Several changes to ICD-9 codes are now in effect

Three separate coding and reimbursement issues are impacting urologists now and will continue to affect practices in 2005. This article will focus on these three issues— ICD-9 changes for 2005, drugs purchased by physicians, and the -59 modifier.

New ICD-9 changes must be implemented now. In the past, we have not implemented ICD-9 codes until the first of the year, and usually we had until April to im-plement new CPT codes. Now, we must start using the new ICD-9 codes when published on Oct. 1 and April 1. This means you should have implemented the new codes into your practice by the time you read this article, and prepare to implement new CPT codes on Jan. 1, 2005. Below are a few of the ICD-9 codes with changed descriptors, deleted codes, and new codes that should have been implemented in your practice as of Oct. 1. 

Remember, as discussed in previous articles, always code to the highest level of knowledge at the time you finish a surgery, procedure, or E&M encounter. Do not wait for lab results or change the diagnosis later because of a path report. 

If you don’t have a definitive diagnosis, signs and symptoms will get you paid just as quickly and just as much on all E&M encounters. 

Update on LHRH payment – 

The law, rules, and suggestions apply to “all drugs furnished incident to a physician service.” By this time you are painfully aware that Medicare rules have changed and in 2005 you will be paid 106% of average sales price (ASP). For a full discussion, refer to Urology Times articles published in September and July . 

The final rules on determining ASP were recently published. There are no big surprises, except that the rules on how manu-facturers will report volume discounts, cash discounts, rebates, etc., were changed to allow adjustments to the actual sales price to be reported on a running 12-month average. Therefore, if a manufacturer decides to give a steep discount on a drug in one quarter, the ASP for the next quarter will only be affected by the running 12-month average and not the exact amount discounted the previous quarter. This is not only interesting, but probably smart. The entire process will probably continue to drive down prices on all drugs in which there is competition. 

This brings us back to the bottom line. I would encourage you not to sign contracts for next year until: 

The actual payment for drugs in 2005 is published by CMS on Oct. 31. 

You know all your options for purchase. The pharmaceutical companies understand the issues and are exploring the op-tions on how they can best work with you. 

All contracts should allow for quarterly changes based on changes in payment. Again, let me emphasize that the payments will be based on the national ASP and not what you paid for the drug. 

Modifier -59 vs. modifier -51 Bundling and unbundling multiple procedural reductions and the appropriate use of modifiers -51 and -59 continues to mystify a number of urologists and coders. I will attempt to simplify and summarize the rules. For details, refer to earlier articles on bundling, multiple procedures, and modifier -59.

Modifier -51: This modifier should be appended to the lesser of two procedures, if they are not bundled. This modifier will not pull a procedure out of a bundle. 

Modifier -59: This modifier should be appended to the lesser of two procedures, if the two are bundled and if it meets the definition of the modifier. Modifier -59 indicates to the payer that in this particular case, the lesser procedure should be unbundled and paid for. 

In both cases, the greater, more comprehensive procedure will be paid at 100%, and the lesser procedure will be paid at 50%. This is called “multiple procedural reductions” and should be applied to all procedures performed on the same patient, by the same physician, at the same patient encounter. It doesn’t matter whether it’s through the same incision, on a different part of the body, or is a totally separate surgery. There is actually some logic to this automatic reduction. 

The payment for each procedure includes payment for preoperative care, history and physical, surgical prep time, the operation, postoperative hospital visits, and other postoperative follow-up care. Approximately 50% of the payment is for the actual surgery, and the other 50% is for the pre- and post-op care.

 

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook

Disclaimer:

 

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written.  However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.