Knowledge Base Category -

Q:

We have ER patients who get intramuscular (I.M.) injections of Rabies Immune Globulin. What CPT code should be billed for the injection of Rabies Immune Globulin?

A:

When an I.M. injection of an immune globulin is administered, use CPT code 96372, representing an intramuscular / subcutaneous injection of a therapeutic drug. This applies to all immune globulins given by I.M. route, such as Rhogam, Hepatitis B immune globulin, and the others listed on the first page of the Medicine section in CPT. This instruction is part of the parenthetical CPT guidelines on the same page, and as such, would apply to all payers.

Q:

We have a record with documentation of Recurrent Depression (F33.x) and Bipolar Disorder (F31.x).  The excludes1 note under each code seem to exclude each other.  Do we code both conditions?

A:

Bipolar Disorder includes Depression, so only the code for Bipolar Disorder (F31.9) would be coded and reported.  A separate code for Depression would not be reported in addition.

Reference

Coding Clinic for ICD-10-CM/PCS, First Quarter 2020: Page 23

Q:

We had a patient in the ER who was having a miscarriage, and she received an intramuscular injection of Methotrexate.  What CPT code should be used to report the Methotrexate injection in this scenario?

A:

Methotrexate is classified as a chemotherapy drug, specifically an antimetabolite. Therefore, the intramuscular injection of Methotrexate should be reported with CPT code 96401, representing injection of a non-hormonal antineoplastic.  You should not report the injection using CPT code 96372 for a therapeutic drug.

Per CPT guidelines, the CPT codes for chemotherapy administration should be used when an anti-neoplastic drug is given, even if the diagnosis is not related to cancer.

It is unusual for a chemotherapy type drug to be given in the ER, so you may need a new charge code created for those rare circumstances when a drug such as Methotrexate is given by intramuscular route.

Q:

On January 19, 2021, CMS issued a final Decision Memo that included revised criteria for Medicare coverage of Transcatheter Edge-to-Edge Repair (TEER) for mitral regurgitation formerly known as Transcatheter Mitral Valve Repair (TMVR). When should our hospital start following the new criteria such as the requirements for treatment of functional (secondary) mitral regurgitation?

A:

Medicare is a huge bureaucracy and to change rules is not simply a snap of the fingers – there are manuals to update, Medicare contractors and providers to educate, and electronic systems to tweak. This means changes are not instantaneous and take some time to fully implement.

There are differences in the expected compliance with a coverage decision memorandum and a National Coverage Determination (NCD).  CMS addresses this in the Medicare Program Integrity Manual, Chapter 13, section 13.1.1:

A Decision Memo is not immediately binding on Medicare contractors though they are encouraged to consider it. Here is the language from the Medicare Program Integrity Manual, Chapter 13 concerning decision memos:

“Coverage Decision Memorandum- CMS prepares a decision memorandum before preparing the national coverage decision. The decision memorandum is posted on the CMS Web site, that tells interested parties that CMS has concluded its analysis, describes the clinical position, which CMS intends to implement, and provides background on how CMS reached that stance. Coverage Decision Memos are not binding on contractors or ALJs. However, in order to expend MR funds wisely, contractors should consider Coverage Decision Memo posted on the CMS Web site. The decision outlined in the Coverage Decision Memo will be implemented in a CMS-issued program instruction within 180 days of the end of the calendar quarter in which the memo was posted on the Web site.”

Providers need to bear in mind however, that the final NCD backdates the effective date of the changes to the date of the decision memo. The issue lies with the implementation date which is communicated in a CMS Transmittal once the NCD changes are finalized. Medicare Administrative Contractors (MACs) will not start enforcing the new rules until the implementation date, but then they will enforce rules for dates of service on and after the date of the decision memo. This means once the final update to the NCD is made and manualized, the effective date will revert to the date of the decision memo but following the new rules will be based on an implementation date.  Claims submitted on and after the implementation date, will follow the new guidelines for dates of service on and after January 19, 2021 (decision memo date).

