Knowledge Base Category -
A recent story by National Public Radio (NPR) discussed the delay in the implementation of the law requiring physicians to consult clinical guidelines before ordering certain imaging tests. The story notes that critics believe the delay has resulted in unnecessary costs and radiation exposure. I am not agreeing or disagreeing with any of the concerns raised by the story, but I want to point out a few things I know based on my understanding of the new requirements and my experience in healthcare. First, not all physicians order unnecessary tests. The article quotes studies that have found widespread overuse, including one study that reported 26% of the CTs and MRIs they reviewed were inappropriate. However, this was at a large academic medical center, so hopefully most physicians use their training to appropriately order advanced imaging exams.
A fallacy in the story in my opinion is how easy the new process will be – “4 clicks on the computer – or less than a minute.” I am skeptical that the ordering physician’s process will be that easy and there are numerous requirements on the back end, i.e. the performing entity and the interpreting professional claim requirements. Beginning July 1, 2018 through December 31, 2019, providers could voluntarily participate in the program. January 1, 2020 through December 31, 2020 is the Educational and Operations Testing Period in which providers are encouraged to participate, but claims will not be denied. These voluntary and testing periods are beneficial to providers to work out the kinks in what is an anything-but-simple process.
On July 26, 2019, CMS released a transmittal that details the requirements for the Testing Period in 2020. The basic premise of the program - Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging is:
Step One – When an advanced imaging service is ordered for a Medicare beneficiary, the ordering professional must consult a qualified Clinical Decision Support Mechanism (CDSM), an interactive, electronic tool that assists practitioners in making the most appropriate treatment decision for a patient’s specific clinical condition. The CDSM will provide the ordering professional with a determination of whether the order adheres to AUC, does not adhere to AUC, or if there is no AUC applicable (for example, no AUC is available to address the patient’s clinical condition).
Step Two – The ordering physician must communicate the status and outcome of use of the CDSM to the furnishing entity and physician.
Step Three – The furnishing providers and practitioners must report on their Medicare claim, modifiers describing the CDSM status and decision, if applicable, and when appropriate, a HCPCS indicating which CDSM was used.
The AUC program applies to:
- Advance imaging services such as computed tomography (CT), Positron emission tomography (PET), Nuclear medicine (NM), and Magnetic resonance imaging (MRI). The specific CPT/HCPCS codes affected are listed in the transmittal.
- The following settings:
- Physician offices
- Hospital outpatient departments (including emergency departments)
- Ambulatory Surgical Centers (ASCs)
- Independent diagnostic testing facilities
- Services paid under the Medicare Physician Fee Schedule (MPFS), the Hospital Outpatient Prospective Payment System (OPPS), or the Ambulatory Surgical Center (ASC) fee schedule
CMS does allow exceptions to participation in the program for ordering professionals with a significant hardship (such as limited access to the internet, etc.), patients with an emergency medical condition, and inpatients paid under Medicare Part A. It is confusing to me why applicable settings include hospital emergency departments when patients with an emergency medical condition are exempt. I have submitted a question to CMS for clarification regarding this and will share through the Wednesday@One newsletter any information I receive.
The modifiers to be reported (MA-MH and QQ) describe whether a CDSM was consulted or not and if not, the reason, or if so, the outcome/decision. The modifier is to be appended to the advanced imaging line item code on the claim. If a modifier is reported that indicates a CDSM was consulted (ME, MF or MG), then the claim should additionally contain a G-code (on a separate claim line) to report which qualified CDSM was consulted. These are informational-only G-codes that will not result in any payment, similar to the codes previously required for Functional Limitation Reporting for therapy services. Providers will have to deal with the same issues of submitting a $0 or minimal charge for these codes. The transmittal includes descriptions of all the modifiers and G-codes.
The plan at this time is to fully implement the requirements of AUC effective January 1, 2021. Upon full implementation, claims for the affected imaging services will be denied if they do not contain information regarding the ordering professional’s consultation with CDSM, or exception to such consultation. The ultimate goal of the program is to identify professionals with outlier-ordering patterns and require those practitioners to obtain prior authorizations for these tests. That requirement will likely be several more years down the road.
