Knowledge Base Category -

Q:

We are getting a CCI edit between our nuclear medicine bone scans and the radiopharmaceutical we always use in conjunction with bone scans (technetium medronate / MDP). The edit is telling us we cannot report the bone scan CPT code and HCPCS code A9503 for the MDP on the same date of service – with or without a modifier. Can you explain?

A:

This is a new CCI edit that became effective January 1, 2020. We sent actual patient examples to NCCI asking for clarification. We received notification from NCCI that, after review of the issue, CMS has made a decision to delete the January 1, 2020 edits in the table below. Review the table carefully, as the changes include radiopharmaceuticals besides A9503.

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.

Q:

I recently read the MMP article New Modifiers for Therapy Assistant Services. Are you aware of any other payors adopting a similar policy?

A:

Humana published Policy Number CP2018009 on December 10, 2019. This policy applies to both Medicare Advantage and Commercial Coverage. Similar to CMS guidance, effective January 1, 2020 or later Humana requires providers to submit a “charge for an outpatient occupational or physical therapy service…with modifier CO or modifier CQ, as applicable standards in the Federal Register and relevant CMS guidance direct.”

You can find the entire policy on Humana’s website at https://www.humana.com/provider/medical-resources/claims-payments/claims-payment-policies.

CMS’ guidance for Medicare Fee-for-Service beneficiaries is available in the November 1, 2019 Transmittal 4440 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019downloads/R4440cp.pdf.

Q:

I recently read the MMP article New Modifiers for Therapy Assistant Services. Are you aware of any other payors adopting a similar policy?

A:

Humana published Policy Number CP2018009 on December 10, 2019. This policy applies to both Medicare Advantage and Commercial Coverage. Similar to CMS guidance, effective January 1, 2020 or later Humana requires providers to submit a “charge for an outpatient occupational or physical therapy service…with modifier CO or modifier CQ, as applicable standards in the Federal Register and relevant CMS guidance direct.”

You can find the entire policy on Humana’s website at https://www.humana.com/provider/medical-resources/claims-payments/claims-payment-policies.

CMS’ guidance for Medicare Fee-for-Service beneficiaries is available in the November 1, 2019 Transmittal 4440 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019downloads/R4440cp.pdf.

Q:

How is CMS responding to the Court ruling to immediately cease the clinic visit provided at excepted off-campus PBDs payment reduction for CY 2019?

A:

According to an announcement about Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments in the December 12th edition of MLN Connects, “CMS installed a revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines. The revised Pricer went into production on November 4, 2019, and applies to claims with a line item date of service of January 1, 2019, and after. Starting January 1, 2020, and over the next few months, the Medicare Administrative Contactors will automatically reprocess claims paid at the reduced rate; no provider action needed.”

In the 2019 OPPS Final Rule, CMS determined to pay for certain outpatient clinic visit services (HCPCS code G0463) provided at excepted off-campus Provider-Based Departments (PBDs) at the same rate that CMS uses to pay non-excepted off-campus PBDs for those services under the separate Physician Fee Schedule (PFS). The PFS payment rate for services in non-excepted off-campus PBDs is equal to 40% of the OPPS rate, a reduction of 60%. CMS phased in the payment reduction for clinic visits in excepted off-campus PBDs over 2 years, with a 30% reduction for 2019 (i.e. rates of 70% of OPPS rates) and the full 60% reduction planned for 2020.

Despite the court’s decision that CMS must pay 2019 clinic visits in excepted off-campus PBDs at the regular OPPS rate, CMS proceeded with the second year of the payment reduction in the 2020 OPPS Final Rule. See the prior Wednesday@One article for more information about this but here are some excerpts from that article:

“CMS claims they are ‘removing the payment differential that drives the site-of-service decision and, as a result, unnecessarily increases service volume.’ They further claim they are doing this under authority of a certain section of the Social Security Act that gives them power ‘to adopt a method to control unnecessary increases in the volume of covered outpatient department services.’ … CMS states they have appeal rights and are still considering whether to appeal the final judgement or not.”

Q:

I have noticed that the Medicare (CMS) Detailed Notice of Discharge (DND) form we are using at our hospital has an expiration date of 10/31/19. Is it still ok to be using this form?

A:

For now, yes. As a reminder, the DND is used when a Medicare patient requests expedited review by the Quality Improvement Organization (QIO) of a discharge decision. The form provides the specific reasons the hospital, Medicare (or Medicare Advantage plan), and the patient’s doctor think the patient is ready for discharge. The form allows a review of the case by the QIO.

According to an update on Medicare’s Beneficiary Notices Initiative (BNI) website concerning the DND form with an expiration date of 10/31/19 – “This notice is now going through the Paperwork Reduction Act clearance process. The currently available hospital notice is covered under an extension and hospitals should continue using the current notice until CMS publishes the updated notice. Hospitals following this direction are fully compliant with our requirements.”

Q:

Is it appropriate to bill evaluation and management (E/M) codes or a clinic visit code on the same day as other wound care services such as debridement?

A:

It depends. Providers need to be cautious however, because as explained in a recent article from First Coast, the Medicare Administrative Contractor (MAC) for Jurisdiction N, data reflects improper billing of wound care and E/M codes on the same date of service. Providers may report an E/M service with modifier “25” when a significant, separately identifiable E/M service by the same physician on the day of a procedure is performed. If that separate E/M service involves the use of facility resources, a separate clinic visit code may be reported by the facility also.