Best practice is for providers to educate all key stakeholders on the changes in the decision memo and implement new requirements, such as documentation of persistent symptoms in a patient with functional mitral regurgitation despite maximally tolerated guideline-directed-medical therapy (GDMT), as quickly as possible. Until an implementation date is communicated, providers should not stop complying with the requirements of the current NCD if they are continuing to submit claims for the service.  Another option for providers is to follow the new criteria in the Decision Memo and hold claims until after the implementation date of the revised NCD.

Q:

Is there a HCPCS code for the drug Zepzelca?

A:

Effective 01-01-2021, there is a new HCPCS code J9223 for this drug.  The generic name is Lurbectedin, which is why you may not have seen it.  The HCPCS code dose is per 0.1 mg, so you want to be sure to assign the appropriate conversion factors / multipliers since the doses with be greater than 0.1 mg.

For Medicare, It has a status indicator G, so you don’t have to worry about assigning modifier JG if you are purchasing it through a 340B discount program.

For Medicare, if

1. the date of service for the claim was between June 15 2020 and December 31, 2020, and if
2. the drug was used to treat metastatic small cell lung cancer, look at HCPCS code C9399.

This code represents a new drug that has received FDA approval but for which a HCPCS code has not yet been assigned. Click here for the FDA link. For more information about HCPCS code C9399, refer to the Medicare Claims Processing Manual, chapter 17, section 90.3.

Q:

Where can one find information about the Most Favored Nation Model and are there any recent updates?

A:

CMS announced the Most Favored Nation (MFN) Model on November 20, 2020. Information about this Model is available on the MFN Model web page on the CMS Innovation Center.

This model was set to begin January 1, 2021 and end December 31, 2027. Similar to the Comprehensive Care for Joint Replacement (CJR) Model, this is a “mandatory nationwide model that requires participation from Medicare-participating providers and suppliers that receive separate Medicare Part B fee-for-service payment for the model’s included drugs, with certain exceptions.” Specifically MFN participants includes:

• Medicare-participating physicians,
• non-physician practitioners, supplier groups (such as group practices),
• hospital outpatient departments (HOPDs) including 340B covered entities,
• ambulatory surgical centers (ASCs), and
• other providers and suppliers that receive separate Medicare Part B fee-for-service payment for the model’s included drugs, with certain exceptions

This Model focuses on approximately 50 Medicare Part B drugs that accounts for a high percentage of Medicare Part B drug spending. The January 2021 MFN Model Drug HCPCS Codes List and January 2021 MFN Model Drug Pricing File have both been posted on the MFN Model webpage.

Also available on the MFN webpage is an MLN Fact Sheet (ICN MLN2761019 December 2020) titled Billing Information for Most Favored Nation (MFN) Model Drugs.

You will note that earlier I mentioned that this model “was set to begin January 1, 2021.” However, a December 28, 2020 Update available on the MFN webpage indicates that “on December 28, 2020, the U.S. District Court for the Northern District of California issued a preliminary injunction in Biotechnology Innovation Organization v. Azar, No. 3:20-cv-08603, which preliminarily enjoins HHS from implementing the Most Favored Nations Rule.”

On December 31, 2020, the U.S. District Court for the Southern District of New York issued a preliminary injunction in Regeneron Pharmaceuticals v. United States Department of Health and Human Services, No. 7:20-cv-10488, which preliminarily enjoins HHS from applying the Most Favored Nation Rule to Regeneron's drug EYLEA.

Additionally, the public comment period for the MFN Model Interim Final Rule with Comment Period (IFC) does not end until January 26, 2021. If you have concerns I encourage you to submit comments to CMS.

Q: 

I have heard there are new ICD-10 codes related to COVID-19 that will be effective on January 1, 2021. Where can I find information about the new codes?

