305.000 UNIVERSAL CODE FOR REPORTING MEDICAL SERVICES

305.990           Fair Compensation for Prior Authorization and Appeal of Service Denials

MSSNY advocates and requests that upon adoption of CPT codes by the AMA CPT Panel at the May 2024 meeting for payor authorization services and appeals of denied services, the AMA immediately starts advocacy on federal and state levels for legislative mandates for coverage of CPT Codes for work involved for payor authorization and appeals of wrongful denials of services (visits, tests, procedures, medications, devices, and claims), whether pre- or post-service denials; and further that model legislature satisfies the requirements enumerated in RUTLEDGE, ATTORNEY GENERAL OF ARKANSAS v. PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION.

MSSNY requests that our AMA report at the 2025 Meeting on the progress of implementation of this resolution. (HOD 2024 – Emergency resolution A)

305.991           CPT Codes for Preauthorization Denials and Fair Compensation

MSSNY will advocate that the AMA include fair compensation based on CPT codes for appeal of wrongfully denied services in any Model Legislation and as a basis for all advocacy, including those for prior authorization reforms and that CPT codes must fully reflect the aggregated time and effort expanded by physician practices.

MSSNY will urge the AMA to have the AMA CPT Editorial Panel establish a CPT code which would account for administrative work involved in prior authorizations and that reflects the actual time expended by physician practices advocating on behalf of patients and complying with insurer requirements.

MSSNY will urge the AMA to have the AMA CPT Editorial Panel establish a CPT code which would account for administrative work that reflects the actual time expended by physician practices and their billing vendors in successfully appealing wrongful pre- and post-service denials. (HOD 2021-254 and 255

305.992           Obsolete ICD and CPT Codes

The Medical Society of the State of New York (MSSNY) will seek legislation and regulation that would:

• Provide a grace period where new ICD and CPT codes could be phased in, and
• Prevent insurers from denying those portions of a claim coded with an obsolete or  superseded ICD or CPT code, and

• Require that the period for ICD and CPT revisions are instituted be concurrent (e.g. January 1).

MSSNY will send this resolution to the AMA HOD.  (HOD 2020-261)

305.993           ECG/Stress Test Billing Bundle

The MSSNY will seek legislation and regulation to prevent insurers from being permitted to bundle an ECG (CPT cod 93000) with a stress test (code 93015) when these separate procedures are medically necessary to be performed on the same day.  (HOD 2019-258) 

305.994           ECG/Office Visit Billing Bundle

The MSSNY will seek legislation and regulation to prevent insurers from being allowed to bundle an ECG (CPT code 93000) with a visit, when medically necessary.  (HOD 2019-259)

305.995           Violation of HIPAA Electronic Transaction Standards by Insurer Failure to Upload ICD-10 Revisions

The Medical Society of the State of New York (MSSNY) will survey its members asking whether they have experienced claim denials, claims resubmission, or appeals because the insurer (federal, state or commercial) failed to upload the October 1, 2016, version of ICD-10 in a timely fashion.

Additionally, the Medical Society of the State of New York (MSSNY) will urge the American Medical Association (AMA) to present information on ICD-10 improper claim denials to the Centers for Medicare and Medicaid Services (CMS) and its Office of E-Health Standards & Services, to determine whether the insurers’ failure to properly update their claims processing systems has constituted a violation of the HIPAA Electronic Transaction Standards and should trigger disciplinary or corrective actions to prevent these occurrences in the future.  (HOD 2017-253)

305.996           Unknown Diagnosis Coding Under ICD-10

The Medical Society for the State of New York (MSSNY) will ask the Centers for Medicare and Medicaid Services (CMS) to enforce Unknown Diagnosis Coding and ICD-10 Policy with private insurers and managed care organizations, in that such policy is mandatory for all entities covered by the Health Insurance Portability and Accountability (HIPAA) law, but is being ignored by private insurers and managed care organizations.

MSSNY will urge the Centers for  Medicare and Medicaid Services (CMS) to require all private and managed care insurers to  formally adopt the longstanding policy of CMS (reflected in ICD-10), that if a physician (1) does not  know the diagnosis at the start of an encounter; (2) has not established a definitive diagnosis by  the end of the encounter; and (3) is facing a “probable,” “suspected,” “questionable,” “rule-out,” or “working diagnosis” scenario, then it is acceptable for him or her to report codes for signs, symptoms, abnormal test results, exposure to communicable disease, or other reason for the visit.

MSSNY will urge CMS to require private and managed care insurers to adopt the policy of CMS (reflected in ICD-10) that when the physician does not have enough clinical information about a particular health condition to assign a more specific code (e.g. if he or she suspects a diagnosis of pneumonia but by the end of the encounter has not determined the underlying cause of the pneumonia — bacterial, et al), it is acceptable to report the appropriate “unspecified” code. (HOD 2016-252)

305.997           ICD-10: SUNSET HOD 2024

305.998           HCFA Provision of Coding Information Free of Charge: SUNSET HOD 2014

305.999           Universal Code for Reporting Medical Services and Procedures Performed by New York State Physicians: SUNSET HOD 2013