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AMA Coding Guidance

Code Set Updates

Hot Topics

Accountable Care Organizations

   By Patty Telgener, RN, MBA

Medicare has historically paid doctors and hospitals on a fee for service that paid providers per test or per procedure. An Accountable Care Organization (ACO) is a network of providers such as primary care doctors, physician specialists, hospitals, and/or home care agencies that would share responsibility for that patient. The intent of Accountable Care Organizations (ACOs) is to give doctors and hospitals financial incentives to provide quality care to Medicare beneficiaries while keeping down costs.

On October 20, 2011, the Centers for Medicare and Medicaid Services (CMS) released the final rule for accountable care organizations (ACOs). In the final rule, Medicare outlined the two components of the ACO program which are the Shared Savings Program and the Advanced Payment Model. In response to an overwhelming number of public comments to the proposed rule, the final rule made a number of significant changes.

First, the final rule delays the start date. The original start date was to be January 2012. But the final rule announced that the program will “be established” by January 2012 with the initial agreements starting in April-July of 2012.

To be eligible to participate in the Shared Savings Program, ACOs must be accountable for at least 5,000 beneficiaries a year for each of the 3 years of the agreement. Originally, physicians in group practices, individual practitioner networks, and/or hospitals were the only providers that could sponsor an ACO. However, that list was expanded in the final rule to include collaborations between Rural Health Clinics and Federally Qualified Health Centers. To be eligible for the shared savings, ACO participants will be required to report on four quality measurement domains such as quality standards, care coordination, preventive health, and at-risk populations. The final rule reduced the number of quality measures that must be reported from sixty five to thirty three. In the first year, ACOs will only be required to report on these measures to receive payment. However, they will need to meet pay-for-performance standards on twenty five of the measures in the second year to receive payment, which will then be expanded to meeting thirty two measures in the third year.

The final rule made some changes to how Medicare beneficiaries would be assigned to ACOs, noting that "determination of whether an Accountable Care Organization was responsible for coordinating care for a beneficiary will be based on whether that person received most of their primary care services from the organization." But Medicare beneficiaries receiving care from providers participating in an Accountable Care Organization will retain their rights to see any physician or hospital that participates in the Medicare program. An ACO cannot restrict care or limit a Medicare beneficiary’s access to other physicians or providers.

To encourage participation in the Shared Savings Program, CMS announced that they would have money available to physicians, hospitals, and others for major capital investments under the Advanced Payment Model. The Advanced Payment Model was designed to support physician-owned and rural ACOs with upfront infrastructure investments. These providers will receive payments in advance that will then be recouped as these providers achieve savings. There are three ways provider groups may receive these payments:

  • Upfront fixed payment
  • Upfront payment based on the number of Medicare patients served
  • Monthly payment based on the number of Medicare patients

The Advanced Payment Model is only available for physician-owned organizations, critical access hospitals, and rural providers participating in the Shared Savings Program. CMS created this model to determine if pre-paying a portion of future shared savings would increase participation in the Medicare Shared Savings Program.

On the same day as CMS released the final rule, several federal agencies issued additional guidance on antitrust laws. CMS has worked closely with the Department of Justice (DOJ) and the Federal Trade Commission (FTC) to provide guidance antitrust issues as they relate to ACOs.

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FDA-CMS Parallel Review

   By Beth Bontemps, RN, MSN, NP, CCS

The Federal Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS) announced a memorandum of understanding (MOU) in the Federal Register in August of last year (Vol. 75, No. 154). The purpose of the MOU was to promote the sharing of information and expertise between the FDA and CMS. The goals of the collaboration are to explore ways to further enhance information sharing efforts through more efficient and robust inter-agency activities, promote efficient utilization of tools and expertise for product analysis, validation, and risk identification, and build infrastructure and processes that meet the common needs for evaluating the safety, efficacy, utilization, coverage, payment, and clinical benefit of drugs, biologics, and medical devices. The MOU allows for the sharing of FDA data submissions with CMS, and reciprocal sharing of Medicare data with the FDA. The MOU also includes protections from unauthorized public disclosure of trade secrets and other confidential commercial information that would be protected from public disclosure by Federal statutes.