A separate and distinct E/M service could involve the management of the patient’s underlying medical conditions in addition to the management of wound care. Reporting the E/M code with modifier “25” attests that the patient’s condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed. If the sole purpose of the visit is wound care management, only the wound care codes should be reported. This includes measurements and assessment of the wound(s) as well as debridement, dressings, or other wound treatments performed.

The First Coast article includes excerpts from their Wound Care LCD. The key to supporting a separate E/M code with wound care services is documentation. The documentation should clearly indicate the other conditions that were addressed and managed during the wound care visit.

Q:

Does Medicare Part B cover tetanus vaccinations?

A:

Yes, but not as a preventive service. Tetanus vaccinations are eligible for Medicare Part B coverage when they are directly related to the treatment of an injury or direct exposure to a disease or condition. Claims including tetanus vaccinations must include the proper procedure and diagnosis codes to support the medical necessity for the vaccination. According to a recent article by First Coast, the Medicare Administrative Contractor (MAC) for Jurisdiction N, “Claims must be coded to the highest level of specificity, with related documentation supporting what’s been billed (i.e., specific body part where injury occurred). If no appropriate diagnosis code is present, First Coast will deny the claim as not medically necessary.” The article goes on to list a few examples of ICD-10-CM codes identifying injuries that Medicare allows for tetanus vaccinations.

The First Coast article also explains that routine tetanus vaccination services are not covered by Medicare. “If you are billing for a routine tetanus vaccination, it is recommended to append the GY modifier. This modifier is defined via the Healthcare Common Procedure Coding System as identifying an ‘Item or service statutorily excluded’ or ‘Does not meet the definition of any Medicare benefit.’ Lines with this modifier are thereby submitted as non-covered and will be denied.”

Medicare does cover some routine vaccinations:

• Influenza Virus Vaccine is covered once a flu season. A physician’s order is not required for a patient to obtain a flu shot.
• Pneumococcal Pneumonia Vaccine – CDC recommends pneumococcal vaccination (PCV13 or Prevnar13®, and PPSV23 or Pneumovax23®) for all adults 65 years or older:
• Give a dose of PCV13 to adults 65 years or older who have not previously received a dose. Then administer a dose of PPSV23 at least 1 year later.
• If the patient already received one or more doses of PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose of PPSV23.
• Medicare covers both of these vaccines and a physician’s order is not required.
• Hepatitis B Vaccine – Medicare provides coverage under Part B for hepatitis B vaccine and its administration, furnished to a Medicare beneficiary who is at high or intermediate risk of contracting hepatitis B.

Refer to Section 50.4.4.2 – Immunizations of Chapter 15 of the Medicare Benefit Policy Manual for more information on routine immunizations.

Q:

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

A:

Yes. MLN Matters Article MM11532 updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2020. These thresholds were previously known as “therapy caps.” For CY 2020, the KX modifier threshold amounts are:

1. $2,080 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and
2. $2,080 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 for CY 2020. 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:

Is it appropriate to bill Medicare for a therapy evaluation and therapy treatment on the same day of service?

A:

Yes, it is appropriate to bill these services on the same day as long as they are separate and distinct – that means each service is provided separately in its own time period.

Here is wording from Section 220.1.2 A of Chapter 15 of the Medicare Benefit Policy Manual (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf) - see page 163.

 “Treatment under a Plan.  The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits.  It is appropriate that treatment begins when a plan is established.”

 The therapy evaluation must be done first and a plan of care established. Then it would be appropriate to provide and bill for the treatment. There are usually no CCI edits for these combinations of codes, but check to be sure, and only use a modifier if required.

Q:

Our hospital sometimes receives automated medical necessity denials related to a National Coverage Determination (NCD). Where can I find a listing of the acceptable ICD-10 diagnosis codes that support medical necessity for services with an NCD?

A:

Although a listing of the covered diagnoses is not available for all NCDs, you can find many of them on CMS’s Medicare Coverage General Information ICD-10.  At the bottom of the page, there is a table, “Links related to ICD-10 NCDs (as of 05/13/2019).” This table contains links to all the transmittals concerning code changes for NCDs “related to 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.”

The easiest way to find code edits for a particular NCD is to do a search for the NCD number on this webpage. Select “Find” from the Menu option or “Control+F,” and enter the NCD number in the search box. If you need to find the current ICD-10 requirements for a service, choose the latest transmittal by date that contains the NCD number you are looking for. If you are looking for the requirements for a certain point in time, select the transmittal that addresses the relevant NCD and is from the last transmittal date prior to the date you are interested in.

Once you select the correct transmittal, find the link in the transmittal to the NCD spreadsheets included with the related Change Request Transmittal (CR). This will open a file with spreadsheets for all the NCDs with revisions at the time of the date of the transmittal. Select the NCD/service you are researching and open the spreadsheet. The spreadsheets have tabs for “ICD Diagnosis,” “ICD Procedures,” and “Rule Description” which contain the expected information. Medicare contractors use these edit tables to control Medicare coverage with automated denials if a required diagnosis is not present on the claim. Being aware of the specific codes required can assist hospitals in being proactive about Medicare coverage with education and the use of Advance Beneficiary Notices (ABNs).

Notice in the title of the table referenced above, that the title includes an “as of” date. For dates after the as of date, I recommend searching the current transmittal listing for the term “NCD” or “ICD-10.” Also sign up for Medicare transmittal updates through Medicare’s Listserv Signup so that you will aware for any changes in these edits and other Medicare information. At the link above, scroll to the bottom right of the page to find a “Receive Email Updates” box where you can enter your email address to receive updates.