example: mid-level office visit

APC: $1063

Pro Fee: $525

Total: $158

APC: $53 (at 50% rate) interim rule Pro Fee: $525

Total: $105

CY 2017 OPPS: Page 79699-79718 of the Federal Register dated November 14, 2016. See Appendix for the link.MPFS Relative Value Files for 2017 and 2016 are available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html


COMMON CODING SCENARIOS


AV NODE ABLATION WITH PACEMAKER IMPLANT

• Based on medically necessity, an AV node ablation is performed and then a single chamber pacemaker with a lead in right ventricle is inserted.

Description CPT 2017 National

Payment

AV node ablation 93650 $618

Insert SC ventricular pacer 33207 $251**

Total Estimated Payment $869

SC: Single ChamberAV: Atrioventricular** Multiple procedure reduction is applicable; Modifier -51 Multiple Procedures may be required by some payers

PFS Relative Value Files for 2017 are available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html


PULMONARY VEIN ISOLATION (PVI) ABLATION


Payment

PVI ablation 93656 $1,174Intracardiac echocardiography +93662-26 $147

Total Estimated Payment $1,321

• A patient with paroxysmal atrial fibrillation undergoes a comprehensive EPS and PVI. Intracardiac echocardiography is used to assist with transseptal sheath placement. After the successful PVI, the physician ensures there are no additional spontaneous or induced arrhythmias.

Modifier 26: Professional Component



DUAL CHAMBER PACEMAKER UPGRADE TO ICD


Payment

Remove PM generator 33233 $126**Insert ICD generator and RV lead 33249 $963DFT 93641-26 $169**

Total Estimated Payment $1,258

• A patient with previously placed DC pacemaker has VT and requires an ICD. Defibrillator threshold testing (DFT) is performed.

DC: Dual ChamberICD: Implantable Cardioverter DefibrillatorModifier 26: Professional Component** Multiple procedure reduction is applicable; Modifier -51 Multiple Procedures may be required by some payers



Upgrade Single Chamber Pacemaker to CRT-P


Payment

Upgrade PM SC to DC 33214 $497Insert left ventricular lead +33225 $491


• A patient with a previously placed SC pacemaker develops Class III Heart Failure. The physician also determines the patient would benefit from dual chamber pacing.

CRT-P: Cardiac Resynchronization Therapy-PacemakerPM: PacemakerSC: Single ChamberDC: Dual Chamber



Upgrade Single Chamber Defibrillator to CRT-D


Payment

Insert left ventricular lead +33225 $491

Remove/replace ICD generator,

dual lead system 33262 $388


• A patient with a previously placed SC defibrillator develops Class III Heart Failure.

CRT-D: Cardiac Resynchronization Therapy-DefibrillatorPM: Implantable Cardio DefibrillatorSC: Single Chamber



Medicare Coverage Policies


THE ROAD TO REIMBURSEMENT

COVERAGE – establishes criteria to allow paymentWill Medicare cover this service?Will Private Payers cover this service?

CODING – allows a service to be submitted for paymentWhat was done? (procedure code)Why was it done? (diagnosis code)

PAYMENT – establishes amount to be paid once coding and coverage are secured

How much is paid?Who pays?

1. Coding+

2. Coverage+

3. Payment

Reimbursement: All three elements must be secured!

=


REIMBURSEMENT for Leadless Pacemakers (LPM)?

CODINGCMS has published ICD-10 procedure code 02HK3NZ and MS-DRG assignmentfor FY 2017 LPM Inpatient Procedures.

COVERAGE: Currently NO CMS or Commercial Coverage for LPMs.

PAYMENTMedicare has established payment for the codes used to describe LPM implants.

LPM implants are not reimbursed until all three elements are secured.


