Knowledge Base Category -

Most of us know the dangers of assumptions. We have all heard the play on letter divisions within the word “ass/u/me.” Medicare and Medicare providers are not immune to the negative consequences of assumptions. Such was the case with the physician supervision rules for hospital outpatient services.

In the 2009 Outpatient Prospective Payment System (OPPS) Proposed and Final Rules, Medicare shocked the provider community with their “clarification” of the physician supervision requirements. Prior to this “clarification,” hospitals had not worried much about meeting the physician supervision requirements on the hospital campus because CMS stated in the original OPPS rule that “we assume the physician supervision requirement is met on hospital premises because staff physicians would always be nearby within the hospital.” But according to Medicare, providers misinterpreted their meaning of the word “assume” and Medicare always expected hospital outpatient therapeutic services to be provided under the direct supervision of physicians in the hospital and in all provider-based departments (PBDs) of the hospital, specifically, both on-campus and off-campus departments of the hospital.

Thus began the on-going discussions, clarifications, adjustments, and exceptions to physician supervision requirements for hospital services. So where are we today with supervision requirements for hospital outpatient services?

Therapeutic Services

Generally, “CMS requires direct supervision by an appropriate physician or non-physician practitioner in the provision of all therapeutic services to hospital outpatients, including CAH outpatients.”

Facts about Direct Supervision:

• Applies to therapeutic services furnished in the hospital or CAH or in an on-campus or off-campus outpatient department of the hospital or CAH.
• Non-physician practitioners (NPPs) may furnish the required supervision of hospital outpatient therapeutic services that they are allowed to personally furnish. NPPs include licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives.
• The physician or NPP must be immediately available to furnish assistance and direction throughout the performance of the procedure. Immediately available means the immediate physical presence of the supervisory physician or NPP.
• The physician is not required to be present in the room where the procedure is performed or within any other physical boundary as long as he or she is immediately available.
• Lack of immediate availability would be situations where the supervisory physician is performing another procedure or service that he or she could not interrupt.
• Though not specifically defined in terms of time or distance, the supervisory physician or NPP may not be so physically distant on-campus from the location where hospital/CAH outpatient services are being furnished that he or she could not intervene right away.
• An allowed practitioner can furnish direct supervision from any location in or near an off-campus hospital or CAH building that houses multiple hospital provider-based departments where the services are being furnished as long as the supervisory practitioner is immediately available.
• The supervisory physician or NPP must have, within his or her State scope of practice and hospital-granted privileges, the knowledge, skills, ability, and privileges to perform the service or procedure.
• CMS expects the supervisory practitioner to be knowledgeable about the therapeutic service and clinically able to furnish the service.
• The supervisory responsibility is more than the capacity to respond to an emergency, and includes the ability to take over performance of a procedure or provide additional orders.
• The supervisory practitioner must be clinically able to supervise the service or procedure.
  This means an ER physician does not meet the supervision requirements for a specialized service such as Radiation Oncology.
• The moratorium on enforcement of direct supervision requirements for CAHs and rural hospitals has expired. For 2015 and beyond, CMS requires a minimum of direct supervision for all outpatient therapeutic services furnished in all hospitals, including rural hospitals and CAHs, unless different supervision requirements are assigned as explained below.

CMS may assign certain hospital outpatient therapeutic services either general supervision, personal supervision or extended duration services supervision.

• General supervision means the procedure or service is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure.
• Personal supervision requires the physician must be in attendance in the room during the performance of the service or procedure.
• For nonsurgical extended duration therapeutic services (“extended duration services”), CMS requires a minimum of direct supervision during the initiation of the service which may be followed by general supervision for the remainder of the service at the discretion of the supervisory practitioner.
• “Initiation” means the beginning portion of the extended duration service, ending when the supervisory practitioner believes the patient is stable enough for the remainder of the service to be safely administered under general supervision.
• The point of transition to general supervision must be documented in the patient’s progress notes or medical record.
• The list of services that may be furnished under general supervision or that are defined as non-surgical extended duration therapeutic services is available on the Hospital OPPS Webpage.

Diagnostic Services

Payment is allowed under the hospital outpatient prospective payment system for diagnostic services only when those services are furnished under the appropriate level of supervision.