The anticipated benefits of an FDA-CMS Parallel Review program include facilitating development of innovative new products as well increased efficiency in the Agencies' review processes. The need arose from the Agencies’ recognition that innovators have generally focused solely on obtaining FDA approval, only to later realize that Medicare payment may not automatically be forthcoming.

In follow-up to the MOU, the FDA and the CMS have established a pilot program for concurrent review of certain FDA premarket review submissions for medical devices and CMS national coverage determinations. The pilot program was announced in the Federal Register (Volume 76, Number 196) on Tuesday, October 11, 2011. By reducing the interval between FDA marketing approval and Medical coverage, this process will facilitate the development of innovative products and shorten the time it takes to bring these important products to patients.

The FDA and the CMS are soliciting nominations from sponsors of innovative device technologies to participate in a pilot program for concurrent review of certain FDA premarket review submissions and CMS national coverage determinations. The Agencies are now providing notice of the procedures for voluntary participation in the pilot program, as well as the guiding principles the Agencies intend to follow.

During its pilot phase, the agencies will offer to perform parallel review for up to five innovative devices per year. Appropriate candidates for the parallel review pilot are medical devices that meet one of the following criteria:

    1. New technologies for which the sponsor/requester has a pre-investigational device exemption (IDE) or an approved IDE application designation.
    2. New technologies that would require an original or supplemental application for premarket approval (PMA) or a petition for de novo review.
    3. New technologies that fall within the scope of a Part A or Part B Medicare benefit category and are not subject to a national coverage decision (NCD).

The pilot program is voluntary and will not change the existing separate and distinct review standards for FDA device approval and CMS coverage determination. It is only available for medical device technologies that meet the above criteria.

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Diabetes Self-Management Training (DSMT) Provided in a Pharmacy Setting

   By Patty Telgener, RN, MBA

Diabetes is a chronic condition whose treatment and outcomes are dependent on patients monitoring and managing their disease outside of the health care setting. Diabetes Self-Management Training (DSMT) is a collaborative process where patients learn skills needed to modify behaviors and successfully self-manage their disease and its related conditions.

In order for a Medicare patient to be eligible for DSMT, patient must meet one of the following diagnostic laboratory criterion:

DSME/T Diagnostic Criteria
Diabetes: At least 1 of 3 laboratory criteria required.
  • Fasting blood glucose (FBG) of greater then or equal to 126 mg/dl on two different occasions.
  • Two hour post-glucose challenge test of greater than or equal to 200 mg/dl on two different occasions.
  • Random glucose test or greater than or equal to 200 mg/dl for person with symptoms of uncontrolled diabetes.

Medicare covers an initial DSMT one-time benefit of ten hours of instruction in 12 consecutive months. Nine of the ten hours must be provided in group format, unless the beneficiary meets Medicare’s criteria for individualized DSMT. Otherwise, only one hour of the ten may be used for an individual visit. Patient is eligible for two hours of follow-up DSMT in the subsequent calendar years either in a group or individual setting. The HCPCS codes and allowable benefit are outlined below:

HCPCS Code Description Utilization Limits in Initial Episode of Care and Provision Utilization Limits in Follow-Up Episode of Care and Provisions of Hours

Diabetes outpatient self-management training services (DSMT); group session (2 – 20 individuals*), face-to-face with patient, each 30 minutes of training.


*Note: 2 - 20 individuals must be patients; not all patients need be Medicare beneficiaries.


DSMT program must be accredited as meeting the ten National Standards of DSME by either the American Diabetes Association or the American Association of Diabetes Educators. 

10 hours in first consecutive 12 months upon written referral by physician (MD or DO) or qualified non-physician practitioner; 9 hours to be in group, unless:


Ÿ Barriers that hinder group learning  documented by referring provider

Ÿ No DSMT program  scheduled within 2 months of referral date 

Ÿ Referring provider orders additional insulin training

2 hours in subsequent calendar years, starting with calendar year following the year in which beneficiary completed initial 10 hours of DSMT, upon another written referral by physician (MD or DO) or qualified non-physician practitioner; 2 hours may be individual or group; documentation of learning barriers not required in order to provide individual follow-up DSMT.
G0108 Diabetes outpatient self-management training services (DSMT); individual session, face-to-face with patient, each 30 minutes of training.

