Knowledge Base Category -

When my son was in college, he fell and broke his leg while playing a pick-up game of basketball. Last year my elderly father fell and broke his leg. Was their rehabilitative therapy experience the same? Hardly. Was the therapist’s time, effort and consideration for the therapy evaluation the same? Hardly. A physical therapy or occupational therapy evaluation for a young, healthy teenager with no other medical conditions is not the same as a therapy evaluation for an elderly patient who has numerous other medical conditions and pre-existing limitations in functional abilities. Beginning January 2017, that fact is being addressed with new CPT codes for rehabilitative therapy evaluations based on complexity.

CMS is proposing to accept the new CPT codes for physical and occupational therapy evaluation and re-evaluation services for 2017. The new evaluation codes are tiered based on the complexity of an evaluation that may vary due to the severity and complexity of the patient’s condition. The current evaluation codes and their respective replacement codes are:

• 97001, PT evaluation will be replaced with three new codes: 97x61, 97x62, and 97x63
• New PT re-evaluation code 97x64 will replace 97002
• 97003, OT evaluation will be replaced with three new codes: 97x65, 97x66, and 97x67
• New OT re-evaluation code 97x68 will replace 97004

As discussed in the Medicare Physician Fee Schedule (MPFS) Proposed Rule , Medicare will not have tiered payments for the new codes, but will continue to make one payment amount for all three levels of evaluation. CMS states concerns about potential risk of upcoding as therapists are learning to use the new codes, the incentive to upcode differential payment rates would create, and unknown utilization of the various levels. Perhaps CMS will reconsider tiered payment rates in the future once the learning curve is past and they have some historical data on code usage. Until then payment for evaluations and re-evaluations will likely be similar to current payment rates.

CMS also identified several other therapy codes they consider to be “misvalued” that may have a negative payment rate adjustment for next year. We will have to wait on the final MPFS rule to know exact payment rates. Those CPT codes are:

• 97032 – unattended electrical stimulation,
• 97035 – ultrasound therapy,
• 97110 – therapeutic exercises,
• 97112 – neuromuscular re-education,
• 97113 – aquatic therapy/exercises,
• 97116 – gait training,
• 97140 – manual therapy,
• 97530 – therapeutic activities,
• 97535 – self care management training,
• G0283 – unattended electrical stimulation other than wound care

Therapy codes continue to be subject to the Multiple Procedure Payment Reduction (MPPR) which means only one unit of the highest paid code reported for a day of service is paid at 100%. Additional units and codes are paid at a reduced payment rate.

See Table 19 on page 350 of the MPFS proposed rule for the complete long descriptions and specific components of each new code. The PT re-evaluation code, 97x64 requires an examination with review of history, standardized tests and measures, and a revised plan of care. CPT 97x68, OT re-evaluation, also requires a revised plan of care based on assessment of the patient’s functional or medical status with an updated occupational profile. Information on the new evaluation codes is summarized in a table you can dowload by clicking here.

Therapists must educate themselves on how to appropriately use the new codes and the documentation required to support the codes. Therapists are used to scrutiny of their documentation to support the services they provide. These new tiered codes add yet another documentation challenge for therapists.

Senseless massacres and suicides of prominent people in recent years have drawn attention to mental health issues in America. Some in our elderly population face a diagnosis of Alzheimer’s or other forms of dementia as they age. Our youth and all ages are at risk of life-altering drug and alcohol addictions. According to a Washington Post article from 2012, although the United States spends over $113 billion on mental health treatment, that is still not enough to serve all those who need it. Costs, limited access, and attitudes about mental health remain big barriers to treatment. One positive cited by the article is that recent federal legislation requires more expansive insurance coverage for mental health services.

Medicare covers a continuum of mental health services from inpatient hospital services, to partial hospitalization, to outpatient services. The coverage requirements of psychiatric Partial Hospitalization Program services are described in the Medicare Benefits Policy Manual, Chapter 6, section 70.3.

What a PHP Is

“Partial hospitalization is active treatment that incorporates an individualized treatment plan which describes a coordination of services wrapped around the particular needs of the patient, and includes a multidisciplinary team approach to patient care under the direction of a physician. The program reflects a high degree of structure and scheduling. According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission.”

What a PHP Is Not

A PHP is not a program that is:

• Comprised primarily of diversionary activity, social, or recreational therapy
• A psychosocial program which provides only a structured environment, socialization, and/or vocational rehabilitation
• Only for monitoring the management of medication for patients whose psychiatric condition is otherwise stable

Patients eligible for a PHP program are patients trying to avoid a new or continued hospitalization for psychiatric services – hence, the need for the acute, intense, structured combination of services provided by a PHP. Patients participating in a PHP program must:

• Be under the care of a physician who certifies the need for PHP
• Have a plan of care that requires at least 20 hours a week of therapeutic services
• Have a mental disorder which severely interferes with multiple areas of daily life, including social, vocational, and/or educational functioning (generally acute in nature)
• Have an adequate support system to sustain/maintain themselves outside the PHP and must not be an imminent danger to themselves or others
• Be willing and able to participate with active treatment of their mental disorder and tolerate the intensity of a PHP

