Knowledge Base Category -

Q:

Can you help me understand what a provisional affirmation prior authorization (PA) decision is as it pertains to the Outpatient Prior Authorization Program set to begin on July 1, 2020? 

A:

Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M posted the following information about the Outpatient Department Prior Authorization in their June 22, 2020 Daily Newsletter:

“A provisional affirmation prior authorization (PA) decision is a preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare’s coverage, coding and payment requirements. The provisional affirmation PA decision is valid for 120 days from the date decision was rendered.

Palmetto GBA's Outpatient Department Prior Authorization Calculator will help you determine the time you have remaining to perform the approved procedure before the authorization expires. Just enter the date of the Prior Authorization Affirmation and click Calculate. The tool will tell you the last date your authorization will be valid.”

• Jurisdiction J Part A Outpatient Department Prior Authorization Calculator
• Jurisdiction J Part B Outpatient Department Prior Authorization Calculator
• Jurisdiction M Part A Outpatient Department Prior Authorization Calculator
• Jurisdiction M Part B Outpatient Department Prior Authorization Calculator

Q:

Has CMS released information about the July 2020 Hospital Outpatient Prospective Payment System update? 

A:

Yes. On June 5th CMS released Change Request 11814 - Transmittal R10166CP and related MLN Article MM1184. This recurring update notification describing changes to and billing instructions for various payment policies implemented in the July 2020 OPPS update. This update includes changes in response to the COVID-19 pandemic and the secretary declaring a public health emergency (PHE). Following is a list of key updates for July 1, 2020:

• COVID-19 Laboratory Tests and Services and Other Laboratory Tests Coding Update
• Status Indicator Changes for Certain Virtual Services (Telephone services)
• New Telehealth Code for a Telehealth Distant Site Service Furnished by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) Only
• Other Telehealth Distant Site Codes for RHCs and FQHCs in the OPPS Addendum B and I/OCE
• New CPT Category III Codes Effective July 1, 2020
• The American Medical Association (AMA) released CPT Category III codes twice a year: In January, for implementation beginning the following July, and in July, for implementation beginning the following January. CMS is implementing 25 CPT Category III codes on July 1, 2020.
• CPT Proprietary Laboratory Analyses (PLA) Coding Changes Effective July 1, 2020
• The AMA CPT Editorial Panel deleted five PLA codes (CPT codes 0124U through 0128U) and established 30 new PLA codes (CPT codes 0172U through 0201U)
• Hemodialysis Arteriovenous Fistula (AVF) Procedures: Replacement Codes for HCPCS Codes C9754 and C9755
• New Device Pass-Through Categories
• New CY 2020 HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and Radiopharmaceuticals Receiving Pass-Through Status
• There are eleven new HCPCS codes for reporting drugs and biologicals in the hospital outpatient setting, where there have not previously been specific codes available (i.e., C9059 Injection, meloxicam, 1mg).
• Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals That Will Start To Receive Pass-Through Status
• Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals With Pass-Through Status Ending on June 30, 2020
• Drugs and Biologicals that have Changes to Status Indicators 
• Newly Established HCPCS Codes for Drugs, Biologicals, and Radiopharmaceuticals as of July 1, 2020
• Skin Substitutes – New Products
• New Separately Payable Procedure Codes – Surgical Procedures
• New HCPCS Codes Describing Strain-Encoded Cardiac Magnetic Resonance Imaging (MRI)
• New HCPCS Codes Describing Peripheral Intravascular Lithotripsy
• Supervision of Outpatient Therapeutic Services
• This section discusses several changes that have been made in response to the COVID-19 outbreak and the Secretary declaring the existence of a public health emergency (PDE).

Finally, CMS reminds providers that “the fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.”

Resources:

Link to Transmittal: https://www.cms.gov/files/document/r10166cp.pdf

Link to MLN Article MM11814: https://www.cms.gov/files/document/mm11814.pdf

Q:

What is the Prior Authorization for Certain Outpatient Department (OPD) Services Program and what resources are available to learn more about the program?

