Knowledge Base Category -

Q:

During a procedure when only one or two lymph nodes are removed; would the correct “Root Operation” be “Resection” or “Excision”?

A:

Lymph nodes are known to form together in clusters, better known as a “chain of nodes”. There are generally numerous amounts of lymph nodes within a chain of nodes. It can be difficult to know for sure whether all nodes were removed or not during any one particular procedure. One example of this would be when a patient is extremely obese.

Assign root operation “Resection”:

• When all nodes in a chain are removed.
• When total removal of lymph nodes is the physician’s intent but difficult to determine if they have actually all been removed.

Assign root operation “Excision”:

• When only a partial amount of lymph nodes are removed from the chain.

Assign root operation “Excision”:

• Sampling of nodes removed – example would be Sentinel Nodes

The operative report should be read carefully to determine the exact intent for the lymph node removal.

References Coding Clinic 3rd Quarter 2014 (ICD-10-CM/PCS) pages 9 and 10

Q:

How do you report the quantity of a drug with a HCPCS code when the HCPCS dose is different from the dose that was given?

A:

You can round up the quantity when needed with any of the drug HCPCS codes.

So if the HCPCS code is “per 5 MG” and you gave 10 MG, you would report the HCPCS code with a quantity of 2. If the HCPCS code is “per 5 MG” and gave 8 MG, you would round up and report the HCPCS code with a quantity of 2.

Reference: Medicare Claims Processing Manual, chapter 17, section 10

“Hospitals must report all appropriate HCPCS codes and charges for separately payable drugs, in addition to reporting the applicable drug administration codes. Hospitals should also report the HCPCS codes and charges for drugs that are packaged into payments for the corresponding drug administration or other separately payable services. Historical hospital cost data may assist with future payment packaging decisions for such drugs. Drugs are billed in multiples of the dosage specified in the HCPCS code long descriptor. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit based on the HCPCS long descriptor for the code in order to report the dose provided. If the full dosage provided is less than the dosage for the HCPCS code descriptor specifying the minimum dosage for the drug, the provider reports one unit of the HCPCS code for the minimum dosage amount.”

Q:

What is the KX modifier and when should it be used?

A:

The KX modifier is defined as “Requirements specified in the medical policy have been met.” It is a multipurpose informational modifier.

CMS has further defined some specific circumstances when providers should report the KX modifier.

• To report an automatic exception to therapy caps. Adding the KX modifier to the line items that exceed the therapy caps indicates that the clinician attests that services at and above the therapy caps are medically necessary and justification is documented in the medical record.
• When billing for permanent cardiac pacemakers under the latest NCD revision effective August 13, 2013. Appending the KX modifier is an attestation by the provider that documentation is on file verifying the patient has non-reversible symptomatic bradycardia.
• To bill additional optional sessions of cardiac rehab or pulmonary rehab. Medicare allows 36 sessions, with the option for an additional 36 sessions for each of these services. Sessions beyond the initial 36 sessions, up to 72 sessions, require the KX modifier.
• To report FDG PET scans for subsequent treatment strategy beyond the 3rd scan. Each different cancer diagnosis is allowed one (1) initial treatment strategy (-PI modifier) FDG PET Scan and three (3) subsequent treatment strategy (-PS modifier) FDG PET Scans without the -KX modifier. The fourth FDG PET Scan and beyond for subsequent treatment strategy for the same cancer diagnosis will always require the -KX modifier.
• On MRIs for patients with implanted pacemakers that are FDA-approved for use in an MRI environment.Inclusion of the KX modifier on the claim line(s) means that the provider attests that documentation is on file verifying that FDA-approved labeling requirements are met.

Q:

What should we do when Acute Respiratory Failure is documented but the clinical signs and symptoms describing the patient do not reflect the severity of the diagnosis?

