Wednesday, December 5, 2018

What is CPC+ - General Guide


GENERAL

Q: Why is CMS testing CPC+?

CMS believes that through multi-payer payment reform and practice transformation, primary care practices will be able to build capabilities and care processes to deliver patient-centered, high quality care and lower the use of unnecessary services that drive total costs of care. Payment redesign by payers, both public and private, will offer the ability for greater cash flow and flexibility for primary care practices.

Q: When will CPC+ Round 2 start and how long will it last? Can my practice join later? CPC+ Round 2 is expected to begin on January 1, 2018. Eligible practices located in the CPC+ Round 2 regions can apply from May 18-July 13, 2017.

CPC+ Round 2 consists of five performance years, as identified in the table below. CMS expects practices to participate for the full five years of their respective round of the model and will not allow practices to join the model after CMS selects practices to participate in each round of the Model.

PERFORMANCE YEARS FOR CPC+ Round 2 Calendar Year Round 2 Performance Year

2018 1
2019 2
2020 3
2021 4
2022 5

Q: Are practices required to participate in CPC+ for the full five years?

CMS expects practices to participate in CPC+ for the full five years. However, participation in CPC+ is voluntary and practices may withdraw from the model without penalty during the fiveyear performance period. Practices are required to notify CMS at least 90 calendar days before the planned day of withdrawal. Departing the model before completion of a performance year (PY) puts a practice at risk for recoupment of unearned CPC+ payments.

Q: Where will CPC+ Round 2 be implemented?

CPC+ Round 2 will be implemented in four regions throughout the U.S.:

1. Louisiana: Statewide
2. Nebraska: Statewide
3. North Dakota: Statewide
4. New York: Greater Buffalo Region

The CPC+ Round 2 regions were selected based on payer alignment and market density to ensure that CPC+ practices have sufficient payer support to make fundamental changes in their primary care delivery.

Q: How is CMS defining the “Greater Buffalo Region (NY)”? 

Based on payer alignment and market density, CMS is defining the Greater Buffalo region with the following counties:

• New York: Greater Buffalo Region: Erie County, NY; Niagara County, NY Only practices located in these counties are eligible to apply and participate in CPC+ Round 2.

Q: Which payers have been selected to partner in CPC+ Round 2?

 CPC+ Round 2 payer partners in the four new CPC+ Round 2 regions:

1. Louisiana: Amerigroup Louisiana, Inc., AmeriHealth Caritas Louisiana, Inc., Blue Cross Blue Shield of Louisiana

2. Nebraska: Blue Cross Blue Shield of Nebraska

3. New York: Greater Buffalo Region: HealthNow New York Inc., Independent Health Association, Inc.

4. North Dakota: Blue Cross Blue Shield of North Dakota

Q: When and how can a practice apply to participate in CPC+ Round 2? 

Based on payer interest and proposed alignment, CMS announced four regions for CPC+ Round

2. Practices located in these regions are eligible to apply via an online portal (https://app1.innovation.cms.gov/cpcplus/) from May 18-July 13, 2017. For questions about the Model or the solicitation process, please email CPCPlusapply@telligen.com or call 1-877-309- 6114.

Q: How many practices will be accepted in CPC+ Round 2? 

CMS expects to accept up to 1,000 practices in CPC+ Round 2.

Q: Why will new practice applications only be accepted in CPC+ Round 2 regions? CPC+ is a voluntary test of primary care payment and delivery system changes at the practice level, and will be independently evaluated throughout the five years of each Round of the model. The evaluation compares practices in each region to similar practices in the same region. CMS is unable to add new practices in the existing regions without potentially compromising the evaluation. Therefore, new practices will only be able to apply for participation in CPC+ in new regions selected for CPC+ Round 2, not in the 14 Round 1 regions.

Q: What is expected of the control group practices in CPC+ Round 2?

CMS will randomly assign eligible practices to an intervention group and a control group. The control group practices will not be required to implement the CPC+ care delivery practice changes, will not receive CPC+ Payments, and will not participate in the CPC+ learning communities, and will sign a different CPC+ Participation Agreement with CMS than the   intervention group. Additionally, they will not be considered participants in an Advanced APM through participation in the CPC+ control group, but may otherwise be Advanced APM participants through their participation in other CMS models or programs. Control group practices may be compensated for their participation in CPC+ evaluation-related activities. CMS also expects to promulgate a rule that could allow for control group practices to potentially receive favorable scoring under the Improvement Activities category of the Merit-based Incentive Payment System (MIPS), subject to notice and comment rulemaking. More details for control group practices will be announced in late 2017.

Q: Are practices outside of the CPC+ Round 2 regions eligible to apply and participate in CPC+?

