Knowledge Base Category -

Q:

What is the principal diagnosis if a patient presents to the hospital with Sepsis and COVID-19?

A:

If a patient has COVID-19 that has progressed to sepsis, we are instructed to see Section I.C.1.d. Sepsis, Severe Sepsis, and Septic Shock.  If sepsis meets the definition of principal diagnosis, sepsis should be sequenced first, followed by COVID-19. 

When COVID-19 meets the definition of principal diagnosis, and sepsis develops after admission, code U07.1 (COVID-19) should be sequenced first, followed by the appropriate code for sepsis.

Remember:  Code only confirmed cases of COVID-19

If a physician documents “presumed” COVID-19, and has tested positive for the virus, code U07.1 (COVID-19) as confirmed.  A positive test at a local or state level can be coded as COVID-19.  The Center for Disease Control and Prevention (CDC) confirmation of local and state tests for the COVID-19 virus is no longer required.

If a physician documents “suspected”, “possible”, “probable”, or “inconclusive” COVID-19, do not assign code U07.1.  Assign a codes(s) explaining the reason for the encounter such as fever, or contact with and (suspected) exposure to other viral communicable diseases (Z20.828).

Resources:

ICD-10-CM Official Coding and Reporting Guidelines (April 1, 2020 through September 30, 2020)

https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

https://www.cdc.gov/nchs/data/icd/ICD-10-CM-April-1-2020-addenda.pdf

American Hospital Association (AHA) Coding Clinic webinar ICD-10-CM Coding for COVID-19

Watch the FREE AHA webinar on COVID-19 and receive one CEU.  https://www.codingclinicadvisor.com/webinar/icd-10-cm-coding-covid-19

Q:

Sometimes modifier 59 is still confusing to us when we are trying to work through CCI edits for Medicare. Is there any new information about modifier 59 that can help us better understand?

A:

Correct Coding Initiative edits are still referred to by a lot of people as “CCI edits”, so we know exactly what you are talking about. Instead of CCI edits, CMS now refers to these as “Procedure to Procedure” edits (PTP). It’s a different name, but the concept is still the same, and hospitals still have to “work through” – as you say – all these edits to determine when to add a modifier.

In March 2020, CMS released a MLN Matters Article SE1418 regarding the proper use of modifier 59 and modifiers –X{EPSU}. In my opinion, the article includes helpful examples of separate practitioner, structure, and encounter.

You asked about Modifier 59, but as you read through the MLN article, you will also see examples for using the X{EPSU} modifiers instead of modifier 59. Remember, the X{EPSU} modifiers are considered more specific than modifier 59 and should be used in lieu of modifier 59 whenever possible. Be sure to incorporate all of this information into your efforts when deciding if a modifier is needed.

I doubt anyone will ever have all the answers about modifier 59, and I say this based on the number of related inquiries we receive every week. With over 1 million code pairs involved, it’s no wonder there’s ongoing confusion. 

Q:

When Medicare changes the status indicator for separately payable drugs, do we have to revise the related modifiers assigned to these drugs in the chargemaster (CDM) / pharmacy system?

A:

Yes. If your hospital purchased the drug through the 340B Program, you must bill the applicable modifier JG or TB for the drug to Medicare. This is specific to drugs / biologicals assigned status indicator G or K in Addendum B under the Outpatient Prospective Payment System (OPPS).

If the drug is assigned status indicator K, Medicare wants to reduce your reimbursement for the drug if it was purchased through 340B.  In that scenario, it is your responsibility to bill the drug to Medicare with modifier JG. If you purchase a status indicator K drug through the 340B program, but do not bill the drug with modifier JG, you will be overpaid.

Modifier TB should be billed for drugs assigned status indicator G which are purchased through the 340B program.  Even though modifier TB is for informational purposes, it is still required, just like modifier JG. This modifier does “not” trigger a reduced payment from Medicare.

If a drug /biological was “not” purchased through a 340B program, modifier JG / TB should not be billed.

This creates a challenge for CDM coordinators, because this type of CDM maintenance is absolutely essential to compliant Medicare billing of these items. You should expect some status indicator changes quarterly. We acknowledge some hospitals manage pharmacy modifiers in a pharmacy system separate from the CDM.

