Extreme Makover: HCPCS Coding Edition

Vol. 15 •Issue 11 • Page 20
Extreme Makover: HCPCS Coding Edition

CMS gives the HCPCS issuance process a new look.

Don’t like your house, your facial features or your body? Well, why not make them over? TV’s latest hit Extreme Makeover has given many houses, families and individuals new beginnings—a fresh start.

And that’s just what the Center for Medicare and Medicaid Services (CMS) has decided to do with the Healthcare Common Procedure Coding System (HCPCS) issuance process. The foundation is in place, but the public’s input is lacking and the requirements need tweaking.

In a statement released in October 2004, CMS announced its plans (see sidebar) to makeover the HCPCS Level II system “to update the code sets that make it possible to pay for certain health care items and services,” CMS announced. And in return, patients will benefit from the streamlined issuance of codes for new technology.

The Public’s Input

One of the major changes to the codes—used by Medicare, Medicaid, private insurers, providers and suppliers—is the expansion of the public meetings.

In 2000, Congress passed the Medicare, Medicaid and State Children’s Health Insurance Program (SCHIP) Benefits Improvement and Protection Act (BIPA), mandating “that CMS establish procedures that permit public consultation for coding and payment determinations for new durable medical equipment (DME).

“As part of HCPCS reform, CMS has expanded the public meeting forum to include all public requests as of the 2005-2006 coding cycle,” according to CMS.

Cindy Hake, chairperson of the CMS HCPCS Workgroup, explained that the congressional mandate is only part of the reason CMS has reformed. “We want to have a more open and responsive government, and we feel the public’s input CMS receives is valuable, because it helps us to make quality decisions,” she stated.

The public forums are also a favorable time for coding professionals to voice their opinions. “It gives coders and others in the medical community the opportunity to come forth with ideas for improvement and to have a meeting in which those ideas can be heard,” assured Sheri Poe Bernard, CPC, CPC-H, secretary of the national advisory board, American Academy of Professional Coders; and senior director of product management, Ingenix.

Bernard previously managed the ICD-9 product line at Ingenix, and as a result, attended the public forums for the Coordination and Maintenance (C&M) committee for more than 10 years. She wanted to emphasize the impact coders have in the process, so she offered this example:

“A representative from the New York HIM association, who was also a Certified Professional Coder, came to the C&M committee meeting several years ago, addressing the denials she received for bone scans performed on post-menopausal women. There was no code for post-menopausal women unless there were complications or symptoms, so insurers kept denying her claims.

“There was a code for a woman who’s on medication, there was a code for a woman with hot flashes, but if you were an asymptomatic, post-menopausal woman, there was no code. After her presentation at the meeting, CMS came up with the V code that currently exists for asymptomatic, post-menopausal women.”

So coders can have an impact on the HCPCS coding system, and government meetings provide the opportunity to impact the future of coding. “Coders have already been successful impacting the ICD-9 levels I and III. These new meetings will be a great opportunity for coders who want to clarify and fix some problem areas in the HCPCS code set,” Bernard stated.

Next month, CMS will be holding the HCPCS public forums on June 7-8, 14-16 and 21-22.

“Still pending this year, we’ll be publishing the notice of the preliminary decisions on our Web site, and along with that the agendas for the public meetings and the online registration information,” Hake continued. “Visit www.cms.hhs.gov/medicare/hcpcs for continuing information on the process.” It’s also important to note that the public meeting agendas will be split into coding groups, so attendance can be based on specific areas of interest.

Missed the Show?

If you’re not able to attend, CMS now has all the application summaries, which were due Jan. 3, 2005 (three months earlier than the previous April deadline), live on its Web site. “With adding the public meeting process to all coding requests and expanding that from just DME to every HCPCS code, we needed more time,” Hake stated.

Susan Hull, practice manager, American Health Information Management Association, felt that the final count of 182 applications was much lower than the usual 300 applications received each year. She considered that the earlier deadline impacted the number of applications.

But Hake explained, “The 300 number from previous years included internal changes, and some requests have six, eight or 10 codes; people are asking for a series of codes. So the number of physical requests can be a little misleading.”