Practices will only be eligible to apply to Round 2 if they are located in one of the selected Round 2 regions. The purpose of the CPC+ multi-payer design is to ensure that primary care practices receive the adequate support from multiple payers to change care delivery for a practice’s entire panel of patients. The CPC+ regions were carefully selected to ensure adequate payer support for participating practices.

a Greater Kansas City Region is defined as Johnson County, KS; Wyandotte County, KS; Clay County, MO; Jackson County, MO; Platte County, MO

b North Hudson-Capital Region of New York is defined as Albany County, NY; Columbia County, NY; Dutchess County, NY; Greene County, NY; Montgomery County, NY; Orange County, NY; Rensselaer County, NY; Saratoga County, NY; Schenectady County, NY; Schoharie County, NY; Sullivan County, NY; Ulster County, NY; Warren County, NY Washington County, NY

c Ohio-Northern Kentucky Region is defined as all counties in Ohio; Boone County, KY; Campbell County, KY; Grant County, KY; Kenton County, KY

d Greater Philadelphia Region is defined as Bucks County, PA; Chester County, PA; Delaware County, PA; Montgomery County, PA; Philadelphia County, PA

e Greater Buffalo Region is defined as Erie County, NY and Niagara County, NY

Q: Is CPC+ an Advanced APM under the Quality Payment Program?

CPC+ is included on the list of Advanced APMs. This determination was based on medicalhome model-specific requirements. For payment years 2019 through 2024, clinicians who meet the threshold for sufficient participation in Advanced APMs and who meet requirements, as applicable for 2018 onward, regarding parent organization size are excluded from the Meritbased Incentive Payment System (MIPS) reporting requirements and payment adjustments and qualify for a five percent APM incentive payment.

Q: Where can practices find more information about the QPP and Advanced APMs? 

More information about the QPP and Advanced APMs can be found on the new website from CMS: https://qpp.cms.gov.

Q. What role do other payers play in CPC+?

Multi-payer engagement is an essential goal of CPC+, as it enables both public and private payers to sponsor comprehensive primary care reform. CMS will partner with payers that share Medicare’s interest in strengthening primary care in each of the CPC+ regions. Payer partners, both public and private, will provide their own financial support to practices, separate from that of Medicare Fee-for-Services (FFS). Any questions regarding non-Medicare payer support should be directed to the payer partner.

Thursday, September 6, 2018

APG payment - part 2 , Grouping and use of modifiers


2.4 GROUPING ELEMENTS OF THE APG PAYMENT SYSTEM:

The APG System uses three methods for grouping different services provided into a single payment unit: ancillary packaging, significant procedure consolidation or bundling; and multiple significant procedure and ancillary discounting.

Ancillary Packaging: Ancillary packaging refers to the inclusion of certain ancillary services in the APG payment rate for a significant procedure or a medical visit. When ancillaries are packaged, the costs of the ancillaries are included in the payment amount for the significant procedure or medical visit. Under APGs, ancillary lab and radiology services that are inexpensive or frequently provided are generally packaged into the payment for the significant procedure or medical visit. Other ancillary services, particularly those that are expensive or infrequently ordered such as MRIs are paid as separate ancillary APGs. Uniform packaging of ancillaries is used in the APG payment system. Ancillaries that are uniformly packaged include ancillaries that are performed for a wide range of different visits and which are relatively low cost in comparison with the average cost of the significant procedure and medical visit APGs.

To view the list of ancillaries which are always packaged, called the Uniform Packaged Ancillary List, please visit: www.nyhealth.gov/health_care/medicaid/rates/apg/docs/apg_uniform_packaging.pdf.

Significant Procedure Consolidation: Significant procedure consolidation refers to the collapsing of multiple related significant procedure APGs into a single APG for the purpose of determining payment. The APG system relies on a significant procedure consolidation list developed on the basis of clinical judgment which identifies for each significant procedure APG, the other significant procedure APGs that are an integral part of the procedure and which can be performed with relatively little additional effort. The APG grouping logic consolidates related significant procedures. (Example: a Level I (primarily diagnostic) lower gastrointestinal endoscopy is consolidated into the Level II (primarily therapeutic) gastrointestinal endoscopy.) Unrelated significant procedures are not consolidated. Multiple unrelated significant procedures on the same date of service also are not consolidated in the APG classification system, but payment for additional unrelated significant procedures will be discounted.

Discounting: Discounting refers to a reduction in the standard payment rate for an APG. The APG payment system applies discounting when multiple unrelated significant procedures are performed or the same ancillary service is performed multiple times during a visit. Discounting recognizes that the marginal cost of providing a second procedure to a patient during a single visit is less than the cost of providing the procedure itself (e.g. the cost of doing two procedures at the same time is less than the cost of doing those same procedures at two different times).

In summary, the APG payment system is a visit-based prospective payment system with uniform ancillary packaging, significant procedure consolidation and multiple unrelated procedure discounting. Packaged ancillaries, incidental procedures, and lower cost drugs, biologicals and supplies are included in the payment amount for a significant procedure and medical visit. Exceptions are identified in Chapter 4. Effective January 1, 2010, medical visits will no longer package with higher intensity significant ancillary procedures (e.g., mammograms, MRIs, CAT scans, etc.) and will pay separately at the line level. Similarly, medical visits will no longer package with dental procedures; physical, speech and occupational therapy; and counseling services. When provided on the same date as an E&M visit, these services will pay at the line level.

Effective January 1, 2010, multiple same APG discounting (rather than consolidation) which currently applies to most dental services (e.g., APG 352 Periodontics) will be expanded to include occupational therapy ( APG 270), physical therapy (APG 271), speech therapy (APG 272) and most mental hygiene APGs (APG 323). For a complete list of APGs that will discount rather than consolidate when combined with other same or similar APGs, visit: http://www.nyhealth.gov/health_care/medicaid/rates/apg/docs/apg_multiple_discounting.pdf Also, effective April 1, 2010, some APGs will discount at rates other than 50%.

