Knowledge Base Category -
MEDICARE TRANSMITTALS
Updating Language to Clarify for Providers Chapter 3, Section 20 and Chapter 5, Section 70 of the Medicare Secondary Payer Manual
Additional clarification regarding when and where to obtain information from Medicare beneficiaries, or authorized representatives, for inpatient admissions or outpatient encounters
User CR: FISS to Add Additional Search Features to Provider Direct Data Entry (DDE) Screen
Allows providers who use DDE to look up the claims associated with an Accounts Receivable (AR) by using the invoice number on the AR to find the Document Control Number (DCN), and then using the DCN to look up the claims.
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)
A maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - October 2018 Update
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2019
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2018 Update
Effective with dates of service on or after July 12, 2018, the Q5108 (Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg) is payable by Medicare.
Quarterly Influenza Virus Vaccine Code Update - January 2019
This update includes one new influenza virus vaccine code: 90689.
Update to Medicare Claims Processing Manual, Chapter 24, Section 90
Clarifies the Administrative Simplification Compliance Act (ASCA) waiver process guideline in the Medicare Claims Processing Manual (for requesting waiver to submit non-electronic claims).
Updates to the Medicare Claims Processing Manual, Chapter 24, ASCA Waiver Review Form of Letters, Exhibits A-H
Update to the language contained in the Form Letters the MACs use to inform certain providers of Administrative Simplification Compliance Act (ASCA) waiver reviews. The CR gives you clear directions for communicating with your MACs regarding ASCA waiver review-related questions when you receive a review Form Letter.
System Changes to Implement Epoetin Alfa Biosimilar, Retacrit for End Stage Renal Disease (ESRD) and Acute Kidney Injury (AKI) Claims
Updates the list of supplies, drugs, and labs included in the End Stage Renal Disease (ESRD) consolidated billing list and therefore included in the base rate payment for Acute Kidney Injury (AKI).
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2019
Required changes as part of the annual IPF PPS update.
October 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Internet Only Manual (IOM) Update to Publication 100-02, Chapter 11 - End Stage Renal Disease (ESRD), Section 100
This revision does not represent a policy change. Specifically, the manual has been updated to state that Erythropoietin Stimulating Agents (ESAs) are included in the bundled payment amount for treatments administered to patients with Acute Kidney Injury (AKI).
New Waived Tests
Describes the latest laboratory tests approved by the FDA as waived tests under CLIA.
Quarterly Update to 2018 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
Updates the lists of HCPCS codes that are excluded from the CB provision of the SNF PPS.
Services excluded from SNF PPS and CB may be paid to providers, other than SNFs, for beneficiaries, even when in a SNF stay.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2018
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Effective January 1, 2018, CLFS rates will be based on weighted median private payer rates as required by the Protecting Access to Medicare Act (PAMA) of 2014. These rates are updated quarterly.
Adding a Targeted Probe and Educate (TPE) Sub-Section Into Section 3.2 of Chapter 3 in Publication (Pub.) 100-08
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R819PI.pdf
MEDICARE RULES
2019 Medicare Inpatient Prospective Payment System Final Rule
Addresses Hospital IPPS for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2019 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Promoting Interoperability Programs) Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Medicare Cost Reporting Requirements; and Physician Certification and Recertification of Claims
https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-16766.pdf
2019 Medicare Outpatient Prospective Payment System Proposed Rule
Addresses Proposed Changes to Hospital OPPS and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Requests for Information on Promoting Interoperability and Electronic Health Care Information, Price Transparency, and Leveraging Authority for the Competitive Acquisition Program for Part B Drugs and Biologicals for a Potential CMS Innovation Center Model
https://www.gpo.gov/fdsys/pkg/FR-2018-07-31/pdf/2018-15958.pdf
OTHER MEDICARE UPDATES
Redesigned Medicare Recovery Audit Program Website
Patients Over Paperwork July Newsletter
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/July2018Newsletter.pdf
CMS Review Contractor Interactive Map
Updated map available.
2019 ICD-10-CM Official Guidelines for Coding and Reporting released
“These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of classification take precedence over guidelines…Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).”
https://www.cdc.gov/nchs/icd/icd10cm.htm
KEPRO’s Case Review Connections Summer 2018 Newsletters
A quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)
Acute Care Edition: https://www.keproqio.com/providers/summer-2018-acute-newsletter/
Post-Acute Care Edition: https://www.keproqio.com/providers/summer-2018-post-acute-newsletter/
MEDICARE EDUCATION
CMS YouTube Presentation: Provider Minute: Physician Orders/Intent to Order Laboratory Services and Other Diagnostic Services
https://www.youtube.com/watch?v=GLnXayr3GsE&feature=youtu.be
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Reporting Changes in Ownership – Reminder
- Cochlear Devices Replaced Without Cost: Bill Correctly -- Reminder
Some bundles are great – a bundle may refer to a “bundle” of money; you can have bundles of fun; or expecting parents look forward to their little bundle of joy. Other bundles – not so great. One such bundle that is not a bundle of fun is the bundled payment Medicare makes for Intensity-Modulated Radiation Therapy (IMRT) planning services. Payment bundles are fairly common in the Medicare world, but the onus is on providers to understand appropriate billing rules so they are not overpaid for bundled services. A recent Office of Inspector General (OIG) report found errors in IMRT planning billing that resulted in over $25 million in Medicare overpayments for the audit period (2013-2015). The report recommended education for providers on billing IMRT planning services correctly, and edits in Medicare’s billing system to prevent overpayments.