CMS is currently on track to make approximately 1,000 changes to the code set this year; the same amount made last year.

In accordance with the expansion of the public meetings, the public can also submit written comments on each application up until the June meetings.

“Anyone can comment on an application,” Hull stated. “If I felt that issuing a code is a bad idea for a certain product, I can submit my opinion up until the day of the public hearing to that effect.”

The applications were published online in more detail this year. “Trying to capture the essence of each application was a challenge. We may have to reformat that for next year and have a summary for publication submitted with the application. However, it’s extremely worth while to have that information there,” explained Hake.

Source of Inspiration

Bernard couldn’t agree more. The code application information is an essential tool for coders, she stressed. “At Ingenix, we receive the HCPCS codes, so we can develop the code books, and some of the code descriptions have no context. So we initially have no idea what the government had in mind when they issued the code.”

The application documents assist coders in comprehending the purpose of the code and how the code is expected to be used. “It’s important to know why a code is created. It helps you understand, so the code can be used correctly. It’s a real advantage,” Bernard assured.

Frank Joutras, president, Inverse Technology Corp., Lincoln, NE, submitted an application for a functional neuromuscular control device. He fully appreciates the public’s chance to comment. “It’s an excellent move. The reason this product has survived without public notice is because it works. We have 20,000 patients that would testify for us that it’s helped them,” he assured.

Inverse is a small company that initiated the establishment of the L1885 code in 1996. “Initially, we didn’t know we had to alert the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC), which is under contract with CMS, to inform them that we were using code L1885,” Joutras explained.

So over some time, other manufacturers improperly started using the code. In January 2004, Joutras was informed that L1885 was going to be eliminated because of abuse, and it was going to be cross walked to code E1810. Joutras’ application summary helps explain the situation:

• Request #05.26

Frank Joutras of Inverse Technology Corp. submitted a request to establish a code for a functional neuromuscular control device, trade name: Protonics. Requester claims that instruction to code at E1810 is inappropriate because the product is not being used for what E1810 was originally intended; Protonics is not a spring-loaded device or intended for non-functional use after surgery. Requester claims this is causing confusion to third-party payers. Therefore requester is seeking a new E code. According to the requester, Protonics is an external limb component that is added to, or part of an orthosis. This device is used only while the patient is functioning to control neuromuscular activation of certain muscle groups during motion allowing the device to influence joint kinematics and contact areas associated with the pelvis, femur and patella resulting in increased function and decreased pain during activities. Protonics uses a patented and unique form of functional resistance to influence certain neuromuscular activity only while the patient is walking or performing functional movements. Usage of the device needed on a daily basis is patient dependent, but most patients will need to use the device extensively over the first few months, and then periodically based on their activity level.


Joutras has spoken with Hake and with Doran Edwards, MD, medical director, SADMERC, about the situation and right now Joutras and CMS are attempting to resolve the issue. “Some insurance companies are rejecting our device, because they see E1810 and think our device is a dynamic splint, and therefore feel it’s experimental to use on any conditions other than what the code intended. They’re asking, ‘How can a dynamic splint do anything for pain?’” Joutras explained. “Close to a third of our patients have not been able to be reimbursed because our code was cross walked to E1810,” he stated.

So Joutras feels the public’s input will help his application and the background information provided certainly helps coders understand where E1810 originated.

There are some, however, who feel the public input could do more harm than good. Take Andrew Jones, president, Northwest Medical Physics Equipment Inc., Lynwood, WA, for example. He submitted an application for implanted gold markers to improve the accuracy of radiation therapy doses. “I don’t think [public input] is a good idea. Comments may not be relevant to the subject matter or they may be based on personal reference,” he continued, “It also has the possibility of opening the door to competitors who have a similar product, allowing them to fire off any comment saying that the code is unnecessary.”

But Hake feels that varying opinions is the point of the public’s involvement. “The way we look at it is the more input the better quality decision. We see it as a good thing,” she explained.