• Supervision levels for diagnostic tests are listed in the quarterly updated Medicare Physician Fee Schedule (PFS) Relative Value File. For guidance regarding the numeric levels assigned to each CPT or HCPCS code in the PFS Relative Value File, see the Medicare Benefit Policy Manual, Chapter15, Section 80, “Requirements for Diagnostic X-ray, Diagnostic Laboratory, and Other Diagnostic Tests.”
• The definitions of “general” and “personal” supervision listed above apply.
• “Direct supervision” means that the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure following the same rules for direct supervision as discussed above. This applies to diagnostic services provided:
• Directly or under arrangement,
• In the hospital or in an on-campus or off-campus outpatient department of the hospital.
• Non-physician practitioners cannot provide the required physician supervision when other hospital staff are performing diagnostic tests.

For more information on supervision requirements, see the Medicare Benefit Policy Manual, Chapter 6, sections 20.4.4, 20.5.2, and 20.7.

It is unknown if or how Medicare will enforce these supervision requirements, but we definitely don’t want to “assume” they will not.

Another article in this week’s Wednesday@One newsletter reviews the different definitions of the word “confusion.” There are also numerous definitions for the verb “observe” but let’s concentrate on two of these definitions. One definition of “observe” is “to watch, view, or note for a scientific, official, or other specialpurpose.” This definition fits the services provided to a patient in a hospital stay for “observation services” – the patient is being watched for a special purpose. But observe also means to “obey or comply” as providers of services to Medicare patients must “observe” Medicare rules and regulations. In fact, these providers must “observe the rules of observation services.”

Since there was not a lot of MAC Medical Review activity this month, let’s look beyond the MAC reviews to a finding reported in the OIG compliance review of Northwestern Memorial Hospital released in March 2015. The OIG reported that the hospital incorrectly billed Medicare for observation hours resulting in incorrect outlier payments. In this review, the overpayment amount for observation services was less than $4,000 but findings from this review were extrapolated expanding overpayments of around $272,000 to a refund amount of over $6M. Other OIG compliance reviews over the years have identified cases of over $20,000 in outlier overpayments related to incorrect reporting of observation hours.

The most common reason for over-reporting observation hours is the inclusion of observation time for services that were part of another Part B service including postoperative monitoring or standard recovery care. According to the Medicare Claims Processing Manual, Chapter 4, Section 290.2.2, observation services should not be billed:

• For services that are part of another Part B service, such as postoperative monitoring during a standard recovery period (e.g., 4-6 hours);
• For routine preparation services furnished prior to diagnostic testing and recovery afterwards; or
• Concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure.

Medicare allows hospitals the discretion of determining the most appropriate way to account for concurrent time. Hospitals may deduct the actual time spent in procedures with active monitoring or use an average length of time for the interrupting service.

Another problem identified by this and previous OIG reviews was including inappropriate time before or after observation services.

• Observation time begins at the clock time documented in the patient’s medical record, which coincides with the time that observation care is initiated in accordance with a physician’s order. You cannot bill for observation hours prior to the time of the physician’s order for observation. Keep this in mind especially when using Condition Code 44 to convert an inappropriate inpatient admission to an outpatient stay. The entire stay, from the time of the inpatient admission order, becomes outpatient status, but if the order is to “change to outpatient with observation services”, observation only begins at the time of that order.
• Observation time ends when all medically necessary services related to observation care are completed. This could be before, at the time of, or after the time of the discharge order. The key here is when medically necessary services are complete. Consider if the patient is still receiving medical care related to the observation services. Once medical care/assessment is complete, observation services are complete and the billing of observation hours should stop at that point.

There were also issues with physician’s orders – either missing orders or untimely orders. There must be a signed order for observation services – section 290.1 of Chapter 4 of the Medicare Claims Processing manual states, “Observation services are covered only when provided by the order of a physician or another individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient services.” In the OIG review that noted untimely orders, one order was signed after the observation care was no longer necessary and the other order was signed when the observation services were nearly complete. Observation orders must be medically necessary at the time they are written, which leads nicely into the final issue.

The final observation issue noted in the OIG review - the patient’s condition did not warrant observation services. Providers must consider the medical necessity of observation services just like they consider the medical necessity of all procedures and services. This applies to an initial decision for observation services and the continuation of observation services.

“Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. … In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours.”

Observation is short term treatment or assessment while the physician is deciding whether the patient needs to be admitted as an inpatient or is medically stable enough to send home. Once this is decided and short term treatments and assessments are complete, observation services are no longer medically necessary.

To be compliant with the reporting of observation services, providers must consider - is observation reasonable and necessary, is there a physician’s order, and is observation time being counted correctly? As with all things Medicare, there are a lot of details, in this case for observing the rules of observation.

