Webinar On Gastroenterology coding update 2018

1. Gastroenterology Coding Updates for 2018 O N L I N E A U D I O T R A I N I N G By : T erry Fletcher www.onlineaudiotraining.com

2. ICD-10-CM GUIDELINES RELEASED!! Just released on Thursday, Aug. 10 are the Official ICD-10-CM/PCS Coding and Reporting Guidelines for the 2018 fiscal year, totaling 117 pages. The National Center for Health Statistics, via the CDC (Centers for Disease Control and Prevention), has posted the guidelines on its websitehere:https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf. Readers should note that the time frame to which these guidelines apply to is Oct. 1, 2017 to Sept. 30, 2018. When you review the guidelines for this coming fiscal year, please take note the following: Narrative changes appear in boldtext Items underlined have been moved within the guidelines since the FY 2017 version Italics are used to indicate revisions to headingchanges     The conventions for ICD-10-CM are the general rules for use of the classification, independent of the guidelines, and there remain 19 of these conventions, as in the FY 2017 guidelines. Convention No. 15, “with,” does have some revised narrative, so every coding professional should read this over carefully. Here’s a portion of this revision, highlighted in bluefont: The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the TabularList. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”). 2

3. New for2018  Changes proposed to diverticulitis with perforation for ICD-10 coding to better clarify the severity of the patient’s problem and whether generalized peritonitis occurred Distinctions between cholecystitis without gangrene or perforation, cholecystitis with gangrene without perforation, and cholecystitis with perforation are proposed new codes to more accurately characterize the severity of cholecystitis  A finding indicating the presence of multiple pouches, usually in the colonic or gastric wall. K57 Diverticular disease of intestine K57.0 Diverticulitis of small intestine with perforation and abscess K57.00…… without bleeding K57.01…… with bleeding K57.1 Diverticular disease of small intestine without perforation or abscess K57.10Diverticulosis of small intestine without perforation or abscess without bleeding K57.11Diverticulosis of small intestine without perforation or abscess with bleeding K57.12Diverticulitis of small intestine without perforation or abscess without bleeding K57.13Diverticulitis of small intestine without perforation or abscess with bleeding K57.2 Diverticulitis of large intestine with perforation and abscess K57.20…… without bleeding K57.21…… with bleeding K57.3 Diverticular disease of large intestine without perforation or abscess K57.30Diverticulosis of large intestine without perforation or abscess without bleeding K57.31Diverticulosis of large intestine without perforation or abscess with bleeding K57.32Diverticulitis of large intestine without perforation or abscess without bleeding K57.33Diverticulitis of large intestine without perforation or abscess with bleeding K57.4 Diverticulitis of both small and large intestine with perforation and abscess K57.40…… without bleeding K57.41…… with bleeding K57.9 Diverticular disease of intestine, part unspecified, without perforation or abscess K57.90Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding K57.91Diverticulosis of intestine, part unspecified, without perforation or abscess with bleeding K57.92Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding K57.93Diverticulitis of intestine, part unspecified, without perforation or abscess with bleeding                           For example: A 64-year-old male is seen for follow-up of diverticulitis. Without documentation of location or complications, the correct code is K57.92. 3

4. Six New Hypertension Codes2018 ICD-10-CM 2018 brings us 6 new codes for pulmonary hypertension, which effects the arteries of the lungs and theheart. New codes are asfollows: I27.20 (Pulmonary hypertension,unspecified) I27.21 (Secondary pulmonary arterial hypertension) I27.22 (Pulmonary hypertension due to left heart disease) I27.23 (Pulmonary hypertension due to lung diseases and hypoxia) I27.24 (Chronic thromboembolic pulmonary hypertension) I27.29 (Other secondary pulmonary hypertension)       You may see these codes more often with Right Heart Cath coding and possible valve replacement coding. 4

5. 2018 E / M servicesupdate Physician practices should note several changes to E/M codes, which includes a new “star” symbol added to CPT to designate possible “Synchronous Telemedicine Health” code inclusions, and several revised code descriptor sections. Pay close attention to modifier -95 and-GT PlushCare VIP Care Telehealth eVisit • • • • 5

6. Coding for TelehealthServices-preview Reporting Telehealth Services with the appropriate modifiers-Only ½ the story Submit your Medicare and Medicaid claims for telehealth services using the appropriate CPT® or HCPCS code for the telehealth service along with the modifier GT (via interactive audio and video telecommunications systems)- for example, 99202-GT. By coding and billing the GT modifier with a covered telehealth procedure code, you are certifying that the beneficiary was present at an eligible originating site when your physician or qualified approved practitioner furnishes the telehealth service. By coding and billing the GT modifier with the covered ESRD- related service telehealth code, you are certifying that your provider furnishes one “hands on” visit per month to examine the vascular accesssite. For Federal telemedicine demonstration programs in Alaska or Hawaii, your submitted claims with the appropriate CPT® or HCPCS code for the professional service along with the GQ modifier, to certify a asynchronous telecommunications system was used. ! Reminder: CMS states that POS 02 is effective January 1st, 2017. A CMS transmittal (R3586CP) mentions that any time claims for telehealth services are reported that include modifier GT or GQ on either the CPT® or HCPCS code, but do not include new POS 02, they will be denied. It also mentions that if the new POS 02 is used and the modifiers are not included, the service will be denied by Medicare. Make sure you attend one of our Telemedicine Webinars in 2018 to become even more informed on this topic. *Terry Fletcher is a member of the American Telemedicine Association 2017 6