Does the issuance of codes provide a sense of legitimacy to manufacturers, so competitors’ opinions could be harmful? Bernard thinks so, and she believes it’s one of the dangers in how codes are created. “Once a product receives a code, its manufacturers tend to think they can really sell it because even the government is agreeing that it’s a good thing,” she maintained.

Bernard offered that during the C&M meetings, CMS has been judicious about what codes are issued. “I think they need to be. The government is in a tough position dealing with the onslaught of manufacturers looking for specific codes. CMS does a good job of sorting out the ones that are unique and require a separate code.”

Another point Bernard added was that it’s now a public forum. “So it means letting your competition know what you’re being aggressive about and it gives competitors the opportunity to rebut in public,” she continued. “Business doesn’t prefer to operate that way.”

Hitting the Runway

But “business” does prefer the other changes to the HCPCS issuance process. “There were changes in the application form itself, and there were changes in the requirements. Drug companies were required to submit a 6-month history of marketing, but now that’s been altered and it’s easier to submit an application,” Hull explained.

The application was streamlined by decreasing the overall number of questions, and reducing the requirements for marketing data was positively received.

The market requirements have been reduced to 3 months for some items and none for others. For code issuance on drugs, CMS is even accepting the FDA approval 3 months after the application deadline.

“CMS seems fully dedicated to improving the use of technology; it’s on track with all of the goals stated in the October 2004 press release,” Hull noted.

“We’ve been quite committed in both helping new technology and new products get to the market quicker and also reducing the overall time from request to implementation that a coding application would take,” Hake stated.

CMS has also initiated an appeals process to begin in 2007 and it has restructured its relationship with the National Panel, so it’s now receiving input from all payers: Medicare, Medicaid and private insurers.

Hake mentioned that the open forum, held last October, had more than 600 participants and the majority were in favor of the changes.

Revealing the New Look

Announcing the changes is also an important area in the HCPCS issuance process. “Codes are only the first step,” Bernard stated.

There was a new ICD-9-CM code issued last year for a repeated PAP test, for someone who has human papilloma virus (HPV), because more frequent testing is medically required of patients with HPV. Bernard has noticed that most health plans, whether private payer or Medicare, only cover one PAP test a year. “When I checked with coders last January, everyone using the new code was getting claims rejected for lack of medical necessity. The new code wasn’t recognized. Just because a code is created to solve a problem doesn’t mean the problem is solved,” Bernard explained.

This new technology improvement to HCPCS is important and beneficial, but that’s only the front end. “That says here’s how to code it, but supplying information to the payment end and making sure the providers are aware are essential to speeding up the process,” assured Bernard.

Tricia Cassidy is an assistant editor at ADVANCE.

CMS’ Makeover Plans

In the October 2004 press release, CMS publicized its plans to revamp the HCPCS issuance process:

1) Expansion of the Public Meetings—The current public meetings related to durable medical equipment (DME) will be expanded to include all public requests in advance, including descriptions of the coding requests, the requestor and the name of the product or service. This change will provide more opportunities for the public to become aware of coding changes under consideration, as well as opportunities for public input into decision making.

2) Appeals Process—We expect to implement an appeals process in the 2007 coding cycle, whereby denied applicants will be allowed to appeal the decision and an opportunity to have their application reconsidered during the same coding cycle.

3) Public Notice of Decisions—All preliminary decisions will be published on the CMS Web site prior to public meetings, to facilitate effective public discussion and comment. Final decisions based on public comments, as well as decisions resulting from appeals, will be similarly published.

4) Revision of the HCPCS Code Application Form—The application format is being revised to be more streamlined, user-friendly, and to incorporate helpful suggestions received as a result of the stakeholder survey.

5) Elimination of Requirement for Marketing Data for Drugs—The standard requirement for submission of 6 months of marketing data will be waived when the application pertains to a drug. The FDA approval documentation will be accepted after the application deadline.

6) Reduction in Marketing Data for Non-Drug Items—The marketing requirement for DME, orthotics and supplies will be reduced from 6 months to 3 months.

7) Consideration of National Medicaid Program Operating Needs—CMS is working with State Medicaid Directors to establish a process to consider coding changes that may be needed based on national Medicaid program operating needs.

–Information courtesy of CMS