Knowledge Base Category -
I like people with a passion for life and enthusiasm for the things they do. It certainly makes life more enjoyable if you love what you are doing. However, it is important to balance enthusiasm with appropriate limits. I am enthusiastic about reading and I read for pleasure nightly before bedtime, but I have to cut myself off at some point to ensure I have time for a good night of sleep. Others may have to balance exercise or other activities with their physical limitations, especially when they are not as young as they once were. And it is good to love your job, but important to take time off too. Bottom line - it is good to have passion, but also good to know your limits.
Hopefully as healthcare workers, we have passion for our jobs. I understand that healthcare disciplines for rehabilitative therapy want to ensure their patients get the maximum benefit from the services Medicare covers. However, most Medicare rehabilitative services have duration limits.
Specifically:
- Cardiac rehabilitation (CR) program sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor.
- Pulmonary rehabilitation (PR) program sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions if medically necessary.
- There are physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) therapy thresholds (formerly therapy cap amounts) above which services are only covered if services beyond the threshold are medically necessary as justified by appropriate documentation in the medical record. For CY 2019 this therapy threshold amount is:
- $2,040 for PT and SLP services combined, and
- $2,040 for OT services.
The good news for enthusiastic rehabilitative therapists and providers is that Medicare does allow medically necessary additional services up to a defined point. This is where the KX modifier comes in.
For cardiac and pulmonary rehab, Medicare contractors shall accept the inclusion of the KX modifier on the claim lines as an attestation by the provider of the service that documentation is on file verifying that further treatment beyond the 36 sessions is medically necessary up to a total of 72 sessions for that beneficiary.
For PT, OT, and Speech therapy, claims with therapy services exceeding the threshold amounts must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.
This means that for CR, PR, PT, OT, and SLP services exceeding Medicare’s duration limits as described above, a KX modifier is required on the line item(s) in order for Medicare to make payment for the services. In reviewing Medicare remittances, I often see denials of these types of services with Claim Adjustment Reason Code (CARC) 119 - Benefit maximum for this time period or occurrence has been reached. Many of these denials could be avoided with the inclusion of the KX modifier. Providers should only use the KX modifier for rehabilitative services when it is appropriate – that is, the services are medically necessary and there is documentation in the medical record to support that. Properly applying the KX modifier requires that providers keep up with the number of sessions for CR and PR, and with the beneficiary’s therapy amounts for PT, OT, and SLP. The Medicare eligibility systems contain information on therapy spending to date as well as information on the number of PR and CR sessions billed to date.
Other things to remember about these duration limits - Cardiac Rehab is limited to 72 sessions for an episode of care. Within that episode, sessions beyond 72 will deny for payment even if the KX modifier is included. There is not a lifetime limit of 72 sessions for cardiac rehab; a patient qualifies for 36 (within 36 weeks) and up to 72 sessions after each qualifying cardiac episode. Pulmonary rehab is limited to a maximum of 72 sessions in a lifetime and PR sessions beyond 72 will deny for payment even if the KX modifier is included. Unlike the time limit of 36 sessions within 36 weeks for cardiac rehab, there is no stated time limit for providing the 36-72 sessions of pulmonary rehab.
There are no set dollar limits for PT, OT, and SLP therapy, other than the requirements for medical necessity and patient benefit. At some point, therapy treatment for a condition generally reaches a plateau where further therapy adds no benefit for the patient or simply becomes routine maintenance therapy that does not require the skills of a therapist and therefore does not meet the Medicare therapy benefit definition. Also note that PT and SLP services combined, and OT services are subject to a targeted medical review (MR) at a threshold amount of $3,000. Not all claims exceeding the MR threshold amount are subject to review as they once were, but only selected claims based on billing patterns.
The lesson for hospitals here is to proactively be aware of the session and dollar limits for rehabilitative services and appropriately use the KX modifier to ensure proper payment. It is also a good idea to monitor your claim denials, specifically looking for denials with CARC 119. Once denied, you would have to appeal the claim to receive payment, which may not be worth the time and effort. However, reviewing these denials will let you know if upfront systems are working. If not, you may want to make process changes to ensure appropriate reimbursement. No matter how much passion we have for healthcare, we still need to be paid to keep the doors open.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update
Update of the HCPCS code set for codes related to drugs and biologicals.