For a complete list of “variable discounting’ APGs, please visit: http://www.nyhealth.gov/health_care/medicaid/rates/apg/docs/apg_discounting_percentage.pdf

2.5 USE OF MODIFIERS IN APGS:

Use of modifiers provides the means by which providers can indicate that a service or procedure has been altered by some specific circumstances while not changing the definition or the code for the service. The APG system recognizes the following seven billing modifiers.

CPT Modifier 25 (Distinct Service): This modifier is used when there is a significant, separately identifiable evaluation and management service by the same physician on the same date of service as a significant procedure.

The CPT Modifier 25 should be used on an E&M code only when the patient’s condition requires a significant, separately identifiable E&M service above and beyond the significant procedure performed on the same date of service. This modifier should not be used to report an E&M service that resulted in a decision to perform the significant procedure.

** Note: During the initial phase of APGs, Modifier 25 will be disabled and the use of Modifier 25 will have no effect on payment. The EAPG Grouper/Pricer will package the cost of the medical visit flagged with a Modifier 25 in the payment for the significant procedure APG (i.e., the initial APG weights were developed taking into account the disabling of Modifier 25 logic). In the future, Modifier 25 may be activated and the APG weights will be modified accordingly.

CPT Modifier 27 (Multiple E&M visit): This modifier is used when there are multiple outpatient E&M encounters on the same date of service. The CPT Modifier 27 should be used when a patient receives multiple E&M services performed by different physicians in multiple outpatient settings (e.g. hospital emergency department and clinic) on the same date of service. Modifier 27 should be appended to the second E&M code

when reporting more than one E&M service to indicate that the E&M service is a “separate and distinct” encounter provided the same day.

** Note: This Modifier should not be used for reporting of multiple E&M services performed by the same physician on the same date of service.

** Note: Normally, the second E&M will group into APG 449, “additional undifferentiated medical visit,” when Modifier 27 is used. However, during the initial phase of APGs, the weight for APG 449 will be set to zero, which will disable Modifier 27. The initial APG weights for medical visits were developed taking into account the disabling of Modifier 27 (i.e., payment for additional medical visits on the same date of service was packaged in the payment for the primary medical visit). In the future, Modifier 27 may be activated by re-weighting APG 449, with the other medical visit APG weights revised accordingly.

CPT Modifier 50 (Bilateral Procedure): CPT Modifier 50 should be used to report bilateral procedures that are performed during the same operative session.

** Note: This modifier should not be used to report surgical procedures that are identified in code terminology as “bilateral” or to report procedures identified in code terminology as “unilateral or bilateral.” When Modifier 50 is used, both procedures will be reimbursed, but the APG Grouper/Pricer calculates the payment at 100% rate for the first procedure and at 50% of the rate for the second procedure.

CPT Modifier 52 (Reduced Services): CPT Modifier 52 should be used when a service or procedure is partially reduced or eliminated at the physician’s discretion or when an initial bilateral procedure cannot be performed as such. As with CMS, NYSDOH does not allow the use of Modifier 52 when the endoscopic procedure is incomplete and there is a CPT or HCPCS/level II code to describe the actual service performed. If a code is available that fully describes the outpatient procedure performed, this code choice supersedes the reporting of a code describing the intended, albeit not performed, procedure. When Modifier 52 is used, the payment for the procedure will be discounted by 50%.

CPT Modifier 59 (Separate Procedures or Distinct Procedural Service): CPT Modifier 59 should be used to designate instances when distinct and separate multiple services with the same APG are provided to the patient on a single date of service (eg. separate encounters, different surgeries, different sites or organ systems, separate incisions). Modifier 59 may also be used to report those procedures/services considered a component of another procedure, when the service is carried out independently or considered unrelated or distinct from the other procedures/services provided at the same time. Normally when multiple procedures map to the same APG, the additional occurrences (beyond the first) will consolidate (i.e., no payment at the line level). However, when Modifier 59 is used, the additional same APG procedures will pay at 50% of the amount paid for the first procedure.

CPT Modifier 73 (Terminated Procedure): CPT Modifier 73 should be used when a surgical procedure is cancelled subsequent to the patient’s surgical preparation (but prior to the administration of anesthesia) due to extenuating circumstances or those that threaten the well-being of the patient. ** Note: Modifier 73 should not be used for elective cancellation of a procedure before administration of anesthesia. If Modifier 73 is reported and the procedure is an approved Ambulatory Surgery Center service, the payment will be discounted by 50%.

CPT Modifier UD (340B Drugs): Drugs obtained at the 340B price are identified by the UD modifier and it is not required that an NDC code be provided when submitting a claim. However, the actual acquisition cost of the drug should be listed on the claim. See the Medicaid Update (December 2007 and April 2008) articles entitled ‘National Drug Code Required on Medicaid Claims’ and ‘Coming Soon: Easy Identification of 340B Priced Claims’ for details at the following links:

http://nyhealth.gov/health_care/medicaid/program/update/2007/index.htm.
http://nyhealth.gov/health_care/medicaid/program/update/2008/index.htm.

