November 2015

Last week, the Centers for Medicare and Medicaid Services (CMS) issued two final rules that established payment and policies for 2016 under the Medicare program.

The first rule, known as Medicare Physician Fee Schedule governs payment and payments for Part B physician services and other providers. CMS estimates that it will make $1.78 billion in Medicare payment to pulmonary physicians and that the final rule will have 0.0% impact on 2016 payments.  CMS also estimates that it will make $296 million in Medicare payments to critical care physicians and that total impact of the final rule will have 0.0% impact on critical care provider payments. CMS does not estimate payment impact for sleep medicine. 

The rule does contain three new codes and one revised code ATS members should be aware of, these codes were establish to bundle EBUS with bronchoscopy services:

• 31652 with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures
• 31653 with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures
• 31654 with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to code for primary procedure[s])

Revised code, this code was revised for clarity:

• 94640 Pressurized or non-pressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device.

The second major rule is known as the Hospital Outpatient Prospective Payment System rule and governs policy and payments for hospital outpatient services. Compared to the Medicare Physician Fee Schedule, the Hospital Outpatient final rule saw far more payment fluctuation in pulmonary and sleep codes. Pulmonary function tests saw significant variation, with some codes increasing in payment, while others declined. Similar winners and losers are found in interventional bronchoscopy codes. Unattended sleep studies saw cuts ranging from 27 percent to 48 percent, while attended tests saw payment gains (CPT 95808 sleep study attended +72%). Pulmonary rehabilitation services (G0424 + 7%) and respiratory therapy (G0237 +74%, G0238 +7%, G0239 +4%) continued to make payment gains.

Both rules provide guidance on how providers should code for the new "shared decision making visit" associated with Medicare's lung cancer screening program. Medicare has created a new G code for shared decisions making visits:

• G0296 (Counseling visit to discuss need for lung cancerscreening (LDCT) is a 15-minute code with reimbursement of $69.65 in the hospital outpatient setting and $54.10 in physician offices.

The final rule clarified that the G0296 code can be billed on the same day as an EM (providing medical necessity is met) and should be billed with the 25 modifier.  CMS further clarified that the shared decision making visit is a preventive service benefit and therefore no patient copays are applicable.  The final rule did not address if more than one provider can bill the code for the same patient.  CMS has released billing instruction for use of the G0296 coding (insert hotlink).  The CMS policy requires that G0296 claims have the appropriate disease code–ICD-9 V15.82 – for share decision making visits held prior to 10/1/2015 or ICD-10 Z87.891 for shared decision making visits held on or after 10/1/2015).  Any claim without the appropriate code will be denied.

The December issue of the ATS Coding and Billing Quarterly will have more detailed analysis of both rules, correct use of the new and revised codes and provide specific payment information on pulmonary, critical care, and sleep CPT codes and the lung cancer screening shared decision making visit. Shared decision making