A:

The program was finalized in the Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) Final Rule and is specific to the Hospital Outpatient Department setting. A Prior Authorization will be required for the following five procedures:

• Blepharoplasty
• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein ablation

You can access a list of the specific HCPCS codes for each of these procedures on the CMS Prior Authorization for Certain Hospital OPD Services webpage.

CMS believes this program will be an effective tool in controlling unnecessary increases in volume by ensuring payments are only being made for medically necessary services.

As required by CMS, Medicare Administrative Contractors have been educating providers about this program by posting information on their websites and webinars. Likewise, CMS has created a webpage with information specific to this program and held a Special Open Door Forum on May 28, 2020.

This program is set to begin July 1, 2020. However, a week from today on June 17, 2020, hospitals can begin submitting prior authorization requests (PARs) to Medicare Administrative Contractors for services to be provided on or after July 1, 2020.   

Following are links to resources to assist you as you prepare for this new program:

• CMS Prior Authorization for Certain Hospital OPD Services webpage https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services
• Note, this page includes a link to the list of applicable HCPCS codes for the program, the ODF slides, an FAQ document about the program and an Operational Guide.
• Calendar Year 2020 Outpatient Prospective Payment System Final Rule https://www.govinfo.gov/content/pkg/FR-2019-11-12/pdf/2019-24138.pdf
• Note, information about this program starts on page 61446
• Palmetto GBA Outpatient Department PA https://www.palmettogba.com/palmetto/providers.nsf/docsr/Providers"JJ%20Part%20A"Medical%20Review"Outpatient%20Department%20PA
• Note, this page include articles about the program. The last article was posted on June 3rd and is an OPD eServices Submission Guide.

Q:

How do you code Type 2 Diabetes Mellitus with Peripheral Neuropathy?  Is Polyneuropathy the same as Peripheral Neuropathy in Diabetes?

A:

Yes.  According to the ICD-10-CM Code Book, Type 2 Diabetes Mellitus with Peripheral Neuropathy codes to Type 2 Diabetes Mellitus with Polyneuropathy (E11.42).  Let’s follow the alphabetic index:

Neuropathy

                        peripheral (nerve) (see also Polyneuropathy) G62.9

            In order to capture Diabetes Mellitus, we need to ‘see also Polyneuropathy’.

                Polyneuropathy (peripheral) G62.9

                Notice that (peripheral) is a modifier for polyneuropathy

                                diabetic - see Diabetes, polyneuropathy

                When we ‘see Diabetes, polyneuropathy’, it takes us to:

                Diabetes, diabetic; due to underlying condition; with; polyneuropathy E08.42

                Under the code category for E08, there is an Excludes1 note for several conditions, including type 2 diabetes mellitus.

                type 2 diabetes mellitus (E11.-)

Go to E11 Type 2 diabetes mellitus

                                E11.4 Type 2 diabetes mellitus with neurological complications

                                                E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy

Polyneuropathy means multiple nerve damage is causing peripheral neuropathy.  These are the nerves that connect your spinal cord to the rest of your body.  Both these terms are often used at the same time and generally mean the same thing.

References

ICD-10-CM Official Code Set

https://www.empowher.com/community/ask/what-difference-between-peripheral-neuropathy-and-poly-neuropathy

Q:

I know that the new MOON is available for use. What I don’t know is when are we required to use the new form?

A:

The new CMS 10611-MOON has been approved by the Office of Management and Budget (OMB) and has an expiration date of 12/31/2022. The following update was posted to the CMS MOON webpage on April 6, 2020:

“Hospitals are strongly encouraged to begin using the new Medicare Outpatient Observation Notice (MOON) as soon as possible, but no later than May 1, 2020.