A:

Coders in this day and time have to know and be aware of more clinical factors than ever before. Look at the patient’s clinical presentation and what tests are performed. Below is a listing of just a few basic things MMP suggests looking for:

1.Documented signs / symptoms

• SOB (shortness of breath) / Respiratory distress
• Delirium and/or anxiety
• Pursed lips
• Syncope
• Use of accessory muscles
• Tachycardia
• Tachypnea
• Confusion
• Sleepiness
• Depressed consciousness
• Cyanosis (bluish color to skin, lips and/or fingernails)

2.Per Coding Clinic, Acute Respiratory Failure is supported as a diagnosis when at least 2 of the following critical values (ABG’s) are met.

• pH < 7.35
• PO2 < 60
• PCO2 > 50

Note: The above ABG levels may not apply to the patient with chronic lung disease (e.g., COPD). If a baseline PO2 is known, a decrease by 10mmHg or more indicates acute Hypoxic Respiratory Failure.

3.Type of oxygen treatment, i.e., oxygen via mask, Bipap, nasal cannula or vent?

4.Generally, patients are placed in ICU for close monitoring.

MMP recommends coding Acute Respiratory Failure if there are sufficient clinical indications and the physician has documented the diagnosis. Most importantly, if you don’t see sufficient clinical signs/symptoms/indicators documented, the physician should be queried for clarification. It is recommended that all clinical indications in the record and the type of treatment the patient received, be documented in the physician query.

Q:

Have the Medicare coverage requirements for pneumococcal vaccinations changed?

A:

Yes, the Advisory Committee on Immunization Practices (ACIP) has issued new recommendations for pneumococcal vaccinations and Medicare has modified their coverage requirements in response to the new recommendations.

As announced in MLN Matters Article MM9051, effective for dates of service on and after September 19, 2014, Medicare will cover the administration of two different pneumococcal vaccinations.

• An initial pneumococcal vaccine to all Medicare beneficiaries who have not previously received a vaccine (based on ACIP recommendations a 13-valent pneumococcal conjugate vaccine – PCV13 should be administered first)
• Followed by a second, different vaccine a year later (23-valent pneumococcal polysaccharide vaccine – PPSV23)

Patients, age 65 and older, who have already received the PPSV23 vaccine, should receive the PCV13 vaccine a year or more after the date of their last PPSV23 vaccine.

These new guidelines differ from the previous coverage of pneumococcal vaccine which was only for individuals at high risk of serious pneumococcal disease (age 65 and older, risk from chronic disease, or immune-compromised patients) with a repeat vaccine after five years for only patients at highest risk (May 1, 1981- September 18, 2014).

Note that a physician’s order is not required for patients to obtain a pneumococcal vaccine.

Q:

How should laceration repairs by steri-strips or dermabond be coded?

A:

According to the CPT manual a wound closure/repair with adhesive strips as the sole repair material are not reported with a separate CPT code but as part of the evaluation and management (E/M service). This means that laceration repairs performed in the Emergency Department using only steri-strips would be included as part of the determination of the ED visit level.

For tissue adhesives, which would include dermabond, you can report a CPT code from the repair section.

This guidance is in the first paragraph under the ‘Repair (Closure)’ section in the CPT book. The complete paragraph reads:

“Use the codes in this section [CPT codes 12001-13160] to designate wound closure utilizing sutures, staples, or tissue adhesives (eg, 2-cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips. Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code.”

Q:

Sometimes a physician may dilate more than one stricture during an endoscopy procedure. Should we code the dilation of each stricture?

A:

The answer depends on the patient’s insurance because CPT and the NCCI manual provide different coding instructions.

Effective January 2015, CPT guidance allows the reporting of each stricture dilated utilizing modifier 59. Parenthetical notes for CPT codes 43213, 45340, and 45386 state, “For transendoscopic balloon dilation of multiple strictures during the same session, report ‘code’ (43213, 45340, or 45386) with modifier 59 for each additional stricture dilated.”

The National Correct Coding Initiative (NCCI) Policy manual guidance applies to coding and billing for Medicare and Medicaid claims. The 2015 NCCI manual update includes this instruction concerning dilation of multiple strictures:

“Gastrointestinal endoscopy CPT codes describing dilation of stricture(s) (e.g., CPT codes 43213, 45340, 45386) include dilation of all strictures dilated during the endoscopic procedure. These codes should not be reported with more than one (1) unit of service if more than one stricture is dilated.”

