Knowledge Base Category -

Q:

Can we give Medicare patients an Advance Beneficiary Notice (ABN) and bill them when services are denied for exceeding a Medically Unlikely Edit (MUE)?

A:

No. Medically Unlikely Edits (MUEs) define correct coding and therefore the denials are coding denials. This means the provider is liable. Advance Beneficiary Notices (ABNs) are to be used when the provider expects denials related to the medical necessity of services. Since an MUE denial is a coding denial and not a medical necessity denial, an ABN is not appropriate.  The Medicare patient cannot be billed for services denied for exceeding MUE limits.

The MUE program began in January 2007 and was implemented to reduce the Medicare paid claims error rate. The MUE is a limit on the number of units Medicare will adjudicate. MUE values are adjudicated either against units reported on a line item of a claim or on an entire date of service. For date of service (DOS) MUEs, if units reported for a HCPCS code for one day exceed the MUE limit, no payment will be made for that code unless the denial is overturned on a provider-initiated appeal.

The type of MUE can be determined by the “MUE adjudication indicator” (MAI) in the MUE edit table. These indicators describe the type of MUE and how it is adjudicated.

• An MAI of “1” is a claim line edit. The MUE may be by-passed when appropriate by reporting units exceeding the MUE on separate lines with an acceptable modifier.
• An MUE with an indicator of “2” is an absolute date of service edit. Units of service exceeding the MUE value are considered “impossible” because they are contrary to statute, regulation or sub-regulatory guidance, including correct coding policies. Denials for services with an MAI of “2” will not be overturned on appeal.
• MUEs for HCPCS codes with an MAI of “3” are date of service edits based on clinical guidelines. These edits will cause an automatic denial if the units for a date of service exceed the limit, but the denial may be overturned on appeal if there is adequate documentation of medical necessity of correctly reported units.

A recent article by Palmetto GBA (the Medicare Administrative Contractor (MAC) for Jurisdictions J and M) discusses MUE denials and ABNs.  Additional information on MUEs can be found on CMS’s NCCI/MUE website at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html including an NCCI FAQs download that addresses questions about procedure-to-procedure (PTP) edits and MUEs. Much of the discussion above was from a prior Wednesday@One article that readers may also find helpful. 

For more information on ABNs, see the MLN Booklet Medicare Advance Written Notices of Noncoverage.

Q:

During a Posterior Lumbar Interbody Fusion (PLIF) of L4-L5, the surgeon also placed autograft and allograft in the “gutters”.  Where are the “gutters” located on the spine and is there a corresponding PCS code for this procedure?

A:

The term “gutter” is referring to the Transverse Process of the spine, which is part of the posterior column.  Therefore, bone graft placed in the gutter(s) of L4-L5 is assigned a PCS code for Posterior Lumbar Fusion with a Qualifier of ‘1’ for Posterior Approach, Posterior Column.

It is common for both a PLIF and a Posterior Lumbar Fusion to be performed together.  In addition, we have Spinal Fusion Guidelines specifying that both types of fusions should be reported when performed together:

• PCS Guideline B3.10b: A separate procedure code is assigned for each vertebral joint that uses a different device and/or qualifier.

For this scenario, the following fusion codes would be assigned:

• Fusion of Lumbar Vertebral Joint with Interbody Fusion Device, Posterior Approach, Anterior Column, Open Approach (0SG00AJ)
• Fusion Lumbar Vertebral Joint with Autologous Tissue Substitute, Posterior Approach, Posterior Column, Open Approach (0SG0071)

Resources:

• ICD-10-PCS Coding of Complicated Spinal Fusions: Qualifier J, Posterior Approach to Anterior Column, Lynn Kuehn, RHIA, CCS-P, FAHIMA
• 2018 Coding Handbook, Spinal Fusion and Refusion
• ICD-10-PCS Coding Guidelines for Fusion Procedures of the Spine

Q:

How do we determine which CPT codes are affected by the new laboratory date of service policy?

A:

The new lab date of service policy determines the date of service for molecular pathology tests and Advanced Diagnostic Laboratory Tests (ADLTs) that are not packaged under the Outpatient Prospective Payment System (OPPS) in certain circumstances.  The date of service for these tests is the date the test is performed for outpatients when:

• The physician orders the test following the date of a hospital outpatient’s discharge from the hospital outpatient department;
• The specimen was collected from a hospital outpatient during an encounter (as both are defined 42 CFR 410.2);
• It would be medically inappropriate to have collected the sample from the hospital outpatient other than during the hospital outpatient encounter;
• The results of the test do not guide treatment provided during the hospital outpatient encounter; and
• The test was reasonable and medically necessary for the treatment of an illness.

