Knowledge Base Category -

This is Respiratory Care Week and we at MMP would like to thank all of you who provide respiratory care for your hard work and dedication to improving the respiratory health of your patients. When my oldest son was eleven, he had severe pneumonia that required an extended hospitalization. I remember anxiously watching as the respiratory care team provided wonderful services that helped him to recover. Healthcare is most appreciated when truly needed and I am most appreciative of the care given by those respiratory therapists to my young son.

That son now has two beautiful children, the youngest a one-year old daughter. She now understands the word “no” but very much does not like to hear it. Like her, for all of us, it is sometimes hard to be told “no” constantly. Unfortunately, Medicare’s National Correct Coding Initiative (NCCI) often tells providers “no” about the reporting of certain code combinations. Respiratory services are no exception and in honor of Respiratory Care Week, I thought I would review some of the CCI edits for respiratory services. The complete CCI edits can be found at the Medicare NCCI webpage. The information below comes from the NCCI Policy Manual, Chapter 11. Please refer to this manual for more information.

• Alternate methods of reporting data obtained during a spirometry or other pulmonary function session should not be reported separately. For example, the flow volume loop is an alternative method of calculating a standard spirometric parameter. CPT code 94375 is included in standard spirometry (rest and exercise) studies.
• If multiple spirometric determinations are necessary to complete the service described by a CPT code, only one unit of service should be reported. For example, CPT code 94070 describes bronchospasm provocation with an administered agent and utilizes multiple spirometric determinations as in CPT code 94010. A single unit of service includes all the necessary spirometric determinations.
• Complex pulmonary stress testing (CPT code 94621) is a comprehensive stress test with a number of component tests separately defined in the CPT Manual. It is inappropriate to separately code venous access, ECG monitoring, spirometric parameters performed before, during and after exercise, oximetry, O2consumption, CO2production, rebreathing cardiac output calculations, etc., when performed as part of a complex pulmonary stress test.
• CPT code 94060 (bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) describes a diagnostic test that is utilized to assess patient symptoms that might be related to reversible airway obstruction. It does not describe treatment of acute airway obstruction. CPT code 94060 includes the administration of a bronchodilator. It is a misuse of CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) to report 94640 for the administration of the bronchodilator included in CPT code 94060. The bronchodilator medication may be reported separately.
• CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) and CPT code 94664 (demonstration and/or evaluation of patient utilization of an aerosol generator...) generally should not be reported for the same patient encounter. The demonstration and/or evaluation described by CPT code 94664 is included in CPT code 94640 if it utilizes the same device (e.g., aerosol generator) that is used in the performance of CPT code 94640. If performed at separate patient encounters on the same date of service, the two services may be reported separately.
• CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) describes either treatment of acute airway obstruction with inhaled medication or the use of an inhalation treatment to induce sputum for diagnostic purposes. CPT code 94640 should only be reported once during a single patient encounter regardless of the number of separate inhalation treatments that are administered. If CPT code 94640 is used for treatment of acute airway obstruction, spirometry measurements before and/or after the treatment(s) should not be reported separately. It is a misuse of CPT code 94060 to report it in addition to CPT code 94640. The inhaled medication may be reported separately.

There has been a lot of discussion about the last bullet point, which was new for 2014, that states that inhalation treatment “should only be reported once during a single patient encounter”. The issue is the definition of the term “encounter”. According to a statement issued by a coding specialist for NCCI, “encounter” in this instance means “direct personal contact in the hospital between a patient and a physician (or other clinician)… If the professional completes the inhalation service(s) and terminates the patient encounter but returns later that day to initiate additional inhalation treatment(s) reportable as CPT code 94640, an additional UOS (unit of service) of CPT code 94640 may be reported for this subsequent patient encounter.” We encourage all providers to clarify the interpretation of the term “encounter” with your Medicare Administrative Contractor (MAC) and other payers.

These NCCI rules again demonstrate that healthcare involves more than just providing patient care. Coding and billing play a major part in all aspects of healthcare. So someone in your Respiratory Care department needs to be aware of and understand the coding and billing requirements for Medicare and other payers. Because when Medicare says “no”, they mean “no”.

This week, March 9-15, 2014, is Pulmonary Rehabilitation Week. MMP would like to thank all of the healthcare professionals who enhance the quality of life of individuals with lung disease through a Pulmonary Rehab program. We are glad that Medicare finally recognized Pulmonary Rehab as a distinct payable comprehensive program. But along with the benefit of Medicare coverage comes the challenges of meeting all of Medicare’s requirements for coverage. And for Pulmonary Rehab, like a lot of other services, that is no easy task.

