How Will Changes to the Physician Fee Schedule

Affect Your Practice?

By Susan Dooley

Did you remember to check the Medicare Physician Fee Schedule Database (MPFSDB) for July? CMS
implements the changes on July 5, 2016, but some of the changes will be effective back to Jan. 1, 2016.

Check Out Key Changes in July Update

CMS requires Medicare Administrative Contractors (MACs) to amend payment files to conform with the
July changes. Note that MACs will not search their files to retract payment for claims already paid, nor
will they retroactively pay claims. However, they will adjust claims that are brought to their attention.
We talked yesterday about some of the new CPT Category III codes added to the MPFS. Next week
well go over changes to HCPCS codes and to National Correct Coding Initiatives (CCI) edits. But today,
lets focus on the CPT Category I codes affected by the 2016 MPFS changes.

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

Review Ways the Fee Schedule Changes Payment for These Codes
The MPFS adjusts the following CPT codes by adding one of several indicators that affect
reimbursement for these services. The codes official descriptors are unchanged.

+10036, Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle,
radioactive seeds), percutaneous, including imaging guidance; each additional lesion

Multiple Surgery Indicator = 0

Note that Medicares multiple procedure rule allows payment of a reduced amount for subsequent
procedures performed during the same session. The indicator digit listed in the Physician Fee Schedules
Multiple Procedure column tells the amount that the reimbursement is reduced. Heres what Chapter
1 of the National Correct Coding Initiative (NCCI) Policy Manual tells us about indicator 0: 0=No
payment adjustment rules for multiple procedures apply. This means that reporting multiple instances
of +10036 will not result in reduced or no reimbursement for the additional instances.

37188, Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural

pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on
subsequent day during course of thrombolytic therapy

Multiple Surgery Indicator = 0

This means that for 37188, no payment adjustment for multiple procedures applies to this code.

45346, Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes
pre- and post-dilation and guide wire passage, when performed)

Endo Base Code = 45330

The endo base code rule is similar to the multiple procedure rule, in that it affects the reporting of two
or more endoscopic procedures. CPT and CMS classify endoscopic procedure codes by family. Each
family is made up of related services with a parent code consisting of an endoscopic base code,
representing the most basic version of that endoscopic service. The base code for 45346 is 45330, a
flexible sigmoidoscopy with or without collection of specimens. This means that if a gastroenterologist
performs diagnostic sigmoidoscopy (45330), and finds lesions that require ablation, you can only report
45346. This is because the ablation procedure includes the work of the diagnostic sigmoidoscopy
procedure.

+61651, Endovascular intracranial prolonged administration of pharmacologic agent(s) other

than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and
imaging guidance; each additional vascular territory (List separately in addition to code for
primary procedure)

Multiple Surgery Indicator = 0

As noted above, a Multiple Surgery Indicator of 0 tells us that no payment adjustment for multiple
procedures applies to this code.

65855, Trabeculoplasty by laser surgery

Bilateral Indicator = 1
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

Bilateral indicators identify which procedures can be billed as bilateral. A bilateral indicator of 0 means
the criteria doesnt apply. An indicator of 1 means the procedure is Conditional Bilateral. This means
that if you report 65855 with modifier 50 to indicate a bilateral procedure, Medicare will reimburse at
150 percent of the allowed amount.

69209, Removal impacted cerumen using irrigation/lavage, unilateral

PC/TC indicator = 3
This indicator 3 designates 69209 as a technical component only code, which is a standalone code
describing the technical component (that is, staff and equipment costs) of this diagnostic test.

What About You?

Do you think these changes will have a big effect on your practice? Please let us know.

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Contact Us:
Name: Sam Nair
Title: Associate Director
Email: shyamn@codinginstitute.com
Direct: 704 303 8150

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com