Medicare recently released a MLN Matters Special Education (SE) Article SE1607 describing edits being implemented to enforce the requirement for a minimum of 20 hours per week of therapeutic services for patients in a Partial Hospitalization Program (PHP). There are three edits that will become effective July 2016:

• IOCE Edit 95 (FISS Reason Code W7095) - Partial hospitalization claim span is equal to or more than 4 days with insufficient number of hours of service
• IOCE Edit 96 (FISS Reason Code W7096) - Partial hospitalization interim claim from and through dates must span more than 4 days
• IOCE Edit 97 (FISS Reason Code W7097) - Partial hospitalization services are required to be billed weekly

Initially all three edits will cause the claim to “return to provider” (RTP) for correction, but beginning with the October 2016 IOCE updates, edit 95 (insufficient hours) will cause the claim to deny.

In addition to the amount of treatment, documentation requirements for a PHP admission include an initial physician certification that identifies the patient’s diagnosis, psychiatric need, and that the patient would require inpatient treatment if not for the PHP. Recertifications, required at day 18 and at least every 30 days after that, describe the patient’s response to treatment, reason for continued need for PHP and goals to facilitate discharge. Patients in a PHP must be under a treatment plan that:

• Is prescribed and signed by a physician,
• Identifies treatment goals that directly address the presenting symptoms and are the basis for evaluation of patient response,
• Describes a coordination of services including a multidisciplinary team approach to patient care, and
• Is individualized and structured to meet the particular needs of the patient.

Documentation must also include progress notes showing the services were provided, the nature of the treatment service, the patient’s response to the therapeutic intervention and its relation to the goals indicated in the treatment plan.

Hopefully expanded mental health coverage, growing awareness of mental health issues, and programs such as the partial hospitalization programs will make a positive impact on this country’s mental health. It is an issue that could affect any of us, directly or indirectly. It is a cry for help.

If you are involved at all with issues relating to the Hospital Outpatient Prospective Payment Rule (OPPS), you likely already know that payment for observation services changed from a composite payment to a comprehensive payment for 2016. But what does this really mean for hospitals?   Whether you are paid more or less than last year for a particular claim depends on the number and types of services being performed. As Medicare intends when creating payment bundles, there are “winners” and “losers” when looking at individual claims – that is, some claims will receive higher reimbursement and some lesser than the previous year.

That said, I still thought it would be interesting to look at some individual observation claims and the differences in Medicare payment amounts from 2015 to 2016. First, a review of the rules for observation services:

The purpose of observation services has not changed in many years. As stated in the Medicare Benefits Policy Manual, Chapter 2, section 60.1 – “Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.” In simpler language – the patient is too sick to be sent home and not sick enough to expect a two-midnight hospital stay (inpatient admission), so they are kept in a hospital bed for treatment and tests to determine if they need to be admitted or may safely be sent home. Under the two-midnight rule, patients receiving necessary hospital care that will pass a second midnight should be admitted as inpatients. A physician’s order is required for a patient to receive observation services.

Observation services are billed per hour with HCPCS code G0378. In order to receive separate payment for observation services, the following criteria must be met:

• The patient must receive 8 or more hours of observation services,
• Observation hours must be billed on the day of or the day after certain visit codes:
• An ED visit, type A or type B (CPT codes 99281-99285 or HCPCS codes G0380-G0384) – this requirement was changed for 2016 to include all ED visit levels; previously only high level ED visits qualified for observation payment.
• Critical care services (CPT 99291)
• A clinic visit (HCPCS code G0463)
• A direct referral to observation (HCPCS code G0379) on the same day as observation hours
• There must be no other services on the claim that have an OPPS status indicator (SI) of “J1” (services paid under comprehensive APCs).
• There must be no other services on the claim that have an OPPS status indicator (SI) of “T” (surgical services) – another change from previous years where observation was not paid if there was a T status procedure on the day of or the day before observation hours. For 2016 the observation payment will not be made if there is a T status procedure on any day on the claim.

As a Comprehensive APC, observation now has a status indicator of “J2” and the Medicare unadjusted comprehensive observation payment amount is $2,174.14. Since it is a comprehensive APC, the payment for all adjunctive services is bundled into the observation payment with only a few exceptions. This means for a claim that contains observation services that meets the above criteria, your hospital will receive one payment of approximately $2,174 for the entire claim. Other services on the claim will not be paid separately. As stated above, this is the Medicare national unadjusted payment rate; most hospitals will receive less based on their wage index and a portion of the adjusted payment (around $430) is the patient’s co-pay. Let’s look at some examples.

These are just some general examples about observation payments. These examples do not include discussion of services that were packaged in 2015, such as labs and routine, lower-cost ancillary services since this has not changed in 2016. All references to payment are based on the Medicare unadjusted fee schedules for 2015 and 2016.

Example 1: A level 4 ED visit with an ensuing 17 hours of observation services. Patient received a CTA of the lower extremity and two IV push injections. Total Medicare unadjusted payment for 2015 equals " $1657. 2016 Comprehensive Observation payment " $2,174. Increase for 2016 of $517.