A:

CMS Guidance

On November 25th CMS released the following announcement regarding an updated ICD-10 MS-DRGs Version 38.1 and 2021 ICD-10-PCS Code Files that will be effective on January 1, 2021:

“In response to the national emergency that was declared concerning the COVID-19 outbreak, the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is implementing new diagnosis codes into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), effective January 1, 2021.  In addition, the Centers for Medicare & Medicaid Services (CMS) is implementing 21 new procedure codes to describe the introduction or infusion of therapeutics, including monoclonal antibodies and vaccines for COVID-19 treatment, into the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS), also effective January 01, 2021.

The ICD-10 MS-DRG V38.1 Grouper Software, Definitions Manual Table of Contents, and the Definitions of Medicare Code Edits V38.1 manual to accommodate these new diagnosis and procedure codes, effective for discharges on or after January 01, 2021 will be available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software.html

CDC Guidance

On December 3rd, the CDC posted information about the new codes on their ICD-10-CM webpage. The new ICD-10-CM codes effective January 1, 2021 include:

• Encounter for screening for COVID-19 (Z11.52)
• Contact with and (suspected) exposure to COVID-19 (Z20.822)
• Personal history of COVID-19 (Z86.16)
• Multisystem inflammatory syndrome (MIS) ( M35.81)
• Other specified systemic involvement of connective tissue ( M35.89)
• Pneumonia due to coronavirus disease 2019 (J12.82)

The CDC goes on to note that “full addenda information regarding the new codes and the final code titles will be published shortly.”

AHACoding Clinic® Advisor Announcement

In addition to the CMS and CDC websites, you can read similar announcements on the AHACoding Clinic® Advisor home page at https://www.codingclinicadvisor.com/.

Q:

Are there any updates for rehabilitative therapy services’ threshold amounts for the coming year?

A:

Yes. MLN MM12014 updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2021. These thresholds were previously known as “therapy caps.” For CY 2021, the KX modifier threshold amounts are:

• $2,110 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and
• $2,110 for Occupational Therapy (OT) services.

Providers can track a patient’s year-to-date therapy amounts on Medicare eligibility screens. The KX modifier must be appended to therapy services’ line-items on the claim for medically necessary therapy services above the threshold amounts. The medical necessity of services beyond the threshold amount must be justified by appropriate documentation in the medical record. Services provided beyond the threshold that are not billed with the KX modifier will be denied with Claim Adjustment Reason Code 119 - Benefit maximum for this time period or occurrence has been reached.

There is also a therapy threshold related to the targeted medical review process, now known as the Medical Record (MR) threshold amount. This threshold remains at $3,000 for PT and SLP combined and a separate $3,000 for OT until CY 2028. Not all therapy services exceeding the $3,000 thresholds will be reviewed. CMS will analyze data to select claims exceeding this threshold for review.

Q:

MMP’s November 11, 2020 COVID-19 Updates article included the November 9th FDA announcement where they had issued an emergency use authorization (EUA) for the investigational monoclonal antibody therapy Bamlanivimab. How should our hospital code and bill for providing this drug?

A:

As a reminder from the November 11th article, Bamlanivimab is not authorized for patients already hospitalized due to COVID-19. Instead, it is to be given in an outpatient setting and  “is authorized for patients with positive results of direct SARS-CoV-2 viral testing who are 12 years of age and older weighing at least 40 kilograms (about 88 pounds), and who are at high risk for progressing to severe COVID-19 and/or hospitalization. This includes those who are 65 years of age or older, or who have certain chronic medical conditions.”

November 10, 2020: CMS Posts Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction

CMS posted the document Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction on the CMS Current Emergencies Coronavirus Disease 2019 webpage in the Billing & Coding section. CMS notes that during the public health emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA). The following Coding and Billing Guidance is excerpted from the CMS Infusion Program Instruction.

Coding for Monoclonal Antibody COVID-19 Infusion

CMS identified specific code(s) for the monoclonal antibody product and specific administration code(s) for Medicare payment:

Eli Lilly and Company's Antibody Bamlanivimab (LY-CoV555), EUA effective November 9, 2020

Q0239:

• Long descriptor: Injection, bamlanivimab-xxxx, 700 mg
• Short descriptor: bamlanivimab-xxxx

M0239:

• Long Descriptor: intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring
• Short Descriptor: bamlanivimab-xxxx infusion

Billing for Monoclonal Antibody COVID-19 Infusion Administration

Health care providers can bill for the administration of the monoclonal antibody infusion on a single claim for COVID-19 monoclonal antibody administration or submit claims on a roster bill, in accordance with the FDA EUA.