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2
October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2019
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.3 Effective October 1, 2019
Notice of New Interest Rate for Medicare Overpayments and Underpayments -4th Qtr Notification for FY 2019
The Medicare contractors shall implement an interest rate of 10.625 percent effective July 17, 2019 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R318FM.pdf
OTHER MEDICARE TRANSMITTALS
Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program
Modifications to Medicare’s claims processing systems to ensure that the Medicare Summary Notice (MSN) appropriately differentiates between QMB claims that are paid and denied and to show accurate patient payment liability amounts for beneficiaries enrolled in QMB.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA). Since these tests are marketed immediately after approval, the Centers for Medicare & Medicaid Services (CMS) must notify the MACs of the new tests so that they can accurately process claims.
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements
Appropriate Use Criteria (AUC) related HCPCS modifiers on claims to be accepted January 1, 2020.
MEDICARE SPECIAL EDITION ARTICLES
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations
Revised to provide an update on Round 3 testing and to announce a delay of full implementation until October 2019.
Pre-Diabetes Services: Referring Patients to the Medicare Diabetes Prevention Program
Information on this new Medicare covered service.
Emergency Medical Treatment and Labor Act (EMTALA) and the Born-Alive Infant Protection Act
Medicare Plans to Modernize Payment Grouping and Code Editor Software
CMS is modernizing its grouping and code editor software. Medicare processes all Original Medicare institutional claims through one of three sub-systems within the Fiscal Intermediary Shared System (FISS):
- The Medicare Code Editor (MCE)
- The Inpatient Grouper (MS-DRG)
- The Integrated Outpatient Code Editor (IOCE).
These sub-systems are built with an antiquated programming language (Assembler) that is difficult to extend, maintain, support and test. Modernizing these programs will protect CMS from future quality and integration risks.
MEDICARE COVERAGE UPDATES
Acupuncture Coverage for Chronic Low Back Pain
CMS proposes to cover acupuncture for chronic low back pain for Medicare beneficiaries enrolled in approved studies.
https://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=295
Update to Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home
Updates the list of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for the coverage of IVIG for treatment of Primary Immune Deficiency Diseases (PIDD) in the home.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Cardiac Device Credits: Medicare Billing
Palmetto GBA Hyperbaric Oxygen Therapy Module
Explains HBO therapy, covered and non-covered conditions as indicated per NCD 20.29 for treatment, as well as documentation guidelines pertinent to establishing medical necessity when submitting claims to Medicare
https://www.palmettogba.com/internet/eLearn3.nsf/HyperbaricOxygenTherapy/story_html5.html
OTHER MEDICARE UPDATES
KEPRO Updates for Healthcare Providers
Since Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) started transitioning into a new 5-year contract with the Centers for Medicare & Medicaid Services (CMS), KEPRO has been making necessary changes to help streamline processes. During the next few weeks, we will share periodic updates with you in a special bulletin.
https://www.keproqio.com/providers/transition/
Comprehensive Care for Joint Replacement Model
Jun 27, 2019 Announcement: Second annual evaluation report and associated materials posted.
https://innovation.cms.gov/initiatives/cjr
ESRD Treatment Choices (ETC) Model
Proposed required model aims to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with end-stage renal disease (ESRD).
https://innovation.cms.gov/initiatives/esrd-treatment-choices-model
Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First
“Within 60 days of the date of this order, the Secretary of Health and Human Services shall propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information…”
CMS Announces Extension of Enforcement Discretion Period for Laboratory Date of Service Exception Policy Under the Medicare Clinical Laboratory Fee Schedule Until January 2, 2020
During the enforcement discretion period, hospitals may continue to bill for advanced diagnostic laboratory tests (ADLTs) and molecular pathology tests that would otherwise be subject to the laboratory DOS exception.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Lab-DOS-Policy.html (see Downloads section)
CY 2020 Home Health Prospective Payment System (HH PPS) Proposed Rule
Proposes routine updates to the home health payment rates for calendar year (CY) 2020, and also includes: a proposal to modify the payment regulations pertaining to the content of the home health plan of care; a proposal to allow therapist assistants to furnish maintenance therapy; and a proposal related to the split percentage payment approach under the Home Health Prospective Payment System (HH PPS). Finally, this rule will include proposals related to the implementation of the permanent home infusion therapy benefit in 2021.
Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-14913.pdf
Monday, July 29, 2019, CMS released three important Medicare proposed payment rules for 2020:
- The OPPS and ASC Proposed Rule - https://www.cms.gov/newsroom/press-releases/cms-takes-bold-action-implement-key-elements-president-trumps-executive-order-empower-patients-price
- The MPFS Proposed Rule - https://www.cms.gov/newsroom/press-releases/trump-administrations-patients-over-paperwork-delivers-doctors
- The ESRD and DME Proposed Rule - https://www.cms.gov/newsroom/press-releases/new-cms-proposals-strengthen-medicare-unleash-innovation-and-promote-competition-provide-kidney
Way back in January 2017, CMS published two transmittals (MM9613 and MM9907) that described the requirement for hospitals’ service addresses reported on claims to be an exact match to the facility’s practice locations reported on their CMS 855A enrollment form. The correct reporting of service addresses to Medicare is required to allow accurate payments based on service location. Per the Background information in MLN Matters Article SE19007,
“Increasingly, hospitals operate an off-campus, outpatient, provider-based department of a hospital. In some cases, these additional locations are in a different payment locality than the main provider. For Medicare Physician Fee Schedule (MPFS) and OPPS payments to be accurate, CMS uses the service facility address of the off-campus, outpatient, provider-based department of a hospital facility to determine the locality in these cases.”
Although the requirements for correct service address reporting became effective back in 2017, Medicare did not put systematic validation edits in place at that time. With the release of MLN Matters Article SE18023 in October 2018, edits were scheduled to go into place on April 1, 2019. CMS had already conducted one round of “behind-the-scenes” testing and concluded that “many providers are not sending the correct exact service facility location on the claim that produces an exact match with the Medicare enrolled location as based on the information entered into the PECOS for their off-campus provider departments.” Most of the discrepancies had to do with spelling variations (Road vs Rd, for example). After a second round of testing in November 2018, CMS decided to:
- delay implementation until July 2019,
- provide further guidance to hospitals,
- make the practice location address screen available to providers in DDE beginning April 2019, and
- conduct additional round(s) of testing “to ensure that we have a smooth implementation of the edits.”
This resulted in the March 2019 release of SE19007 referenced above with link provided. For more details on the reporting requirements of service locations, read SE19007 and see this prior Wednesday@One article.
Hospitals must finally be paying attention to the requirement because a recent updated version of SE19007 “discovered no major issues during round 3 testing” conducted in June 2019. However, CMS is still being cautious so in response to stake-holder comments and to further evaluate the results of round 3 testing, they are again delaying the claim edits, this time until October 1, 2019.
Unless there are more delays, at that time, CMS will direct the Medicare Administrative Contractors (MACs) to permanently turn on the edits. Claims with service location addresses that do not exactly match the address in PECOS will Return-to-Provider (RTP). Per the article, “Providers can make corrections to their service facility address for a claim submitted in the DDE MAP 171F screen for DDE submitters. Providers who need to add a new or correct an existing practice location address will still need to submit a new 855A enrollment application in PECOS.”
In the final sentence of the article, CMS states they think 2 ½ years has been ample time for providers to prepare for these edits and get their systems in order. I have to agree with CMS on this one – 2 ½ years to get an address correct is plenty of time.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2
July 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Describes changes to and billing instructions for various payment policies implemented in the July 2019 OPPS update.
OTHER MEDICARE TRANSMITTALS
Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment
Removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit and adds information on E&M code that may be billed with superficial radiation treatment.
New to State Operations Manual (SOM), Appendix X, Survey Protocol and Interpretive Guidelines for Organ Transplant Programs
Adds Appendix X to the SOM to outline the survey process and interpretive guidelines for the Conditions of Participation for organ transplant programs.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R189SOMA.pdf
Updates to Medicare Financial Management Manual Chapter 4, Section 20 and 20.1 Demand Letters
Every demand letter, regardless of the cause of the overpayment or the status of the provider, shall meet certain requirements as to form and content.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R316FM.pdf
MEDICARE SPECIAL EDITION ARTICLES
Chimeric Antigen Receptor (CAR) T-Cell Therapy Revenue Code and HCPCS Setup Revisions
Updated reporting instructions for CAR T-Cell Therapy.