The Medicare rules for Pulmonary Rehab can be found in the Medicare manuals, specifically the Benefit Policy Manual, Chapter 15, section 231 and the Claims Processing Manual, Chapter 32, section 140.4. Also, some local Medicare Administrative Contractors (MACs) have coverage policies or articles that further define coverage, such as specific diagnosis codes. Pulmonary Rehab professionals need to be fully aware of Medicare’s requirements and ensure that their program is in compliance.

A recent medical review of Pulmonary Rehab programs by Palmetto GBA, the Part A MAC for Jurisdiction 11 (North Carolina, South Carolina, Virginia, and West Virginia) found charge denial rates of 76-93%. All PR providers could learn from the results of these reviews so I would like to share some of the major findings.

Claims were denied for the following reasons related to the requirements for:

Diagnosis

• The documentation submitted does not represent a patient with moderate to severe chronic obstructive pulmonary disease (COPD) as defined by the Gold Classification II, III, and IV per 42 CFR 410.47.
• The documentation of post-bronchodilator pulmonary function studies does not meet the requirement of FEV1 less than 80% of predicted and FEV1/FVC of less than 70%.

Physician Referral

• There is no physician’s order/referral for admission to pulmonary rehabilitation services present.

Required Program Components

• Does not contain the required components for pulmonary rehabilitation program as defined in 42 CFR 410.47
• There is no psychosocial assessment of the individual's mental and emotional functioning as it relates to their rehabilitation or respiratory condition.
• There is no outcomes assessment as a written evaluation of patient progress related to the rehabilitation.
• Does not contain mandatory individualized treatment plans as a written, established, reviewed, and signed by a physician every 30 days as defined in 42 CFR 410.47.
• There is no physician's prescribed exercise program present in the documentation.
• There is no documentation of the patient's education or training as it relates to care and treatment.

Frequency and Limits

• The documentation submitted does not meet the requirements for pulmonary rehabilitation services up to 36 and no more than two sessions per day as defined in 42 CFR 410.47.
• The documentation submitted does not meet the requirements for pulmonary rehabilitation services up to 72 sessions, with KX modifier and no more than two sessions per day as defined in 42 CFR 410.47.

Physician Oversight

• The documentation submitted does not indicate the supervising physician was available and accessible for medical consultations and emergencies at all times, when services were provided under the program as defined in 42 CFR 410.47.

As you can see, there are a lot of requirements which equals a lot of reasons for Medicare to deny your Pulmonary Rehab claim. Make sure you are following all of Medicare’s requirements so that you can continue to provide this valuable service and actually get paid for your work.

Every year, there are a number of Medicare provisions that expire on a particular date. For the requirements of these provisions to continue past the expiration date, Congress must take action through a new law. Such was the case for several rehabilitative therapy provisions set to expire at the end of 2013. The Pathway for SGR Reform Act of 2013, signed into law on December 26, 2013 extended the following provisions related to payments for Medicare outpatient therapy services through March 31, 2014.

Application of therapy caps and therapy threshold to therapy services furnished in a hospital outpatient department -

Therapy caps are a financial limitation on the amount Medicare allows for outpatient therapy services for a single Medicare patient in a given calendar year. The therapy cap amount for each patient starts over each January 1st. For 2014, the therapy cap is $1,920 for physical therapy (PT) and speech language pathology (SLP) services combined; and a separate $1,920 for occupational therapy (OT) services.

Exceptions process for outpatient therapy caps -

When providers of therapy services furnish medically necessary therapy services beyond the therapy cap, they may request an exception by appending the KX modifier to the appropriate therapy services on the claim. Additional information about the exception process for therapy services may be found in the http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf">Medicare Claims Processing Manual, Pub.100-04, Chapter 5, Section 10.3.

Manual medical review of outpatient therapy services exceeding the threshold amount -

Medicare mandates that a Medicare contractor perform a manual medical review of therapy services exceeding a $3,700 threshold for PT and SLP services combined and a $3,700 threshold for OT services. Currently this review function is being handled by Medicare Recovery Auditor contractors.

Critical Access Hospitals will also want to study MLN Matters Article MM8426 concerning the application of therapy caps, the exceptions process, and manual medical review to outpatient therapy services provided in the CAH setting.

So we are all set for … well, three months. If this year follows the pattern of previous years, another law will likely extend these provisions through the remainder of 2014. But, we will just have to wait and see.

CMS’s Medicare Learning Network (MLN) offers a number of articles, booklets, podcasts and other educational materials to educate providers concerning Medicare requirements. MMP encourages providers to utilize these resources but also to be aware of the topics addressed. MLN educates concerning issues that Medicare contractors or other government entities have found to be at-risk areas for non-compliance. So the benefit of the MLN products is two-fold: identification of issues that you may need to consider for internal review and guidance on achieving compliance.

