For the Week of April 25, 2016

Is modifier -59 (distinct procedural service) or XU (unusual non-overlapping service) better to use for a diagnostic cardiac catheterization that led to decision to place a coronary stent at the same session? 

At the present time, either would be appropriate. Modifier use is specific to each payer, so check with your local Medicare administrative contractor (MAC) for its guidelines. 

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Are there any laboratory services that aren’t packaged under the OPPS?

For non-patient referred specimens, hospitals will continue to report services on type of bill (TOB) 141 (hospital non-patient). The three other scenarios below also will not be packaged under the hospital outpatient prospective payment system (OPPS).

  • Outpatient lab-only encounters
  • Unrelated lab procedures
  • Fee-for-service. 

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What ICD-10 codes can be assigned for opioid abuse?

For opioid abuse, the ICD-10 subcategory is F11.1, and for opioid dependence, the subcategory is F11.2. ICD-10 also has a subcategory for opioid use, which is F11.9.

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We have begun receiving denials for some of our radiopharmaceutical HCPCS codes.  Do you know why this might be? 

Beginning in October 2015, Medicare instituted procedure to procedure (PTP) edits for some radiopharmaceutical HCPCS codes with certain CPT procedure codes.  This came about because the Centers for Medicare & Medicaid Services (CMS) and the Society of Nuclear Medicine and Molecular Imaging (SNMMI) discovered many claims with incorrect CPT / HCPCS code combinations.  Providers should check to make sure that the HCPCS code they bill is the correct code for the material provided. 

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My question relates to the payment for airway endoscopy procedures. It appears that the payment rates have changed for the codes in these APCs. Can you confirm?

For 2016 the Centers for Medicare & Medicaid Services (CMS) issued all new APC groupings for airway endoscopy procedures. Beginning January 1, 2016 new APC payment values took effect. The procedures are divided into five APCs, and the April 2016 update to the OPPS lists the range as $141.31 for level 1 airway endoscopy to $3,066.48 for level 5 airway endoscopy.

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What qualifier do I use for ICD-10 diagnosis codes on electronic claims? 

The following answer to that question comes directly from the Centers for Medicare & Medicaid Services (CMS) (FAQ12889). 

For X12 837P 5010A1 claims, the HI01-1 field for the Code List Qualifier Code must contain the code “ABK” to indicate the principal ICD-10 diagnosis code being sent. When sending more than one diagnosis code, use the qualifier code “ABF” for the Code List Qualifier Code to indicate up to 11 additional ICD-10 diagnosis codes that are sent.

For X12 837I 5010A1 claims, the HI01-1 field for the Principal Diagnosis Code List Qualifier Code must contain the code “ABK” to indicate the principal ICD-10 diagnosis code being sent. When sending more than one diagnosis code, use the qualifier code “ABF” for each Other Diagnosis Code to indicate up to 24 additional ICD-10 diagnosis codes that are sent.

For NCPDP D.0 claims, in the 492.WE field for the Diagnosis Code Qualifier, use the code “02” to indicate an ICD-10 diagnosis code is being sent.

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