MEDICARE COVERAGE UPDATES
Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430R)
The Centers for Medicare & Medicaid Services (CMS) will cover Transcatheter Aortic Valve Replacement (TAVR) for the treatment of symptomatic aortic valve stenosis through Coverage with Evidence Development (CED).
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=293
MEDICARE PRESS RELEASES
CMS Seeks Public Input on Patients over Paperwork Initiative to Further Reduce Administrative, Regulatory Burden to Lower Healthcare Costs
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Outpatient Rehabilitation Therapy Services: Comply with Medicare Billing Requirements
- Bill Correctly for Device Replacement Procedures
Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements
OTHER MEDICARE UPDATES
April-June 2019 Quarterly Provider Updates
CMS publishes this Update to inform the public about the following:
- Regulations and major policies completed or cancelled.
- New/Revised manual instructions
Kepro BFCC-QIO FAQs for Healthcare Providers
Frequently asked questions (FAQs) related to KEPRO’s services.
MEDICARE TRANSMITTALS – RECURRING UPDATES
Notice of New Interest Rate for Medicare Overpayments and Underpayments -3rd Qtr Notification for FY 2019
The Medicare contractors shall implement an interest rate of 10.375 percent effective April 17, 2019 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R313FM.pdf
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)
A maintenance update of International Classification of Diseases, 10th Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Claim Status Category and Claim Status Codes Update
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update
Updates the HCPCS code set for codes related to drugs and biologicals.
OTHER MEDICARE TRANSMITTALS
Implementation to Exchange the List of Enrollment in Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System
Introduces the enrollment process for the providers who intend to get their Additional Documentation Request (ADR) letters electronically (as eMDR) through their registered Health Information Handler.
Re-implementation of the AMCC Lab Panel Claims Payment System Logic
Because CMS no longer has payment logic to roll up panel pricing for organ or disease-oriented panels (also known as Automated Multi-Channel Chemistry or AMCC tests), laboratories must report the HCPCS code for the AMCC panel test where appropriate and not report separately the tests that make up that panel.
Documentation of Evaluation and Management Services of Teaching Physicians
A change in policy of documentation for teaching physicians providing evaluation and management (E/M) services.
Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
Effectuates changes to the SNF Prospective Payment System (PPS) that are required for the PDPM. These changes were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162). SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X, (subject to SNF PPS) will be subject to these requirements.
Reporting the HCPCS Level II Modifiers of the Patient Relationship Categories and Codes
Provides educational information regarding reporting of the HCPCS Level II code modifiers for the Patient Relationship Categories and Codes (PRC).
Additional Processing Instructions to Update the Standard Paper Remit (SPR)
Effective October 1, 2019, MACs will mask the Patient Control Number field (also named the Patient CNTRL Number) or the Patient Account Number (ACNT) field on any print file used to create an SPR for mailing if it contains a HICN or SSN in accordance with the Social Security Number (SSN) Fraud Prevention Act of 2017.
MEDICARE SPECIAL EDITION ARTICLES
Proper Use of Modifier 59
Clarifies existing policy on the proper use of Modifier 59. Revised article to correct updated CPT code.
MEDICARE COVERAGE UPDATES
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
CMS covers diagnostic laboratory tests using next generation sequencing when performed in a CLIA-certified laboratory when ordered by a treating physician and when specific requirements are met.
Delay in Final Chimeric Antigen Receptor (CAR) T-cell therapy National Coverage Determination
CMS will not be issuing a final National Coverage Determination on CAR T-cell therapy for cancer today (5-17-19), but a decision is forthcoming.