Just thinking of the processes hospitals and radiologists will have to put into place to make this happen makes my head spin. And that is all after the process the ordering practitioner goes through – (no need to worry about that though as it is only 4 clicks on the computer). Now is the time, during this Testing phase, for hospitals to develop and implement the necessary processes for this program – how will you receive, document, and internally communicate the information from the ordering practitioner; how will the correct modifier get on the claim line item; and how will the appropriate G-code get added to the claim. And still to be worked out is how institutional providers will report line level ordering physician information on the institutional claim since that capability is not currently available.
Sometimes there are good reasons for delaying a well-intentioned idea.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update
Update of the HCPCS code set for codes related to drugs and biologicals.
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2
October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2019
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.3 Effective October 1, 2019
Notice of New Interest Rate for Medicare Overpayments and Underpayments -4th Qtr Notification for FY 2019
The Medicare contractors shall implement an interest rate of 10.625 percent effective July 17, 2019 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R318FM.pdf
OTHER MEDICARE TRANSMITTALS
Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program
Modifications to Medicare’s claims processing systems to ensure that the Medicare Summary Notice (MSN) appropriately differentiates between QMB claims that are paid and denied and to show accurate patient payment liability amounts for beneficiaries enrolled in QMB.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA). Since these tests are marketed immediately after approval, the Centers for Medicare & Medicaid Services (CMS) must notify the MACs of the new tests so that they can accurately process claims.
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements
Appropriate Use Criteria (AUC) related HCPCS modifiers on claims to be accepted January 1, 2020.
MEDICARE SPECIAL EDITION ARTICLES
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations
Revised to provide an update on Round 3 testing and to announce a delay of full implementation until October 2019.
Pre-Diabetes Services: Referring Patients to the Medicare Diabetes Prevention Program
Information on this new Medicare covered service.
Emergency Medical Treatment and Labor Act (EMTALA) and the Born-Alive Infant Protection Act
Medicare Plans to Modernize Payment Grouping and Code Editor Software
CMS is modernizing its grouping and code editor software. Medicare processes all Original Medicare institutional claims through one of three sub-systems within the Fiscal Intermediary Shared System (FISS):
- The Medicare Code Editor (MCE)
- The Inpatient Grouper (MS-DRG)
- The Integrated Outpatient Code Editor (IOCE).
These sub-systems are built with an antiquated programming language (Assembler) that is difficult to extend, maintain, support and test. Modernizing these programs will protect CMS from future quality and integration risks.
MEDICARE COVERAGE UPDATES
Acupuncture Coverage for Chronic Low Back Pain
CMS proposes to cover acupuncture for chronic low back pain for Medicare beneficiaries enrolled in approved studies.
https://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=295
Update to Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home
Updates the list of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for the coverage of IVIG for treatment of Primary Immune Deficiency Diseases (PIDD) in the home.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Cardiac Device Credits: Medicare Billing
Palmetto GBA Hyperbaric Oxygen Therapy Module
Explains HBO therapy, covered and non-covered conditions as indicated per NCD 20.29 for treatment, as well as documentation guidelines pertinent to establishing medical necessity when submitting claims to Medicare
https://www.palmettogba.com/internet/eLearn3.nsf/HyperbaricOxygenTherapy/story_html5.html
OTHER MEDICARE UPDATES
KEPRO Updates for Healthcare Providers
Since Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) started transitioning into a new 5-year contract with the Centers for Medicare & Medicaid Services (CMS), KEPRO has been making necessary changes to help streamline processes. During the next few weeks, we will share periodic updates with you in a special bulletin.
https://www.keproqio.com/providers/transition/
Comprehensive Care for Joint Replacement Model
Jun 27, 2019 Announcement: Second annual evaluation report and associated materials posted.
https://innovation.cms.gov/initiatives/cjr
ESRD Treatment Choices (ETC) Model
Proposed required model aims to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with end-stage renal disease (ESRD).