This means for tests sent from a hospital laboratory to a reference laboratory for testing, the reference laboratory will bill Medicare directly.

What’s Included?

Molecular pathology tests and Advanced Diagnostic Laboratory Tests (ADLTs) under Criterion A (defined below) that are not packaged under the Outpatient Prospective Payment System (OPPS).

Molecular pathology tests are defined by the CPT manual.  There are Tier 1 Molecular Pathology codes 81105 – 81383, Tier 2 codes 81400-81408 and unlisted molecular pathology code 81479. 

An ADLT is a clinical diagnostic laboratory test (CDLT) covered under Medicare Part B that is offered and furnished only by a single laboratory and cannot be sold for use by a laboratory other than the single laboratory that designed the test or a successor owner. Criterion A ADLTs are tests that are an analysis of multiple biomarkers of deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or proteins; when combined with an empirically derived algorithm, yields a result that predicts the probability a specific individual patient will develop a certain condition(s) or respond to a particular therapy(ies); provides new clinical diagnostic information that cannot be obtained from any other test or combination of tests; and may include other assays. There are currently no codes designated as ADLTs.

Laboratory tests not packaged under OPPS will have a Status Indicator (SI) of “A” on the OPPS Addendum B.

Based on this, CPT codes currently affected by the new lab date of service policy are: CPT 81105-81383, CPT 81400-81408, and CPT 81479.

What’s Not Included?

After the Molecular Pathology codes in the CPT manual, there are genomic sequencing procedures (GSPs) codes 81410-81471 and then multianalyte assays with algorithmic analyses (MAAAs) codes 81490 – 81599.  The OPPS Final Rule makes it clear that the GSP and protein-based MAAA codes are not included in the new lab date of service rule.

Also not included are Proprietary Laboratory Analysis (PLAs). The American Medical Association (AMA) assigns PLA codes and includes the following definition on their website: “PLA codes are alpha-numeric CPT® codes with a corresponding descriptor, for labs or manufacturers to more specifically identify their test. Tests with PLA codes must be performed on human specimens and must be requested by the clinical laboratory or manufacturer that offers the test.” Current PLA codes are in the range of 0001U - 0034U.

Criterion B ADLTs (ADLTs cleared or approved by the FDA) are also not included in the revised lab date of service policy.

Q:

1. If an inpatient has a cardiac arrest and does not survive CPR, do you code the ICD-10-CM diagnosis of Cardiac Arrest?

Hospitals thoughts and current coding:

We have not been coding the ICD-10-CM code for cardiac arrest if the patient does not survive the code. The discharge disposition reflects the death of the patient.   The cardiac arrest code provides medical necessity for the CPR procedure code, but everyone’s heart will arrest at the time of death. It will not be everyone’s cause of death.  We ensure that all other conditions that meet the appropriate UHDDS definitions are coded so that the severity of illness and risk of mortality are appropriately captured.                   

2. How do you correctly code CPR in ICD-10-PCS? Does it differ if the patient survives the code?

Hospitals thoughts and current coding:

We have only been coding the “CPR” code: 5A12012 Performance of Cardiac Output Single, Manual.

If the patient was intubated, bagged or defibrillated in addition to the manual chest compressions during CPR, should we code those root operations separately? 

INTUBATION:  The PCS Desk Reference states that if an endotracheal tube is inserted to maintain an airway in patients who are unconscious or unable to breathe on their own, intubation should be coded to the root operation INSERTION.  Does this apply to CPR?

The PCS guideline for devices states that the device should not be coded unless that device remains after the procedure is completed.  If the patient survives and is placed on a ventilator, yes we code the intubation and ventilation.  What if the patient doesn’t survive the code? Should we code the intubation?   Not all physicians intubate their patients when CPR is performed.  Not all physicians use the same method with each patient.   We never see them document “intubated for airway protection” (although it makes sense that airway protection is the reason).  Does the physician need to document intubated for airway protection during CPR in order to code the intubation, even if the patient does not survive?