IMRT uses advanced computer programs to plan and deliver radiation to difficult-to-reach tumors with high precision while reducing exposure to surrounding healthy tissue. IMRT includes planning and delivery services. IMRT planning is a multistep process in which imaging, calculations, and simulations are performed to develop an IMRT treatment plan. Radiation is then delivered to a patient’s tumor at the various intensity levels prescribed in the IMRT treatment plan.
The basic rule for the bundling of IMRT planning services is found in section 200.3.1 of Chapter 4 of the Medicare Claims Processing:
- “Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan. In addition, CPT codes 77280-77290 (simulation-aided field settings) should not be reported for verification of the treatment field during a course of IMRT.”
As evidenced by the OIG’s recommendations, the primary reasons for overpayments were that hospitals were unfamiliar with or misinterpreted CMS guidance and claim processing edits did not prevent overpayments. One of the biggest challenges for both hospitals and CMS is the bundling applies even to services billed on a different date of service than the comprehensive IMRT planning code (CPT 77301). CMS’s NCCI procedure-to-procedure edits applicable to IMRT planning services only applied to planning services billed on the same date of service as the billing of CPT code 77301 for the bundled payment. This application of bundling to different dates of service may also have caused some confusion for hospitals. The services in the OIG sample were billed on a different date of service from the IMRT planning CPT code 77301.
In analyzing payment data, the OIG noted that complex simulations billed using CPT code 77290 made up approximately 84% of the potential overpayments so that is the code they reviewed. They found that “In each case, a complex simulation was billed with CPT code 77290 on a different date of service from the IMRT planning code (i.e., up to 14 days before CPT code 77301 was billed). However, both services were performed for the same treatment site (e.g., the prostate). According to the independent medical review contractor, for each sampled line item, the complex simulation was performed as a part of the beneficiary’s overall IMRT treatment planning and therefore should not have been billed separately.”
The Claims Processing Manual guidance quoted above was updated after the OIG audit period to clarify that complex simulations are included in the APC payment for IMRT planning services “when provided prior to or as part of the development of the IMRT plan” (emphasis added). That was a step in the right direction but the OIG further recommended that CMS:
- Implement an edit to prevent improper payments for IMRT planning services that are billed before (e.g., up to 14 days before) IMRT planning CPT code 77301 is billed, and
- Work with the Medicare contractors to educate hospitals on properly billing Medicare for IMRT planning services.
Hospitals need to evaluate their billing practices for IMRT services now and verify they are not inappropriately billing separately for services included in IMRT planning. After all, a little OIG audit would not be a bundle of joy.
Debbie Rubio
A few weeks ago, when CMS released the 2019 Outpatient Prospective Payment System (OPPS) Proposed Rule, we addressed some of the major proposed changes from that rule in Wednesday@One articles. Specifically, our August 1st newsletter included an article on the proposed changes to payments for off-campus provider-based departments and an article on the proposed changes to the inpatient only list. This week I will review some of the other more modest proposals from that rule.
Increased Payment Rate
CMS is proposing for CY 2019 an OPPS fee schedule increase factor of 1.25%.
- This increase factor is based on proposed hospital inpatient market basket percentage increase of 2.8% minus the proposed multifactor productivity (MFP) adjustment of 0.8%, and minus a 0.75% adjustment required by the Affordable Care Act.
- CMS estimates total payments to OPPS providers for CY 2019 would be approximately $74.6 billion, an increase of approximately $4.9 billion compared to estimated CY 2018 OPPS payments.
- The statutory 2.0% reduction in payments for hospitals failing to meet the hospital outpatient quality reporting requirements would continue for 2019.
Comprehensive APCs
As a reminder, the comprehensive APC (C-APC) payment policy packages payment for adjunctive and secondary items, services, and procedures into the most costly primary procedure under the OPPS at the claim level.
- Services identified by a status indicator (SI) of “J1” are designated as primary services.
- When a primary service is reported on a hospital outpatient claim, Medicare makes a single payment for the claim. Payment for all adjunctive and secondary items, services, and procedure is included in this single payment for the primary service.
- Services with “packaged” payment under C-APCs include diagnostic tests and procedures, visits, DME, therapy services provided during the perioperative period, and drugs, biologicals, and radiopharmaceuticals.
- Services excluded from the C-APC include mammography and ambulance services, brachytherapy seeds, pass-through drugs and devices, self-administered drugs, and certain preventive services.
- Medicare makes an increased payment for complexity adjustments when certain multiple “J1” codes or certain add-on codes are present on the claim.
For CY 2019, CMS is proposing to create three new C-APCs involving ears, nose, and throat (ENT) and vascular procedures: proposed C-APC 5163 (Level 3 ENT Procedures); proposed C-APC 5183 (Level 3 Vascular Procedures); and proposed C-APC 5184 (Level 4 Vascular Procedures). This proposal would increase the total number of C-APCs to 65.
Also related to C-APCs, CMS is proposing to exclude payment for any procedure that is assigned to a New Technology APC from being packaged when included on a claim with a “J1” service assigned to a C-APC.
Device-Intensive Procedures
Currently, device-intensive procedures are those procedure that involve surgically inserted or implanted devices that remain in the patient’s body after surgery and for which the portion of the APC payment attributed to the device (device off-set amount) exceeds 40%. This means the following device-intensive policies apply to these procedures:
- There is a procedure/device edit that requires a device code to be reported on a claim with a device-intensive procedure. Any device code will satisfy the edit and CMS created HCPCS code C1889 to report devices furnished during a device-intensive procedure that are not described by a specific HCPCS code.
- OPPS payment for device-intensive procedures is decreased by the full or partial credit a provider receives for a replaced device, when a hospital furnishes a specified device without cost or with a full or partial credit. Hospitals report on the claim the amount of the credit in the amount portion for value code “FD” when the hospital receives a credit for a replaced device that is 50 percent or greater than the cost of the device.