3.2 SERVICES NOT PAID UNDER APGS:

Certain rate codes and claims remain outside of APGs and will continue to be paid under existing Medicaid payment mechanisms. These include:
** Services provided outside of a facility’s licensure under Article 28 of the Public Health Law (e.g. Mental Hygiene and OMRDD specialty services);
** Child rehabilitation;
** Payments made to Medicaid Obstetrical & Maternal Services (MOMS) Programs and Health Supportive Services providers;
** Payments for HIV Counseling/Testing;
** Payments for Tuberculosis/Directly Observed Therapy;
** Payments for Ordered Ambulatory Services;
** Monthly billings of Medicare co-pays and deductibles for dual eligible enrollees;
** Payments for Screening for Orthodontic Treatment;
** Payments for Comprehensive Medicaid Case Management/Targeted Case Management.

Rate codes which have not been subsumed by APG rate codes are referred to as carved out rate codes.

Thursday, August 16, 2018

What is APG paymnet - how its calculated. type and classification

BACKGROUND AND INTRODUCTION TO AMBULATORY PATIENT GROUPS (APGS)

PURPOSE:


The purpose of this document is to provide Medicaid policy and billing guidance to Article 28 providers billing under the Ambulatory Patient Groups Payment methodology to the extent this methodology is applicable to hospital-based outpatient, ambulatory surgery, and emergency departments, and to free-standing diagnostic and treatment centers and free-standing ambulatory surgery centers.



1.4 SCOPE OF SERVICES:

The APG payment methodology is applicable to outpatient, ambulatory surgery and emergency department services provided by general hospitals and to ambulatory care services provided by diagnostic and treatment centers and free-standing ambulatory surgery centers.

The APG payment methodology is not applicable to:
** services provided outside of a facility’s licensure under Article 28 of the Public Health Law (e.g. APGs are not currently applicable to services certified under the Mental Hygiene Law)
** capitated payments made on behalf of Medicaid managed care or Family Health Plus enrollees;
** payment for Ordered Ambulatory services
** payment for physicians’ services in hospital settings billed using the Physician Fee Schedule;
** payment to Federally Qualified Health Centers (FQHCs), except when the FQHC has voluntarily agreed to participate in the APG reimbursement system, or;
** payment for long term care, home care, personal care.



BLENDING OF APG PAYMENT:

Both hospital-based ambulatory surgery and emergency department services received 100% APG payment with the implementation of the APG reimbursement methodology. However, APG reimbursement for hospital  outpatient departments, diagnostic and treatment centers and free-standing ambulatory surgery centers is phased-in as required by law. In the initial phase of blending, reimbursement for each individual visit is based on 25% of the full amount that the APG methodology would calculate for the visit (based on coded procedures and diagnoses) and 75% of a provider-specific existing payment for the blend amount. The existing payment used for blending purposes is based on a provider’s average per visit reimbursement for services moving to APGs for calendar year 2007.

The APG portion of the blend increases on December 1, 2009, January 1, 2011,and January 1, 2012 according to the following schedule:


Hospital Outpatient Department December 1, 2008 Starting Dec 1, 2008, 25% of payment will be based on APGs. The percentage will increase to 50% on December 1, 2009; to 75% on Jan 1, 2011; and to 100% on Jan 1, 2012.

Hospital Emergency Room January 1, 2009 100% of payment will be based on APGs starting Jan 1, 2009.

Hospital-Based Ambulatory Surgery December 1, 2008 100% of payment will be based on APGs starting Dec 1, 2008.

Free-standing Diagnostic and Treatment Center September 1, 2009 Starting on September 1, 2009, 25% of payment will be based on APGs. The percentage will increase to 50% on December 1, 2009; to 75% on Jan 1, 2011; and to 100% on Jan 1, 2012.

Free-standing Ambulatory Surgery September 1, 2009 Starting on September 1, 2009, 25% of payment will be based on APGs. The percentage will increase to 50% on December 1, 2009; to 75% on Jan 1, 2011; and to 100% on Jan 1, 2012.

When APGs are implemented in facilities licensed under the Mental Hygiene Law, free standing mental hygiene providers (not hospital based providers) will have an APG phase-in period that is distinct from the phase-in schedule for D&TC clinic services listed above. The variable blend percentages will be linked to the APG rate code.


APG GROUPING LOGIC AND USE OF MODIFIERS

2.1 MORE ON THE APG PAYMENT METHODOLOGY:


As previously discussed, APGs are a patient classification system designed to pay providers based on the amount and type of resources used during a patient encounter. Patients in a given APG have similar clinical characteristics as well as similar resource use and cost. APGs require facilities to report all services provided during the patient encounter. Provider payments are directly related to the actual services provided based on patient diagnosis and the CPT/HCPCS codes reported on the Medicaid claim. Medical services requiring a higher level of professional and ancillary care are paid a higher rate than those of a lower intensity.