CMS NATIONAL COVERAGE ANALYSISTIMELINE for LEADLESS PACEMAKERS

National Coverage Analysis (NCA) Initiated

Public Comments Due

CMS Staff Review

Draft Decision Memo Posted

Public Comments Due

Final Decision Memo Posted(NCD)

May 18, 2016 June 17, 2016

Maximum 6 Months

Nov. 14, 2016 with a 30-day Comment period

30 Days 30 Days 60 Days Max

By Approximately Feb. 12, 2017

Maximum 9 Months


MEDICARE COVERAGE RULES MEDICARE COVERAGE RULES

National Coverage Determination (NCD)

Local Coverage Determination (LCD)

No Pre-defined coverage Policy

Decisions made by local Medicare contractors for theirspecific region. Typically used in the absence of, or supplement to a national policy.Example: MACs (Medicare Administrative Contractors)may be issued local coverage policies for CRT-P and CRT-Ds.

All Medicare contractors must comply with evidence-based National Coverage Determinations.Example: Pacemakers and ICDs are covered under separate national coverage policies.

Individual claims based on Medical necessity are filed when there is no national or local coverage policy.When reviewed, decision usually made by MAC medical review personnel, in conjunction with the Medical Director.Coverage decision is limited to that individual claim.

MACs may be releasing Coding and Billing Summary Articles rather than LCDs


MEDICARE NCD FOR PACEMAKER IMPLANTSBACKGROUND

August 13, 2013: Revised NCD in effect for DOS on or after 8/13/2013; NCD 20.8.3

July 7, 2014:Implementation – Claims Processing Rules – Rescinded and Delayed

July 6, 2015:Implementation – Claims Processing Rules; Change Request CR9078, MLN Matters® MM9078 Revised.

To address claims processing issues, CMS instructed the MACs to implement this NCD at the local level until CMS is able to formalize the claims processing instructions.

– By May 2016 all MACs had issued Coding and Billing Summary Articles or an LCD

– Providers should check the individual MAC article or policy.

See Appendix for links to NCD 20.8.3 and MLN Matters MM9078 Revised


CODING AND BILLING ARTICLEEXAMPLE: SINGLE AND DUAL CHAMBER PACEMAKER (PM) IMPLANTS

Nationally Covered Indications: 1. Documented non-reversible symptomatic bradycardia due to sinus node

dysfunction, and2. Documented non-reversible symptomatic bradycardia due to second degree

and/or third degree atrioventricular block.– Submit ICD-10 DX codes for the two NCD indications. Attest with KX modifier

(Outpatient/Physician claims).

– KX modifier: Requirements specified in the medical policy have been met.

Nationally Non-Covered Indications:

Twelve are listed (example: Asymptomatic first degree atrioventricular block)– Additional ICD-10 DX codes allowed by the NCD under “MAC discretion” may be

accepted by your MAC. Attest with KX modifier (Outpatient/Physician claims).

For medically necessary pacemaker insertion for conditions not addressed by the NCD use modifier SC (Outpatient/Physician claims).

– SC modifier: Medically necessary service or supply.

Check with your MAC for Coding and Billing Summaries


MAC LOCAL PACEMAKER POLICIES1

1 CMS website: https://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx


State MAC (Medicare Administrative Contractor)

Number

AL, GA, TN Cahaba GBA A54949

KY, OH Cigna Government Services A54961

FL, PR, VI First Coast Service Options A54926

CT, IL, MA, ME, MN, NH, NY, RI, VT, WI

National Government Services(NGS)

A54909

CA, HI, NV Noridian A54929

AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY

Noridian A54931

AR, CO, DE, DC, LA, MD, MS, NJ, NM, OK, PA, TX

Novitas L34833

NC, SC, VA, WV Palmetto GBA A54831

IA, IN, KS, MI, MO, NE Wisconsin Physician Services A54958

CARDIAC PACEMAKER EVALUATION SERVICES NCD §20.8.1 AND 20.8.1.1 OF CMS PUB. 100-03

The decision as to how often any patient's pacemaker should be monitored is the responsibility of the patient's physician who is best able to take into account the condition and circumstances of the individual patient.