For CY 2019, CMS is proposing to modify the device-intensive criteria to 1) allow procedures that involve single-use devices, regardless of whether or not they remain in the body after the conclusion of the procedure and 2) allow procedures with a device offset percentage of greater than 30 percent to qualify as device-intensive procedures. They are making these proposals because:
- They “no longer believe that whether a device remains in the patient’s body should affect its designation as a device-intensive procedure because such devices could, nonetheless, comprise a large cost of the applicable procedure”
- The lower 30% threshold “allow(s) a greater number of procedures to qualify as device-intensive.”
- “Allowing these additional procedures to qualify for device-intensive status will help ensure these procedures receive more appropriate payment in the ASC (ambulatory surgical center) setting, which will help encourage the provision of these services in the ASC setting.”
- “This proposed change would help to ensure that more procedures containing relatively high-cost devices are subject to the device edits, which leads to more correctly coded claims and greater accuracy in our claims data.”
The most interesting of the above reasons is CMS’s obvious hope that these policy changes would shift more of these procedures from the hospital setting to the lower-cost ASC setting. Addendum P to the proposed rule includes a full list of the proposed CY 2019 OPPS device-intensive procedures. All of the above noted device-intensive policies would apply to these procedures.
Separately Payable Drugs and Biologicals
For CY 2019, CMS is proposing to continue to pay for pass-through drugs and biologicals and separately payable non-pass-through drugs, biologicals, and therapeutic radiopharmaceuticals not purchased through the 340B drug program at ASP (average sales price) +6 percent. The proposed packaging threshold for CY 2019 is $125 a slight increase from the CY 2018 threshold of $120. This means payment for drugs with a per day cost less than or equal to $125 will be packaged and not paid separately.
They are proposing to continue to pay for separately payable Medicare Part B drugs (assigned status indicator “K”), other than vaccines (SI = “L” or “M”) and drugs on pass-through payment status (SI = “G”), acquired with a 340B discount at a rate of ASP minus 22.5 percent when billed by a hospital paid under the OPPS that is not excepted from the payment adjustment. Hospitals to which the payment reduction applies will continue to report modifier “JG” for applicable status “K” drugs. Rural sole community hospitals (SCHs), children’s hospitals, and PPS-exempt cancer hospitals are proposed to continue to be excepted from the 340B payment adjustment. These hospitals would continue to report informational modifier “TB” for 340B-acquired drugs, and continue to be paid ASP+6 percent.
One slight change is for drugs or biologicals for which ASP data is not available. For these drugs/biologicals CMS is proposing to pay WAC (wholesale acquisition cost) +3%, rather than WAC+6% whenever WAC-based pricing is used for a drug or biological. WAC minus 22.5% would continue to apply for drugs acquired under the 340B Program.
Those are some of the more interesting proposals for 2019, but as usual CMS has asked for input on a number of proposals, one related to skin substitutes. Currently CMS assigns skin substitutes to a low cost or high cost category based on either a product’s geometric mean unit cost (MUC) or the product’s per day cost (PDC) exceeding specified thresholds. Payment for skin substitutes is packaged, but application of high cost substitutes is reported with HCPCS codes 15271 through 15278, which receives a higher payment rate than application of low cost substitutes reported with HCPCS codes C5271 through C5278.
Significant fluctuations in the MUC or PDC thresholds from year to year may result in the reassignment of several skin substitutes from the high cost group to the low cost group which, under current payment rates, can be a difference of approximately $1,000 in the payment amount for the same procedure. One solution for CMS has been to maintain assignment of a product to the high cost group if it was in the high cost group the prior year, regardless of whether it exceeds or falls below the CY 2019 MUC or PDC threshold.
However, CMS continues to seek input on other ways to handle the payment of skin substitutes. They have identified four potential methodologies that have been raised and they encourage the public to review and provide comments on these. They “are especially interested in any specific feedback on policy concerns with any of the options presented as they relate to skin substitutes with differing per day or per episode costs and sizes and other factors that may differ among the dozens of skin substitutes currently on the market.” The four potential methodologies include:
- A lump-sum “episode-based” payment for a wound care episode,
- One payment category and set of procedure codes for all skin substitute products,
- Payment of current add-on codes or new additional procedure codes for larger size graft services, or
- A different threshold used to assign skin substitutes in the high-cost or low-cost group.
The discussion of these options can be found on page 37119 of the OPPS 2019 Proposed Rule.
One last thing that hospitals need to know, even though this is not from the OPPS section of the proposed rule. CMS is proposing to add heart catherization and coronary angiography procedures described by CPT codes 93451-93462 to the list of ASC surgical procedures for 2019. This would allow Medicare patients having these procedures to elect to have them in an ASC instead of in a hospital setting.
For hospitals, some of these proposals may not be as modest as they first appear.
Debbie Rubio
On July 25, 2018, CMS finally released the 2019 Proposed Rule for Outpatient Prospective Payment System (OPPS) for hospitals and Ambulatory Surgical Centers (ASCs) (link to Proposed Rule). Toward the end of the OPPS portion of the rule, there is a section titled “Proposed Nonrecurring Policy Changes” that could also be appropriately named, “Bad News for Hospital Off-Campus Provider-Based Departments.”
Background
Before discussing the proposed rule changes, let’s define some terms and examine some history concerning provider-based departments (PBDs). Provider based entities are created or acquired by the main hospital to furnish healthcare services and are under the ownership, administrative, and financial control of the main provider, in accordance with Medicare’s provider-based rules (42 CFR 413.65). PBDs may be on-campus, that is immediately adjacent to the hospital’s main buildings or within 250 yards of the main buildings, or off-campus, which are PBDs located beyond 250 yards from the main hospital buildings.
