pqri measure coding and reporting principles - Indiana Academy of ...

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E. Statutory Basis for Payment 1. §1862(a)(7) of the Social Security Act (the Act) excludes payment for "routine physical checkups." Both physical examinations and diagnostic tests that are performed in the absence of signs or symptoms of illness or injury may be denied as a routine physical checkup under §1862(a)(7) of the Act. The regulatory provision that further explains this policy is contained in 42 CFR Part 411.15(a)(1). 2. §1862(a)(1)(A) of the Act states that no payment will be made for "items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." Both physical examinations and diagnostic tests performed in the absence of signs or symptoms can be denied as unnecessary under §1862(a)(1)(A) of the Act. 3. Through previous program and decision memoranda, Medicare has established a clear hierarchy in the application of these two statutory provisions for use in denying payment for physical examinations and diagnostic tests. Claims are initially evaluated against the statutory requirements of §1862(a)(7) of the Act and, if not denied on that basis, they are evaluated against the statutory requirements of §1862 (a)(1)(A). If they meet the statutory requirements of §1862(a)(1)(A) of the Act, they are paid. In general, §1862(a)(1)(A) of the Act is to be invoked only for denying payment for services that are otherwise covered, and are not otherwise excluded from payment, but which are not covered in a particular case because they are not deemed "medically reasonable and necessary" when performed in that specific situation. F. Applicability of §1862(a)(7) of the Act to Preoperative Services 1. Preoperative Examinations—For purposes of billing under the Physician Fee Schedule, medical preoperative examinations performed by, or at the request of, the attending surgeon do not fall within the statutory exclusion articulated in §1862(a)(7) of the Act. These examinations are payable if they are medically necessary (i.e., based on a determination of medical necessity under §1862(a)(1)(A) of the Act), and meet the documentation requirements of the service billed. Determination of the appropriate E/M code is based on the requirements of the specific type and level of visit or consultation the physician submits on his claim (e.g., established patient, new patient, consultation). 2. Preoperative Diagnostic Tests—When billing under the Physician Fee Schedule, preoperative diagnostic tests performed by, or at the request of, the physician performing preoperative examinations, do not fall within the statutory exclusion articulated in §1862)(a)(7) of the Act. These diagnostic tests are payable if they are medically necessary (i.e., they may be denied under §1862(a)(1)(A)). G. ICD-9 Coding Requirements for Preoperative Service - All claims for preoperative medical examination and preoperative diagnostic tests (i.e., preoperative medical evaluations) must be accompanied by the appropriate ICD-9 code for preoperative examination (e.g., V72.81 through V72.84). Additional appropriate ICD-9 codes for the condition(s) that prompted surgery and for conditions that prompted the preoperative medical evaluation (if any), should also be documented on the claim. Other diagnoses and conditions affecting the patient may also be documented on the claim, if appropriate. The ICD-9 code appearing in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (e.g., V72.81 through V72.84) H. Reasonable and Necessary Services -For the purposes of establishing preoperative services as reasonable and necessary, all claims are subject to applicable national coverage decisions. In the absence of a national coverage decision, reasonable and necessary services are determined by Carrier discretion. Establishing reasonable and necessary preoperative medical evaluations is facilitated when the ICD-9 code(s) for the condition(s) that prompted surgery, and for the conditions that prompted the 5-16 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
preoperative medical evaluation (if any), are documented as additional diagnoses on the claim. [Medicare Carriers Manual, Part 3, Claims Process §15046 – CMS Paper Manual Physician Regulatory Issues Team (PRIT) Issue – History and Physicals by Podiatrists Issue Status Podiatrists have asked that Medicare allow them to perform H&Ps on hospital inpatients. CMS is considering a change to the Hospital Condition of Participation that would permit Podiatrists to perform this service. August 13, 2004 The Hospital Condition of Participation are now in the final approval process. One of 4 PRIT issues which will be resolved in the soon to be released Hospitals October 6, 2004 Conditions of Participation. The PRIT will announce on this website when the Hospital CoP is released. Dec 20, 2004 CMS published a proposed rule - Hospital CoP 3122-P - that addresses this issue. March 25, 2005 The clearance process is very involved for changes to the Conditions of Participation. However, we are confident that the new CoP will be released late May 9, 2006 in 2006 or very early in 2007. Date Issue Created 12/01/2003 Physician Regulatory Issues Team (PRIT) Issue – History and Physicals for Outpatient Surgical Procedures Issue Hospitals have asked if it would be permissible to allow non-credentialed physicians to do the History and Physicals. Status Current interpretive guidelines require that a physician must be credentialed by a hospital in order to be able to do the history and physical which is required before a patient can have ambulatory surgery at that hospital. We will discuss this policy with CMS policy experts and appropriate specialty societies. We have discussed this issue with the American College of Surgeons and we July 15 have a meeting about this issue with the American College of Physicians next week. Surgeons routinely provide focused H&Ps to their surgical patients as part of the September 29 preoperative services which are bundled into the payment for the surgery. Patients who have significant comorbid conditions may require a preoperative visit with an internist or subspecialist in which case that visit would be covered. It would be appropriate for the internist to perform a focused H&P and make recommendations concerning the management of the patient’s comorbid conditions during the preoperative period. Date Issue Created 12/01/2005 LESION DESTRUCTION/EXCISION Coding the destruction or removal of skin lesions can be one of the most challenging coding processes faced by a biller. The anatomical site, number (and size, if necessary) of lesions involved, the type of lesion (e.g., skin tag, benign or malignant), and method of removal must be identified to select the proper code(s). Paring or Cutting To report paring or cutting of benign hyperkeratotic lesions (e.g., corn or callus) see codes 11055-11057 5-17 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
Page 1 and 2: PQRI MEASURE CODING AND REPORTING P
Page 3 and 4: ! The line item charge should be $0
Page 5 and 6: ICD-9: 250.00-250.93, 648.00-648.04
Page 7 and 8: _____ _____ _____ _____ _____ Beta-
Page 9 and 10: Definition: Pharmacologic Therapy:
Page 11 and 12: Definition: Characterization includ
Page 13 and 14: eport the proper CPT II Category II
Page 15: • Physicians and qualified nonphy
Page 19 and 20: The excision of malignant lesion co
Page 21 and 22: complex repairs (CPT codes 13100-13
Page 23 and 24: HEMORRHOIDECTOMY BY SIMPLE LIGATURE
Page 25 and 26: Medicare “Incident to Clarificati
Page 27 and 28: service or other face-to-face servi
Page 29 and 30: HOSPITAL OBSERVATION SERVICES - CPT
Page 31 and 32: If the physicians are each responsi
Page 33 and 34: documented. If the time is not docu
Page 35 and 36: Follow-Up Consultation Service Effe
Page 37 and 38: A physician (primary care or specia
Page 39 and 40: typical severity of the problem(s)
Page 41 and 42: Medicare Part B payment policy does
Page 43 and 44: HOME SERVICES - CPT CODES 99341-993
Page 45 and 46: the medical records must clearly do

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