APG processing uses software that examines the procedure codes and any associated modifiers reported in each of a claim’s service lines and assigns each line an APG code, along with other relevant values (e.g. APG weights, packaging flags, discounting percentages, etc.). Each APG code carries a “weight” based on the group’s average cost, from which appropriate payment levels are established. The APG “weight” can be multiplied by a percentage to reduce or increase the weight, depending on the APG grouper’s evaluation of the service line, resulting in the service line’s final “weight.” For medical visits, the assignment of an APG is dependent on the ICD-9 Primary Diagnosis Code recorded on the claim.

There are a number of procedures (primarily pertaining to eyeglasses, mental hygiene services, rehabilitation therapies and hearing aids) which are assigned a procedure-based weight that is different from the APG weight. In the APG payment methodology, the procedure based weight overrides the APG weight. Additionally, if a procedure is assigned a procedure-based

weight it will pay even if it groups to a Never Pay APG. However, if the procedure groups to an “If Stand Alone Do Not Pay APG”, it will not pay if it is the only procedure on the claim or is accompanied by non-paying procedures. Discounting and consolidating logic will still occur where applicable. Some of the procedure-based weights also recognize units. For example, the physical therapy APG includes units based and non-units based procedures. The units based physical therapy procedures are assigned a procedure based weight that is different from the physical therapy APG weight. When coding a unit- based procedure, the number of units should also be reported on the claim. The procedure-based weight and the number of units are both used in the APG payment calculation for the units based procedure.

The “final weight” for a given visit is multiplied by a provider-associated base rate as part of the APG payment calculation. For hospital outpatient departments and diagnostic and treatment centers, the APG payment is “blended” with a historical weighted average payment of the provider’s pre-APG rates to arrive at the final payment amount. A single claim can be assigned one or more APG values, each of which carries its own “weight,” depending on the service line procedure codes, modifiers, and in some cases, diagnosis codes. The eMedNY system will use the EAPG Grouper/Pricer for processing institutional outpatient claims upon the effective dates of APG implementation as identified in section 1.5 of this document. Affected providers are required to use new rate codes on and after those effective dates. Use of the new rate codes results in payments for services based on the APG classification and payment rules. When a visit consists entirely of “no capital add-on APGs” or “no capital add on procedures” a capital add-on payment is not included in the final APG payment for the visit.

For a complete list of “no capital add-on APGs and procedures” please visit:
http://www.nyhealth.gov/health_care/medicaid/rates/apg/docs/apg_no_capital_add.pdf.
http://www.nyhealth.gov/health_care/medicaid/rates/apg/docs/apg_no_capital_procedures.pdf.

APG TYPES:

The EAPG Grouper/Pricer maps CPT and HCPCS procedure codes and ICD-9 diagnosis codes reported on a claim to APGs to define the ambulatory visit. Multiple APGs may be assigned to a visit. The four primary types of APGs are described below.

Significant Procedures: A procedure/service which constitutes the reason for the visit and dominates the time and resources expended during the visit. (Examples: excision of skin lesion, stress test, insertion of a central venous catheter, treating fractured limb)

Medical Visits: A visit during which a patient receives medical treatment but does not have a significant procedure performed. Evaluation and management codes are assigned to one of the medical visit APGs based on the primary diagnosis reported on the claim. (Examples: follow-up visit for patient with congestive heart failure, chronic obstructive pulmonary disease, hypertension)

Ancillary Tests and Procedures: A test or procedure ordered by the primary physician to assist in patient diagnosis or treatment. (Examples: immunizations, plain film x-rays, laboratory tests) Incidental Procedures: An integral part of a medical visit usually associated with professional services being given to the recipient. (Example: range of motion measurements)

 APG CLASSIFICATION LOGIC:

In the APG classification system, the patient is described by a list of APGs that corresponds to services provided to the patient. The significant procedure (rather than diagnosis) is the initial classification variable. Procedures that could be performed on an ambulatory basis are categorized as either significant procedures or ancillary services. Patients who undergo a significant procedure are assigned to a significant procedure APG on the basis of the CPT code that describes the precise significant procedure. Patients receiving medical treatment that does not involve a significant procedure are assigned to a medical APG based on the ICD-9 diagnosis code. In some instances, a patient may receive a significant procedure and a medical visit, in which case the visit would be assigned to a significant procedure APG. Under the default APG logic, the procedure would be paid at the line level and the medical visit payment would be included (packaged) in the payment for the significant procedure. A patient who neither received medical treatment nor underwent a significant procedure but had an ancillary service performed would be assigned an ancillary service APG. Patients with any significant procedures or therapies are assigned to one or more significant procedure APGs.

If there are no significant procedures present and there is a medical visit (Evaluation and Management CPT code reported), the patient is assigned to a medical visit APG. If there is neither a significant procedure nor a medical visit code, but there are ancillary test(s) or procedure(s) present, then the patient is assigned one or more ancillary APGs.

If there is no significant procedure CPT code, medical visit (evaluation and management CPT) code or ancillary code, the claim is considered an error.

The figure below provides an overview of the APG assignment logic as discussed above. Effective January 1, 2010, the EAPG grouper logic was revised to recognize a list of significant procedures with which medical visits will no longer package. Medical visits will no longer package with: the more significant ancillaries; dental procedures; physical, speech and occupational therapy; and counseling services. When certain significant procedures are performed on the same day as a medical visit, no packaging would occur and payments would be received by the provider for both the medical visit and significant procedure at the line level.