Example 2: A level 5 ED visit with an ensuing 35 hours of observation services. Patient received two CTs (with contrast), a chest x-ray, a vaccine injection, an EEG, an IV infusion and an IV push. Total Medicare unadjusted payment for 2015 equals " $2,044. 2016 Comprehensive Observation payment " $2,174. Increase for 2016 of $130.

Example 3: A level 3 ED visit with an ensuing 10 hours of observation services. Patient received a CTA of the heart, a chest x-ray, and an hour of hydration. Remember that in 2015 a Level 3 ED visit did not qualify for an observation composite payment. Total Medicare unadjusted payment for 2015 equals " $582. 2016 Comprehensive Observation payment " $2,174. Increase for 2016 of $1592.

Example 4: A level 5 ED visit with an ensuing 18 hours of observation services. Patient received a CTA of the chest, a chest x-ray, an IV push, an hour of hydration, a myocardial SPECT study, and an Echo. Total Medicare unadjusted payment for 2015 equals " $3,280. 2016 Comprehensive Observation payment " $2,174. Decrease for 2016 of $1106.

Example 5: A level 5 ED visit with an ensuing 26 hours of observation services. Patient received several MRAs and MRIs without contrast, three hours of hydration, an Echo, a Duplex scan of extracranial arteries, and a CNS visual evoked potential. Total Medicare unadjusted payment for 2015 equals " $2,787. 2016 Comprehensive Observation payment " $2,174. Decrease for 2016 of $613.

So what is a hospital to make of this and are there actions that need to be taken? First, hospitals simply need to be aware of this change in payment structure. The only actions hospitals can take concerning comprehensive observation payments, increased packaging in general, the overall shift to prospective payment systems, and the transition to value-based payments instead of fee-for-service is to operate more effectively and efficiently. Focus on the best outcomes for the least amount of cost. Control utilization of services – do the necessary things that affect patient outcomes, but don’t overdo testing or treatments that are not necessary. Make sure you are treating and testing the patient in the appropriate setting – don’t perform tests that could and should be provided as outpatient services on an observation patient or an inpatient. The healthcare world is changing rapidly and only those providers who rise to the challenge of better outcomes in a cost-effective manner will survive. There will be winners and losers…

Almost everyone reading this newsletter works in the field of healthcare. But even those of us in healthcare often take for granted the amazing advancements in medicine over the last few centuries. Last fall I visited Yorktown, one of the major cities involved in America’s fight for independence (for fellow history buffs, I highly recommend visiting there). Do you realize that during the Revolutionary War almost three times the number of Americans died from disease as were killed in war? Historians believe around 17,000 deaths occurred from disease compared to 6,800 casualties from battle. Modern medicine involves a variety of things that are put into or onto bodies to heal or improve health. Part 2 of our discussion of the January 2016 OPPS Update looks at Medicare’s latest rules for devices, drugs, biologicals, and blood products.

Devices

The key to understanding the rules for Medicare payment for devices is to know that payment for most devices is bundled into the payment for the associated procedure. Medicare does pay for the device – the payment is just part of the procedure payment. In order to be able to adjust payments when a device is separately reimbursed (pass-through payments) or when the hospital incurs no cost or reduced cost for the device (device credits), Medicare calculates the percentage of each APC that is attributable to the cost of the device. This is known as the device-offset amount.

Certain categories of devices are eligible for transitional pass-through payments for 2-3 years. Effective January 1, 2016, HCPCS code C1822, Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system, is being added as a pass-through device. There are a number of considerations related to this new pass-through device.

• Pass-through devices, including C1822, are assigned a status indicator of “H.” This means that the device is reimbursed based on cost. Medicare calculates the payment amount by applying your hospital’s cost-to-charge ratio to the device charge on the claim.
• HCPCS C1822 should always be reported with CPT code 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling) which is assigned to APC 5464.
• Medicare will deduct the device-offset amount for this APC from the pass-through payment amount for the device when HCPCS C1822 is reported.
• The description of HCPCS code C1820 was changed to differentiate it from the C1822. C1820 is Generator, neurostimulator (implantable), non-high frequency, with rechargeable battery and charging system. C1820 is non-high frequency whereas C1822 is high-frequency.

The 2016 APC off-set file can be found at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/passthrough_payment.html .

Another important aspect of understanding device payments is to know that device-intensive APCs are those APCs with a device-offset amount greater than 40%. Over 40% of the APC payment is “payment” for the device. Beginning in 2016, Medicare will make an additional payment adjustment for device-intensive APCs when the procedure is discontinued prior to the administration of anesthesia (reported with modifier -73). Modifier 73 is appended to surgical procedures for which anesthesia is planned, but the procedure is terminated after the patient is prepared and taken to the room where the procedure is to be performed, but prior to the administration of anesthesia. Modifier 73 reduces the procedure payment by 50%. Effective January 1, 2016, the device off-set amount will be deducted from the APC payment and then the 50% reduction will be applied.

Also for 2016, all procedures assigned to a device-intensive APC will require a device code to be present on the claim. Table 42 in the 2016 OPPS Final Rule lists the device-intensive APCs.