Take a look at the upcoming status indicator changes listed in the  April 2020 OPPS Update, excerpted below – effective April 1, 2020. Keep in mind, modifiers JG and TB must be date specific to match the status indicator assigned for respective dates of service on the outpatient Medicare claim.

New CY 2020 HCPCS Codes Effective April 1, 2020 for Certain Drugs, Biologicals, and Radiopharmaceuticals

Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals receiving pass-through status Effective April 1, 2020

HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals with Pass-Through Status Ending Effective March 31, 2020

For more information about billing 340B modifiers under the OPPS, refer to the CMS FAQ document published April 2018. 

Q:

We are getting an edit that CPT codes 92611 (motion fluoroscopic evaluation of swallowing function by cine or video recording) and 74230 (swallowing function with cineradiography / videoradiography) cannot be billed together and no modifier allowed.  Should we only be reporting 92611?

A:

This is another new CCI edit that became effective January 1, 2020. We have received information from NCCI that CMS has since made the decision to revise this edit. The modifier indicator for this code pair will be changed from “0” to “1”. A modifier indicator of “1” indicates an NCCI-associated modifier may be used to bypass the CCI edit under appropriate circumstances.

The changes will be retroactive to January 1, 2020 and will be implemented as soon as technically possible. Providers may choose to delay submission of claims for deleted edits until after the implementation of the replacement edit file with retroactive date of January 1, 2020.

Providers may also choose to appeal claims denied due to the PTP edits to the appropriate MAC including supporting documentation or resubmit claims denied due to the PTP edits after the implementation of the replacement edit file with January 1, 2020 retroactive date, as permitted by the MAC.

Q:

We are getting a CCI edit between our nuclear medicine bone scans and the radiopharmaceutical we always use in conjunction with bone scans (technetium medronate / MDP). The edit is telling us we cannot report the bone scan CPT code and HCPCS code A9503 for the MDP on the same date of service – with or without a modifier. Can you explain?

A:

This is a new CCI edit that became effective January 1, 2020. We sent actual patient examples to NCCI asking for clarification. We received notification from NCCI that, after review of the issue, CMS has made a decision to delete the January 1, 2020 edits in the table below. Review the table carefully, as the changes include radiopharmaceuticals besides A9503.

The changes will be retroactive to January 1, 2020 and will be implemented as soon as technically possible. Providers may choose to delay submission of claims for deleted edits until after the implementation of the replacement edit file with retroactive date of January 1, 2020.

Providers may also choose to appeal claims denied due to the PTP edits to the appropriate MAC including supporting documentation or resubmit claims denied due to the PTP edits after the implementation of the replacement edit file with January 1, 2020 retroactive date, as permitted by the MAC.

Q:

I recently read the MMP article New Modifiers for Therapy Assistant Services. Are you aware of any other payors adopting a similar policy?

A:

Humana published Policy Number CP2018009 on December 10, 2019. This policy applies to both Medicare Advantage and Commercial Coverage. Similar to CMS guidance, effective January 1, 2020 or later Humana requires providers to submit a “charge for an outpatient occupational or physical therapy service…with modifier CO or modifier CQ, as applicable standards in the Federal Register and relevant CMS guidance direct.”

You can find the entire policy on Humana’s website at https://www.humana.com/provider/medical-resources/claims-payments/claims-payment-policies.

CMS’ guidance for Medicare Fee-for-Service beneficiaries is available in the November 1, 2019 Transmittal 4440 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019downloads/R4440cp.pdf.

Q:

I recently read the MMP article New Modifiers for Therapy Assistant Services. Are you aware of any other payors adopting a similar policy?

A:

Humana published Policy Number CP2018009 on December 10, 2019. This policy applies to both Medicare Advantage and Commercial Coverage. Similar to CMS guidance, effective January 1, 2020 or later Humana requires providers to submit a “charge for an outpatient occupational or physical therapy service…with modifier CO or modifier CQ, as applicable standards in the Federal Register and relevant CMS guidance direct.”