A:

According to Coding Clinic 1st Qtr. 2013 page 10, you would report a code for cardiac arrest whether or not the patient was resuscitated.  Sequencing of cardiac arrest would depend on the circumstances of the admission and whether the source of the arrest were known.

You would code each method obtained to resuscitate the patient including intubation.  More than likely they aren’t going to intubate the patient unless they plan on placing the patient on a BiPap/Vent. 

Q:

If there is not a Local Coverage Determination for a drug, how do I determine if its use for a particular indication meets Medicare guidelines?

A:

Medicare provides guidance on the coverage of drugs in the Medicare Benefit Policy Manual, Chapter 15, Section 50.

Specifically, Section 50.4.1 discusses that drugs approved by the Food and Drug Administration (FDA) and used for indications specified on the labeling (package insert) are generally covered by Medicare if they are medically necessary and all other applicable coverage requirements are met.

Off-label uses of an FDA approved drugs, that is when the drug is used for indications other than what is indicated on the official label, may be covered by Medicare if the Medicare Administrative Contractor (MAC) determines the use to be medically accepted.  The MAC will consider information from the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. This is discussed in Section 50.4.2.

Section 50.4.5 specifically addresses the off-label use of drugs and biologicals in an anti-cancer chemotherapeutic regimen. “Off-label, medically accepted indications are supported in either one or more of the compendia or in peer-reviewed medical literature.”  This section includes a list of the approved compendia and acceptable category/wording to support off-label use.

Section 50.4.5 also gives the following guidance on acceptable literature and a list of acceptable publications.  “Peer-reviewed medical literature may appear in scientific, medical, and pharmaceutical publications in which original manuscripts are published, only after having been critically reviewed for scientific accuracy, validity, and reliability by unbiased, independent experts prior to publication.”

Q:

Would you code acute blood loss anemia if the surgeon specifies that acute blood loss anemia is expected after surgery?  Also, acute blood loss anemia was documented after surgery.

A:

Since acute blood loss anemia was documented after surgery, code (D62) for the acute blood loss anemia even though the surgeon said that blood loss was expected.  However, if acute blood loss anemia is not documented after surgery but there are clinical signs and symptoms of blood loss, do not code the acute blood loss anemia.  If anemia is documented after surgery with no further specificity, query the physician for clarification.

References

Coding Clinic, Third Quarter, 2004, page 4
Coding clinic, Second Quarter, 1992, pages 15-16

Q:

Is there any additional guidance on the use of modifiers for the payment reduction of drugs purchased through the 340B program?

A:

Yes.  On December 13, 2017, CMS released a list of Frequently Asked Questions (FAQs) concerning “Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS).”  There are 17 FAQs that contain information on the policy, definitions of types of hospitals, which types of providers have to report which modifiers, and more.

Some of the more surprising answers are:

• Hospitals must report modifier ‘TB’ for pass-through drugs (status indicator of “G”). Pass-through drugs are exempt from the 340B payment reduction and will continue to be paid at ASP+6%. The ‘TB’ modifier is informational to allow CMS to understand the scope of the 340B drug discount program.
• Discarded (wasted) drug amounts of drugs purchased through the 340B drug discount program for applicable entities should be billed on a separate claim line with the JW modifier and the appropriate 340B modifier.
• Non-excepted off-campus provider based departments (those PBDs that are paid under the Medicare Physician Fee Schedule) must report the ‘TB’ modifier for drugs purchased through the 340B program. The payment reduction does not apply to these types of PBDs since they are not paid under OPPS, but they must report the ‘TB’ modifier in addition to modifier “PN” (Nonexcepted service provided at an off-campus, outpatient, provider-based department of a hospital).
• Modifiers ‘JG’ or ‘TB’ can be optionally reported on packaged drugs with a status indicator of “N.” Packaged drugs with a status indicator of “N” do not require either modifier to be reported, but a provider may voluntarily report a modifier with these drugs.

When Medicare is either the primary or secondary payer, the appropriate 340B modifier is required in accordance with the OPPS 340B payment policy.

Q:

Since the 340B Drug Payment Reduction does not apply to Critical Access Hospitals (CAHs), do CAHs have to report modifier TB for drugs purchased through the 340B program?

A:

No, CAHs do not have to report modifier TB. Critical Access Hospitals (CAHs) are not included in the 340B policy change because they are paid based on 101 percent of reasonable costs as required by section 1834(g) of the Act.