Transtelephonic monitoring (TTM) Guidelines I and II are for both single and dual chamber pacemakers. The TTM guidelines are in this NCD.

Pacemaker clinic* service frequency guidelines for routine monitoring are:– Single chamber: Twice in the first 6 months following implant, then once every 12

months

– Dual chamber: Twice in the first 6 months following implant, then once every 6 months

Increased frequency of monitoring must be supported by documented medical necessity.

* Please note that “Pacemaker clinic” also includes “Physician practice” and “Hospital device monitoring departments” Rev. 182, 05-22-15 is available at:http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf


DEVICE MONITORING


DEVICE MONITORING REQUIREMENTSDEVICE MONITORING SERVICES ARE DIAGNOSTIC TESTS

A written order is needed Coding rules must be followed

Diagnosis coding should reflect the reason for the monitoring; Is it medical necessity or routine monitoring?

Documentation: The provider report should support medical necessity and include findings and patient care plan

Coverage rules must be understood and followed CMS has a pacemaker monitoring NCD that affects frequency

Some Medicare contractors have local polices for ICDs.

Carefully check commercial payer coverage for billing and frequency guidelines

Supervision requirements for diagnostic testing must be met These differ from incident-to guidelines used for office visits


DIAGNOSTIC TESTS:MEDICARE ORDER REQUIREMENTS1,2

Diagnostic tests must be ordered by the physician/practitioner treating the patient and who uses the results to treat the patient. (Diagnostic tests ordered by a non-treating physician/practitioner are considered not reasonable and necessary)

What is an order? Communication from the treating physician/practitioner requesting that a

diagnostic test be performed for the Medicare beneficiary

When a physician/practitioner’s order for a diagnostic test does not require a signature, the physician/practitioner must clearly document, in the medical records, his or her intent that the test be performed.

How may an order be delivered? An order may be delivered via signed written document, a telephone call, or via email

1Title 42 Code of Federal Regulations Part 414-Payment for Part B Medical and Other Health Services (Subpart B):http://www.ecfr.gov/cgi-bin/text-idx?SID=c046900b4d8394fad36b02417227da74&mc=true&node=sp42.3.414.b&rgn=div62 Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Fee Schedule Administration and Coding Requirements, §10.1.2: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf


MEDICAL NECESSITY IS KEY TO SUPPORT SERVICESTELL THE PATIENT’S STORY

Remember, documentation should include:

Any prior incidents, signs, symptoms, etc. that might suggest a history of possible arrhythmia

Any significant risk factors or co-morbidities that may affect clinical management

Use/type/duration/findings of any:– Prior cardiac monitoring, including in-hospital telemetry/monitoring

– Any other recent diagnostic testing


CARDIAC DEVICE MONITORING


MEDICARE SUPERVISION REQUIREMENTS TECHNICAL COMPONENT OF DIAGNOSTIC TESTS

GENERAL SUPERVISION

Applies to the technical component for all remote interrogation services. The procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

Medicare supervision requirements for specific procedure codes: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.htmlClick on PFS Relative Value Files, then Calendar Year 2017 to obtain the most updated file.

Medicare Benefit Policy Manual, CMS-Pub. 100-02 Chapter 15, Section 80-Covered Medical and Other Health Services: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf


MEDICARE SUPERVISION REQUIREMENTS TECHNICAL COMPONENT OF DIAGNOSTIC TESTS

Applies to the technical component for all in person cardiac device interrogations/evaluations. A physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.

DIRECT SUPERVISION

Medicare supervision requirements for specific procedure codes: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.htmlClick on PFS Relative Value Files, then Calendar Year 2017 to obtain the most updated file.

In a hospital (facility) setting, direct supervision means that the physician must be immediatelyavailable to furnish assistance and direction throughout the performance of the procedure.

Medicare Benefit Policy Manual, CMS-Pub. 100-02 Chapter 15, Section 80-Covered Medical and Other Health Services: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

BILLING

Under diagnostic testing rules, the physician supervising the in person device monitoring is not required to bill for the service. The physician who reads the professional report may bill for the test (global for office and professional component for facility services). This is different than the billing rules for services that are performed incident-to a physician, such as office visits.


