2018 HJ Ross Network Member Updates

2018 HJ Ross Network Member Updates

CPT 2018

CPT code 97762 was deleted the code was described as Checkout for orthotic/prosthetic use, established patient, each 15 minutes,

97763 was added and replaced 97762

97763- Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent encounter orthotic(s)/prosthetic(s), encounter, each 15 minutes

Description of procedure: Status check of skin integrity and wound changes or abnormalities of incision, sensation, fit of prosthetic/orthotic, observation of movement, and edema observation are performed. These could include alignment, fit; modifying and adjusting etc. The patient is given instruction in the performance of skin checks and skin care; proper care of orthotic and exercises to perform at throughout the day.

Chest X-Ray

Coding for chest x-rays updated to now simply get in line with other codes to simply reflect the number of views and not the type. Historically, chest x-rays were reported with nine different codes to ultimately reflect one to four views being captured. Doing the math, nine codes for what are often relatively straightforward images was often seen as “muddying the waters.” These nine codes have now been trimmed down to four codes based solely on a number of views:

71045 Radiologic examination, chest; single view

71046 Radiologic examination, chest; 2 views

71047 Radiologic examination, chest; 3 views

71048 Radiologic examination, chest; 4 or more views

CCI Edits

Chiropractic manipulative treatment (CMT) of five spinal regions. Physical medicine and rehabilitation services described by CPT codes 97112, 97124 and 97140 are not separately reportable when performed in a spinal region undergoing CMT. If these physical medicine and rehabilitation services are performed in a different region than CMT and the provider is eligible to  report physical medicine and rehabilitation codes under the Medicare program, the provider may report CMT and the above codes

using modifier 59.

When reporting the CPT code 97124 or 97140 in conjunction with CMT codes, there are six criteria that must be documented to validate the service:

1. Manipulation was not performed to the same anatomic region
2. The clinical rationale for a separate and identifiable service must be documented e.g., contraindication to CMT is present
3. Description of the massage or manual therapy technique(s) e.g., manual traction, myofascial release, mobilization, etc.
4. Location e.g., spinal region(s), shoulder, thigh, etc.
5. Time i.e., number of minutes spent in performing the services associated with this procedure meets the timed-therapy services requirement
6. CPT code 97124 and 97140 is appended with the modifier -59 or the appropriate -X modifier

When these procedures are billed together, modifier -59 or the appropriate -X modifier, is required to be appended to CPT code 97140 to delineate that an independent procedure was performed.

CMS has established the following four HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier:

• XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter,
• XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure, (likely most common for CMT with 97124 & 97140)
• XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and
• XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.

Current Procedural Terminology (CPT) instructions state that modifier 59 should not be used when a more descriptive modifier is available. Providers should utilize the more specific –X modifier when appropriate.

Diagnosis

• October 1, 2017 additions & deletions
• M48.06 Spinal stenosis, lumbar region -deleted
• M48.061  Spinal stenosis, lumbar region without neurogenic claudication – new
• M48.062  Spinal stenosis, lumbar region with neurogenic claudication –new

 

Medicare

1. Deductible for 2018 is $183
2. Medicare fees are available for all regions and did adjust slightly higher in most regions
3. When billing physical medicine services 97012-97799 including G0281 and G0283, in 2018 Medicare updated that chiropractors must also include modifier GP. This GP modifier will be in addition to the GY modifier for excluded services. For example, it would be coded in this manner 97110 GY GP. Note physical medicine services are still excluded and not covered by Medicare for a chiropractic provider.

Note these codes and modifiers need not be billed or used unless the chiropractic provider requires a denial for the secondary payer. Medicare does not require billing for excluded services otherwise and all services other than spinal manipulation 98940, 98941 and 98942 are covered by Medicare.

4. There is an update to the ABN issues last August but only pertains to “nonpar” providers which require a strikeout of one line an added sentence. This is to clarify that a provider may charge above the Medicare allowable when services are maintenance.

 

Veterans Choice

Veterans Choice and PC3 billing for chiropractic claims require for payment of physical medicine services (97012-97799 including G0283) a requirement of modifier GP on the physical medicine services. These services are reimbursed to a doctor of chiropractic when authorized.

These benefits are managed through Triwest and Health Net Federal services depending on your region.

Rates of payment for VA choice are at Medicare levels and the veteran has no deductible, copay, coinsurance or any out of pocket liability.