Historically, the typical and most popular practice setting for DSMT programs has been hospital-based outpatient departments. However, in recent years many outpatient hospital DSMT programs have closed due to:

  • Inadequate insurance reimbursement (but in 2011 Medicare has significantly increased the DSMT payment rates).
  • Incorrect claims processing, resulting in rejected and denied claims.
  • Inadequate collection procedures for patient co-payments and deductibles.
  • Ever-increasing costs.
  • Lack of physician referrals (primarily due to inadequate marketing).
  • High patient drop-out rate (the many reasons include class schedule and location that are inconvenient for patients and educators using ineffective compliance counseling rather than patient-friendly empowerment counseling).

This has resulted in a void in the marketplace. Educators have responded by opening up their own DSMT businesses, or implementing DSMT programs in non-hospital community-based settings such as independent and chain pharmacies which is emerging as one of the mainstream settings for DSMT programs.

Establishing a Diabetes Self-Management Training (DSMT) program within a pharmacy can be a rewarding both financially and professionally. By offering DSMT, the pharmacy may distinguish itself from the competition and increase its revenue. The pharmacy must be approved by Medicare as a certified DSMT entity provider in order to direct bill and receive reimbursement for DSMT services.

The pharmacy, not the pharmacist, bills Medicare Part B for the DSMT. However, the pharmacy can partner/contract with an RN or RD who wants to start their own DSMT business. This can be a win-win arrangement with the pharmacy billing on behalf of the entire program. If the pharmacy has never enrolled in Medicare as a DMEPOS supplier, the pharmacy must:

  • First apply for and receive a National Provider Identification (NPI) number for the pharmacy. This is a 10-digit number that replaces the Medicare PIN, and must be used by the pharmacy on all HIPPA-covered transactions and claims with Medicare and all other healthcare plans. NPI application forms are online at the National Plan and Provider Enumeration System (NPPES) at www.nppes.cms.hhs.gov/NPPES
  • Next the pharmacy completes AND submits the CMS-855S application (“Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers”) to enroll in Medicare as a DMEPOS supplier
  • If and when the pharmacy is a DMEPOS supplier, it must then complete the CMS-855B application (“Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers”) to its local Part B carrier.
  • Note: It is recommended that the completed CMS-855B application is sent along with the DSME/T program accreditation application, together, in one envelope, to the Part B carrier in order to decrease the risk of processing errors.

Incorporating DSME/T services into a community pharmacy can be both challenging and rewarding. A pharmacist can successfully navigate through the coverage and reimbursement requirements if they start the process early and takes it one step at a time. In summary, some of the many benefits of a pharmacy offering DSMT services include:

  • Insurance reimbursement for DSMT services and patients’ co-payments.
  • Increase in sales of many types of diabetes-related items
  • Increase in patient satisfaction with the pharmacy, leading to increased store loyalty, leading to increase sales of other general merchandise.
  • Increase in physician’s satisfaction with the pharmacy, leading to increase in patient referrals.

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AMA Coding Guidance

August 2011 CPT Assistant   

 By Jennifer Ridell, CPC

Reporting Cardiothoracic Procedures Using CPT Category I and III Codes (33411, 33863, 33864, 0256T-0259T)


Advancements and changes to current cardiothoracic procedures brought forth the need to update and add CPT codes for 2011. Specifically, changes to codes related to thoracic aortic aneurysms and prosthetic aortic heart procedures were included in CPT 2011. To address recent advancements in catheter-based aortic valve replacement as of July 1, 2010 four new Category III codes were introduced, 0256T - 0259T. Additional changes were made to CPT codes 33405-33413, 33860, 33861, 33863, and 33864.

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2011 Revisions to Modifiers 50, 76, 77, and 78

CPT 2011 included changes to the modifiers 50 and 76 - 78. These changes were made to address appropriate modifier usage.

Modifier 50: The word operative was deleted from the description for this modifier. The reason behind this change is to allow reporting of modifier 50, bilateral procedure, when a procedure is not of an operative nature.

Modifier 76 and 77: The phrase, or other qualified health care professional, was added to the description for modifiers 76 and 77. The reason behind this change is to cover instances where someone other than the original physician repeats the procedure subsequent to the original procedure for a patient either the same day or during the postoperative period.