MAC Medical Review Activity for the month included:

Recently a hospital reported to MMP that they were cited for an underpayment by the Recovery Auditor because they had billed for a portion of a drug that is only available in a single-dose vial. The hospital, following the appropriate United States Pharmacopeia (USP) standards for compounding, had split the single-dose vial into incremental portions in syringes. They billed Medicare for the dose administered to a patient and the wastage amount of one of the prepared syringes. The RAC denied this as an underpayment – what should the hospital do?

My research revealed that the splitting of single-dose vials is a huge controversy. The Centers for Disease Control and Prevention (CDC) has released a statement opposing the splitting of single-use vials due to safety concerns, except in times of severe shortages of medicines.   CMS has even weighed in on the issue with a memo to the State Survey Agency Directors requiring adherence to strict standards for repackaging of single use vials.

But often single-use vials contain more medication than the routine dose. Drug wastage raises concerns about the high costs of drugs and the ever increasing number of drug shortages. For these reasons, hospital pharmacies may aliquot a single-dose vial into smaller doses. A patient will then be administered the ordered dose from the prepared syringe and any remaining amount within the syringe will be wasted. The hospital should bill for the amount of the drug given and wasted from the single syringe used. This will result in the billing of an amount less than the amount in the single-use vial. Like the situation above, this may cause a Medicare contractor to question your billed units.

The hospital will have to appeal the denial and provide documentation to the contractor that supports:

• Their process for splitting the single-use vial, including adherence to the required criteria
• The dosage within the syringe that was used
• The amount administered to the patient and the amount wasted

If the denial comes from a Recovery Auditor and your hospital has time, you may be able to resolve the issue during the discussion period.

And you probably never thought you would object to an underpayment finding!!

Wives, do you ever tell your husband how much money you saved him because you bought something on sale? In the medical realm, hospitals sometimes get medical devices “on sale” – well, actually at reduced or no cost for various reasons, such as premature replacements, product recalls, or as part of a clinical trial. Since the device is free or at a reduced cost, Medicare doesn’t want to reimburse the hospital for a full cost device. Therefore, hospitals must communicate the “special price” to Medicare on the claim with specific codes in order not to receive an overpayment.

Last year CMS changed the way hospitals report devices on outpatient claims when the device is provided at no cost, with full credit, or with partial credit that is 50% or greater than the cost of the device. Prior to this change, hospitals used modifiers –FB and –FC to communicate this information on the claim. Effective January 1, 2014, the use of modifiers FB and FC were discontinued, and hospitals were instructed to use Value Code FD and condition codes 49 or 50 to report device credits. However, condition codes 49 and 50 only describe devices that are replaced –

• Condition Code 49 – Product Replacement within Product Lifecycle
• Condition Code 50 – Product Replacement for Known Recall of a Product

Sometimes the original device for initial implantation is provided to the hospital at no cost, such as a free sample or due to a medical device clinical trial. Therefore for claims received on and after July 1, 2015, CMS is adding a new condition code for hospital reporting to identify medical devices for initial device placement provided at no or reduced cost due to a clinical trial or free sample (MLN Matters MM8961). The new condition code is:

• Condition Code 53 – Initial Placement of a Medical Device Provided as Part of a Clinical Trial or Free Sample

To report medical devices for initial device placement provided at no or reduced cost, hospitals will report the:

• Value Code “FD” (Credit Received from the Manufacturer for a Medical Device)
• The amount of the device credit in the amount portion for value code “FD”
• Condition Code 53
• A charge of $0.00 for the device (or a token charge of $1.00 if required by the billing system)

The OPPS payment deduction for device credits for device-dependent APCs is limited to the lesser of the device credit amount reported in the FD value field or the device offset amount for that APC.

If the device is furnished as part of a clinical trial, the claims requirements for institutional billing of clinical trials must also be followed.

Hospital Compliance Audits performed by the Office of Inspector General (OIG) have consistently identified errors with the lack of reporting device credits. From my years working in a hospital, I realize tracking and reporting such credits would be a very detailed process, involving numerous departments. But to prevent overpayments, hospitals must come up with appropriate processes to know when a credit is received or should be received, the credit amount, the reason for the credit, and get the correct data on the claim to report that credit to Medicare. So as with the wife’s “on sale” purchase, “on sale” devices still come with a price!

I love reading, writing and the English language – I am such a grammar geek that I actually belong to a “grammar” blog. In writing, you want to make sure you are choosing your words wisely and appropriately – in other words, definitions matter. As we see in this quarter’s Medicare Compliance Newsletter, definitions also matter when billing for your services to Medicare, especially the definitions related to procedure and diagnosis codes.