Corneal Tissue

In 2016, Medicare will only pay separately for the procurement or acquisition of corneal tissue when it is used in a corneal transplant procedure. Hospitals should only report HCPCS code V2785 (Processing, preserving and transporting corneal tissue) when corneal tissue is used in a corneal transplant procedure described by one of the following CPT codes:

• 65710 (Keratoplasty (corneal transplant); anterior lamellar);
• 65730 (Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia));
• 65750 (Keratoplasty (corneal transplant); penetrating (in aphakia));
• 65755 (Keratoplasty (corneal transplant); penetrating (in pseudophakia));
• 65756 (Keratoplasty (corneal transplant); endothelial);
• 65765 (Keratophakia);
• 65767 (Epikeratoplasty); and
• Any successor code or new code describing a new type of corneal transplant procedure that uses eye banked corneal tissue.

Blood Products

There are three new blood product codes for 2016 for pathogen-reduced blood products – that is blood products treated to eliminate certain pathogens and reduce the risk of transfusion-associated infections, such as those treated with Amotosalen and UVA light. The new codes are:

‍Drugs

Like devices, payments for drugs have special rules under OPPS. Payment for drugs below a threshold per-day cost ($100 for 2016) is packaged; drugs exceeding this threshold are separately reimbursed at average sales price (ASP) + 6%, which provides payment for both the acquisition cost and pharmacy overhead costs associated with the drug, biological or therapeutic radiopharmaceutical. Pass-through drugs, biologicals and radiopharmaceuticals are also paid at ASP+6%.  The January 2016 OPPS Update article lists a number of new and revised drug HCPCS codes plus other information concerning drug payments.

• See the article for the complete lists – Table 7 for new drug codes, Table 8 for changed codes or revised descriptions, and Table 9 for Corrected Effective Dates for Certain Vaccine Codes.
• For the new codes, remember that Status Indicator
• G is a pass-through drug,
• K is a separately paid non-pass-through drug/biological,
• E is not paid by Medicare for outpatients, and
• N is a packaged drug.
• For changed codes and descriptions, pay close attention to the units in the old and new descriptors, for example
• 2015 - C9443, Injection, dalbavancin, 10 mg; 2016 - J0875, Injection, dalbavancin, 5 mg
• 2015 - J1446, Injection, tbo-filgrastim, 5 micrograms; 2016 - J1447, Injection, tbo-filgrastim, 1 microgram
• 2015 - J7506, Prednisone, oral, per 5mg; 2016 - J7512, Prednisone, immediate release or delayed release, oral, 1 mg
• Biosimilars are paid the ASP of the biosimilar(s) described by the HCPCS code + 6% of the ASP of the reference product. Only the first eligible biosimilar biological product to a reference product will be eligible for pass-through status; subsequent biosimilars to a reference product will not meet the newness criterion.
• New FDA approved drugs, biologicals, and therapeutic radiopharmaceuticals without an assigned HCPCS code should be billed with HCPCS code C9399. New diagnostic radiopharmaceuticals and contrast materials are not to be reported with C9399. Until they are granted pass-through status and a new C code is assigned, report new diagnostic radiopharms with the appropriate HCPCS code:
• A4641 (Radiopharmaceutical, diagnostic, not otherwise classified),
• A9599 (Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (PET) imaging, per study dose), or
• J3490 (Unclassified drugs) (applicable to all new diagnostic radiopharmaceuticals used in non-beta-amyloid PET imaging)
• Report new contrast materials with HCPCS code:
• A9698 (Non-radioactive contrast imaging material, not otherwise classified, per study) or
• A9700 (Supply of injectable contrast material for use in echocardiography, per study

Skin substitute products that do not qualify for pass-through status are also packaged. Payment is packaged into the payment for the associated skin substitute application procedure. The skin substitute products are divided into two groups for packaging purposes:

1. High cost skin substitute products - application reported with CPT codes 15271-15278
2. Low cost skin substitute products - application reported with HCPCS code C5271-C5278

See the MLN Matters article for a list of the skin substitute products’ designations as high or low. All pass-through skin substitute products are to be reported in combination with one of the skin application procedures described by CPT code 15271-15278.

As you can tell from the above discussion, even though there are new advancements in technology, devices, and drugs, in the long run, Medicare may bundle the payment.

Composite is defined as something made up of several parts or elements and comprehensive is including all or nearly all elements of something. These definitions are spot on regarding the reclassification of payment for observation services from a composite payment to a comprehensive payment as announced in the 2016 Outpatient Prospective Payment System (OPPS) Final Rule. This is one of the most significant changes found in this year’s final rule. In this article we discuss the reality of the changes with observation payments and other updates from the Final Rule.

Observation Comprehensive Payment

Under the current composite payment method for observation services, the observation payment is combined with the payment for high level ED visits, clinic visits, or direct referral when the observation services meet certain criteria. Other separately billable services are paid according to OPPS guidelines. This means payment for some services is packaged - most clinical laboratory services (since 2014), routine x-rays and some other minor diagnostic services (since 2015), and some minor procedures such as breathing treatments (since 2015). More extensive services, such as injections and infusions, CTs and MRIs, and separately payable drugs are paid separately from the composite payment.