INCIDENT-TO BILLING

“Incident to” services are defined as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.1

– To qualify as “incident to,” services must be part the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.

– A supervising Physician/Practitioner must be present in the suite (direct supervision).

– The advantage to the incident-to rule is that a service performed by an NPP (such as a NP or PA) may be billed under the supervising physician’s provider number, which means that the service will be paid at the physician rate by Medicare.

– If there is no supervising physician, the service must be billed with the NPP’s provider number and paid at 85% of the physician rate.

The Physician/Practitioner who bills must be the supervising physician/practitioner.

Services provided by non-physician practitioners (NPPs) must be compliant with State laws and State supervision requirements.

1 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf

Pages 71065-71068 of Federal Register dated November 16, 2015.


POSSIBLE DIAGNOSIS CODES FOR MONITORING

Diagnosis CodesICD-10

Description

Routine Monitoring

Z95.0Z95.810

Presence of cardiac pacemakerPresence of automatic implanted cardiac defibrillator (ICD)

Monitoring for Patients with a Complaint/Symptom; device adjustments/ERI

Z45.010 Z45.018 Z45.02

Encounter for checking and testing of cardiac pacemaker pulse generator [battery]Encounter for adjustment and management of other part of cardiac pacemakerEncounter for adjustment and management of ICD

Symptoms - examples

R42 Dizziness and giddiness [light-headedness]

R55 Syncope and collapse [pre-syncope]

R00.2 Palpitations

R07.9 Chest pain, unspecified

ICM Monitoring : for Heart Failure (HF)

Diagnosed HF Report the HF diagnosis code to the highest level of specificity

HF Symptoms e.g. : R06.02R60.9; R60.0

Shortness of breathEdema, unspecified; Edema, localized

http://www.cdc.gov/nchs/icd/icd10cm.htm


IMPLANTABLE LOOP RECORDERS (ILR)REQUIRED DIAGNOSTIC TESTING AND PRIOR AUTHORIZATION

Coverage criteria varies by payer; check coverage policy details before implant.

Be on alert!– Some payers require some type of external monitoring prior to covering an ILR

implant.

Documentation of prior testing should be included in patient’s medical record.

When in doubt, get Prior Authorization– Medtronic recommends that the Provider seek prior authorization from all

payers other than traditional Medicare unless the payer does not require a prior authorization

Prior Authorization does NOT guarantee coverage or reimbursement.

If a provider attempts to obtain a Prior Authorization and is told it is not required, this does not mean the service is automatically covered.

Providers should review medical policy to ensure patient meets outlined criteria (i.e. many payers require prior Holter monitor before considering ILR medically necessary).


NEW MATH

Q: How is 30 days calculated?

A: Currently, it depends on who the payer is…

First day of Monitoring

Date of Service Next Period Start Date

Option 1 4/24/16 5/24/16 5/25/16

Option 2 4/24/16 5/25/16 5/26/16

We believe that currently NGS and FCSO use Option 2


Quality Programs


PQRS : CARROTS TO STICKSPHYSICIAN QUALITY REPORTING SYSTEM

Incentives end 2014 based on 2014 PQRS Reporting

payment incentive is calculated on 2014 payments

Penalties begin 2015 2013 PQRS Reporting affects 2015 penalties 2014 PQRS Reporting affects 2016 penalties2015 PQRS Reporting affects 2017 penalties2016 PQRS Reporting affects 2018 penalties

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/AnalysisAndPayment.html


MEDICARE ACCESS & CHIP REAUTHORIZATION ACT OF 2015 (MACRA) BACKGROUND

The MACRA legislation includes several provisions specifically to encourage quality and shift to value-based payments for health care.

The CMS implementation of MACRA includes the establishment of the Quality Payment Programs for eligible practitioners which establishes a new Medicare physician payment system, and incentives to participate in Alternative Payment Models.