The concern over the past several years with PBDs is that they furnish the same types of services provided in a physician office setting but receive higher Medicare payments due to Medicare’s payment rules for outpatient hospital services versus physician fee schedule payments. The Medicare patient (beneficiary) payment share is also more for hospital-based services. In 2015, Section 603 of the Bipartisan Budget Act of 2015, addressed some of these concerns. The Act required “new” off-campus PBDs to be paid under a payment system other than the OPPS that would provide payments more equitable with physician office payments. “New” off-campus PBDs were those PBDs that did not furnish and bill for services prior to the date of enactment of the Act, November 2, 2015.
CMS created other exceptions to the application of Section 603 so the below entities and services are known as “excepted” provider-based departments. Excepted PBDs and excepted services continue to be paid under OPPS.
- On-campus PBDs
- “Grandfathered” off-campus PBDs – those furnishing and billing for services before November 2, 2015
- Services furnished by a dedicated emergency department
This means “non-excepted” PBDs are those new off-campus PBDs that do not meet one of the above exceptions and that will no longer be paid under OPPS.
To implement the requirements of Section 603, beginning January 1, 2017, services provided by non-excepted off-campus PBDs are paid under the Medicare Physician Fee Schedule (PFS) at special rates established for this provision. Currently, and proposed for 2019, these non-excepted services, that would previously have been paid under OPPS, are paid under the PFS at 40% of the OPPS payment rate. Providers append modifier “PN” to these non-excepted services to trigger the reduced payment rate. In addition to the reduced payment rates, OPPS packaging rules and most adjustments continue to apply to these non-excepted services – a double whammy, so to speak. Excepted off-campus PBD services are reported with modifier “PO” to allow CMS to gather data on the volume of these services, but as stated above, payment for excepted services is currently still made under the OPPS rates.
Continuing Concerns
In the proposed rule, CMS states, “the majority of hospital off-campus departments continue to receive full OPPS payment (including off-campus emergency departments and excepted off-campus departments of a hospital), which is often higher than the payment that would have been made if a similar service had been furnished in the physician office setting.” Also, CMS is extremely concerned about the continuing growth of outpatient hospital services. Despite the implementation of a prospective payment system (OPPS) in 2000 and increased packaging in recent years, “the OPPS has been the fastest growing sector of Medicare payments out of all payment systems under Medicare Parts A and B” which CMS attributes in large part to the payment differential between hospital-based services and physician office services. Here are a few quotes from the proposed rule that highlight CMS’s concerns:
“Total spending has been growing at a rate of roughly 8 percent per year under the OPPS, and total spending under the OPPS is projected to further increase by more than $5 billion from approximately $70 billion in CY 2018 through CY 2019 to nearly $75 billion.”
“We (CMS) are concerned that the rate of growth suggests that payment incentives, rather than patient acuity or medical necessity, may be affecting site-of-service decision-making. This site-of-service selection has an impact on not only the Medicare program, but also on Medicare beneficiary out-of-pocket spending.”
“A large source of growth in spending on services furnished in hospital outpatient departments (HOPDs) appears to be the result of the unnecessary shift of services from (lower cost) physician offices to (higher cost) HOPDs. We would consider these shifts in the sites of service unnecessary if the beneficiary can safely receive the same services in a lower cost setting but instead receives care in a higher cost setting.”
“One-third of the growth in outpatient volume from 2014 to 2015 was due to an increase in the number of evaluation and management (E&M) visits billed as outpatient services. This growth in part reflects hospitals purchasing freestanding physician practices and converting the billing from the Physician Fee Schedule to higher paying hospital outpatient department (HOPD) visits… From 2012 to 2015, hospital-based E&M visits per beneficiary grew by 22 percent, compared with a 1-percent decline in physician office–based visits.”
The Proposed Solutions, i.e. the Bad News
CMS is proposing to take action on several fronts to decrease what they see as unnecessary and excessive spending on services provided in off-campus PBDs.
The most significant of these proposals is capping the OPPS payment for clinic evaluation and management (E&M) visits for excepted off-campus PBDs at the PFS-equivalent rate. This means clinic visits (HCPCS code G0463) provided in excepted off-campus PBDs and currently billed with the PO modifier would be paid at the same reduced OPPS rate as those currently billed with the PN modifier by non-excepted PBDs. This would reduce the payment rate for clinic visits (G0463) in excepted off-campus PBDs from the proposed unadjusted Medicare OPPS payment rate of $116 to the reduced PFS (40% of OPPS) rate of $46. CMS also notes the beneficiary liability would correspondingly decrease from $23 to $9. This proposal is not budget-neutral and CMS estimates total savings of $760 million ($610 M Medicare saving and $150 M beneficiary savings).
A second cost-saving proposal is to expand the reduced payments for drugs purchased through the 340B Program to non-excepted off-campus PBDs. The implementation of reduced 340B drug payments last year did not affect the payments for drugs in non-excepted off-campus PBDs since they are not paid under OPPS. With this proposal, separately payable drugs (those with an OPPS status indicator of “K”) furnished and billed by non-excepted off-campus PBDs and purchased through the 340B program would be paid at ASP-22.5% for 2019 and subsequent years instead of the current payment of ASP+6%. In other words, the payment amount for SI “K” 340B drugs in non-excepted PBDs would decrease by 28.5%. Medicare would continue to pay ASP+6% for SI “K” drugs not purchased through the 340B program billed by non-expected off-campus PBDs.