Things change under the Comprehensive Observation APC. In keeping with the Medicare criteria for comprehensive APCs, payment for all adjunctive services is bundled into the comprehensive payment. This means no separate payment for injections, infusions, CTs, or MRIs, – just the one comprehensive observation payment amount of approximately $2174 (Medicare unadjusted payment rate) for the entire episode of care. There were also some changes to the criteria for eligible observation services. The comprehensive observation APC is paid when there is:

• At least eight hours of observation services (no change)
• Observations services in conjunction with any ED visit level (change from only high level ED visits), clinic visit level, or direct referral to observation
• No surgical procedure on the claim with a status indicator of “J1” or “T” (change from “T” status procedure on the day of or day before obs)

When these criteria are not met, observation services are packaged and there is no separate or additional payment for observation.

Since the Comprehensive Observation is for a combination of services which differs from the criteria for other comprehensive services which are based on a primary service, CMS created a new status indicator for Observation of “J2.” Nine other “J1” Primary Service Comprehensive APCs were also added in the final rule for device-intensive procedures.

Lung Cancer Screening by Low-Dose CT

Medicare issued a National Coverage Determination (NCD) for lung cancer screening by low-dose CT on February 5, 2015. Providers have been anxiously awaiting Medicare guidance on how to bill for this service, specifically what CPT or HCPCS code to report. In the OPPS Final Rule, CMS created new HCPCS code G0297 to report this service on and after January 1, 2016. At that time, they will accept claims for dates of service on and after February 5, 2015, so if you have already been providing this service and holding your claims you can submit them after the first of the year and receive payment. The Medicare unadjusted payment rate for G0297 is $112.49. Timely filing rules do apply so be sure to submit claims before a year has passed since the date of service.

Clinical Laboratory Services

There is good news related to lab services and then there is some really bad news. Let’s get the bad news out of the way first. CMS finalized a reduction of 2.0 percentage points to the CY 2016 conversion factor. This reduction was due to an error CMS made in calculating the impact of lab packaging in 2014. In combination with other financial adjustments for the year, the bottom line is a -0.3% reduction in OPPS payments overall for 2016.

Clinical lab services continue to be packaged in 2016 with the exceptions of molecular pathology codes and preventive services. In fact they will now be packaged per claim instead of per date of service, but I doubt this will be a significant impact. The good news is that CMS created new status indicator “Q4” for lab services so that lab payments will automatically receive separate payment if they are the only type of service reported on the claim. This means laboratories will no longer have to report the L1 modifier when only lab services are performed. The L1 modifier can still be used when lab services are unrelated to other outpatient services on the claim (ordered by a different physician for a different diagnosis), but not having to use it for lab-only outpatient claims should result in a lot less time and effort expended by hospital staff.

Increased Packaging

Since so many minor services have already been packaged in previous years, there was only a minimal increase in packaging of services for 2016. This year CMS is packaging three more APCs:

• Level 4 Minor Procedures will be S, T, V packaged with a status indicator of “Q1”
• Level 3 and Level 4 Pathology will be T packaged with a status indicator of “Q2”

Other Issues

Other issues addressed in the OPPS final rule include:

• Numerous additional requirements for hospitals to bill and receive payment for Chronic Care Management (CCM) services, CPT code 99490.
• Removal of seven procedures from the inpatient only list (vagus nerve blocking therapy, spine surgery procedures and penile implants). Carotid artery stenting remains on the inpatient only list.
• Payment reduction for CT scans (5% in 2016; 15% in 2017) if CT scanner does not meet the NEMA Standard XR-29-2013. Providers are to report new modifier “CT” if the CT scanner does not meet the standards in order to receive the appropriately reduced payment.

The reality of OPPS payment policies is increased packaging in the form of more comprehensive APCs, including an observation C-APC and increased packaging of services. CY 2016 also includes an overall reduction in payment due to adjustments for this and that, including a big adjustment for miscalculation of lab packaging payments. Sometimes the reality is just too real.

Recently a hospital reported to MMP that they were cited for an underpayment by the Recovery Auditor because they had billed for a portion of a drug that is only available in a single-dose vial. The hospital, following the appropriate United States Pharmacopeia (USP) standards for compounding, had split the single-dose vial into incremental portions in syringes. They billed Medicare for the dose administered to a patient and the wastage amount of one of the prepared syringes. The RAC denied this as an underpayment – what should the hospital do?

My research revealed that the splitting of single-dose vials is a huge controversy. The Centers for Disease Control and Prevention (CDC) has released a statement opposing the splitting of single-use vials due to safety concerns, except in times of severe shortages of medicines.   CMS has even weighed in on the issue with a memo to the State Survey Agency Directors requiring adherence to strict standards for repackaging of single use vials.

But often single-use vials contain more medication than the routine dose. Drug wastage raises concerns about the high costs of drugs and the ever increasing number of drug shortages. For these reasons, hospital pharmacies may aliquot a single-dose vial into smaller doses. A patient will then be administered the ordered dose from the prepared syringe and any remaining amount within the syringe will be wasted. The hospital should bill for the amount of the drug given and wasted from the single syringe used. This will result in the billing of an amount less than the amount in the single-use vial. Like the situation above, this may cause a Medicare contractor to question your billed units.