Source: H.R. 2 – 114th Congress: Medicare Access and CHIP Reauthorization Act of 2015.

Permanently repeals the Sustainable Growth Rate Formula (SGR)

Stabilizes Medicare payments to physicians with an annual 0.5% payment update until the start of the Quality Payment Programs in 2019.

Establishes a Medicare physician payment system with consolidated quality and value programs (MIPS)

Encourages providers to participate in advanced alternative payment models (Advanced APMs)


MIPS PAYMENT TRACK DETAILSREPLACES 3 EXISTING PHYSICIAN REPORTING PROGRAMS

• PQRS, VBPM, and the EHR Meaningful Use (MU) Incentive Program will continue through 2018.

• MIPS consolidates and replaces 3 currently existing physician reporting programs into one single MIPS payment adjustment.

PQRS: Physician Quality Reporting System; VBPM: Value Based Payment Modifier; EHR: Electronic Health Records; MU: Meaningful Use

MIPS Scoring Component

Quality Resource Use Advancing Care Information

Clinical Practice Improvement Activities

ExistingProgram

PQRS VBPM EHR / MU N/A


https://qpp.cms.gov/


Resources


CARDIAC RHYTHM AND HEART FAILURE (CRHF) INFORMATION

CRHF ECONOMICS & HEALTH POLICY55

OUR CCP TEAM

Joanne Groenewold Carol Male Laurie Desjardins

CCP: Coding, Coverage and Payment

REGIONAL ECONOMIC MANAGERS


CARDIAC RHYTHM AND HEART FAILURE (CRHF) INFORMATION

CARDIAC RHYTHM AND HEART FAILURE (CRHF) RESOURCES

To ensure you receive advance notification of webcast events, register at www.Medtronic.com/CRDMreimbursement:

Join our E-mail ListSubscribe to receive news and updates.

CRHF

Economics and Health Policy

Visit our website:www.Medtronic.com/CRDMreimbursementEmail us:[email protected]

Access Medtronic Academywww.medtronicacademy.com

Call our Coding Hotline:1 (866) 877-4102


NEW FAQS


APPENDIX


2017 MEDICARE BENEFICIARY RESPONSIBILITY ORIGINAL MEDICARE

Part B – includes Physician and Outpatient Hospital Services Annual deductible: 2017 $183 vs 2016 $166

Coinsurance: 20% of allowable

Outpatient hospital coinsurance limited to inpatient deductible (per service)

Part A – includes Inpatient Hospital services Per benefit period deductible: 2017 $1,316 vs 2016 $1,288

Co-insurance: none for first 60 days of an admission

For more information about the 2017 Medicare Parts A and B premiums and deductibles access the Federal Register publications dated November 15, 2016:https://www.gpo.gov/fdsys/pkg/FR-2016-11-15/pdf/2016-27389.pdfhttps://www.gpo.gov/fdsys/pkg/FR-2016-11-15/pdf/2016-27388.pdfhttps://www.gpo.gov/fdsys/pkg/FR-2016-11-15/pdf/2016-27425.pdf


PHYSICIAN NATIONAL PAYMENT AMOUNTS PACEMAKER/CRT-P CARDIAC DEVICE MONITORING

G: GlobalTC: Technical ComponentPC: Professional Component

The National Medicare Pacemaker Follow-upGuidelines NCD is still in effect.

CY 2017 Medicare physician payments at:http://www.cms.gov/apps/physician-fee-schedule/overview.aspx