For example, MLN recently released an article (SE1401) on overpayments identified by Recovery Auditors when the wrong admission source is reported for a patient transferred from an acute care stay to a distinct-part psychiatric unit in the same facility. Inpatient psych facilities receive additional payment for the first day of admission if the facility has a qualifying emergency department. This payment is not appropriate if the patient is transferred from acute care to psych within the same facility. In order to prevent inappropriate overpayment, the Point of Origin for Admission or Visit Code "D" (formerly the Source of Admission Code) must be used when a patient is discharged from an acute-care stay in a hospital and transferred to the same hospital’s inpatient psychiatric Distinct Part Unit (DPU). This issue has also been identified on several OIG Hospital Compliance Audits.

This quarter’s Provider Compliance Newsletter did not address any inpatient hospital issues (perhaps due to the change in Medicare admission guidelines and the mandated delay in contractor reviews of medical necessity of admissions). Two articles did address outpatient hospital issues related to dose versus units billed for the drugs zolendronic acid (Zometa) and Adenosine. Correct billing of drug units is a long-standing compliance challenge for hospitals. Drugs units billed are based on the dosage administered and the HCPCS code description of the drug. For example, as noted in the Compliance newsletter, adenosine HCPCS code J0152 was defined as 30 mg. So an injection of 30 mg of Adenosine was properly billed as 1 unit of J0152.

Adding to the challenge of billing drug units correctly are changes in codes and/or descriptions. For 2014, Adenosine is now billed with HCPCS code J0151 which is per 1 mg – in 2014 a 30 mg injection of Adenosine will be billed as 30 units of J0151. And although the units describing Zometa have not changed, there have been 3 different codes within the past year (J3487 prior to July 1, 2013; Q2051 from July 1 through December 31, 2013; and J3489 effective January 1, 2014). In order to submit Medicare claims with compliant drug charges, hospitals must:

• have someone diligently watch for Medicare updates to drug codes and descriptions,
• verify their charge description master drug codes and “multiplier” units are correct and updated as needed, and
• ensure correct “translation” from the pharmacy module to the billing module.

One other MLN product that might be of interest to hospitals is the Discharge Planning booklet. Experienced case managers, discharge planners, and social workers are likely familiar with the information in the booklet, but it offers a good overview and links to the relevant Medicare manuals. It would be an excellent resource for new staff members dealing with discharge planning.

Providers should take advantage of the educational products provided by CMS and their area MACs. The information is good and the topics are important. And in the case of errors related to these topics, a hospital wouldn’t have much luck arguing they didn’t know the rules.

For continuing to provide quality patient care while dealing with Medicare’s ever-increasing requirements, MMP applauds the providers of all types of rehabilitative therapy services, with a special recognition of physical therapy providers during October, Physical Therapy Month. We hope our articles on therapy issues help therapists to understand and better implement Medicare’s rules. With that in mind, I would like to address the requirements for the use of the Advance Beneficiary Notice (ABN) for outpatient therapy services.

Prior to January 2013, therapy services provided to a patient that exceeded the therapy cap and were not medically necessary were denied as a benefit category denial. That meant the patient was liable for payment and although encouraged, a notification of liability did not have be given to the patient. The American Tax Relief Act changed denials above the therapy cap amount to be provider liable unless the patient is issued an ABN. Since therapy services below the cap have always required an ABN for patient liability, this change provides more consistency. Now, all therapy services that are not medically necessary, above or below the therapy cap amount, require that an ABN be issued to the patient so that the patient can choose whether to obtain the services and accept financial responsibility for them.

So practically, when would a therapist provide medically unnecessary services? The scenario that requires an ABN be given that I have seen most often is when patients have been receiving therapy services for a condition for a while. The patient’s progress plateaus or reaches its maximum potential for that patient in the therapist’s opinion. Sometimes such patients do not want to discontinue therapy services but the therapy is no longer “medically necessary” according to Medicare requirements. This is an appropriate time to issue an ABN to the patient. The challenge here is explaining the situation to the patient so that he or she understands the Medicare regulations and their impending liability. Just another one of the challenges therapists face beyond their clinical duties!

See the last two pages of MLN Matters Article MM8404 for more information on outpatient therapy services use of an ABN.

The HCPCS codes for the drug medroxyprogesterone acetate changed at the beginning of this year. Medroxyprogesterone acetate is known by the brand names of Depo-Provera, Provera, Prempro, Depo-Provera Contraceptive, Cycrin, Lunelle, Premphase, Amen, depo-subQ provera 104, Curretab, Premphase 14/14.

The “old” codes (for dates of services prior to January 1, 2013) were:

• J1051 – Injection, medroxyprogesterone acetate, 50 mg*
• J1055 - Injection, medroxyprogesterone acetate for contraceptive use, 150 mg*

For dates of service on and after January 1, 2013, the following code replaces the above codes:

• J1050, Injection, medroxyprogesterone acetate, 1 mg

As a result of this code change, Alabama Medicaid is requiring the use of a modifier to distinguish between use of the drug for contraceptive use and other (non-contraceptive) uses. Modifier FP is used to indicate the injection of the drug for contraceptive use and modifier U1 indicates non-contraceptive use. The Medicaid Alert also lists the following restrictions for usage.