Last week we addressed a couple of CERT issues from the January Medicare Quarterly Provider Compliance Newsletter that affected hospital inpatient claims. This week we will look at some deficiencies with outpatient records identified by the Recovery Auditors.

Extracorporeal Photopheresis – CPT 36522

Medicare covers extracorporeal photopheresis (drug and UVA light treatment of white blood cells) only for certain conditions per National Coverage Determination 110.4. This procedure is covered by Medicare for:

• Palliative treatment of skin manifestations of cutaneous T-cell lymphoma that has not responded to other therapy
• Patients with acute cardiac allograft rejection whose disease is refractory to standard immunosuppressive drug treatment
• Patients with chronic graft versus host disease whose disease is refractory to standard immunosuppressive drug treatment

Medicare claims for CPT 36522 must contain one of the following ICD-9 diagnosis codes for the above covered conditions to support medical necessity and be eligible for Medicare payment: 202.10-202.18 and 202.20-202.28, 996.83, or 996.85. A RAC automated review identified overpayments for claims with this service that did not contain an appropriate diagnosis code.

Facet Joint Injections

According to the newsletter, “Medicare will consider facet joint blocks to be reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint.” Due to findings from RAC reviews, Medicare reminds providers about the following facts of facet joint injections:

• It is expected that facet injections reported with CPT codes 64490-64495 will be performed under fluoroscopic guidance.
• Multiple nerves innervate each facet joint, but injections are to be reported per facet joint level, not per nerve. Facet joint levels refer to the joints that are blocked and not the number of medial branches that innervate them. For example, CPT codes 64490 and 64493 are used to report all of the nerves that innervate the first level paravertebral facet joint and not each nerve; CPT codes 64491, 64492, and 64494, 64495 report all nerves at the second and third additional levels and not each additional nerve.
• Codes 64490-64495 are unilateral procedures.
• Use modifier 50 to report bilateral injections (facet joint injections on both the right and left sides of one level of the spine). If multiple bilateral injections are performed, modifier 50 should accompany each facet CPT joint injection code that was performed on both sides of one level.
• Only one facet injection code should be reported at a specific level and side injected (e.g., right L4-5 facet joint), regardless of the number of needle(s) inserted or number of drug(s) injected at that specific level.

IV Infusion Units

Providers are to report only one “initial” intravenous infusion code for chemotherapy and therapeutic infusions (CPT codes 96413, 96365, and 96369) per day unless the patient has two different infusion sites or more than one visit on the same day. In the case of two infusion sites or multiple encounters, it is appropriate to append a -59 modifier to the second “initial” service. An initial infusion code is defined in MLN Matters Article MM3818 as the code that “best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur." Also be sure to follow the CPT reporting hierarchy for drug administration codes in selecting the initial service.

Hospitals need to bear in mind that for drug administrations, observation services spanning more than one day are considered one encounter as explained in the Medicare Claims Processing Manual, Chapter 4, section 230:

“Drug administration services are to be reported with a line item date of service on the day they are provided. In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than 1 calendar day.”

As always, it benefits providers to pay attention to the details when billing Medicare – such as the definitions of “initial” infusion and facet joint “level” versus nerve. In coding and billing, definitions matter!

Some people may not get their gift from Santa this Christmas. When I was a child, I was always told that Santa Claus would not come until I went to sleep. If the number of people having sleep study testing is any indication, a lot of people in the US are having trouble sleeping. An OIG audit reported that from 2005 to 2011, Medicare spending for polysomnography services rose from $407 million to $565 million, an increase of 39 percent.

Because of this dramatic increase in the volume of sleep studies, several Medicare review contractors have sleep studies and polysomnography as one of their review topics. Two such contractors are the Comprehensive Error Rate Testing (CERT) reviewers and the Supplemental Medical Review Contractors (SMRC). (see the SMRC Polysomnography Project )

Medicare covers diagnostic testing of sleep disorders when the patient has symptoms or complaints of narcolepsy, sleep apnea, impotence or parasomnia. Polysomnography for chronic insomnia is not covered. (See Medicare Benefit Policy Manual, Chapter 15 section 70) There is also a National Coverage Determination (NCD 240.4.1) and several Local Coverage Determinations (LCDs) concerning the coverage requirements for sleep studies.