• The EUA for COVID-19 monoclonal antibody treatment bamlanivimab contains specific requirements for administration that are considerably more complex than for other services that are billed using roster billing. CMS expects that health care providers will maintain appropriate medical documentation that supports the medical necessity of the service. This includes documentation that supports that the terms of the EUA are met, including that it is being used for the treatment of mild to moderate coronavirus disease 2019 (COVID-19) for a patient that is at high risk for progressing to severe COVID-19 and/or hospitalization. The documentation should also include the name of the practitioner who ordered or made the decision to administer the infusion, even in cases where claims for these services are submitted on roster bills.
• When COVID-19 monoclonal antibody doses are provided by the government without charge, providers should only bill for the administration. Health care providers should not include the monoclonal antibody codes on the claim when the product is provided for free.

Health care providers who participate in a Medicare Advantage Plan should submit claims for bamlanivimab administration to Original Medicare for all patients enrolled in Medicare Advantage in 2020 and 2021.

Q:

I have been told conflicting information about documenting a positive COVID-19 test. Is physician documentation that a patient has COVID-19 sufficient for the hospital to receive additional payment?

A:

The short answer is no. However, reminiscent of the late Paul Harvey, here is the rest of the story.

COVID-19: Timeline to a New Code

The CDC announced the release of a new code specifically for reporting COVID-19 during the March 18th ICD-10-CM Coordination and Maintenance Committee Meeting. This code became effective on April 1st, 2020. Following is a timeline of events prompting the speed with which this code was made available for use:

• January 31, 2020: An emergency meeting was convened by the World Health Organization (WHO) Family of International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC) and a new ICD-10 emergency code was established.
• U07.1, 2019-nCoV acute respiratory disease

• February 20, 2020: The CDC published supplemental guidance for coding encounters related to COVID-19. At that time hospitals were instructed to used ICD-10-CM code B97.29 (Other coronavirus as the cause of diseases classified elsewhere) when coding a confirmed COVID-19 infection. Note, ICD-10-CM code B97.29 was to be used by hospitals for discharges occurring on or after January 1, 2020, and on or before March 31, 2020.

• March 18, 2020: The Coordination and Maintenance Committee Meeting met virtually. It was announced that the COVID-19 code (U07.1) effective date was changed from October 1, 2020 to April 1, 2020 due to the national health emergency.

• March 31, 2020: The CDC released the document ICD-10-CM Official Coding and Reporting Guidelines for coding COVID-19 April 1, 2020 – September 30, 2020. The guidelines indicated that you are to “Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider, documentation of a positive COVID-19 test result, or a presumptive positive COVID-19 test result. For a confirmed diagnosis, assign code U07.1, COVID-19. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of the type of test performed; the provider’s documentation that the individual has COVID-19 is sufficient.”

• April 1, 2020: The CDC published an ICD-10-CM Tabular Lists of Diseases and Injuries Addenda which established a new chapter (Chapter 22: Codes for special purposes [U00-U85https://www.cdc.gov/nchs/icd/icd10cm.htm">CDC ICD-10-CM webpage as well as the CMS ICD-10-CM webpage. The updated guidelines includes a new section in Chapter 1 (Certain Infectious and Parasitic Diseases) related to coding COVID-19.

Hospital Inpatient Setting: Timeline to Additional Payment for Treating COVID-19 Patients

• March 27, 2020: The Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law. Within this law was the following guidance regarding additional payment for treatment of patients diagnosed with COVID-19:
• Sec. 3710 Medicare Hospital Inpatient Prospective Payment System Add-On Payment for COVID-19 Patients During Emergency Period: “For discharges occurring during the emergency period, in the case of a discharge of an individual diagnosed with COVID-19, the Secretary shall increase the weighting factor that would otherwise apply to the diagnosis-related group to which the discharge is assigned by 20 percent. The Secretary shall identify a discharge of such an individual through the use of diagnosis codes, condition codes, or other such means as may be necessary.”
  