MEDICARE PRESS RELEASES
CMS outlines comprehensive strategy to foster innovation for transformative medical technologies
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
OTHER MEDICARE UPDATES
2020 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule
https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-08330.pdf
Fact Sheet for Proposed Rule - https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute
BFCC-QIO Contract Awarded for 12th Scope of Work to Start July 2019
The 11th Scope of Work is coming to an end. On April 30th KEPRO and LIVANTA were again awarded the BFCC-QIO contracts for the 12th Scope of Work (SOW) that will run from 2019 – 2023
Temporary Pause of BFCC-QIO Short Stay and HWDRG Reviews
CMS has temporarily paused the performance of both Short Stay reviews and Higher Weighted Diagnosis-Related Group (HWDRG) reviews by the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs). CMS took this action to procure a new BFCC-QIO contractor. Going forward, Short Stay reviews and HWDRG reviews will resume with a single organization performing reviews on a national basis. CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019.
https://qioprogram.org/qionews/articles/temporary-pause-bfcc-qio-short-stay-and-hwdrg-reviews
Local Coverage Determination (LCD) Process Modernization Qs & As
Describes recent changes to the LCD process.
https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/LCD_QsAs.pdf
System Edits Will Be Activated for OPPS Providers with Multiple Service Locations
On July 1, 2019, CMS will begin enforcing edit requirements for Outpatient Prospective Payment System (OPPS) providers with multiple service locations submitting claims to Medicare.
There is a new trend going around FaceBook of describing your age by memories and events instead of a number. For example, I am “Walt Disney's Wonderful World of Color on Sunday nights” old. In fact, I am so old that I actually had the measles as a child. Unfortunately, this is becoming a new “event” of present day and a very scary one at that. I had a very light case of the measles as a child, but my little brother was extremely ill, only avoiding hospitalization because our family doctor made frequent house calls to check on him (another phenomenon of the past). The key to preventing a new epidemic of this life-threatening disease is to get the measles vaccine. There are other vaccines that are recommended for children and adults. I am traveling out of the country soon and got two vaccines this week based on the CDC recommendations for travelers. Pediatricians usually keep up with the recommended vaccines for children, but it is harder for adults. Here is an excellent article from NPR about adult vaccines.
Medicare covers vaccines for influenza, pneumococcal pneumonia, and hepatitis B (for higher risk individuals). As always for providers of Medicare services, where there are services provided, there are billing rules. Recently NGS, the Medicare Administrative Contractor (MAC) for Jurisdictions 6 and K, featured influenza vaccines as the topic of their Medicare BLAST. Medicare BLAST is a quick, ten-question game from NGS that challenges the Medicare knowledge of providers and one of the most creative and fun educational tools I’ve encountered.
Here is some information about Influenza Vaccines from the Medicare BLAST and other Medicare resources.
- Influenza vaccines are payable once per flu season. For Medicare pricing purposes the season runs from August to July of the following year, such as from August 2018-July 2019. Frequency limits are based on the flu season, not the calendar year, so a Medicare patient could receive two flu vaccines in the same calendar year. For example, if a Medicare beneficiary gets a shot in January 2019 for the 2018/2019 flu season, they could get another shot in October 2019 for the 2019/2020 flu season.
- Medicare patients can receive an influenza vaccine and a pneumococcal pneumonia vaccine during the same visit. The administration codes (G0008 and G0009 respectively) may be billed together on the same claim for the same date of service. A modifier is not needed when billing the two administration codes for the influenza and pneumococcal vaccine.
- The Part B deductible, coinsurance, or copayment do not apply to the seasonal influenza virus vaccine or its administration. Medicare covers the vaccine as long as the patient is eligible for and enrolled in Traditional Medicare.
- Medicare does not require that a doctor order the vaccine. Therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision. A physician is not required to be present during the administration of the influenza vaccine.
- Vaccines provided to inpatients of a hospital are covered under the vaccine benefit. The hospital bills on type of bill 012x using the discharge date of the hospital stay or the date benefits are exhausted.
- Hospital providers should bill for the vaccines and their administration on the same bill. Hospitals are paid at reasonable cost for the vaccine and under the OPPS payment rate for the vaccine administration.
- Simplified (roster) billing procedures are available to mass immunizers, including hospitals. See section 10.3.2 of the Chapter 18 of the Medicare Claims Processing Manual for more information on roster billing.
In addition to Section 10 of the Medicare Claims Processing Manual, Chapter 18 (at the link above), another good resource on Medicare vaccines is the MLN Educational Tool on Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B.