Also, keep in mind the following guidance from CMS regarding the delivery of Beneficiary Notices during the COVID-19 public health emergency:

If you are treating a patient with suspected or confirmed COVID-19, CMS encourages the provider community to be diligent and safe while issuing the following beneficiary notices to beneficiaries receiving institutional care:

• Important Message from Medicare (IM)_CMS-10065
• Detailed Notices of Discharge (DND)_CMS-10066
• Notice of Medicare Non-Coverage (NOMNC)_CMS-10123
• Detailed Explanation of Non-Coverage (DENC)_CMS-10124
• Medicare Outpatient Observation Notice (MOON)_CMS-10611
• Advance Beneficiary Notice of Non-Coverage (ABN)_CMS-R-131
• Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN)_CMS-10055
• Hospital Issued Notices of Non-Coverage (HINN)

In light of concerns related to COVID-19, current notice delivery instructions provide flexibilities for delivering notices to beneficiaries in isolation. These procedures include:

• Hard copies of notices may be dropped off with a beneficiary by any hospital worker able to enter a room safely. A contact phone number should be provided for a beneficiary to ask questions about the notice, if the individual delivering the notice is unable to do so. If a hard copy of the notice cannot be dropped off, notices to beneficiaries may also be delivered via email, if a beneficiary has access in the isolation room. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice, and when and to where the email was sent.
• Notice delivery may be made via telephone or secure email to beneficiary representatives who are offsite. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice via telephone, and the time of the call, or when and to where the email was sent.

Resource: MLN Matters SE20011 at https://www.cms.gov/files/document/se20011.pdf

Q:

How would Anxiety due to a medical condition be coded?

A:

Per Coding Clinic, 4th quarter 1996, page 29, Anxiety due to a medical condition is assigned to Organic anxiety syndrome (293.84), which crosswalks in I-10 to Anxiety Disorder Due to Known Physiological Condition (F06.4).  Per Coding Clinic, “This condition is characterized by clinically significant anxiety that is judged to be due to the direct physiological effects of a general medical condition.”

Below are some organic conditions that can cause Anxiety:

• Hypo and Hyperthyroidism,
• CHF,
• COPD,
• Pneumonia,
• Neoplasms

References:

• Coding Clinic, 4th Quarter 1996, page 29
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071743/ 

Q:

What is the principal diagnosis if a patient presents to the hospital with Sepsis and COVID-19?

A:

If a patient has COVID-19 that has progressed to sepsis, we are instructed to see Section I.C.1.d. Sepsis, Severe Sepsis, and Septic Shock.  If sepsis meets the definition of principal diagnosis, sepsis should be sequenced first, followed by COVID-19. 

When COVID-19 meets the definition of principal diagnosis, and sepsis develops after admission, code U07.1 (COVID-19) should be sequenced first, followed by the appropriate code for sepsis.

Remember:  Code only confirmed cases of COVID-19

If a physician documents “presumed” COVID-19, and has tested positive for the virus, code U07.1 (COVID-19) as confirmed.  A positive test at a local or state level can be coded as COVID-19.  The Center for Disease Control and Prevention (CDC) confirmation of local and state tests for the COVID-19 virus is no longer required.

If a physician documents “suspected”, “possible”, “probable”, or “inconclusive” COVID-19, do not assign code U07.1.  Assign a codes(s) explaining the reason for the encounter such as fever, or contact with and (suspected) exposure to other viral communicable diseases (Z20.828).

Resources:

ICD-10-CM Official Coding and Reporting Guidelines (April 1, 2020 through September 30, 2020)

https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

https://www.cdc.gov/nchs/data/icd/ICD-10-CM-April-1-2020-addenda.pdf

American Hospital Association (AHA) Coding Clinic webinar ICD-10-CM Coding for COVID-19

Watch the FREE AHA webinar on COVID-19 and receive one CEU.  https://www.codingclinicadvisor.com/webinar/icd-10-cm-coding-covid-19

Q:

Sometimes modifier 59 is still confusing to us when we are trying to work through CCI edits for Medicare. Is there any new information about modifier 59 that can help us better understand?