You can find the entire policy on Humana’s website at https://www.humana.com/provider/medical-resources/claims-payments/claims-payment-policies.

CMS’ guidance for Medicare Fee-for-Service beneficiaries is available in the November 1, 2019 Transmittal 4440 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019downloads/R4440cp.pdf.

Q:

How is CMS responding to the Court ruling to immediately cease the clinic visit provided at excepted off-campus PBDs payment reduction for CY 2019?

A:

According to an announcement about Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments in the December 12th edition of MLN Connects, “CMS installed a revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines. The revised Pricer went into production on November 4, 2019, and applies to claims with a line item date of service of January 1, 2019, and after. Starting January 1, 2020, and over the next few months, the Medicare Administrative Contactors will automatically reprocess claims paid at the reduced rate; no provider action needed.”

In the 2019 OPPS Final Rule, CMS determined to pay for certain outpatient clinic visit services (HCPCS code G0463) provided at excepted off-campus Provider-Based Departments (PBDs) at the same rate that CMS uses to pay non-excepted off-campus PBDs for those services under the separate Physician Fee Schedule (PFS). The PFS payment rate for services in non-excepted off-campus PBDs is equal to 40% of the OPPS rate, a reduction of 60%. CMS phased in the payment reduction for clinic visits in excepted off-campus PBDs over 2 years, with a 30% reduction for 2019 (i.e. rates of 70% of OPPS rates) and the full 60% reduction planned for 2020.

Despite the court’s decision that CMS must pay 2019 clinic visits in excepted off-campus PBDs at the regular OPPS rate, CMS proceeded with the second year of the payment reduction in the 2020 OPPS Final Rule. See the prior Wednesday@One article for more information about this but here are some excerpts from that article:

“CMS claims they are ‘removing the payment differential that drives the site-of-service decision and, as a result, unnecessarily increases service volume.’ They further claim they are doing this under authority of a certain section of the Social Security Act that gives them power ‘to adopt a method to control unnecessary increases in the volume of covered outpatient department services.’ … CMS states they have appeal rights and are still considering whether to appeal the final judgement or not.”

Q:

I have noticed that the Medicare (CMS) Detailed Notice of Discharge (DND) form we are using at our hospital has an expiration date of 10/31/19. Is it still ok to be using this form?

A:

For now, yes. As a reminder, the DND is used when a Medicare patient requests expedited review by the Quality Improvement Organization (QIO) of a discharge decision. The form provides the specific reasons the hospital, Medicare (or Medicare Advantage plan), and the patient’s doctor think the patient is ready for discharge. The form allows a review of the case by the QIO.

According to an update on Medicare’s Beneficiary Notices Initiative (BNI) website concerning the DND form with an expiration date of 10/31/19 – “This notice is now going through the Paperwork Reduction Act clearance process. The currently available hospital notice is covered under an extension and hospitals should continue using the current notice until CMS publishes the updated notice. Hospitals following this direction are fully compliant with our requirements.”

Q:

Is it appropriate to bill evaluation and management (E/M) codes or a clinic visit code on the same day as other wound care services such as debridement?

A:

It depends. Providers need to be cautious however, because as explained in a recent article from First Coast, the Medicare Administrative Contractor (MAC) for Jurisdiction N, data reflects improper billing of wound care and E/M codes on the same date of service. Providers may report an E/M service with modifier “25” when a significant, separately identifiable E/M service by the same physician on the day of a procedure is performed. If that separate E/M service involves the use of facility resources, a separate clinic visit code may be reported by the facility also.

A separate and distinct E/M service could involve the management of the patient’s underlying medical conditions in addition to the management of wound care. Reporting the E/M code with modifier “25” attests that the patient’s condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed. If the sole purpose of the visit is wound care management, only the wound care codes should be reported. This includes measurements and assessment of the wound(s) as well as debridement, dressings, or other wound treatments performed.

The First Coast article includes excerpts from their Wound Care LCD. The key to supporting a separate E/M code with wound care services is documentation. The documentation should clearly indicate the other conditions that were addressed and managed during the wound care visit.