All reasonable and necessary diagnostic tests for the conditions listed above are covered when the following criteria are met:

• The clinic is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic testing routinely performed in disorder clinics may be covered even in the absence of direct supervision by a physician;
• Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physician’s order; and
• The need for diagnostic testing is confirmed by medical evidence, e.g. physician examination and laboratory tests.

Based on the findings from CERT reviews, discussed in the October 2014 Medicare Quarterly Compliance Newsletter, 97% of improper payments are due to insufficient documentation. So what do providers need to do to ensure they receive payment for their polysomnography services? Make sure the documentation in the medical record for sleep studies includes:

• A valid physician’s order for the diagnostic study or documentation to support the intent to order study (if there is no order, evidence of the intent to order PSG documented in the medical record can be accepted)
• A physician’s signature on the procedure note; and
• Clinical documentation to support the reason/need for the diagnostic study (e.g. documentation to support the fact that the beneficiary had symptoms and signs of sleep apnea).

You have to be good (and asleep) to get your presents from Santa, but you have to have complete and appropriate documentation to get your present (payment) from Medicare for sleep testing.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

We may not know if the testing method for drug screening is classified as moderate or high complexity without looking it up, but I bet everyone will agree that the process of selecting the correct CPT/HCPCS codes for drug screen billing is highly complex.

CPT made a lot of changes to drug assays, specifically drug screening and definitive testing of non-therapeutic drugs, for 2015. And to complicate things even further, Medicare is not accepting the new CPT codes and has established some new HCPCS codes for drug identifications. Medical Management Plus will be covering the drug assay code changes in our coding webinar on December 4, 2014 in more detail, but here is a summary of the major changes.

Instead of classifying drug assays by qualitative versus quantitative, CPT now has three types of drug assays:

1. Presumptive drug assays to detect the possible presence of a drug by simpler testing methods,
2. Definitive drug assays that provide specific identification of individual drugs using complex testing methods, and
3. Therapeutic drug assays to monitor clinical response to a known, prescribed medication.

The assignment of CPT codes for presumptive drug assays are based on the drug classification into one of two drug class lists developed by CPT and the complexity of the testing methods. Drug class list A includes drugs generally considered drugs of abuse and identified by simpler testing methods such as optical observation and chemistry analyzer immunoassay or enzyme assay. Drug class list B includes drugs such as acetaminophen, salicylates, etc. and involves most complex immunoassay analyzer or chromatography methods. The CPT codes for drug screening are:

• CPT 80300 - Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (eg immunoassay) capable of being read by direct optical observation, including instrumented-assisted when performed (eg, dipsticks, cups, cards, cartridges), per date of service
• CPT 80301 - Drug screen, any number of drug classes from Drug Class List A; single drug class method, by instrument test systems (eg, discrete multichannel chemistry analyzers utilizing immunoassay or enzyme assay), per date of service
• CPT 80302 - Drug screen, presumptive, single drug class from Drug Class List B, by immunoassay (eg, ELISA) or non-TLC chromatography without mass spectrometry (eg, GC, HPLC), each procedure
• CPT 80303 - Drug screen, any number of drug classes, presumptive, single or multiple drug class method; thin layer chromatography procedure(s) (TLC) (eg, acid, neutral, alkaloid plate), per date of service
• CPT 80304 - Drug screen, any number of drug classes, presumptive, single or multiple drug class method; not otherwise specified presumptive procedure (eg, TOF, MALDI, LDTD, DESI, DART), each procedure

For Medicare, drug screening codes are the same as last year. Although the description for high complexity lists immunoassay and enzyme assay, most immunoassay and enzyme assay methods are actually moderate complexity tests. Test complexity is determined by the FDA and is listed on their website. Laboratory personnel can help in determining the complexity of drug screen tests that your hospital performs. Medicare’s HCPCS code definitions are:

• HCPCS G0431 - Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter
• HCPCS G0434 - Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter

Both CPT and Medicare developed new codes for individual non-therapeutic drug assays. The new CPT codes are CPT codes 80320 – 80377. CPT clarifies that these codes are to be used for complex definitive methods such as those involving mass spectrometry and specifically excludes immunoassay and enzyme assay testing methods. The new HCPCS codes describing individual drug assays accepted by Medicare for 2015 are HCPCS codes G6030 – G6058. So far Medicare has not provided any guidance on the use of these codes, such as if they are limited to particular testing methodologies.

Because of differences in the basis of the code descriptions, it will not be easy to cross-walk the CPT codes and the Medicare HCPCS codes. We also will have to wait and see if Medicare issues any guidance, particularly for the use of the individual drug codes. The chart below provides some suggestions on cross-walking the drug screening codes.