  
• April 24, 2020: MLN Matters Article MM11764 details guidance in Change Request 11764 regarding coding COVID-19 and the implementation of the temporary payment adjustment as mandated by section 3710 of the CARES Act.

• August 14, 2020: Transmittal 10300 (Update to the Implementation of the Increased Payments for COVID-19 Discharges Under the Inpatient Prospective Payment System (IPPS) Under Section 3710 of the CARES Act) was released to prospectively update “the implementation of section 3710 of the CARES Act to require that a positive laboratory test be documented in the patient’s medical record for the increased payment for COVID-19 discharges under the Inpatient Prospective Payment System (IPPS).”
• Note, Transmittal 10300 has since been rescinded and replaced with Transmittal 10361 (Change Request 11925).

• August 17, 2020: MLN Matters Article SE20015 initially released on April 15, 2020 was revised on August 17, 2020 to add the following language:
• “To address potential Medicare program integrity risks, effective with admissions occurring on or after September 1, 2020, claims eligible for the 20 percent increase in the MS-DRG weighting factor will also be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with CDC guidelines. The test may be performed either during the hospital admission or prior to the hospital admission.

For this purpose, a viral test performed within 14 days of the hospital admission, including a test performed by an entity other than the hospital, can be manually entered into the patient’s medical record to satisfy this documentation requirement. For example, a copy of a positive COVID-19 test result that was obtained a week before the admission from a local government-run testing center can be added to the patient’s medical record. In the rare circumstance where a viral test was performed more than 14 days prior to the hospital admission, CMS will consider whether there are complex medical factors in addition to that test result for purposes of this documentation requirement.”

Coding vs. Billing for COVID-19

As indicated earlier in this article, the ICD-10-CM guidelines indicate that you code only confirmed cases of COVID-19 as documented by the provider, documentation of a positive COVID-19 test result, or a presumptive positive COVID-19 test result.

However, CR 11925, for admissions occurring on or after September 1, 2020 hospitals are “required to have a positive COVID-19 laboratory test documented in the patient’s medical record.  Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with CDC guidelines. The test may be performed either during the hospital admission or prior to the hospital admission.”

What do you do when a physician documents that a patient has a confirmed case of COVID-19 but there is no positive test result in the record?

Both, CR 11925 and MLN Matters SE20015 provide the following guidance:

“A hospital that diagnoses a patient with COVID-19 consistent with the ICD-10-CM Official Coding and Reporting Guidelines but does not have evidence of a positive test result can decline, at the time of claim submission, the additional payment resulting from the application at the time of claim payment of the 20 percent increase in the MS-DRG relative weight to avoid the repayment. To do so, the hospital will inform its MAC and the MAC will notate the claim with MAC internal claim processing coding for processing. The Pricer software will not apply the 20 percent increase to the claim when that MAC internal claim processing coding is present on a claim with the ICD-10-CM diagnosis code U07.1 (COVID-19). The updated Pricer software package reflecting this change will be released in October 2020.

To notify your MAC when there is no evidence of a positive laboratory test documented in the patient’s medical record, enter a Billing Note NTE02 “No Pos Test” on the electronic claim 837I or a remark “No Pos Test” on a paper claim.”

Hospital IPPS Payments under Section 3710 the CARES Act

CMS has made available the document COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing. Section F of this document, titled Hospital IPPS Payments under the CARES Act, answers questions about section 3710 of the CARES Act and provides examples illustrating the increase in IPPS operating MS-DRG payments. Note, during the COVID-19 Public Health Emergency (PHE), this document has been updated on a fairly regular basis and as of the October 28, 2020, the update is 152 pages in length. I encourage you to check for updates on a regular basis.