Report 2654 Cancer Duplicate Services & Result Coding Presenter: Janet Overstreet Date: 1/25/ CDP/DPH User Training 1

Reasons Why Services Are Duplicate Issues With Result Codes Reasons Why Services Are Duplicate and Issues With Result Codes Same exact services are reported twice for same patient same date of service Same exact services are reported twice for same patient same date of service Missing modifier (either a “26” or “TC”) Missing modifier (either a “26” or “TC”) Reporting of a Digital mammogram to one component and a non-Digital mammogram to the other component for same patient/same date Reporting of a Digital mammogram to one component and a non-Digital mammogram to the other component for same patient/same date Mammogram or breast ultrasound results not reported in the Over-ride field at Patient Encounter entry of PEF Mammogram or breast ultrasound results not reported in the Over-ride field at Patient Encounter entry of PEF 2

Mammograms and Breast Ultrasounds Mammograms and Breast Ultrasounds Professional (26) and Technical (TC) Components Mammograms and Breast Ultrasounds may be reported with or without the “26 and TC” Modifiers, according to how you Contract for those services If you are Contracting and paying one (1) provider for the entire service; you will not use the modifiers example: R1 – Entering PEF the RESULT Code will be reported in the Over-ride field on the line with the mammogram or breast ultrasound code (example: R1) If you are Contracting and paying two (2) different providers separately for each component; you have to report with a Modifier – Entering PEF the RESULT Code will be reported in the Over-ride Field on the line with the mammogram or breast ultrasound code with the “26” modifier 3

Contract Provider #s to use when reporting the mammograms & breast ultrasounds “245—” Hospitals or other contractors who are getting the images are to have a “245—” Provider # “201—” Radiologist are to have a “201—” Provider # “245—” If you are paying the entire mammogram or breast ultrasound to the hospital or other contractor that is also getting the image (both components paid to same contracted provider), you will report the code(s) to the “245—” Provider# 4

technical-TCprofessional-26 (Examples below of two encounters for same patient--same date with Incorrect Reporting) Reporting by component (technical-TC and professional-26 components) and not keying in the modifier with the CPT code when reporting either or both, also not reporting Result Code (Examples below of two encounters for same patient--same date with Incorrect Reporting) EXAMPLE #1: EXAMPLE #2: 5

technical-TCprofessional-26 OR (Examples below of two encounters for same patient--same date with Correct Reporting) Reporting by component (technical-TC and professional-26 components) and keying in the modifier with the CPT code when reporting OR reporting not by component, and reporting Result Code (Examples below of two encounters for same patient--same date with Correct Reporting) OR correct reporting OR correct reporting when both components are paid to same Contracted Provider Technical component to Hospital Professional component to Radiologist 6

technical-TC professional-26 (Examples below of three encounters reported incorrectly for Technical & Professional on same PEF) Reporting by component (technical-TC and professional-26 ) and not keying in the modifier with the CPT code when reporting either or both, also not reporting Result Code (Examples below of three encounters reported incorrectly for Technical & Professional on same PEF) EXAMPLE #1: no modifiers EXAMPLE #2: no modifiers and two different codes for the same mammogram 7

EXAMPLE #3: correct modifiers but using two different codes for same mammogram EXAMPLE #4: CORRECT REPORTING of TC & 26 on same PEF 8

Reporting PAP, HPV, Mammogram, & Breast Ultrasound and Result Codes PAP and/or HPV: The LHD should report the PAP or HPV lab test code through patient encounter entry IF the LHD will be paying the LAB for the lab test. For patients with a third party payor, ONLY the lab should be coding the Pap smear or HPV code (88142, 88174, 88164, 87621, etc.). For patients with third party payers (Medicaid or Insurance) the LHD should not be reporting a separate collection code (in addition to the Evaluation/Management visit code) when collecting the specimen; with the exception of Medicare, who does not pay an E/M with the G0101 (pelvic & CBE). For the Medicare patient the LHD may code a Q0091 for pap specimen collection when a pap is done along with the pelvic & CBE. 9

You should not be reporting the pap code on the PEF entry if the patient has Medicaid, Medicare or Insurance. If the patient is uninsured and the LHD will be paying for the PAP or HPV on behalf of the patient; then you can either report the PAP or HPV code at the time of service or report the code when you pay the claim and assure appropriate audit labels. RESULTS for PAPs and HPVs provided, reported on a PEF, and paid for by the LHD, and are to keyed into the system through the PERS command. The result code for a pap done on patient with a third party payer is to be reported through the Supplemental Reporting System. 10

Reports 323 (Pap log) and 676 (Mammogram log) Pap log report (323) and Mammogram log report (676) should be reviewed monthly to assure results are listed for each patient reported through the Patient Encounter Reporting System or the Supplemental Reporting System. The pap log report and the mammogram log report runs monthly. If the pap is on the 323 Report with no result; the PERS (with Pt#, CPT code, Date) screen will need to be used to enter the pap result. If the mammogram is on the 676 Report with no result; the PERS (with Pt#, CPT code, Date) screen will need to be used to enter the mammogram. (This is the same screen used to report PAP results.) If the mammogram is on the 676 Report as “Incomplete”; the result code reported at PEF entry was “0”. If mammogram results are not entered at PEF entry; the PEF encounter history screen will also need to be revised with the results. For patients that qualify for the federal B&C program; the patient’s BC Screen will need to be updated with result information. 11

MAMMOGRAM or BREAST ULTRASOUND: For uninsured patients that your agency will be paying for their service should be reported through PEF entry. The receipt of medical records is required before the mammogram or breast ultrasound service may be reported into the system. It is recommended also that the claim for the service(s) be received and reviewed for accuracy against the LHD referral and medical records prior to reported into the system and paid to the independent contractor. The mammogram result code should be entered in the Override Field on PEF Entry (R and number of result). Mammogram and breast ultrasound services are on the sliding fee schedule. Assure appropriate audit labels by asking for a “F” (for 2) or number amount (for more than 2) at PEF encounter entry. The result code for an ultrasound done on patient with a third party payer is to be resulted through Supplemental Reporting. 12