In the last proposal to control increasing payments under OPPS for off-campus PBDs, CMS is proposing to limit the expansion of services in excepted off-campus PBDs. If an excepted off-campus PBD furnishes services from a clinical family of services that it did not furnish in a baseline period, those new services would be non-excepted and paid at the non-excepted reduced PFS payment rate effective January 1, 2019.
- CMS is proposing a one-year baseline period from November 1, 2014 through November 1, 2015, or one year from the first date the PBD furnished services under OPPS for those that began furnishing services after November 1, 2014.
- There are 19 clinical families of services defined by CMS and mapped to the applicable APCs in Table 32 in the Proposed Rule.
One last proposal related to PBDs that does not affect payment – YET – is the creation of a HCPCS modifier to be reported for outpatient hospital services furnished in an off-campus provider-based emergency department. Critical access hospitals (CAHs) would not be required to report this modifier.
It will be interesting to see which of these proposals for discouraging off-campus PBD services paid under OPPS will make it to the final rule. It is clear from reading the proposed rule that CMS is intent on limiting expansion and making payments more site-neutral. This is bad news for hospitals that have increased their bottom line through the expansion of off-campus services.
Debbie Rubio
MEDICARE TRANSMITTALS
Revisions to the Telehealth Billing Requirements for Distant Site Services - REVISED
Revised criteria that allows the GT modifier to be present on Method II CAH claim lines.
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2018 Update - REVISED
The article is revised to show the Type of Service Code for CPT code 90739 remains as V.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 24.3, Effective October 1, 2018
Medical Review of Evaluation and Management (E/M) Documentation
Provides direction to Medicare’s medical review contractors on how to review claims where a medical student documented the E/M service.
Medicare Special Edition Articles
New Medicare Beneficiary Identifier (MBI) Get It, Use It – REVISED
This article was revised on July 11, 2018, to provide additional information regarding the format of the MBI not using letters S, L, O, I, B, and Z (page 2).
MEDICARE RULES
2019 Medicare Physician Fee Schedule (MPFS) Proposed Rule
Addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf
MEDICARE EDUCATIONAL RESOURCES
Medicare Billing for Cardiac Device Credits
Learn about billing Medicare inpatient and outpatient cardiac devices and reducing overpayments.
Beneficiary Notices Initiative (BNI) webpage – updated
New look for Medicare’s Notices webpage.
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html
Medicare Fee for Service Recovery Audit Program webpage – updated
New look for Medicare’s RAC webpage
Transition to New Medicare Numbers and Cards Fact Sheet
Medicare Quarterly Provider Compliance Newsletter – July 2018
Addresses common billing errors and other erroneous activities and provides guidance to help health care professionals address and avoid the top issues of the particular quarter.
MEDICARE FAST FACTS
Medicare Fast Facts resources this month include:
- Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
- Comprehensive Error Rate Testing: Arthroscopic Rotator Cuff Repair
- Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
OTHER MEDICARE UPDATES
Contract Award for A/B MAC Jurisdiction F
CMS awarded the Jurisdiction F contract to Noridian, the current incumbent contractor for JF.
Can I be honest?
I have type 2 diabetes and take a pill for it every day, but I don’t like diabetes coding. Diagnosis code assignment for diabetes and diabetes-related conditions has always been confusing to me. When looking at a chart of a patient with diabetes, I frequently go back to the ICD-10 diagnosis coding guidelines and Coding Clinic articles to validate my understanding.
Based on some of the coding proficiency reviews we’ve done over the past couple of years, I think other coders may share some of my confusion. One of the most common diagnosis coding discrepancies we come across with diabetes coding is the scenario of a patient with Type 2 diabetes who is also taking an oral antidiabetic drug. We usually see the appropriate diagnosis code for Type 2 diabetes, but ICD-10 diagnosis code Z79.84 is not reported for long-term use of an antidiabetic drug when it’s applicable.
Z79.84 was introduced October 2016, and in addition to all the other diabetes-related coding rules we already had, this new code came with, yet, another rule to remember: When E11- is reported for type 2 diabetes, use an additional code to identify control using an oral antidiabetic / hypoglycemic drug.
In talking with coders and coding supervisors, one of the problems in picking up Z79.84 is that coders may not know which drugs are classified as an antidiabetic. The good news is – we don’t have to know if the drug is a biguanide versus an alpha-glucosidase inhibitor versus SGLT 2 inhibitor, etc., we just need to know which oral medications are considered antidiabetic or hypoglycemic.
Below is a list of the more common oral antidiabetic drugs we see. Did you realize the different preparations of Metformin had so many other names? Keep the list handy in case you see one of these drugs in your patient’s record, so you will have a better idea when Z79.84 should be reported in addition to the E11- diabetes code. Click here to see a more comprehensive list on the Healthline.com website.
Metformin / Kazano
Metformin / Invokamet
Metformin / Xigduo XR
Metformin / Synjardy
Metformin / Glucovance
Metformin / Jentadueto
Metformin / Actoplus
Metformin / PrandiMet
Metformin / Avandamet
Metformin / Kombiglyze XR
Metformin / Janumet
Sitagliptin / Januvia
Sitagliptin-Metformin / Janumet
Canagliflozin / Invokana
Canagliflozin-Metformin / Invokamet
Empagliflozin / Jardiance
Glimepiride / Amaryl
Glipizide / Glucotrol
Chlorpropamide / Diabinese
Tolazamide / Tolinase
Tobbutamide / Orinase
Jeffery Gordon
MEDICARE TRANSMITTALS
July 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
CMS supplies MACs with the ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE). Also see related content at PalmettoGBA - “The drug pricing files contain the payment amounts used to reimburse for Part B covered drugs for the applicable quarter of 2018. The payment amounts in the quarterly ASP files are 106 percent of the Average Sales Price (ASP) calculated from data submitted by drug manufactures (ASP X 1.06). The ASP rate must be adjusted before applying the 22.5 percent reduction (for 340B-acquired drugs).”