Pacemaker

One codeany # of leads per encounter

Professional Analysis

any # of leadsUp to 90 days

Technical Support


Transtelephonicone code


MultipleLead

SingleLead

DualLead

In Person Remote

Interrogation Peri-Proceduralin person onlyany # of leads

G: $51TC: $18PC: $33

G: $59TC: $20PC: $39

G: $70TC: $24PC: $46

G: $38TC: $16PC: $22

G: $55TC: $39PC: $16

TC: $27

G: $28TC: $13PC: $15

PC: $34

93286

93279 93280 93281

93288 93294 93296 93293

Programming evaluationper encounter



PHYSICIAN NATIONAL PAYMENT AMOUNTSICD/CRT-D CARDIAC DEVICE MONITORING

G: GlobalTC: Technical ComponentPC: Professional Component ICD

MultipleLead

SingleLead

DualLead

In Person Remote

Interrogation Peri-Proceduralin person onlyany # of leads

G: $64TC: $21PC: $43

G: $83TC: $24PC: $59

G: $92TC: $28PC: $64

G: $37TC: $13PC: $24

93287

93282 93283 93284



Technical Support


93289

One codeany # of leads per encounter

93295 93296

G: $67 TC: $20PC: $47

TC: $27PC: $69

CY 2017 Medicare physician at:http://www.cms.gov/apps/physician-fee-schedule/overview.aspx




PHYSICIAN NATIONAL PAYMENT AMOUNTSICM CARDIAC DEVICE MONITORING


Implantable Cardiovascular Monitor (ICM)

In Personper encounterInterrogation



Technical Support


93297 93299

PC: $27 Contractor Priced

Remote

+

G: $33TC: $11PC: $22


93292



PHYSICIAN NATIONAL PAYMENT AMOUNTSILR CARDIAC DEVICE MONITORING


Implantable Loop Recorder (ILR)



Technical Support


93298 93299

PC: $27 Contractor Priced

+

Interrogation

Remote


G: $43TC: $16PC: $27

93285

G: $37TC: $15PC: $22

In Personper encounter

93291




DIAGNOSIS CODE RANGES THAT MAY SUPPORT AN IMPLANTABLE LOOP RECORDER

Diagnosis CodesICD-10

Description

G45.0 - G45.3, G45.8 - G45.9

Transient cerebral ischemic attacks and related syndromes

I47.0 - I49.9 Paroxysmal tachycardia, atrial fibrillation and flutter, and other cardiac arrhythmias (include secondary diagnosis for long term anticoagulation therapy, Z79.01 if appropriate)

I63.09 Cerebral infarction, unspecified (Stroke NOS)

I69.x- (add ’l digits required)

Sequelae of cerebrovascular disease

R00.2 Palpitations

R42 Dizziness and giddiness [light-headedness]

R55 Syncope and collapse [pre-syncope]

R56.9 Unspecified convulsions [seizures NOS]

R94.31 Abnormal electrocardiogram [ECG] [EKG]

Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits

http://www.cdc.gov/nchs/icd/icd10cm.htm


REFERENCESMPFS CY 2017 Federal Register dated November 15, 2016 is available at:https://www.gpo.gov/fdsys/pkg/FR-2016-11-15/pdf/2016-26668.pdf

The 2017 Relative Value file is available by clicking on “PFS Relative Value Files” at:https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

Data files such as “2017 PFS Final Rule Addenda”, “20167PFS Final Rule List of Medicare Telemedicine Services” and “2017 PFS Final Rule Multiple Procedure Payment Reduction Files” are available at:PhysicianFeeSched/PFS-Federal-Regulation-Notices.html

OPPS CY 2017 Federal Register dated November 14, 2016 is available at: https://www.gpo.gov/fdsys/pkg/FR-2016-11-14/pdf/2016-26515.pdf

Diagnosis coding information is available at Centers for Disease Control and Prevention:http://cdc.gov/nchs/icd/icd10cm.htm

MPFS CY 2016 Federal Register dated November 16, 2015 is available at:http://www.gpo.gov/fdsys/pkg/FR-2015-11-16/pdf/2015-28005.pdf

The 2013-2016 Relative Value file is available by clicking on “PFS Relative Value Files” at:https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html


CMS PHYSICIAN QUALITY RESOURCES

For current MACRA information:https://qpp.cms.gov/

For complete and updated Physician Quality Reporting information please access:http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2016-VM-Fact-Sheet.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1507.pdf


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