People have differing opinions about vaccines, but I am solidly for them. I went to elementary school with a little girl who wore braces from polio, my brother could have died from the measles, my grandfather was one of the few survivors at his Army base of the flu pandemic of 1918, and years ago I thought I was going to die from the flu. I have taken the flu vaccine every year since. Not all vaccines are 100% effective and there may be some side effects, but overall, they help protect you and those around you from serious illnesses.
Debbie Rubio
Over the past several years, there has been a trend for hospitals to acquire and operate more off-campus, outpatient provider-based departments (PBDs). As this shift in place of service has occurred, CMS has made several adjustments to promote site-neutral payments and gather data on the number of such entities and the services they provide. We have seen a transition to a different payment system for new off-campus PBDs at 40% of the usual OPPS rates, modifiers for services provided in new and existing off-campus PBDs, and new edits enforcing requirements for reporting the address of the service location on the claim. The good news for this last requirement is that Medicare continues to give hospitals one more chance to get it right before turning on the edits.
MLN Matters Article SE19007 describes the claim requirements related to the service location address and gives a new implementation date of July 2019. Basically, the requirement is that “Medicare outpatient service providers report the service facility location for an off-campus, outpatient, provider-based department of a hospital in the 2310E loop of the 837 institutional claim transaction. Direct Data Entry (DDE) submitters also must report the service facility location for an off-campus, outpatient, provider-based department of a hospital.” The hard part is that the reported addresses must be an exact match to the information on the Medicare enrollment Form CMS-855A submitted by the provider and entered into the Provider Enrollment, Chain and Ownership System (PECOS). In CMS testing to date, many providers are not reporting the correct service facility location on the claim that produces an exact match with the Medicare enrolled location as based on the information entered into the PECOS. Most of the discrepancies have to do with spelling variations, such as “Road” versus “Rd.”
The MLN article gives specific examples of the required claim reporting for different scenarios based on where the services were provided as seen in the table below:
These are not new requirements but were discussed in CRs 9613 and 9907, both of which were effective on January 1, 2017. CMS released MLN Matters Article SE18023 in October 2018 and originally planned to turn on the edits that would reject claims if the addresses were not an exact match in April 2019. As stated above, this latest MLN SE Article delays the implementation until at least July 2019 with additional testing prior to that date. Another positive is that in the April 2019 system update, the FISS maintainer, at the direction of CMS, has made the practice location address screen available to providers in DDE. This will allow providers to ensure the service location address they are reporting is an exact match to the PECOS address. Another helpful resource is a list of Questions and Answers published by CGS, the Medicare Administrative Contractor (MAC) for Jurisdiction 15.
SE19007 also discusses the use of modifiers PO and PN. Modifier PO is reported on line items for all excepted items provided at an off-campus PBD and modifier PN is reported on line items for all non-excepted items provided at an off-campus PBD. As a reminder, non-excepted off-campus PBDs are those off-campus provider-based departments of a hospital that were not furnishing or billing for services before November 2, 2015. Non-excepted off-campus PBDs are paid under the physician fee schedule (PFS) instead of under OPPS at a rate equal to 40% of the OPPS. Non-excepted services are reported with the PN modifier to trigger the reduced payment. Excepted off-campus PBDs report modifier PO to allow CMS to gather data and monitor billing patterns but, at this time most services continue to be paid under OPPS at regular OPPS payment rates. Beginning in 2019, there is a 30% reduction in payment for clinic visit services (HCPCS G0463) from the regular OPPS rates when provided at excepted off-campus PBDs. This reduction increases to a 60% reduction for 2020 which will equal the 40% of OPPS payment rate received by the non-excepted off-campus PBDs but again, at this time, only for clinic visits for the excepted off-campus PBDs.
Once the edits are turned on, be that July or later, claims submitted with service location addresses that are not an exact match to PECOS will Return to the Provider (RTP). Facilities should take advantage of this implementation delay, the new DDE screen showing the PECOS address, and the expanded reporting instructions to make sure you have it right.
Debbie Rubio
April is National Occupational Therapy Month. The American Occupational Therapy Association (AOTA) states on their website, “Occupational therapy practitioners enable people of all ages to live life to its fullest by helping them promote health, and prevent—or live better with—injury, illness, or disability.” In honor of OT month (and also with a nod to physical therapists and speech language pathologists) today’s article will address the issue of the correct reporting of therapy units.