Claim Status Category and Claim Status Codes Update
HIPAA requires all covered entities to use only Claim Status Category Codes and Claim Status Codes approved by the National Code Maintenance Committee in the ASC X12 276/277 Health Care Claim Status Request and Response transaction standards adopted for electronically submitting health care claims status requests and responses. These codes explain the status of submitted claim(s).
July 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Changes and billing instructions for various payment policies implemented in the July 2018 OPPS update.
July 2018 Integrated Outpatient Code Editor (I/OCE) Specification Version 19.2
The I/OCE is being updated for July 1, 2018. The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital claims) through a single I/OCE.
MEDICARE SPECIAL EDITION ARTICLES
New Medicare Beneficiary Identifier (MBI) Get It, Use It
Explains ways you can get MBIs.
REVISED MEDICARE TRANSMITTALS
Diagnosis Code Update for Add-on Payments for Blood Clotting Factor Administered to Hemophilia Inpatients – REVISED
Revised to correct the code description for ICD-10-CM D68.32.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Provider Minute Vide: The Importance of Proper Documentation
- Bill Correctly for Device Replacement Procedures
- Billing for Stem Cell Transplants
FEDERAL REGISTRY CMS RULES
Medicare Program; Changes to the Comprehensive Care for Joint Replacement Payment Model (CJR): Extreme and Uncontrollable Circumstances Policy for the CJR Model
Finalizes a policy that provides flexibility in the determination of episode spending for Comprehensive Care for Joint Replacement Payment Model (CJR) participant hospitals located in areas impacted by extreme and uncontrollable circumstances for performance years 3 through 5.
https://www.gpo.gov/fdsys/pkg/FR-2018-06-08/pdf/2018-12379.pdf
OTHER MEDICARE UPDATES
Hospital Appeals Settlement Process Update
May 8, 2018, CMS executed settlements with an additional 612 hospitals, representing approximately 72,000 claims.
FY 2019 ICD-10-PCS Procedure Codes
FY 2019 ICD-10-PCS procedure code updates including a complete list of code titles are posted on the 2019 ICD-10-PCS webpage.
FY 2019 ICD-10-CM Codes
FY 2019 ICD-10-CM code updates have been posted on the CDC website at: https://www.cdc.gov/nchs/icd/icd10cm.htm.
We all know the benefits of a healthy diet and exercise. You can hardly go a day without seeing or hearing information on how eating right and exercising will lead to a longer, healthier, and happier life. Unfortunately, not all of us are proactive when it comes to our health. We wait until an episode or condition has occurred before changing our ways. Better late than never, so it is lucky for many that Medicare covers cardiac and pulmonary rehabilitation. For the providers that furnish these services, it is also wise to be proactive to ensure you meet the Medicare requirements of coverage and billing. Better late than never is not a wise option for providers since your facility could lose valuable reimbursement if you fail to follow the Medicare rules.
In May 2018, the Office of Inspector General added review of outpatient cardiac and pulmonary rehabilitation services to their Work Plan. The OIG notice reminds providers, “For these services to be covered, however, they must be medically necessary and comply with certain documentation requirements. Previous OIG work identified outpatient cardiac and pulmonary rehabilitation service claims that did not comply with Federal requirements.” In addition to prior OIG reviews, some Medicare Administrative Contractors (MACs) have also reviewed cardiac and pulmonary rehab services. The MAC reviews found significant error rates for these services.
If your facility provides one or both of these services, what should you do to ensure you comply with Federal requirements? The obvious first step is being familiar with Medicare’s requirements. The Medicare Benefits Policy manual, chapter 15 discusses the coverage of pulmonary rehab in section 231 and cardiac rehab in section 232. Chapter 32 of the Medicare Claims Processing Manual provides instructions on these programs in section 140.
If you do provide these services, it is likely you know the covered conditions and required components of each. So, in this article, let’s focus on the areas that are most prone to be deficient.
Pulmonary rehab is covered for patients with moderate to very severe chronic obstructive pulmonary disease (COPD) (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease. Cardiac rehab is covered for patients with
- Acute myocardial infarction within the preceding 12 months;
- Coronary artery bypass surgery;
- Current stable angina pectoris;
- Heart valve repair or replacement;
- Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;
- Heart or heart-lung transplant.
- Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.
In the case of a medical review, the patient’s diagnosis should be stated as part of the treatment plan but in addition, your record must substantiate the covered diagnosis with documentation from physicians’ office notes, hospital records, findings of diagnostic testing, and/or operative notes. Also verify timeframes (AMI within the last 12 months, optimal heart failure therapy for at least 6 weeks for CHF) and the inclusion of specific measures when required (GOLD class II, III, or IV; VEF of 35% of less; NYHA class II – IV symptoms) are addressed with supporting documentation.
Denials of pulmonary and cardiac rehab from prior MAC reviews were often cited as due to lack of all the required components. Both pulmonary and cardiac rehab require the following components.
- Physician-prescribed exercise,
- Education or training (for cardiac risk factor modification in the case of cardiac rehab)
- Psychosocial assessment
- Outcomes assessment
- Individualized treatment plan
It is unknown how strict a particular Medicare reviewer will be, so best practice is to address each of these elements with the following strategy – 1) what does the patient need, 2) what is the plan for addressing that need, 3) what was done for the patient based on the plan, 4) how did the patient respond and 5) modifications based on patient failure to progress. Years ago, CGS published an article that described the requirements for cardiac rehab. That article is no longer available, but MMP provided details from that publication in a prior Wednesday@One article that you might find helpful.