As high complexity is a determining factor in drug testing, it also appropriately describes the process of determining which codes to use for billing. This year, it just seems to become even more complex and even worse, Medicare is packaging the payment for all drug screening codes. All of this work and brain drain for no reward!!

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

“The ABC’s of …” refers to the basic facts of a topic. This article looks at the basic facts of the rehabilitative therapy updates for 2015, which involve C’s (caps and codes), D’s (documentation), E’s (exceptions and extensions), and F’s (functional reporting). So the ABC’s of the CDEF’s of therapy are…

There are not a lot of changes for rehabilitative therapy for 2015 like there have been the past few years. But all of the changes from previous years remain in place, at least for now. So let’s look at what is new and review some of the ongoing requirements for therapy services.

Therapy Caps

• The 2015 therapy cap for physical therapy and speech-language pathology combined is $1,940
• The cap for occupational therapy is $1,940 for 2015
• There is an exception process for therapy services beyond the cap limit if services are reasonable and necessary
• Use KX modifier on therapy services to request exception to therapy caps
• KX modifier - therapist is attesting that the services above the therapy caps are reasonable and necessary and that there is documentation of medical necessity for the services in the beneficiary’s medical record
• See MLN Matters Article MM8970

Therapy Code List

• Two new codes created to describe negative pressure wound therapy with the use of a disposable system
• CPT Code 97607 – Negative pressure wound therapy utilizing disposable, non-durable medical equipment …, total wound(s) surface are less than or equal to 50 square cm
• CPT Code 97608 – Negative pressure wound therapy utilizing disposable, non-durable medical equipment …, total wound(s) surface are greater than 50 square cm
• CPT codes 97607 and 97608 designated as “Sometimes Therapy”
• Negative pressure wound therapy CPT codes 97605 and 97606 revised to specify the use of durable medical equipment
• G-codes (G0456 and G0457) that described negative pressure wound therapy using disposable device are being deleted
• See MLN Matters Article MM8985

Extension of Therapy Provisions

The Protecting Access to Medicare Act of 2014 (PAMA) extended the following provisions through March 31, 2015:

• The exceptions process for outpatient therapy caps
• The manual medical review process for therapy services exceeding threshold of $3,700 (one threshold for PT/SLP combined; one for OT)
• The application of the therapy caps and related provisions to services furnished in hospital outpatient departments
• The patient’s performance on the Berg Balance Scale (score 46 out of 56) indicates that she is a low fall risk according to the interpretive guidance provided. However, the patient is a moderate fall risk due to the added contribution of lower extremity muscle weakness and reduced vision. The patient classifies as between 20%-40% impaired (CJ). Due to ongoing visual impairment, the patient is expected to obtain a goal of 1-20% impairment (CI) with the recommended therapy plan of care.

Functional Limitation Reporting

Reporting of the functional limitation G-codes and severity modifiers is now a requirement for rehabilitative therapy claims to allow Medicare to gather data on therapy usage and outcomes to assist in reforming the Medicare payment system for outpatient therapy services. From therapy reviews performed by Medical Management Plus, it appears providers are generally reporting these correctly. The one issue that needs improvement is the documentation of the rationale for selection of the severity modifiers. The Medicare manual states – “Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.”

Documentation should clearly indicate the measures and reasons the therapist selected a particular degree of impairment. Some examples of documentation that meets these requirements are:

• The patient’s performance on the Berg Balance Scale (score 46 out of 56) indicates that she is a low fall risk according to the interpretive guidance provided. However, the patient is a moderate fall risk due to the added contribution of lower extremity muscle weakness and reduced vision. The patient classifies as between 20%-40% impaired (CJ). Due to ongoing visual impairment, the patient is expected to obtain a goal of 1-20% impairment (CI) with the recommended therapy plan of care.
  (Paraphrased from APTA Functional Limitation Reporting Toolkit at the following link: http://www.apta.org/Payment/Medicare/CodingBilling/FunctionalLimitation/)

• Patient’s goal for PT is to be able to walk in her house and around the community (G8978) with minimal to no assist. Her current impairment is 80% (CM) based on her OPITMAL, Berg Balance, and 10 meter walk scores. She is expected to be able to walk with minimal assistance with around 30% (G8979 CJ) impairment after 6 weeks of therapy.

Therapists definitely need to know their alphabet for billing, coding and documentation.

