Regulatory & 3rd Party Payer Issues

ICD-10 Update

On Oct 1, 2015, ICD-10 codes are required for all claims submitted to Medicare or other carriers. It will take some time for physicians to become comfortable using the new code and for Medicare to work out any glitches with the new codes. Below is some valuable information and resources to help you to navigate the new system.

Most importantly, CMS has announced some flexibility in processing claims during the first 12 months using ICD-10. Claims for services on or after October 1 may not use ICD-9 codes and must include a valid ICD-10 code. CMS has provided the following guidance:

“While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD- 10 code from the right family is submitted, Medicare fee-for-service will process and not audit valid ICD-10 except under limited circumstances. See Clarifying Questions for guidance on the ICD-10 flexibilities.

Please use this website to convert your ICD-9 codes to ICD-10.

 

New CPT Code Changes re: Vertebral Fracture Assessment (VFA)

The Centers for Medicare and Medicaid Services have adopted new CPT codes that will affect those physicians who perform VFA. The new code for VFA when performed alone is 77086 (formerly CPT 77082). If DXA and VFA are performed on the same day, they should be billed under one new CPT code: 77085. If DXA is billed alone, there is no change. The CPT code remains 77080.

These changes will occur in both the office and facility settings. CMS is using these new CPT codes to implement changes in reimbursement when DXA and VFA are performed together. These changes were proposed and adopted by the AMA’s Relative Value Update Committee (RUC). The ISCD objected to these changes at every stage of this process and was successful in heading off their implementation for a number of years. Click here to see the ISCD’s most recent objections filed with CMS.

 DXA and VFA in the Office Setting:

The new CPT codes and corresponding reimbursement rates for 2015 for DXA and VFA are:

CPT 77080: DXA performed alone– $40.46 ($30.07 technical component and $10.38 professional component)

CPT 77085: DXA and VFA performed together– $56.57 ($41.17 technical component and $15.39 professional component)

CPT 77086: VFA performed alone–$35.80 ($26.85 technical component and $8.95 professional component).

DXA and VFA reimbursement in the Facility Outpatient setting:

CMS has “packaged” services that are integral, ancillary, supportive, dependent or adjunctive to a primary service. CMS has determined that VFA is such a service in relation to DXA and therefore is subject to the new packaging requirement.

The new CPT codes and reimbursement rates for DXA and VFA are:

77080: DXA only–$110.28 ($99.90 for the technical component and $10.38 for the professional component)

77085: DXA and VFA performed together–$115.29 ($99.90 for the technical component and $15.39 for the professional component)

77086: VFA performed alone–$71.37 ($62.42 for the technical component and $8.95 for the professional component).

If you have questions about these changes, please contact Donna Fiorentino at dfiorentino@iscd.org.

Click here for an easy to read payment chart.

ISCDs Final Comments on the rule change.  ISCDs Comments on the 2015 Hospital Outpatient Schedule.

CMS Proposes New Rules Regarding Imaging Services in Physicians’ Offices. Impact on DXA Testing is Unclear.

On June 30, 2008 CMS proposed new rules that may have far-reaching implications for physicians providing diagnostic imaging services, including central DXA, to Medicare beneficiaries in their offices. CMS-1403-P would require physicians providing these services in a non-facility setting to comply with regulations that already apply to Independent Diagnostic Testing Facilities (IDTFs).1

The CMS proposed rule would require physicians performing diagnostic imaging services in their offices to:

Enroll as an IDTF;
Undergo inspection by the Medicare carrier;
Ensure the licensure and/or certification of non-physician personnel such as technologists; and
Have a supervising physician who must be proficient in the performance and interpretation of each type of diagnostic procedure. The proficiency may be documented by certification in a specific medical specialty or subspecialties or by criteria established by the Medicare carrier.

It is unclear how this proposal would be interpreted by local Medicare carriers and how it would affect physicians and technologists providing DXA testing. Carriers have interpreted the IDTF regulations in a very restrictive manner by requiring that most imaging procedures be supervised by a radiologist. The proposed rule would also impose minimum standards on technologists if the imaging procedure is performed in a state that does not regulate radiologic technologists.

CMS has requested comments and feedback regarding this proposed rule. The rule specifically requests comments by individuals and groups to respond to the following questions:

Should the new requirements only apply to advanced imaging services such as PET, CT and MRI, and exclude X-ray, DXA, ultrasound and fluoroscopy?
Should the new requirements apply only to imaging services or to other diagnostic testing services such as electrocardiograms?
What should the appropriate criteria be for application of the new requirements?

These questions make it clear that the parameters of the proposed rule have not yet been finalized. ISCD will submit comments to CMS on the proposed rule by the August 28 deadline and will keep you posted regarding its status. As soon as ISCD has thoroughly analyzed the CMS proposal and developed our response, we will call upon our members to submit comments to CMS by the August 28 deadline. If you have questions or want to provide feedback on this issue, please contact ISCD Legislative Counsel, Donna Fiorentino.

Click here to view a relevant excerpt of CMS 1403-P.
Click here for the portion of the CMS regulations regarding IDTFs that would apply to diagnostic testing performed in physicians’ offices.
1
IDTFs by definition provide diagnostic testing in a location other than a hospital or physician’s office, cannot bill for therapeutic or interventional radiology procedures and must provide at least one general supervision physician, who is on the premises and immediately available and is responsible for overall direction and quality control of the testing.

ISCD Objects to Proposed Medicare Rule

On August 27, 2008 the ISCD filed comments on the latest Medicare proposed rule, CMS-1403-P. The rule included several provisions that threaten our ability to care for osteoporosis patients. In addition to the administrative burden on physicians, the adoption of this proposed rule represents another assault on the availability of quality DXA.

The ISCD argued against the adoption of a new rule that would require physicians performing diagnostic imaging in their offices to enroll as an independent diagnostic testing facility (IDTF) and comply with certain standards in order to be eligible for reimbursement. The proposed rule in part focused on the qualifications for both physician and non-physician personnel performing these imaging procedures. CMS indicated that the impetus for this proposal was the result of comments by personnel at IDTFs who bristled under new requirements that only applied to imaging procedures performed in their facilities. They argued that regulations applying to imaging procedures should apply across the board regardless of where the location of physician performing it.

When implementing the rule on IDTFs, a majority of Medicare carriers require the supervising physician for DXA scans be limited to radiologists and/or internists. In addition, a majority of these carriers have not recognized the ISCD Certification of technologists. We argued that the rule would exclude a substantial and highly skilled portion of the provider community.

ISCD also opposed the inadequate reimbursement rate for DXA and urged CMS to reevaluate the reimbursement for DXA to more accurately reflect the cost of providing the service.
Click here to read the full text of the ISCD’s comments to CMS-1403-P.

ISCD-10

Clarifying Questions Regarding ICD-10 Flexibility

final-iscd-cms-comments-2016

Last modified: September 26, 2016