Cardiac and pulmonary rehabilitation program sessions are limited to a maximum of two (2) 1-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions if medically necessary. MMP sees Medicare denials of cardiac and pulmonary rehab services with Claim Adjustment Reason Code (CARC) 119 - Benefit maximum for this time period or occurrence has been reached. This could occur when:
- Cardiac/pulmonary rehab services exceed two (2) units for a single day of service
- Cardiac/pulmonary rehab services exceed 36 sessions without a –KX modifier included on the claim line
- Cardiac/pulmonary rehab services exceed 72 sessions
Medicare will assign liability for these services to the provider unless an Advance Beneficiary Notice (ABN) was obtained.
If a patient requires medically necessary cardiac/pulmonary rehab services beyond 36 sessions (up to a maximum of 72 sessions), a –KX modifier should be appended to the claim line. The –KX modifier indicates the services provided meet the medical necessity requirements of the applicable medical policy/regulation and there is supporting the rehab services beyond 36 sessions. For example, a patient may be benefiting from rehab but may not meet exit criteria after the initial 36 sessions. This is an example when use of the –KX modifier would be appropriate.
Also, be sure your documentation specifies the amount of time the patient is participating in cardiac or pulmonary rehab. In order to report one session of cardiac/pulmonary rehabilitation services in a day, the duration of treatment must be at least 31 minutes. Two sessions may only be reported in the same day if the duration of treatment is at least 91 minutes. If several shorter periods of cardiac/pulmonary rehabilitation services are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.
Now is a good time to look at your own cardiac or pulmonary rehab records to verify they meet all the Federal requirements before the OIG, a MAC, or another Medicare reviewer comes calling for those records. Be proactive before it is too late.
Debbie Rubio
MEDICARE TRANSMITTALS
Revisions to the Telehealth Billing Requirements for Distant Site Services
Implements requirements for billing modifier GT for Telehealth Distant Site Services. As of January 1, 2018, the GT modifier is only allowed on institutional claims billed by a Critical Access Hospital (CAH) Method II.
Implementation of Changes to the Pre-Payment Additional Documentation Request (ADR) Letters for Medical Review
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2083OTN.pdf
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Updates to Publication 100-04, Chapters 1 and 27, to Replace Remittance Advice Remark Code (RARC) MA61 with N382
MACs will use N382 in place of MA61 to communicate reject/denials for patient identifiers (HICN or MBI) in all remittance advices and 835 transactions. However, MACs will continue to use RARC MA61 only when/if communicating rejections/denials related to a missing/incomplete/invalid social security number.
Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Extensions per the Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act Included in the Bipartisan Budget Act of 2018
Information and implementation instructions for:
- Section 50204 – Extension of Increased Inpatient Hospital Payment Adjustment for Certain Low-Volume Hospitals
- Section 50205 – Extension of the Medicare-Dependent Hospital (MDH) Program
- Section 51005 – Adjustments to the LTCH Site Neutral Payment Rate
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) – REVISED
The article was revised on May 15, 2018, to clarify that one of the requirements of the SET program is it must be conducted in a hospital outpatient setting or in a physician’s office.
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2018 Update – REVISED
A sentence is added to show that Part B payment for Q9995 includes the clotting factor furnishing fee.
Intent to Reopen
Provides instructions for contractors to: provide notification of the reopening process and to notify the provider or supplier of their intent to reopen a specific claim when requested documentation is received after a denial of the claim has been made.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R796PI.pdf
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2018 Update
MEDICARE COVERAGE UPDATES
International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)
CR10622 makes coding and clarifying adjustments to the following NCDs:
- NCD 110.18 Aprepitant
- NCD 150.3 Bone Mineral Density Studies
- NCD 190.11 Prothrombin Time/International Normalized Ratio (PT/INR)
- NCD 220.6.16 Positron Emission Tomography (PET) for Infection/Inflammation
- NCD 220.6.17 PET for Solid Tumors
- NCD 220.13 Percutaneous Image-Guided Breast Biopsy
MEDICARE PRESS RELEASES
CMS Announces Agency’s First Rural Health Strategy
The agency’s first Rural Health Strategy intended to provide a proactive approach on healthcare issues to ensure that the nearly one in five individuals who live in rural America have access to high quality, affordable healthcare.
CMS Unveils Enhanced “Drug Dashboards” to Increase Transparency on Drug Prices
For the first time, the dashboards include year-over-year information on drug pricing and highlight which manufactures have been increasing their prices.
MEDICARE EDUCATIONAL RESOURCES
Palmetto JM Provider Contact Center (PCC) Frequently Asked Questions (FAQs): January 2018 - April 30, 2018
MLN Fact Sheet Complying with Medicare Signature Requirements
Targeted Probe and Educate Video
MEDICARE RULES
Hospital IPPS and LTC 2019 FY Proposed Rule
The proposed rule proposes updates to Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). Also includes proposal concerning Quality Programs, EHR Incentive Programs, Cost-Reporting and Physician Claim Certifications.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-08705.pdf
Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) Proposed Rule for FY 2019, SNF Value-Based Purchasing Program, and SNF Quality Reporting Program
This proposed rule would update the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2019.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-09015.pdf
Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2019
This proposed rule would update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2019.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-08961.pdf
FY 2019 Inpatient Psychiatric Facilities Prospective Payment System and Quality Reporting Updates for Fiscal Year Beginning October 1, 2018 (FY 2019)
This proposed rule would update the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs), which include psychiatric hospitals and excluded psychiatric units of an acute care hospital or critical access hospital.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-09069.pdf
OTHER MEDICARE UPDATES
Kepro Case Review Connections, Acute Care Edition, Spring 2018
A quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).