Although the reporting of timed therapy codes would seem to be more difficult than untimed codes, this April’s Medicare Quarterly Provider Compliance Newsletter addresses errors identified by the Recovery Auditors for the reporting of untimed therapy codes. To cover all our bases, let’s review both.
A number of CPT codes, such as constant attendance modalities and most therapeutic procedures, specify a time frame of 15 minutes as the direct one-on-one time spent providing the therapy service to the patient. These are referred to as “timed” therapy procedure codes.
When a therapy service is not defined by a specific timeframe, it is an “untimed” therapy procedure (CPT or HCPCS) code. Untimed codes are billed with a unit of one (1) per date of service. The unit for untimed codes is one regardless of how long the evaluation or service took. Providers should enter a 1 in the ‘units bill’ column per date of service. Below is a table of the untimed therapy codes. There may be exceptions to a unit of one if a patient has more than one encounter on the same day.
Timed therapy codes include in their CPT description the time frame of “each 15 minutes” and units are calculated based on the total time of all “timed” code services. Per the Medicare Claims Processing Manual, chapter 5, section 20.2, “Providers report these “timed” procedure codes for services delivered on any single calendar day using CPT codes and the appropriate number of 15 minute units of service.” The total number of units billed for “timed” services are based on the total time of the “timed” services according to the following chart. If more than one “timed” service is provided, add the minutes of all “timed” services together and get the total number of “timed” units to be billed. These are then divided appropriately among the various “timed” services provided. Although Medicare requires providers to report the total treatment time (timed and untimed services), do not add the minutes of “untimed” codes when calculating the units of “timed” services.
Pattern continues…
Do not report any units if total minutes of timed therapy services is less than 8 minutes
See Section 20.2 of Chapter 5 of the Claims Processing Manual for examples of the billing of timed codes. Here is a straight forward example from the Manual:
“Example 1 –
- 24 minutes of neuromuscular reeducation, code 97112,
- 23 minutes of therapeutic exercise, code 97110,
- Total timed code treatment time was 47 minutes.
See the chart above. The 47 minutes falls within the range for 3 units = 38 to 52 minutes.
Appropriate billing for 47 minutes is only 3 timed units. Each of the codes is performed for more than 15 minutes, so each shall be billed for at least 1 unit. The correct coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service that took the most time.”
Other examples in the Manual address trickier situations, such as the division of an odd number of units if both services are the same length, division of units if the number of different services exceeds the number of units, and the counting of services lasting less than 8 minutes.
One of the most common time errors I see when reviewing therapy records is the inclusion of the time of “untimed” codes in the time used to calculate code minutes. Remember, untimed codes are billed with 1 unit per day of service and “untimed” code minutes do not affect the overall units of codes.
- For example, a patient receives 25 minutes of therapeutic exercise (CPT 97110) and 10 minutes of unattended e-stim (HCPCS G0283).
- Do not add the 10 minutes of unattended e-stim to the 25 minutes of ther ex for a total of 35 minutes, limiting your total units to 2.
- In this situation, 35 minutes is the total treatment time, but the total “timed” code minutes is 25 for 2 units of ther ex (97110). The unattended e-stim, as an untimed code, is reported with units of 1.
Separate your “timed” and “untimed” minutes when determining units – untimed codes = units of one (1); timed codes = units based on total minutes of “timed” codes only.
Therapy providers should know their “timed” versus “untimed” code and keep them separate for calculating units. Again, we at MMP wish a timely Happy OT Month to all the dedicated and hard-working Occupational Therapists who help their patients “live life to its fullest.”
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
July 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2019
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.2 Effective July 1, 2019
OTHER MEDICARE TRANSMITTALS
Billing for Hospital Part B Inpatient Services
Provides billing instructions for hospital Part B inpatient services.
Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment – REVISED
Revised to clarify that providers need to bill the 25 modifier when performing E/M services with CPT code 77401.
Pub. 100-04, Chapter 29 – Appeals of Claims Decisions – Revisions
Incorporates the following policy updates to the Medicare Claims Processing Manual:
- The policy on use of electronic signatures
- Timing of signatures on transfer of appeal rights and the appointment of representative forms
- Tolling an adjudication timeframe when trying to cure a defective appointment form
- Limiting scope of redetermination review in certain instances
- Application of good cause for late filing involving beneficiary accessibility
- Application of good cause where there is a declared disaster
New Waived Tests
Informs MACs of new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
MEDICARE SPECIAL EDITION ARTICLES
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations
Claim information for Outpatient Prospective Payment System (OPPS) providers that have multiple service locations.