Other insurers may choose to follow some of the NCCI coding guidance. Check with the payer to determine their policy regarding these instructions.

Q:
What does Medicare expect from providers concerning limiting drug wastage? For example, if a chemo drug comes in two sizes of single-dose vials, 100 mg and 160 mg and the patient’s dose is 237 mg, could we use three 100mg vials with a wastage of 63 mg, or must we use one 100mg and one 160mg vial for the least amount of wastage (23mg)? 

A:

The Medicare Claims Processing Manual, Chapter 17, section 40 states, “The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.”

Medicare is generally not concerned if you have to jump through extra hoops in order to comply with their guidelines.

Since…

• This drug is separately reimbursed by Medicare
• Medicare has done targeted reviews of some of the other chemo drugs specific to waste issues
• Medicare has instructed hospitals how to report drug waste

 ……MMP recommends you try to minimize waste, even if it involves extra steps.

If you have only the 100 MG dose vials available, then you use what you have. In this case, you are allowed to bill the waste as long as there is not another patient getting the same drug for which the unused portion could have been used.

If you are reviewed by a Medicare reviewer, and they question your billing, you might have to provide invoices, or other documentation proving why you billed as you did.  

Q:

Where can I find the new QIO contact information that we should put on the Important Message from Medicare (IM) letter?

A:

As of August 1st, the QIO Program began its 11th Scope of Work (SOW). The newly created Beneficiary and Family Centered Care – Quality Improvement Organizations (BFCC-QIOs) are responsible for managing discharge appeals.

There are two BFCC-QIOs for the nation. CMS awarded the two BFCC-QIOs contracts to Livanta, LLC located in Annapolis Junction, Maryland and KePRO located in Seven Hills Ohio. The 50 states, DC, Puerto Rico and the Virgin Islands have been divided into Five (5) Areas.

CMS has provided a 2014 QIO Program Transition Fact Sheet for Providers and Suppliers. In this fact sheet CMS instructs Providers that a list of current BFCC-QIOs as well as the Quality Innovation Network (QIN) QIOs can be found at http://www.qioprogram.org under Locate Your QIO.

The Office of Inspector General (OIG) regularly posts reports of their audit findings. A number of these reports relate to hospital payment errors, although the reports often address the same issues from hospital to hospital. However, I always read through the findings to see if there are any new twists to the issues and to remind myself of these OIG target areas – in other words to see what’s in it for me.

Recently the OIG released three reports of hospital audits – two related to drug payment errors and one general compliance review. Here are a couple of issues from these reports worth noting.

Non-covered Use of Reteplase

The drug reteplase (HCPCS code J2993 – injection, reteplase, 18.1 mg) is approved by the Food and Drug Administration (FDA) to treat cardiac conditions using a single-use dose. The OIG identified a billing error that occurred when a provider billed Medicare for one full single-use dose of reteplase when they had actually split a single dose into multiple doses and used them as a thromblytic agent to clean dialysis patient catheters. This is a non-covered use of reteplase and resulted in an overpayment to the facility. (OIG Report Drug Overpayments Jurisdiction 13)

Bundled IMRT Planning Services

In the OIG Medicare Compliance Review of Good Samaritan Hospital, the OIG identified that the hospital had billed separately for services performed as part of Intensity Modulated Radiation Therapy (IMRT) planning resulting in an overpayment. These services are included in the payment for IMRT planning even when provided on a different date of service.

Hospitals are to report CPT code 77301 for IMRT planning. The Medicare Claims Processing Manual, Chapter 4, section 200.3.2 states that “Payment for the services identified by CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 is included in the APC payment for IMRT planning when these services are performed as part of developing an IMRT plan that is reported using CPT code 77301.” Therefore these codes should not be billed in addition to IMRT planning (CPT 77301), regardless if provided on the same or different dates of service, unless they are not provided as part of developing the IMRT treatment plan.

A quick review of OIG reports relating to hospital findings is a great way to become familiar with the OIG target areas and to evaluate issues against your hospital’s practices. Better to be proactive than regretfully reactive.