https://www.keproqio.com/providers/spring-2018-acute-newsletter/
Trump Administration Releases Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs
The relationship between physicians and hospitals could be described as a symbiotic partnership, that is, a mutually beneficial relationship between different groups. Physicians need hospitals to provide the resources and personnel to care for their patients and hospitals need physicians to refer patients to the hospitals for such care when medically necessary. Physicians direct a patient’s care and decide when and what services are necessary. It also often falls on the physicians’ documentation to support that services and care provided and paid for by Medicare meet the requirements of being medically necessary. Unfortunately for hospitals, it is often their payment at risk if a physician provides a service in the hospital setting that is not medically necessary or fails to document sufficiently to support the medical necessity of the service. Because directing the patient’s care is the physician’s responsibility, many Medicare education resources about compliance are directed to the physicians. Likewise, hospitals must work with physicians to ensure services are appropriately provided and documented. Such is the case for ophthalmology services.
Though a number of ophthalmology services determined by the Office of Inspector General (OIG) to be at risk of “questionable billing” are more likely to be performed in a physician office setting, there are also services that could be performed in a hospital setting. Hospitals need to be aware of the concerns and requirements for these types of ophthalmology services.
A December 2014 OIG audit found that Medicare paid $22 million for ophthalmology claims in 2012 that were potentially inappropriate, according to national and local coverage requirements. The three eye conditions for which Medicare pays the most each year are cataracts, wet age-related macular degeneration (wet AMD), and glaucoma. The concerns for inappropriate payments related to these conditions are:
- Cataracts
- Medicare has a national requirement stating that it will not routinely cover more than one comprehensive eye examination and scan for beneficiaries whose only diagnosis was cataracts.
- It is medically impossible to perform more than one cataract surgery on the same eye because an eye’s natural lens will never grow back.
- Submitting disproportionately more claims for complex than standard cataract surgery.
- Wet AMD
- Some Medicare Administrative Contractors (MACs) have local coverage determinations (LCDs) limiting the number of wet AMD diagnostic or evaluation services for which a provider may bill annually.
- Medicare paid providers substantially more for treating wet AMD with the expensive biologic Lucentis instead of other biologic treatments that are similarly effective.
- Some MACs have LCDs specifying that Lucentis injections are not covered more frequently than once per month per eye. These guidelines are in keeping with the Food and Drug Administration (FDA)-approved dosing guidelines that Lucentis injections should be administered between once monthly and once every 3 months.
- Medicare has a national requirement that it covers each step of ocular photodynamic therapy only when both steps are performed on the same date. These steps are billed separately, but they must be performed within 30 minutes of one another.
- Glaucoma
- A national requirement states that Medicare covers either of two types of screening services once every 12 months for beneficiaries at high risk for glaucoma.
A September 2015 follow up OIG report found Medicare paid $171 million for services associated with the measures on which certain providers demonstrated questionable billing.
Prior to these OIG reports, the Recovery Auditors identified overpayments associated to outpatient hospital providers billing more than one unit of cataract removal for the same eye for the same date of service. CMS published MLN Special Edition Article SE1319 in response to these findings. It reminded providers,
“According to the “National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services,” Chapter 8, Section D #3, cataract removal codes are mutually exclusive of each other and can only be billed once for the same eye. Because CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another, providers may not report multiple codes for the same eye even if more than one technique is used or more than one code could be applicable. Only one code from this CPT code range may be reported for an eye.”
The NCCI Policy Manual chapter and section noted above addresses 25 other correct coding guidelines for ophthalmology services of which providers should be aware.
For another ophthalmology service, CMS clarified in a 2005 ruling that a Medicare beneficiary may request insertion of a presbyopia-correcting intraocular lenses (IOLs) in place of a conventional IOL following cataract surgery. However, if the Medicare patient selects a presbyopia-correcting IOL, he/she is responsible for payment of that portion of the charge for the presbyopia-correcting IOL and associated services that exceed the charge for insertion of a conventional IOL following cataract surgery. The MLN Article describing this ruling included payment policies for facilities and physicians. The policy relevant to hospital services states:
- For an IOL inserted following removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the hospital outpatient prospective payment system (OPPS) or the inpatient prospective payment system (IPPS), respectively;
- Payment for the IOL is packaged into the payment for the surgical cataract extraction/lens replacement procedure. Medicare does not make separate payment to the hospital for an IOL inserted following removal of a cataract.
- For a presbyopia-correcting IOL inserted following removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the OPPS or the IPPS, respectively;
- The facility will bill for removal of a cataract with insertion of a conventional IOL, regardless of
- whether a conventional or presbyopia-correcting IOL is inserted.
- When a beneficiary receives a presbyopia-correcting IOL following removal of a cataract, hospitals and ASCs shall report the same CPT code that is used to report removal of a cataract with insertion of a conventional IOL.
- There is no Medicare benefit category that allows payment of facility charges for services and supplies required to insert and adjust a presbyopia-correcting IOL following removal of a cataract that exceed the facility charges for services and supplies required for the insertion and adjustment of a conventional IOL.
- There is no Medicare benefit category that allows payment of facility charges for subsequent treatments, services and supplies required to examine and monitor the beneficiary who receives a presbyopia-correcting IOL following removal of a cataract that exceed the facility charges for subsequent treatments, services and supplies required to examine and monitor a beneficiary after cataract surgery followed by insertion of a conventional IOL.
The article also addresses coding requirements, beneficiary liability and notification requirements for these services.
Both hospitals and physicians must be aware of and follow the Medicare requirements for providing and billing ophthalmology services. Working together to “get it right” keeps the relationship between physicians and hospitals mutually beneficial for both parties and for Medicare.
Debbie Rubio
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