MEDICARE COVERAGE UPDATES
CMS Proposes Updates to Coverage Policy for Transcatheter Aortic Valve Replacement (TAVR)
CMS is updating the coverage criteria for hospitals and physicians to begin or maintain a TAVR program.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing
- Provider Minute Video: The Importance of Proper Documentation
OTHER MEDICARE UPDATES
April 2019 Patients Over Paperwork Newsletter
Updates on ongoing work to reduce administrative burden and improve the customer experience for hospitals.
GAO Report for Medicare and Medicaid:
CMS Should Assess Documentation Necessary to Identify Improper Payments
GAO examined: (1) Medicare and Medicaid documentation requirements and factors that contribute to improper payments due to insufficient documentation; and (2) the extent to which Medicaid reviews provide states with actionable information.
On March 26, 2019 CMS published a Proposed Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430R). In a related CMS Press Release CMS noted they would continue to cover TAVR under Coverage with Evidence Development (CED) when furnished according to an FDA-approved indication.
TAVR Background
CMS first released National Coverage Determination (NCD) 20.32 Transcatheter Aortic Valve Replacement (TAVR) with an effective date of May 1, 2012. At that time, TAVR was considered a new technology for use in treating patients with aortic stenosis where a biprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve.
TAVRs are performed in a cardiac catheterization lab or a hybrid operating room/cardiac catheterization lab with advanced quality imaging and with the ability to safely accommodate complicated cases that may require conversion to an open surgical procedure. The interventional cardiologist and cardiothoracic surgeon jointly participate in the intra-operative technical aspects of TAVR.
NCD 20.32 allows for coverage of the TAVR Procedure under Coverage with Evidence Development (CED) with specific conditions being met, appropriate volume requirements and a heart team and hospitals participation in a prospective, national, audited registry. For indications not approved by the FDA, CMS covers TAVR under CED when a patient is enrolled in a qualifying clinical study.
Registry and Clinical Study Approvals by CMS can be found on the CMS Coverage with Evidence Development TAVR webpage. https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/TAVR.html
TAVR Hospital Volumes
TAVR procedures are on the Medicare Inpatient Only Procedure List and sequence to the MS-DRG Pair 266 and 267 (Endovascular Cardiac Valve Replacement with MCC and without MCC respectively). In CMS Fiscal Year (FY) 2015 through 2017, this MS-DRG pair also included ICD-10-PCS codes for replacement of pulmonary valves. In FY 2018 an additional 4 mitral valve codes and 8 new tricuspid valve codes were also added to this MS-DRG pair.
To provide you with a glimpse into these types of procedures, I utilized Medicare Fee-for-Service paid claims data from our sister company RealTime Medicare Data (RTMD) for CMS FY 2015 through 2018. The following table highlights an increase in volumes and average charges and a decrease in actual average payment and average length of stay (ALOS) for Medicare Fee-for-Service paid claims in Alabama, Georgia and Tennessee.
Proposed Decision Memo: Changes and CMS’ Request for Comments
The Decision Memo proposes to update “the coverage criteria for hospitals and physicians to begin or maintain a TAVR program. The proposed decision provides more flexibility in how providers can meet the requirements performing TAVR, while continuing to ensure good health outcomes for patients receiving the procedure.”
The CMS Press Release notes they are also seeking to gather additional information and specifically proposed “a question regarding the relationship between other metrics and patient health outcomes, which could inform a future change to replace the volume criteria with a different metric.”
Key stakeholders at your hospital should take the time to read the Proposed Decision Memo and provide public comments. There is a 30-day public comment period ending April 25th and a final decision will be issued no later than 60 days after the conclusion of the 30-day public comment period. All public comments may be submitted at https://www.cms.gov/medicare-coverage-database/indexes/nca-open-for-public-comment-index.aspx.
Link to NCD 20.32: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=355&ncdver=1&bc=AAAAgAAAAAAAAA%3d%3d&
Beth Cobb
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