Utilizing the CMS Website for Additional Coding Direction

By Megan DeVoe, CCS

Editor’s Note: This is the final article in a three-part series on how to master the information available on the Centers for Medicare and Medicaid Services website.

Have you ever wondered how a code becomes a code? Thinking about this question can easily bring to mind the Schoolhouse Rock classic “I’m Just a Bill.” If you become inspired to write your own rendition of “I’m Just a Code,” you can find all the information you need to do so on the Centers for Medicare and Medicaid Services (CMS) website. The ICD-10 Coordination and Maintenance Committee meets twice a year to discuss code changes. These meetings are streamed live and worth taking the time to watch. It is incredibly interesting to see the key stakeholders discuss new technologies, procedures, and clinical issues. Not only do they discuss code changes in these meetings, but the history and reasoning behind the changes are presented as well. It often happens that a doctor will provide detailed information on conditions and procedures that would be difficult to find elsewhere. It is so helpful to understand what you are coding and why it is important to select the most appropriate code. Even better, you can get free CEUs for watching.

CMS handles the ICD-10-PCS code process and the Centers for Disease Control and Prevention (CDC) handles the ICD-10-CM code process. Both agencies do a great job of crosslinking their websites so it is easy to access the meeting information. To review meeting materials for the ICD-10 Coordination and Maintenance Committee (C&M), go to the page titled “ICD-10 C and M Meeting Materials” at www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD-9-CM-C-and-M-Meeting-Materials.html. Do not be alarmed when you see that the URL still has “ICD-9-CM” in it. It will still take you to the listing of the ICD-10 meeting materials.

For each meeting you will find an agenda and handouts in the downloads section of the web page. Each agenda contains detailed information on the codes proposed during that meeting as well as important dates relating to the C&M and the ICD-10-PCS codes. ICD-10-PCS index and table information for the upcoming October changes may also be included.

The screenshot in Figure 1 below shows the March 2018 C&M meeting materials page and where you can find the handouts, as well as an excerpt from the agenda for a meeting.

Figure 1: ICD-10 C and M Meeting Materials Web Page and Agenda Excerpt

Source: Centers for Medicare and Medicaid Services. ICD-10 C and M Meeting Materials web page. www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD-9-CM-C-and-M-Meeting-Materials-Items/2018-03-06-MeetingMaterials.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending.

The May 2018 Coding Notes article “Understand CMS Outpatient Hospital Edits in 10 Minutes or Less” discussed the National Correct Coding Initiative (NCCI) hospital procedure to procedure (PTP) edits. There are also practitioner PTP edits. Those edits can be found using the same URLs mentioned in that article. Each quarter, a new version of the edits is released, available at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html. When coding for physician services, these are the PTP edits coding professionals will want to use to help decide when CPT/HCPCS codes may or may not be assigned together.

CMS also provides the Medicare Physician Fee Schedule files and a handy look-up tool on their physician fee schedule web page at www.cms.gov/apps/physician-fee-schedule/overview.aspx. In the look-up tool, a coding professional can search by code to find code information relating to the fee schedule.

For example, the screenshot of the look-up tool in Figure 2 below provides information on laterality, global period, and modifier usage.

Figure 2: Screenshot of Look-up Tool

Source: Centers for Medicare and Medicaid Services. Physician Fee Schedule Search web page. www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=1&HT=0&H1=45378&M=5.

Along with all the information above and in the previous articles of this Coding Notes series, CMS provides yet another fantastic resource—the Medicare Claims Processing Manual. This manual explains the history of instruction for hospital and provider services. There are 38 chapters, each dealing with a different service or instruction. The screenshot in Figure 3 below is a sampling of the chapters available in the manual.

Figure 3: Sample of Chapters Available in Medicare Claims Processing Manual

Source: Centers for Medicare and Medicaid Services. Details for title: 100-04 web page. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html.

The chapters will provide very specific information for the chapter topic and links to applicable transmittals for that chapter. They include coding and modifier direction as well as claims processing information. Bookmark these manuals rather than downloading them so you can be sure you are looking at the most recent information. The screenshot in Figure 4—below—shows an excerpt from Chapter 4 – Part B Hospital.

Figure 4: Excerpt from Medicare Claims Processing Manual

Source: Centers for Medicare and Medicaid Services. “Medicare Claims Processing Manual. Chapter 4 – Part B Hospital (Including Inpatient Hospital Part B and OPPS).” www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf.

Finally, let’s talk about medical necessity. CMS provides all Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), and local coverage articles on the Medicare Coverage Database web page. On this page you can search by document ID or document type. There is also an advanced search where you can search using multiple parameters. The screenshot in Figure 5—below—shows the Quick Search function.

Figure 5: Quick Search Function on Medicare Coverage Database Web Page

Source: Centers for Medicare and Medicaid Services. Medicare Coverage Database web page. www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.

The NCDs provide direction on the national level for Medicare services. You can view the NCDs alphabetically or by chapter/section. Each NCD section will describe the section service, indications and limitations of coverage, and any non-covered indications. NCDs generally do not provide coding instruction but do provide links to the appropriate LCDs, coverage transmittals, and change requests. Also contained in the NCDs are any frequency limitations and age restrictions.

For example, the screenshot in Figure 6 below shows the indications and limitations of coverage for Prostate Cancer Screening Tests defined in the NCD for Prostate Cancer Screening Tests (210.1), which are covered at a frequency of once every 12 months for men who have attained age 50 (when at least 11 months have passed following the month in which the last Medicare-covered screening prostate specific antigen test was performed). Since the NCDs provide indications for coverage, this can help providers ensure their documentation will sufficiently represent the need for the service.

Figure 6: Prostate Cancer Screening Tests

Source: Centers for Medicare and Medicaid Services. National Coverage Determination (NCD) for Prostate Cancer Screening Tests (210.1) web page. www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=268&ncdver=2&bc=AAAAQAAAAAAA&.

LCDs are policy decisions made by Medicare contractors for their geographic area where a NCD does not exist or needs clarification. LCDs do provide procedure codes and may indicate which diagnosis codes will meet medical necessity. Along with LCDs, contractors may provide local coverage articles to communicate additional local coverage information. Like NCDs, LCDs provide a description of the service and any limitations. They can even include which revenue code and bill type to use. Again, documentation requirements are listed and links provided to any related local coverage documents. The screenshot in Figure 7 below shows the codes that meet medical necessity for screening mammograms defined in L36342, as well as the related local coverage documents.

Figure 7: Codes that Meet Medical Necessity for Screening Mammograms and Related LCDs

Source: Centers for Medicare and Medicaid Services. Local Coverage Determination (LCD): Screening and Diagnostic Mammography (L36342) web page. www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36342&ver=31&DocType=Active&bc=AAIAAAAAAAAA&.

This article series has discussed how to use the information publicly available on the CMS website to enhance and substantiate coding decisions. While several key areas were covered, this series barely scratches the surface. Coding professionals are encouraged to get familiar with the information available on this website and get curious. It is important to understand what is being coded and why it needs to be coded that way. As instruction, technology, and medicine evolve, we must keep pace and embrace change. Never a dull moment, right?

Megan DeVoe (mdevoe@earthlink.net) is senior product specialist at TruCode.

Article citation:
DeVoe, Megan. “Utilizing the CMS Website for Additional Coding Direction.” Journal of AHIMA 89, no. 7 (July-August 2018): 68-73.