A:

Correct Coding Initiative edits are still referred to by a lot of people as “CCI edits”, so we know exactly what you are talking about. Instead of CCI edits, CMS now refers to these as “Procedure to Procedure” edits (PTP). It’s a different name, but the concept is still the same, and hospitals still have to “work through” – as you say – all these edits to determine when to add a modifier.

In March 2020, CMS released a MLN Matters Article SE1418 regarding the proper use of modifier 59 and modifiers –X{EPSU}. In my opinion, the article includes helpful examples of separate practitioner, structure, and encounter.

You asked about Modifier 59, but as you read through the MLN article, you will also see examples for using the X{EPSU} modifiers instead of modifier 59. Remember, the X{EPSU} modifiers are considered more specific than modifier 59 and should be used in lieu of modifier 59 whenever possible. Be sure to incorporate all of this information into your efforts when deciding if a modifier is needed.

I doubt anyone will ever have all the answers about modifier 59, and I say this based on the number of related inquiries we receive every week. With over 1 million code pairs involved, it’s no wonder there’s ongoing confusion. 

Q:

When Medicare changes the status indicator for separately payable drugs, do we have to revise the related modifiers assigned to these drugs in the chargemaster (CDM) / pharmacy system?

A:

Yes. If your hospital purchased the drug through the 340B Program, you must bill the applicable modifier JG or TB for the drug to Medicare. This is specific to drugs / biologicals assigned status indicator G or K in Addendum B under the Outpatient Prospective Payment System (OPPS).

If the drug is assigned status indicator K, Medicare wants to reduce your reimbursement for the drug if it was purchased through 340B.  In that scenario, it is your responsibility to bill the drug to Medicare with modifier JG. If you purchase a status indicator K drug through the 340B program, but do not bill the drug with modifier JG, you will be overpaid.

Modifier TB should be billed for drugs assigned status indicator G which are purchased through the 340B program.  Even though modifier TB is for informational purposes, it is still required, just like modifier JG. This modifier does “not” trigger a reduced payment from Medicare.

If a drug /biological was “not” purchased through a 340B program, modifier JG / TB should not be billed.

This creates a challenge for CDM coordinators, because this type of CDM maintenance is absolutely essential to compliant Medicare billing of these items. You should expect some status indicator changes quarterly. We acknowledge some hospitals manage pharmacy modifiers in a pharmacy system separate from the CDM.

Take a look at the upcoming status indicator changes listed in the  April 2020 OPPS Update, excerpted below – effective April 1, 2020. Keep in mind, modifiers JG and TB must be date specific to match the status indicator assigned for respective dates of service on the outpatient Medicare claim.

New CY 2020 HCPCS Codes Effective April 1, 2020 for Certain Drugs, Biologicals, and Radiopharmaceuticals

Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals receiving pass-through status Effective April 1, 2020

HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals with Pass-Through Status Ending Effective March 31, 2020

For more information about billing 340B modifiers under the OPPS, refer to the CMS FAQ document published April 2018. 

Q:

We are getting an edit that CPT codes 92611 (motion fluoroscopic evaluation of swallowing function by cine or video recording) and 74230 (swallowing function with cineradiography / videoradiography) cannot be billed together and no modifier allowed.  Should we only be reporting 92611?

A:

This is another new CCI edit that became effective January 1, 2020. We have received information from NCCI that CMS has since made the decision to revise this edit. The modifier indicator for this code pair will be changed from “0” to “1”. A modifier indicator of “1” indicates an NCCI-associated modifier may be used to bypass the CCI edit under appropriate circumstances.

The changes will be retroactive to January 1, 2020 and will be implemented as soon as technically possible. Providers may choose to delay submission of claims for deleted edits until after the implementation of the replacement edit file with retroactive date of January 1, 2020.

Providers may also choose to appeal claims denied due to the PTP edits to the appropriate MAC including supporting documentation or resubmit claims denied due to the PTP edits after the implementation of the replacement edit file with January 1, 2020 retroactive date, as permitted by the MAC.