For a complete list of “significant procedures with which medical visits do not package,” please visit: http://www.nyhealth.gov/health_care/medicaid/rates/apg/docs/apg_not_package.pdf.

Thursday, May 24, 2018

What is content of service

CONTENT OF SERVICE

Content of service refers to specific services and/or procedures that are considered to be an integral part of previous or concomitant services or procedures to the extent that separate reimbursement is not recognized. Not all content of service issues are identified in the policies and procedures. BCBSKS staff may identify and classify specific coding and nomenclature issues as they arise. Examples of services that can be considered content of service are:


• Examination of the patient.
• History of illness and/or review of patient records.
• Evaluation of tests or studies (i.e., radiology or pathology).
• Any entries into the patient's records.
• Evaluation of reports of tests or studies earlier referred to another physician for an opinion and subsequently returned for use in the office visit being conducted.
• Advice or information provided during or in association with the visit.
• Case management.
• The prescription of any medicinals, home supplies or equipment during or as a result of the visit.
• The application or the re-application of any standard dressing during a visit.
• Therapeutic, prophylactic, or diagnostic injection administration provided on the same day as an office visit, home visit, or nursing home visit.
• Additional charges beyond the regular charge for services requested after office hours, holidays or in an emergency situation.
• Items of office overhead such as malpractice insurance, telephones, personnel, supplies, cleaning, disinfectants, photographs, equipment sterilization, etc.
• Telephone calls and web-based correspondence are content of service when billed with another service on the same day. Such services are not covered if billed separately and the only service rendered on that day.
• Anesthesia provided in an office setting is considered content of service and not reimbursed separately. The provider cannot require the patient to sign a waiver or bill the patient for this service.
Some content of service issues related to specific services and/or procedures are identified throughout the policy and procedure documents.

NOTE: All-inclusive procedure codes must be used when available.


PATIENT-DEMANDED SERVICES

A. If a provider prescribes services that he knows will not be covered because of a lack of medical necessity or the procedure being considered is experimental or investigational and he alerts the patient of the non-coverage, yet the patient still insists on the services, the provider may bill the patient if the request is properly documented and signed by the member. (See Section X. WAIVER FORM)

B. Providers must obtain a waiver on any mental health consultation, testing, or evaluation that is performed by agreement or at the direction of a court for the purpose of assessing custody, visitation, parental rights, or to determine damages of any kind of personal injury action and if the service is not otherwise medically necessary. To enable the provider to bill a patient for such services, BCBSKS will deny benefits for such services as lacking medical necessity.

Wednesday, December 6, 2017

icd 10 code for insomnia F51.02, F51.01

Surgical Treatment of Obstructive Sleep Apnea (OSA) and Upper Airway Resistance Syndrome (UARS) 

Uvulopalatopharyngoplasty (UPPP) may be considered medically necessary for the treatment of clinically significant obstructive sleep apnea syndrome (OSA) in appropriately selected adult patients who have not responded to or do not tolerate nasal continuous positive airway pressure (CPAP). Clinically significant OSA in this case is defined as those patients who have:

• Apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than or equal to 15 events per hour, or

• AHI or RDI greater than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

Hyoid suspension, surgical modification of the tongue, and/or maxillofacial surgery, including mandibular-maxillary advancement (MMA), may be considered medically necessary in appropriately selected adult patients with clinically significant OSA and objective documentation of hypopharyngeal obstruction who have not responded to or do not tolerate CPAP. Clinically significant OSA in this case is defined as those patients who have:

• AHI or RDI greater than or equal to 15 events per hour, or

• AHI or RDI greater than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

CPAP (E0601) may be considered medically necessary for:

• Patients in whom polysomnography has documented sleep disordered breathing, with an RDI (respiratory disturbance index) of greater than fifteen, or

• Patients in whom polysomnography has documented sleep disordered breathing, with an RDI (respiratory disturbance index) of greater than five and any of the following associated symptoms:

Excessive daytime sleepiness

Impaired cognition

Mood disorders

Insomnia

Documented hypertension

Ischemic heart disease

History of stroke

• Patients who do not have sleep apnea, but who have restrictive lung disease and documented desaturation at night, requiring nocturnal ventilation

• Under individual consideration APAP may be allowed in selective patients in lieu of repeated CPAP titration when the attending sleep center physician indicates that, in his/her opinion the member would be a suitable candidate for this approach based upon member’s knowledge, behavior, and health status.

Diagnosis of OSA with abnormal Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI)

1. AHI or RDI =15; Or

2. AHI or RDI between 5 and 14 (requires one)

a. Excessive daytime sleepiness (ESS)

b. Impaired cognition

c. Insomnia

d. Mood disorder

e. Hypertension;

MSLT is considered not medically necessary in the following four situations:

• When performed for routine diagnosis of obstructive sleep apnea; OR

• For routine follow-up after treatment of sleep related disorders; OR

• For evaluation of sleepiness in medical or neurological disorders (other than narcolepsy or idiopathic hypersomnia), including, but not limited to, insomnia,
circadian rhythm disorders, and Shift Work Sleep Disorder (SWSD); OR

• Portable MSLT performed in the home setting.