Modifier 78: The phrase, or other qualified health care professional, was added to the description for modifier 78. The reason behind this change it to cover instances where someone other than the original physician returns to the operating room to perform another procedure during the patient's postoperative or global period for a different procedure.

These modifier changes were effective January 1, 2011.

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Coding Consultation: Questions and Answers

An article by the CPT Editorial Panel answers questions posed to the panel regarding the subjects of surgery/cardiovascular, digestive, and endocrine systems, radiology/diagnostic radiology (diagnostic imaging), Category III codes, and modifiers. The responses answer multiple questions including: may code 36593 be reported for declotting an implanted pleural catheter and is it appropriate to report remote real-time interactive videoconferenced critical care in addition to the critical care service codes 99291 and 99292?

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To view these articles via CCH Coding Comply, search from the Search Code Sets tab in Coding Comply for any of the codes listed above, view the Related Documents by clicking on the paper icon next to the code, then select the article. To view these articles in The Coding Suite, go to the CPT Assistant Archives folder and in the Search field within this folder and enter “July 2011.”

Code Set Updates

October 2011 APC Update

The October 2011 APC update has been released and is now reflected in CCH Coding Comply and the Coding Suite. The APC update, effective October 1, 2011, has 3 new codes (C1830, C1840, C9286) and over 250 values changes.

To view the updated Code Set go to the Search Code Sets tab in CCH Coding Comply, select the appropriate code set, select added, modified, and/or deleted in the Filter Actions and in the Start Date field enter 10/01/2011. Via the search results, you will be able to export all or some codes in Excel format by checking the box next to individual codes or the “Select All” box; and then clicking on the “Export” icon in the upper right corner of the screen. To view the updated Code Sets in the Coding Suite there is a link on the Coding tab for each code set and users should choose the appropriate code set and then view the download page for the most recent changes.

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NOTE: To follow the MediRegs links above, you will need to be a subscriber to the Coding Suite of products and if prompted, enter your username and password. If you cannot remember your user name or password go to: http://wk.mediregs.com/login_fs.html and the system will let you request a reminder. For the Internet Research Network or IntelliConnect links, you will need to be a subscriber to the CCH Coding Comply.

Requests for information about article submission and comments from readers are welcome and should be directed to at Nicole Stone at Nicole.Stone@wolterskluwer.com, Fax 847-267-2514. Customer service inquiries should be directed to 800-449-9525. CCH Coding Compliance Advisor is published monthly by CCH, a Wolters Kluwer business.

©2011 CCH. All rights reserved. No claim is made to original government works; however, the gathering, compilation, and arrangement of such materials, the historical, statutory and other notes and references, as well as commentary and materials in this Publication are subject to CCH copyright. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the publisher is not engaged in rendering legal, accounting or other professional service. If legal advice or other expert assistance is required, the services of a competent professional should be sought. For more information about the The Coding Suite or CCH Health Care Portfolio, please visit our online store at http://mediregs.com or http://health.cch.com.

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About the Authors

Patty Telgener, RN, MBA, is a Senior Director of Reimbursement at Emerson Consultants, Inc. a company focused on offering Reimbursement, Regulatory, Clinical and Market Development consulting to the medical device, biologic and pharmaceutical industries. Patty is a board member of the 2011 CCH & MediRegs Coding Compliance Advisory Board.

Beth Bontemps, RN, MSN, NP, CCS, is a Clinical and Reimbursement Consultant at JR Associates, Inc. JR Associates is a medical reimbursement consultancy that provides comprehensive coding, coverage and payment solutions and strategies for device manufacturers, venture capital firms and healthcare practitioners, worldwide. Beth is a board member of the 2011 CCH & MediRegs Coding Compliance Advisory Board.

Jennifer Ridell, CPC, is the Data Application Coordinator for CCH Coding comply, CCH Reimbursement Toolkit, CCH Health Reform Toolkit and creates all value-add content in the CCH and MediRegs Coding Suite product line. She is the lead editor for the weekly Coding Comply newsletter and also writes for the CCH Medicare and Medicaid Guide weekly report letter where she serves as a coding and billing expert contributor.


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