7. Modifier 25Alert!-2018 E/M Codes with modifier -25 may face drastic pay reductions for some practices. Watch your E/M Claims where you append the modifier 25 (Significant, separately identifiable E/M service) if your patients have insurance with a Medicare Advantage carrier that operates in 25 states. This started on August 1st, when Independence Health Group, which covers almost 9 million people under private health insurance and Medicare Advantage plans, announced via their website and provider emails, it would apply a “payment reduction of 50%” to an E/M service when it is billed/reported with a modifier 25 on the same date as a minor procedure. The company also said it would cut payment at the same 50% rate for E/M services billed with modifier 25 when a preventative code is also billed. The policy document lists 17 preventative service codes that apply, including 99381-99387, 99391-99397, G0438 and G0349 the AWV. This revised payment policy will significantly impact reimbursement for many practices around the country. I fear this could have physicians bringing patients back on a different day to get paid for both services at 100%. We strongly urge providers who are participating with this plan to fight it with the provider relations department of that payer. There is no basis for this. 7

8. New Patient relationship Modifiers for 2018-per CMS Next year CMS plans to give physicians and some non-physician practitioners the opportunity to test drive modifiers that indicate the relationship between provider and patient. CMS was required to create codes that will be appended to Medicare claims to “facilitate the attribution of patients and episodes to one or more clinicians” ~ byMACRA Here are the proposed modifiers for the 2018 physician feeschedule: *X1- (Continuous/broad services) Principal care no plannedendpoint *X2- (Continuous/focused services) Clinicians whose expertise is needed for ongoingmanagement *X3- (Episodic/broad services) Clinicians who have broad responsibility for comprehensive needs, i.e. hospitalist *X4- (Episodic/focused services) Specialty clinicians who provide time-limited care, i.e surgery, radiationetc.. *X5- (Only as ordered by another clinician) Example a radiologist or cardiologist who interprets a diagnostic test These modifiers are intended for use by physicians and applicable NPP’s. The Jan 1st, 2018 rollout of the codes is required by law. However the use of the modifiers will not be mandatory in 2018. The modifiers “may be voluntarily reported on Medicare claims, and will not effect payment”. They should not be used with quality measures. 8

9. A D V A N C E D C A R E P L A N N I N G2018 Call it funding for death panels or w hatever else you please, but beginning January 1, 2016, Medicare finally will pay physicians and non- physician practitioners for time spent providing face-to-face advance care planning(ACP). In the Final Rule, C M S provided the following directives on providing and billing for A C P , while also promising to issue further sub regulatoryguidance: -There are no specific performance standards, special training, or quality measures a provider must satisfy to billforA C P . But a helpful w ebsite www .Vitaltalk.orgcan w alk you through the steps of these importantconversations. - A C P m a y be furnished and billed separately on the sa me day as an evaluation and ma n a g e me n t (E/M)visit. - A C P is subject to cost-sharing requirements, unless furnished in conjunction with the We l co m e to Medicare visit or an annual w ellnessvisit. -Presently , A C P is not reimbursable if furnished via telehealth. - A C P m a y be furnished “incident-to,” subject to directsupervision. - A C Pwillbeastand-alonebillablevisitinaruralhealthclinic( R HC )orFederallyQualifiedHealthCenter(FQHC),w h e n furnishedbyanR H CorF Q H Cpractitionera ndallotherpr ogramrequirementsaremet.Iffurnishedonthesa m edateasanother billablevisitatanR H C orF Q H C ,onlyonevisitwillbepaid. -C C I 22.0 H a s edits w h e n coded with 99221-99222 and on any Observation C o d e s 99218-99220 and99224-99226. 9

10. EHR/EMR Certification mandatory for qualityreporting Compliance: eClinicalWorks is the first EHR vendor to get into legal trouble for falsifying certification compliance, but it won’t be the last. The HHS-IT agency in charge of EHR certification, will have an increased interest in whether certain EHR products meet the requirementsor should be decertified. So many EHR/EMR companies rushed to be certified and not all are. Physicians are required to use CERTIFIED EHR technology, (CEHRT) in order to comply with the merit-based incentive payment system (MIPS) and other payment initiatives. EHR users should look for: Take any alerts from your EHR vendor seriously. Review these notes and install any updates right away. Review your EHR contract. Check warranties, litigation issues, and patient safety issues, and decertification possibilities. Review any promotion arrangements your clinicians have with your vendor. The DOJ claimed that eClinicalWorks’ payments to providers for promoting their products violated the anti-kickback laws; Some vendors provide remuneration in the form of discounted maintenance or payment for referrals, references and other promoted activities. Consider filing for a hardship exception if you find out your system is decertified. CMS announced in its proposed QPP released June 20th, a new hardship exemption for providers if their EHR software is decertified. 1. 2. 3. 4. 10