The hospital will have to appeal the denial and provide documentation to the contractor that supports:

• Their process for splitting the single-use vial, including adherence to the required criteria
• The dosage within the syringe that was used
• The amount administered to the patient and the amount wasted

If the denial comes from a Recovery Auditor and your hospital has time, you may be able to resolve the issue during the discussion period.

And you probably never thought you would object to an underpayment finding!!

Some people may not get their gift from Santa this Christmas. When I was a child, I was always told that Santa Claus would not come until I went to sleep. If the number of people having sleep study testing is any indication, a lot of people in the US are having trouble sleeping. An OIG audit reported that from 2005 to 2011, Medicare spending for polysomnography services rose from $407 million to $565 million, an increase of 39 percent.

Because of this dramatic increase in the volume of sleep studies, several Medicare review contractors have sleep studies and polysomnography as one of their review topics. Two such contractors are the Comprehensive Error Rate Testing (CERT) reviewers and the Supplemental Medical Review Contractors (SMRC). (see the SMRC Polysomnography Project )

Medicare covers diagnostic testing of sleep disorders when the patient has symptoms or complaints of narcolepsy, sleep apnea, impotence or parasomnia. Polysomnography for chronic insomnia is not covered. (See Medicare Benefit Policy Manual, Chapter 15 section 70) There is also a National Coverage Determination (NCD 240.4.1) and several Local Coverage Determinations (LCDs) concerning the coverage requirements for sleep studies.

All reasonable and necessary diagnostic tests for the conditions listed above are covered when the following criteria are met:

• The clinic is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic testing routinely performed in disorder clinics may be covered even in the absence of direct supervision by a physician;
• Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physician’s order; and
• The need for diagnostic testing is confirmed by medical evidence, e.g. physician examination and laboratory tests.

Based on the findings from CERT reviews, discussed in the October 2014 Medicare Quarterly Compliance Newsletter, 97% of improper payments are due to insufficient documentation. So what do providers need to do to ensure they receive payment for their polysomnography services? Make sure the documentation in the medical record for sleep studies includes:

• A valid physician’s order for the diagnostic study or documentation to support the intent to order study (if there is no order, evidence of the intent to order PSG documented in the medical record can be accepted)
• A physician’s signature on the procedure note; and
• Clinical documentation to support the reason/need for the diagnostic study (e.g. documentation to support the fact that the beneficiary had symptoms and signs of sleep apnea).

You have to be good (and asleep) to get your presents from Santa, but you have to have complete and appropriate documentation to get your present (payment) from Medicare for sleep testing.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

We may not know if the testing method for drug screening is classified as moderate or high complexity without looking it up, but I bet everyone will agree that the process of selecting the correct CPT/HCPCS codes for drug screen billing is highly complex.

CPT made a lot of changes to drug assays, specifically drug screening and definitive testing of non-therapeutic drugs, for 2015. And to complicate things even further, Medicare is not accepting the new CPT codes and has established some new HCPCS codes for drug identifications. Medical Management Plus will be covering the drug assay code changes in our coding webinar on December 4, 2014 in more detail, but here is a summary of the major changes.

Instead of classifying drug assays by qualitative versus quantitative, CPT now has three types of drug assays:

1. Presumptive drug assays to detect the possible presence of a drug by simpler testing methods,
2. Definitive drug assays that provide specific identification of individual drugs using complex testing methods, and
3. Therapeutic drug assays to monitor clinical response to a known, prescribed medication.

The assignment of CPT codes for presumptive drug assays are based on the drug classification into one of two drug class lists developed by CPT and the complexity of the testing methods. Drug class list A includes drugs generally considered drugs of abuse and identified by simpler testing methods such as optical observation and chemistry analyzer immunoassay or enzyme assay. Drug class list B includes drugs such as acetaminophen, salicylates, etc. and involves most complex immunoassay analyzer or chromatography methods. The CPT codes for drug screening are:

• CPT 80300 - Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (eg immunoassay) capable of being read by direct optical observation, including instrumented-assisted when performed (eg, dipsticks, cups, cards, cartridges), per date of service
• CPT 80301 - Drug screen, any number of drug classes from Drug Class List A; single drug class method, by instrument test systems (eg, discrete multichannel chemistry analyzers utilizing immunoassay or enzyme assay), per date of service
• CPT 80302 - Drug screen, presumptive, single drug class from Drug Class List B, by immunoassay (eg, ELISA) or non-TLC chromatography without mass spectrometry (eg, GC, HPLC), each procedure
• CPT 80303 - Drug screen, any number of drug classes, presumptive, single or multiple drug class method; thin layer chromatography procedure(s) (TLC) (eg, acid, neutral, alkaloid plate), per date of service
• CPT 80304 - Drug screen, any number of drug classes, presumptive, single or multiple drug class method; not otherwise specified presumptive procedure (eg, TOF, MALDI, LDTD, DESI, DART), each procedure

For Medicare, drug screening codes are the same as last year. Although the description for high complexity lists immunoassay and enzyme assay, most immunoassay and enzyme assay methods are actually moderate complexity tests. Test complexity is determined by the FDA and is listed on their website. Laboratory personnel can help in determining the complexity of drug screen tests that your hospital performs. Medicare’s HCPCS code definitions are:

• HCPCS G0431 - Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter
• HCPCS G0434 - Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter

Both CPT and Medicare developed new codes for individual non-therapeutic drug assays. The new CPT codes are CPT codes 80320 – 80377. CPT clarifies that these codes are to be used for complex definitive methods such as those involving mass spectrometry and specifically excludes immunoassay and enzyme assay testing methods. The new HCPCS codes describing individual drug assays accepted by Medicare for 2015 are HCPCS codes G6030 – G6058. So far Medicare has not provided any guidance on the use of these codes, such as if they are limited to particular testing methodologies.