I enjoy what I do. For some weird reason, I like to read and do my best to interpret the Medicare regulations. I hope my efforts make it easier for hospitals to receive the appropriate reimbursement for the healthcare services they provide by helping them to follow Medicare’s documentation, coding and billing requirements. But unfortunately, the news I share is not always the best news or even fun. So before I get into the “not so fun” part of this article, I want to acknowledge National Radiologic Technology Week.

As in many areas of healthcare, radiology includes many different types of services, such as plain x-rays, computed tomography (CT), magnetic imaging resonance (MRI), ultrasound, nuclear medicine, interventional radiology, radiation oncology, and others. Radiologic technologists provide a valuable contribution to healthcare. How many times over the past year have you, your family or friends received radiologic services? How would your care have been affected without this technology? Within my own circle of family and friends – an x-ray for a broken wrist, annual mammogram, Dexa scan, MRI for spinal stenosis, and CT to rule out a pulmonary embolism. So thanks to all our radiology friends!

A few weeks ago an article reviewed some of the National Correct Coding Initiative (NCCI) guidance for respiratory services for their recognition week. Continuing that theme for National Radiology Week, let’s look at some of the NCCI instructions that apply to Medicare coding and billing for radiology services.

A recent NCCI edit (July 2014) bundled spinal myelography procedures (72240-72270) into procedures for CT neck, chest and lumbar studies (72125-72133). The code pairs may be reported together with the appropriate modifier when warranted. If both tests are medically necessary, distinctly ordered, and there is a separate interpretation for each procedure, then it is appropriate to append modifier 59 to the CT of the spine with contrast code to identify that it is a separate and distinct procedure. (CPT Assistant September 2014)

The following are selected excerpts from the Radiology chapter of the NCCI manual. For complete information regarding these topics and other radiologic issues, please see Chapter IX of the NCCI Policy Manual found in the downloads section of the Medicare NCCI Website.

• CPT code descriptors that specify a minimum number of views include additional views if there is no more comprehensive code specifically including the additional views.
• CPT Manual instructions state that in the presence of a clinical history suggesting urinary tract pathology complete ultrasound evaluation of the kidneys and urinary bladder constitutes a complete retroperitoneal ultrasound study (CPT code 76770). A limited retroperitoneal ultrasound (CPT code 76775) plus limited pelvic ultrasound (CPT code 76857) should not be reported in lieu of the complete retroperitoneal ultrasound (CPT code 76770).
• When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. Similarly when an emergency endotracheal intubation procedure (CPT code 31500), chest tube insertion procedure (e.g., CPT codes 32550, 32551, 32554, 32555), or insertion of a central flow directed catheter procedure (e.g., Swan Ganz)(CPT code 93503) is performed, a chest radiologic examination is usually performed to confirm the location and proper positioning of the tube or catheter. The chest radiologic examination is integral to the procedures, and a chest radiologic examination (e.g., CPT codes 71010, 71020) should not be reported separately.
• CPT code 75635 describes computed tomographic angiography of the abdominal aorta and bilateral iliofemoral lower extremity runoff. This code includes the services described by CPT codes 73706 (computed tomographic angiography, lower extremity...) and 74175 (computed tomographic angiography, abdomen...). CPT codes 73706 and 74175 should not be reported with CPT code 75635 for the same patient encounter. CPT code 73706 plus CPT code 74175 should not be reported in lieu of CPT code 75635.
• Diagnostic angiography (arteriogram/venogram) performed on the same date of service by the same provider as a percutaneous intravascular interventional procedure should be reported with modifier 59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59.
• Fluoroscopy reported as CPT codes 76000 or 76001 is integral to many procedures including, but not limited, to most spinal, endoscopic, and injection procedures and should not be reported separately. For some of these procedures, there are separate fluoroscopic guidance codes which may be reported separately.
• Computed tomography (CT) and computed tomographic angiography (CTA) procedures for the same anatomic location may be reported together in limited circumstances. If a single technical study is performed which is utilized to generate images for separate CT and CTA reports, only one procedure, either the CT or CTA, for the anatomic region may be reported. Both a CT and CTA may be reported for the same anatomic region if they are performed at separate patient encounters or if two separate and distinct technical studies, one for the CT and one for the CTA, are performed at the same patient encounter. The medical necessity for the latter situation is uncommon.
• If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with mammographic guidance (e.g., 19281,19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.
• CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.
• The code descriptor for CPT code 77417 states “Therapeutic radiology port film(s)”. The MUE value for this code is one (1) since it includes all port films.
• An MRI study of the brain (CPT codes 70551-70553) and MRI study of the orbit (CPT codes 70540-70543) are separately reportable only if they are both medically reasonable and necessary and are performed as distinct studies. An MRI of the orbit is not separately reportable with an MRI of the brain if an incidental abnormality of the orbit is identified during an MRI of the brain since only one MRI study is performed.