Contraceptive Use Restrictions (J1050-FP)

• Limited to female recipients 10-55 years of age
• Dosage of 104 – 150 mg per injection
• Allowed once every 70 days
• Claim must include a contraceptive management diagnosis code

Non-contraceptive Use Restrictions (J1050-U1)

• Covered for recipients of all ages
• Limited to 1000 mg per injection
• Claim must not include a contraceptive management diagnosis code

Providers should report the drug units based on the new “per 1 mg” description – for example 150 mg would be billed with 150 units, 500 mg with 500 units. Alabama Medicaid reimburses J1050 at $ 0.20 per unit (per mg). Claims for J1050 billed without a modifier will be denied by Alabama Medicaid. See the link above for complete information.

I remember from my days in Hospital Compliance that one of the most difficult issues was billing the correct drug units. This evidently continues to be a challenge for facilities based on the ongoing reminders from CMS and the numerous OIG audits that find errors in the billing of drug units.

Some of the issues that make this such a challenging area are:

• Drug HCPCS codes must be billed based on the amount, such as milligrams (mgs) in the HCPCS code description, not on standard usage or packaging amounts.
• Most hospitals accomplish this by using a “multiplier” in their charge description master (CDM), which presents the challenges of making sure all drugs that need a multiplier have one, there are no errors or typos in the multiplier amounts, and the multipliers are kept updated with code description changes.
• CMS often changes drug HCPCS codes and/or the HCPCS description. This is especiallychallenging when the amount in the description changes.
• Medical record documentation should include the dosage amount in the physician’s order and in the administration record.
• If the dose administered does not match the dosage amount the physician ordered, a corrected order should be obtained from the ordering physician.
• If the drug dose is based on the patient’s weight, there should be documentation in the medical record of the patient’s weight.
• Medicare does not allow providers to bill for wastage of multi-dose vials.
• When billing for wastage associated with single-dose vials, there should be documentation in the medical record of the dose given and the amount wasted.
• Medicare is applying Medically Unlikely Edits (MUEs) to a number of drug quantities. Although there are no published MUEs for drugs (HCPCS “J” codes), it is the understanding of MMP, Inc. that the quantity limitations are based on manufacturer package inserts. Providers should carefully review Medicare remittances to determine which drugs are being denied for MUEs and the likely MUE quantity.

Recent OIG audits have identified some drugs that have had repeated billing errors by multiple facilities. The first has to do with the billing of the drug Herceptin (J9355- Injection, trastuzumab, 10 mg). It is the understanding of MMP, Inc. that Herceptin is only available in a multi-dose vial of 440 mg (44 units). There have been problems with a number of facilities billing for entire vials of Herceptin instead of the dosage administered to the patient. Since Herceptin is a multi-dose vial, it is not appropriate to bill for drug wastage. MMP, Inc. recommends that providers review any claims with Herceptin units in multiples of 44 (such as 44, 88, etc.) and verify that the units billed match the dosage administered to the patient. Note that in addition to the OIG audits, this issue is also targeted by Recovery Auditors (RAs) and Medicare Administrative Contractor (MAC) pre-payment audits.

Another interesting drug issue has to do with the drug Lupron. There are two HCPCS codes for Lupron Depot –

• HCPCS code J1950 injection, leuporlide acetate (for depot suspension), per 3.75 mg)
• FDA approved specifically for uterine disorders
• Medicare ASP payment rate July 2012 of $653.299
• HCPCS code J9217 (Leuporlide acetate (for depot suspension), 7.5mg).
• FDA approved solely for advanced prostatic cancer
• Medicare ASP paymentrate July 2012 of $216.750

Since the payment amount for the smaller dosage amount is over 3 times the amount of the payment for the larger dosage, using the incorrect HCPCS code can result in significant over or under-payment. Reference OIG report A-04-11-03069 for further discussion.

Other drugs that have been noted in recent OIG reports for incorrect units include:

• adenosine
• alpha 1–proteinase inhibitor
• baclofen
• bortezomib
• cetuximab
• doxorubicin HCl liposome
• epoetin alfa
• immune globulin
• paclitaxel
• pemetrexed
• rituximab

MMP, Inc. encourages providers to be diligent in your reporting of the correct drug units by staying up to date on HCPCS code descriptions and changes, verifying correct multipliers in your CDM and by reviewing OIG, RA, and MAC audits to be aware of problem-prone drugs. For MMP, Inc. clients, note that we data-mine your 835 files for possible errors with high-risk, high-dollar drug units. Please contact MMP, Inc. if you have further questions concerning the billing of drug units.