Because of differences in the basis of the code descriptions, it will not be easy to cross-walk the CPT codes and the Medicare HCPCS codes. We also will have to wait and see if Medicare issues any guidance, particularly for the use of the individual drug codes. The chart below provides some suggestions on cross-walking the drug screening codes.

As high complexity is a determining factor in drug testing, it also appropriately describes the process of determining which codes to use for billing. This year, it just seems to become even more complex and even worse, Medicare is packaging the payment for all drug screening codes. All of this work and brain drain for no reward!!

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

“The ABC’s of …” refers to the basic facts of a topic. This article looks at the basic facts of the rehabilitative therapy updates for 2015, which involve C’s (caps and codes), D’s (documentation), E’s (exceptions and extensions), and F’s (functional reporting). So the ABC’s of the CDEF’s of therapy are…

There are not a lot of changes for rehabilitative therapy for 2015 like there have been the past few years. But all of the changes from previous years remain in place, at least for now. So let’s look at what is new and review some of the ongoing requirements for therapy services.

Therapy Caps

• The 2015 therapy cap for physical therapy and speech-language pathology combined is $1,940
• The cap for occupational therapy is $1,940 for 2015
• There is an exception process for therapy services beyond the cap limit if services are reasonable and necessary
• Use KX modifier on therapy services to request exception to therapy caps
• KX modifier - therapist is attesting that the services above the therapy caps are reasonable and necessary and that there is documentation of medical necessity for the services in the beneficiary’s medical record
• See MLN Matters Article MM8970

Therapy Code List

• Two new codes created to describe negative pressure wound therapy with the use of a disposable system
• CPT Code 97607 – Negative pressure wound therapy utilizing disposable, non-durable medical equipment …, total wound(s) surface are less than or equal to 50 square cm
• CPT Code 97608 – Negative pressure wound therapy utilizing disposable, non-durable medical equipment …, total wound(s) surface are greater than 50 square cm
• CPT codes 97607 and 97608 designated as “Sometimes Therapy”
• Negative pressure wound therapy CPT codes 97605 and 97606 revised to specify the use of durable medical equipment
• G-codes (G0456 and G0457) that described negative pressure wound therapy using disposable device are being deleted
• See MLN Matters Article MM8985

Extension of Therapy Provisions

The Protecting Access to Medicare Act of 2014 (PAMA) extended the following provisions through March 31, 2015:

• The exceptions process for outpatient therapy caps
• The manual medical review process for therapy services exceeding threshold of $3,700 (one threshold for PT/SLP combined; one for OT)
• The application of the therapy caps and related provisions to services furnished in hospital outpatient departments
• The patient’s performance on the Berg Balance Scale (score 46 out of 56) indicates that she is a low fall risk according to the interpretive guidance provided. However, the patient is a moderate fall risk due to the added contribution of lower extremity muscle weakness and reduced vision. The patient classifies as between 20%-40% impaired (CJ). Due to ongoing visual impairment, the patient is expected to obtain a goal of 1-20% impairment (CI) with the recommended therapy plan of care.

Functional Limitation Reporting

Reporting of the functional limitation G-codes and severity modifiers is now a requirement for rehabilitative therapy claims to allow Medicare to gather data on therapy usage and outcomes to assist in reforming the Medicare payment system for outpatient therapy services. From therapy reviews performed by Medical Management Plus, it appears providers are generally reporting these correctly. The one issue that needs improvement is the documentation of the rationale for selection of the severity modifiers. The Medicare manual states – “Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.”

Documentation should clearly indicate the measures and reasons the therapist selected a particular degree of impairment. Some examples of documentation that meets these requirements are:

• The patient’s performance on the Berg Balance Scale (score 46 out of 56) indicates that she is a low fall risk according to the interpretive guidance provided. However, the patient is a moderate fall risk due to the added contribution of lower extremity muscle weakness and reduced vision. The patient classifies as between 20%-40% impaired (CJ). Due to ongoing visual impairment, the patient is expected to obtain a goal of 1-20% impairment (CI) with the recommended therapy plan of care.
  (Paraphrased from APTA Functional Limitation Reporting Toolkit at the following link: http://www.apta.org/Payment/Medicare/CodingBilling/FunctionalLimitation/)

• Patient’s goal for PT is to be able to walk in her house and around the community (G8978) with minimal to no assist. Her current impairment is 80% (CM) based on her OPITMAL, Berg Balance, and 10 meter walk scores. She is expected to be able to walk with minimal assistance with around 30% (G8979 CJ) impairment after 6 weeks of therapy.