ICD-10 DiagnosisCode ICD-10 Diagnosis Description

F40.241 Acrophobia

F43.0 Acute stress reaction

F43.22 Adjustment disorder with anxiety

F43.21 Adjustment disorder with depressed mood

F43.24 Adjustment disorder with disturbance of conduct

F43.23 Adjustment disorder with mixed anxiety and depressed mood

F43.25 Adjustment disorder with mixed disturbance of emotions and conduct

F43.29 Adjustment disorder with other symptoms

F43.20 Adjustment disorder, unspecified

F51.01 Primary insomnia

F51.02 Adjustment insomnia

F51.03 Paradoxical insomnia

F51.04 Psychophysiologic insomnia

F51.05 Insomnia due to other mental disorder

F51.09 Other insomnia not due to a substance of known physiological condition

F98.5 Adult onset fluency disorder

F40.01 Agoraphobia with panic disorder

F40.02 Agoraphobia without panic disorder

F40.00 Agoraphobia, unspecified

F10.180 Alcohol abuse with alcohol-induced anxiety disorder

F10.14 Alcohol abuse with alcohol-induced mood disorder

F10.150 Alcohol abuse with alcohol-induced psychotic disorder with delusions

F10.151 Alcohol abuse with alcohol-induced psychotic disorder with hallucinations

F10.159 Alcohol abuse with alcohol-induced psychotic disorder, unspecified

F10.181 Alcohol abuse with alcohol-induced sexual dysfunction

F10.182 Alcohol abuse with alcohol-induced sleep disorder

F10.121 Alcohol abuse with intoxication delirium

F10.188 Alcohol abuse with other alcohol-induced disorder

F10.19 Alcohol abuse with unspecified alcohol-induced disorder

F10.280 Alcohol dependence with alcohol-induced anxiety disorder

F10.24 Alcohol dependence with alcohol-induced mood disorder

F10.26 Alcohol dependence with alcohol-induced persisting amnestic disorder

F10.27 Alcohol dependence with alcohol-induced persisting dementia

F10.250 Alcohol dependence with alcohol-induced psychotic disorder with delusions

F10.251 Alcohol dependence with alcohol-induced psychotic disorder with hallucinations

F10.259 Alcohol dependence with alcohol-induced psychotic disorder, unspecified

F10.281 Alcohol dependence with alcohol-induced sexual dysfunction

F10.282 Alcohol dependence with alcohol-induced sleep disorder

F10.221 Alcohol dependence with intoxication delirium

F10.288 Alcohol dependence with other alcohol-induced disorder

F10.29 Alcohol dependence with unspecified alcohol-induced disorder

F18.951 Inhalant use, unspecified with inhalant-induced psychotic disorder with hallucinations

F18.959 Inhalant use, unspecified with inhalant-induced psychotic disorder, unspecified

F18.921 Inhalant use, unspecified with intoxication with delirium

F51.05 Insomnia due to other mental disorder

F51.12 Insufficient sleep syndrome

F63.81 Intermittent explosive disorder

F63.2 Kleptomania

F33.2 Major depressive disorder, recurrent severe without psychotic features

F33.42 Major depressive disorder, recurrent, in full remission

F33.41 Major depressive disorder, recurrent, in partial remission

F33.40 Major depressive disorder, recurrent, in remission, unspecified

F33.0 Major depressive disorder, recurrent, mild

F33.1 Major depressive disorder, recurrent, moderate

F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms

F33.9 Major depressive disorder, recurrent, unspecified

F32.5 Major depressive disorder, single episode, in full remission

F32.4 Major depressive disorder, single episode, in partial remission

F32.0 Major depressive disorder, single episode, mild

F32.1 Major depressive disorder, single episode, moderate

F32.3 Major depressive disorder, single episode, severe with psychotic features

F32.2 Major depressive disorder, single episode, severe without psychotic features

F32.9 Major depressive disorder, single episode, unspecified

F52.21 Male erectile disorder

F52.32 Male orgasmic disorder

F30.4 Manic episode in full remission

F30.3 Manic episode in partial remission

F30.11 Manic episode without psychotic symptoms, mild

F30.12 Manic episode without psychotic symptoms, moderate

F30.10 Manic episode without psychotic symptoms, unspecified

F30.2 Manic episode, severe with psychotic symptoms

F30.13 Manic episode, severe, without psychotic symptoms

F30.9 Manic episode, unspecified

F42.2 Mixed obsessional thoughts and acts

F06.31 Mood disorder due to known physiological condition with depressive features

F06.32 Mood disorder due to known physiological condition with major depressive-like episode

F06.33 Mood disorder due to known physiological condition with manic features

F06.34 Mood disorder due to known physiological condition with mixed features

F06.30 Mood disorder due to known physiological condition, unspecified

F91.8 Other conduct disorders

F32.8 Other depressive episodes

F80.89 Other developmental disorders of speech and language

F88 Other disorders of psychological development

F50.8 Other eating disorders

F98.29 Other feeding disorders of infancy and early childhood

F64.8 Other gender identity disorders

F45.29 Other hypochondriacal disorders

F63.8 Other impulse disorders

F51.09 Other insomnia not due to a substance or known physiological condition

F42.8 Other obsessive compulsive disorder

F30.8 Other manic episodes

F41.3 Other mixed anxiety disorders

F40.228 Other natural environment type phobia

F65.89 Other paraphilias

F34.8 Other persistent mood Âșaffective» disorders

F07.89 Other personality and behavioral disorders due to known physiological condition