There are more rules on coding and reporting radiology services on a claim than there are slices of a CT scan. And that is not so fun!

This is Respiratory Care Week and we at MMP would like to thank all of you who provide respiratory care for your hard work and dedication to improving the respiratory health of your patients. When my oldest son was eleven, he had severe pneumonia that required an extended hospitalization. I remember anxiously watching as the respiratory care team provided wonderful services that helped him to recover. Healthcare is most appreciated when truly needed and I am most appreciative of the care given by those respiratory therapists to my young son.

That son now has two beautiful children, the youngest a one-year old daughter. She now understands the word “no” but very much does not like to hear it. Like her, for all of us, it is sometimes hard to be told “no” constantly. Unfortunately, Medicare’s National Correct Coding Initiative (NCCI) often tells providers “no” about the reporting of certain code combinations. Respiratory services are no exception and in honor of Respiratory Care Week, I thought I would review some of the CCI edits for respiratory services. The complete CCI edits can be found at the Medicare NCCI webpage. The information below comes from the NCCI Policy Manual, Chapter 11. Please refer to this manual for more information.

• Alternate methods of reporting data obtained during a spirometry or other pulmonary function session should not be reported separately. For example, the flow volume loop is an alternative method of calculating a standard spirometric parameter. CPT code 94375 is included in standard spirometry (rest and exercise) studies.
• If multiple spirometric determinations are necessary to complete the service described by a CPT code, only one unit of service should be reported. For example, CPT code 94070 describes bronchospasm provocation with an administered agent and utilizes multiple spirometric determinations as in CPT code 94010. A single unit of service includes all the necessary spirometric determinations.
• Complex pulmonary stress testing (CPT code 94621) is a comprehensive stress test with a number of component tests separately defined in the CPT Manual. It is inappropriate to separately code venous access, ECG monitoring, spirometric parameters performed before, during and after exercise, oximetry, O2consumption, CO2production, rebreathing cardiac output calculations, etc., when performed as part of a complex pulmonary stress test.
• CPT code 94060 (bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) describes a diagnostic test that is utilized to assess patient symptoms that might be related to reversible airway obstruction. It does not describe treatment of acute airway obstruction. CPT code 94060 includes the administration of a bronchodilator. It is a misuse of CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) to report 94640 for the administration of the bronchodilator included in CPT code 94060. The bronchodilator medication may be reported separately.
• CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) and CPT code 94664 (demonstration and/or evaluation of patient utilization of an aerosol generator...) generally should not be reported for the same patient encounter. The demonstration and/or evaluation described by CPT code 94664 is included in CPT code 94640 if it utilizes the same device (e.g., aerosol generator) that is used in the performance of CPT code 94640. If performed at separate patient encounters on the same date of service, the two services may be reported separately.
• CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) describes either treatment of acute airway obstruction with inhaled medication or the use of an inhalation treatment to induce sputum for diagnostic purposes. CPT code 94640 should only be reported once during a single patient encounter regardless of the number of separate inhalation treatments that are administered. If CPT code 94640 is used for treatment of acute airway obstruction, spirometry measurements before and/or after the treatment(s) should not be reported separately. It is a misuse of CPT code 94060 to report it in addition to CPT code 94640. The inhaled medication may be reported separately.

There has been a lot of discussion about the last bullet point, which was new for 2014, that states that inhalation treatment “should only be reported once during a single patient encounter”. The issue is the definition of the term “encounter”. According to a statement issued by a coding specialist for NCCI, “encounter” in this instance means “direct personal contact in the hospital between a patient and a physician (or other clinician)… If the professional completes the inhalation service(s) and terminates the patient encounter but returns later that day to initiate additional inhalation treatment(s) reportable as CPT code 94640, an additional UOS (unit of service) of CPT code 94640 may be reported for this subsequent patient encounter.” We encourage all providers to clarify the interpretation of the term “encounter” with your Medicare Administrative Contractor (MAC) and other payers.

These NCCI rules again demonstrate that healthcare involves more than just providing patient care. Coding and billing play a major part in all aspects of healthcare. So someone in your Respiratory Care department needs to be aware of and understand the coding and billing requirements for Medicare and other payers. Because when Medicare says “no”, they mean “no”.