All other hospitals under the OPPS are currently paid the same rate for separately payable drugs (ASP+6 percent), regardless of whether the hospital purchased the drug at a discount through the 340B Program. The new rule decreases the payment for drugs purchased through the 340B program from ASP+6% to ASP-22.5% (for an overall decrease of 28.5%). Hospitals to which the reduction applies must report modifier JG on 340B drugs in order for the drug payment to be paid at the reduced amount.

There were concerns from commenters about the drug payment reduction being especially harmful to certain type of OPPS hospitals:

• Rural hospitals are in a “hospital closure crisis” (since 2010, 80 rural hospitals have closed and one-third of remaining rural hospitals are vulnerable to closure, with 41 percent operating at a financial loss)
• Children’s hospitals furnish services under Medicare to children with end-stage renal disease (ESRD). Pediatric ESRD patients require high levels of care and rely on life-saving pharmaceuticals that often come at a high cost.
• PPS-exempt cancer hospitals treat the most vulnerable and underserved patients and communities. Also, children’s and PPS-exempt cancer hospitals receive transitional outpatient payments which would likely offset any reduction in payment of 340B drugs.

For these reasons, CMS excepted rural sole community hospitals (SCHs), children’s hospitals and PPS-exempt cancer hospitals from the 340B payment adjustment. CMS still wants to collect information on which drugs being billed to Medicare are acquired under the 340B program. Therefore the 2018 OPPS Final Rule states, “Accordingly, these three types of hospitals (rural SCHs, children’s hospitals, and PPS-exempt cancer hospitals) will still be required to report an informational modifier “TB” for tracking and monitoring purposes.” The TB modifier does not trigger a payment reduction and drugs reported with a TB modifier will be paid at ASP+6%.

Q:

Can we report the NIHSS stroke score with our hemorrhagic strokes, code ranges I61 – I62?

A:

Only assign the NIHSS stroke scale score with category

I63 - Cerebral Infarction. The Inpatient ICD-10-CM Coding Guidelines, Coding Clinic 4th Qtr. 2016 page 61, and The AHA’s Coding Handbook FY 2018 all specify to use with category I63. The subcategory, NIHSS score, R29.7-, has an instructional note to code first the type of cerebral infarction (I63-), and does not include hemorrhagic infarctions.  The I63 subcategory also has an instruction note to add a code for the NIHSS score, if known, whereas, the subcategory for the hemorrhagic infarctions does not.

Resources:

FY 2018 Inpatient ICD-10-CM Coding Guidelines
Coding Clinic, 4th Quarter 2016, page 61
The AHA’s Coding Handbook FY 2018

Q:

Will Medicare payments be reduced for 2018 for X-rays taken using computed radiography imaging?  If so, why?

A:

Yes, payments for imaging services taken using computed radiography imaging will be reduced for CY 2018 and subsequent years. The Consolidated Appropriations Act, 2016, which was enacted on December 18, 2015, contains provisions to incentivize the transition from traditional X-ray imaging to digital radiography by reducing payment for older imaging technology. 

The reduction for computed radiography (CR) will be phased in over several years. The Act requires that payments for CR services furnished during CY 2018, 2019, 2020, 2021, or 2022, be reduced by 7%, and if such services are furnished during CY 2023 or a subsequent year, by 10%. Computed radiography technology is defined as cassette-based imaging which utilizes an imaging plate to create the image involved.

CMS created a new modifier – modifier “FY” (X-ray taken using computed radiography technology/cassette-based imaging) to be reported on claims to identify those HCPCS codes that describe X-rays taken using CR technology. The payment reduction (7% for 2018) will be taken when this modifier is reported with the applicable HCPCS code(s) to describe imaging services that are taken using CR technology.

Already implemented beginning in 2017 as a requirement of the Act, payment for X-rays taken using film is reduced by 20 percent. Providers are required to report modifier “FX” (X-ray taken using film) with the appropriate HCPCS codes to identify x-rays taken using film.  The 20% payment reduction is taken when this modifier is reported with the applicable HCPCS code(s) for film x-rays. This 20% reduction began in January 1, 2017 and continues for subsequent years.

Due to increased packaging of payment for ancillary services over the past few years, payment for some x-ray services is packaged into the payment for the primary service. When payment for an X-ray service taken using film or computed radiography imaging is packaged into the payment for another item or service under the OPPS, no separate payment for the X-ray service is made. Therefore, there will be no payment reduction for packaged x-ray services.