Therapists definitely need to know their alphabet for billing, coding and documentation.

I enjoy what I do. For some weird reason, I like to read and do my best to interpret the Medicare regulations. I hope my efforts make it easier for hospitals to receive the appropriate reimbursement for the healthcare services they provide by helping them to follow Medicare’s documentation, coding and billing requirements. But unfortunately, the news I share is not always the best news or even fun. So before I get into the “not so fun” part of this article, I want to acknowledge National Radiologic Technology Week.

As in many areas of healthcare, radiology includes many different types of services, such as plain x-rays, computed tomography (CT), magnetic imaging resonance (MRI), ultrasound, nuclear medicine, interventional radiology, radiation oncology, and others. Radiologic technologists provide a valuable contribution to healthcare. How many times over the past year have you, your family or friends received radiologic services? How would your care have been affected without this technology? Within my own circle of family and friends – an x-ray for a broken wrist, annual mammogram, Dexa scan, MRI for spinal stenosis, and CT to rule out a pulmonary embolism. So thanks to all our radiology friends!

A few weeks ago an article reviewed some of the National Correct Coding Initiative (NCCI) guidance for respiratory services for their recognition week. Continuing that theme for National Radiology Week, let’s look at some of the NCCI instructions that apply to Medicare coding and billing for radiology services.

A recent NCCI edit (July 2014) bundled spinal myelography procedures (72240-72270) into procedures for CT neck, chest and lumbar studies (72125-72133). The code pairs may be reported together with the appropriate modifier when warranted. If both tests are medically necessary, distinctly ordered, and there is a separate interpretation for each procedure, then it is appropriate to append modifier 59 to the CT of the spine with contrast code to identify that it is a separate and distinct procedure. (CPT Assistant September 2014)

The following are selected excerpts from the Radiology chapter of the NCCI manual. For complete information regarding these topics and other radiologic issues, please see Chapter IX of the NCCI Policy Manual found in the downloads section of the Medicare NCCI Website.

• CPT code descriptors that specify a minimum number of views include additional views if there is no more comprehensive code specifically including the additional views.
• CPT Manual instructions state that in the presence of a clinical history suggesting urinary tract pathology complete ultrasound evaluation of the kidneys and urinary bladder constitutes a complete retroperitoneal ultrasound study (CPT code 76770). A limited retroperitoneal ultrasound (CPT code 76775) plus limited pelvic ultrasound (CPT code 76857) should not be reported in lieu of the complete retroperitoneal ultrasound (CPT code 76770).
• When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. Similarly when an emergency endotracheal intubation procedure (CPT code 31500), chest tube insertion procedure (e.g., CPT codes 32550, 32551, 32554, 32555), or insertion of a central flow directed catheter procedure (e.g., Swan Ganz)(CPT code 93503) is performed, a chest radiologic examination is usually performed to confirm the location and proper positioning of the tube or catheter. The chest radiologic examination is integral to the procedures, and a chest radiologic examination (e.g., CPT codes 71010, 71020) should not be reported separately.
• CPT code 75635 describes computed tomographic angiography of the abdominal aorta and bilateral iliofemoral lower extremity runoff. This code includes the services described by CPT codes 73706 (computed tomographic angiography, lower extremity...) and 74175 (computed tomographic angiography, abdomen...). CPT codes 73706 and 74175 should not be reported with CPT code 75635 for the same patient encounter. CPT code 73706 plus CPT code 74175 should not be reported in lieu of CPT code 75635.
• Diagnostic angiography (arteriogram/venogram) performed on the same date of service by the same provider as a percutaneous intravascular interventional procedure should be reported with modifier 59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59.
• Fluoroscopy reported as CPT codes 76000 or 76001 is integral to many procedures including, but not limited, to most spinal, endoscopic, and injection procedures and should not be reported separately. For some of these procedures, there are separate fluoroscopic guidance codes which may be reported separately.
• Computed tomography (CT) and computed tomographic angiography (CTA) procedures for the same anatomic location may be reported together in limited circumstances. If a single technical study is performed which is utilized to generate images for separate CT and CTA reports, only one procedure, either the CT or CTA, for the anatomic region may be reported. Both a CT and CTA may be reported for the same anatomic region if they are performed at separate patient encounters or if two separate and distinct technical studies, one for the CT and one for the CTA, are performed at the same patient encounter. The medical necessity for the latter situation is uncommon.
• If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with mammographic guidance (e.g., 19281,19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.
• CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.
• The code descriptor for CPT code 77417 states “Therapeutic radiology port film(s)”. The MUE value for this code is one (1) since it includes all port films.
• An MRI study of the brain (CPT codes 70551-70553) and MRI study of the orbit (CPT codes 70540-70543) are separately reportable only if they are both medically reasonable and necessary and are performed as distinct studies. An MRI of the orbit is not separately reportable with an MRI of the brain if an incidental abnormality of the orbit is identified during an MRI of the brain since only one MRI study is performed.

There are more rules on coding and reporting radiology services on a claim than there are slices of a CT scan. And that is not so fun!