F84.8 Other pervasive developmental disorders

F40.8 Other phobic anxiety disorders

F19.121 Other psychoactive substance abuse with intoxication delirium

F19.122 Other psychoactive substance abuse with intoxication with perceptual disturbances

F19.188 Other psychoactive substance abuse with other psychoactive substance-induced disorder

F19.180 Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder

F19.14 Other psychoactive substance abuse with psychoactive substance-induced mood disorder

F19.16 Other psychoactive substance abuse with psychoactive substance-induced persisting amnestic disorder

F19.17 Other psychoactive substance abuse with psychoactive substance-induced persisting dementia

F19.150 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delus

F19.151 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with hallu

F19.159 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder, unspecifi

F19.181 Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction

F19.182 Other psychoactive substance abuse with psychoactive substance-induced sleep disorder

F15.159 Other stimulant abuse with stimulant-induced psychotic disorder, unspecified

F15.181 Other stimulant abuse with stimulant-induced sexual dysfunction

F15.182 Other stimulant abuse with stimulant-induced sleep disorder

F15.19 Other stimulant abuse with unspecified stimulant-induced disorder

F15.221 Other stimulant dependence with intoxication delirium

F15.222 Other stimulant dependence with intoxication with perceptual disturbance

F15.288 Other stimulant dependence with other stimulant-induced disorder

F15.280 Other stimulant dependence with stimulant-induced anxiety disorder

F15.24 Other stimulant dependence with stimulant-induced mood disorder

F15.250 Other stimulant dependence with stimulant-induced psychotic disorder with delusions

F15.251 Other stimulant dependence with stimulant-induced psychotic disorder with hallucinations

F15.259 Other stimulant dependence with stimulant-induced psychotic disorder, unspecified

F15.281 Other stimulant dependence with stimulant-induced sexual dysfunction

F15.282 Other stimulant dependence with stimulant-induced sleep disorder

F15.29 Other stimulant dependence with unspecified stimulant-induced disorder

F15.921 Other stimulant use, unspecified with intoxication delirium

F15.922 Other stimulant use, unspecified with intoxication with perceptual disturbance

F15.988 Other stimulant use, unspecified with other stimulant-induced disorder

F15.980 Other stimulant use, unspecified with stimulant-induced anxiety disorder

F15.94 Other stimulant use, unspecified with stimulant-induced mood disorder

F15.950 Other stimulant use, unspecified with stimulant-induced psychotic disorder with delusions

F15.951 Other stimulant use, unspecified with stimulant-induced psychotic disorder with hallucinations

F15.959 Other stimulant use, unspecified with stimulant-induced psychotic disorder, unspecified

F15.981 Other stimulant use, unspecified with stimulant-induced sexual dysfunction

F15.982 Other stimulant use, unspecified with stimulant-induced sleep disorder

F95.8 Other tic disorders

F45.41 Pain disorder exclusively related to psychological factors

F45.42 Pain disorder with related psychological factors

F41.0 Panic disorder Âșepisodic paroxysmal anxiety» without agoraphobia

F51.03 Paradoxical insomnia

F60.0 Paranoid personality disorder

F20.0 Paranoid schizophrenia

F65.9 Paraphilia, unspecified

F63.0 Pathological gambling

F65.4 Pedophilia

F34.9 Persistent mood Âșaffective» disorder, unspecified

F07.0 Personality change due to known physiological condition

F60.9 Personality disorder, unspecified

F84.9 Pervasive developmental disorder, unspecified

F40.9 Phobic anxiety disorder, unspecified

F98.3 Pica of infancy and childhood

F43.11 Post-traumatic stress disorder, acute

F43.12 Post-traumatic stress disorder, chronic

F43.10 Post-traumatic stress disorder, unspecified

F07.81 Postconcussional syndrome

F52.4 Premature ejaculation

F32.81 Premenstrual dysphonic disorder

F51.11 Primary hypersomnia

F51.01 Primary insomnia

F48.2 Pseudobulbar affect

F06.2 Psychotic disorder with delusions due to known physiological condition

F06.0 Psychotic disorder with hallucinations due to known physiological condition

F53 Puerperal psychosis

F63.1 Pyromania

F43.9 Reaction to severe stress, unspecified

F94.1 Reactive attachment disorder of childhood

F20.5 Residual schizophrenia

F98.21 Rumination disorder of infancy

F65.50 Sadomasochism, unspecified

F25.0 Schizoaffective disorder, bipolar type

F25.1 Schizoaffective disorder, depressive type

F25.9 Schizoaffective disorder, unspecified

F60.1 Schizoid personality disorder

F20.9 Schizophrenia, unspecified

F20.81 Schizophreniform disorder

F21 Schizotypal disorder

F13.121 Sedative, hypnotic or anxiolytic abuse with intoxication delirium

F13.188 Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolyticinduced disorder

F13.180 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced anxiety disorde

F13.14 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced mood disorder

F13.151 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced psychotic disor

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