https://innovation.cms.gov/initiatives/esrd-treatment-choices-model
Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First
“Within 60 days of the date of this order, the Secretary of Health and Human Services shall propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information…”
CMS Announces Extension of Enforcement Discretion Period for Laboratory Date of Service Exception Policy Under the Medicare Clinical Laboratory Fee Schedule Until January 2, 2020
During the enforcement discretion period, hospitals may continue to bill for advanced diagnostic laboratory tests (ADLTs) and molecular pathology tests that would otherwise be subject to the laboratory DOS exception.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Lab-DOS-Policy.html (see Downloads section)
CY 2020 Home Health Prospective Payment System (HH PPS) Proposed Rule
Proposes routine updates to the home health payment rates for calendar year (CY) 2020, and also includes: a proposal to modify the payment regulations pertaining to the content of the home health plan of care; a proposal to allow therapist assistants to furnish maintenance therapy; and a proposal related to the split percentage payment approach under the Home Health Prospective Payment System (HH PPS). Finally, this rule will include proposals related to the implementation of the permanent home infusion therapy benefit in 2021.
Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-14913.pdf
Monday, July 29, 2019, CMS released three important Medicare proposed payment rules for 2020:
- The OPPS and ASC Proposed Rule - https://www.cms.gov/newsroom/press-releases/cms-takes-bold-action-implement-key-elements-president-trumps-executive-order-empower-patients-price
- The MPFS Proposed Rule - https://www.cms.gov/newsroom/press-releases/trump-administrations-patients-over-paperwork-delivers-doctors
- The ESRD and DME Proposed Rule - https://www.cms.gov/newsroom/press-releases/new-cms-proposals-strengthen-medicare-unleash-innovation-and-promote-competition-provide-kidney
Sometimes providers do not pay as much attention to the Medicare documentation requirements for diagnostic tests as they do for therapeutic services. There are several reasons for this. Diagnostic tests generally do not pay as much as therapeutic services, they are less likely to have a coverage policy, the documentation required is not as extensive as the documentation requirements for therapeutic services, and they are less likely to be reviewed by Medicare contractors. Therefore, the financial risk, even if some claims are reviewed, is not that significant for an individual provider. For Medicare however, due to the large volumes of diagnostic services, overpayments could result in significant costs.
The Medicare Comprehensive Error Rate Testing (CERT) program contractor audits random claims to determine if the Medicare Administrative Contractors (MACs) are paying claims appropriately. This means the CERT contractor looks at all types of claims, including those for diagnostic tests. WPS, the MAC for Jurisdictions 5 and 8, recently published an article containing documentation reminders related to CERT denials of diagnostic tests. Those documentation reminders are:
- “Only the treating physician, nurse practitioner, clinical nurse specialist or physician assistant can sign and date an order.
- The order must specify the exact test(s) ordered. Stating “x-ray” is not sufficient.
- The physician or non-physician must document the medical necessity in a signed and dated progress note.
- Medicare will not consider unsigned and/or undated orders; this includes laboratory requisition forms.
- Providers cannot use a signature attestation statement used in place of an unsigned order.”
These are the basics of which every provider should already be aware. But the article states the CERT contractor has “noted significant error findings for diagnostic services.” So, where do providers go wrong? First, nurses in a physician’s office cannot sign an order. Physicians and non-physician practitioners may delegate the writing of orders to others in the office, but they have to actually be the ones to validate and sign the orders. Remember that Medicare contractors do not accept late signatures or signature attestations for orders. Unsigned orders are “ignored” by Medicare reviewers – an unsigned order is the same as a non-existent order. Orders and progress notes describing the orders must be specific – for example, a progress note that states “labs ordered” or “x-rays ordered” is not sufficient.
The other big issue for diagnostic tests besides signed and dated orders is documentation supporting the medical necessity of the test. Years ago, if you had a signed and dated order that included a diagnosis or a diagnosis code, that was sufficient for medical necessity. These days, most Medicare reviewers want to also see the documentation from the physician, such as an office progress note, describing the medical necessity for the test. And remember any physician progress notes submitted to a Medicare contractor also have to be signed and dated by the practitioner. The good thing about CERT reviews is that the CERT contractor generally communicates the need for any additional documentation needed and gives the provider several chances to submit that before denying the claim.
Some other diagnostic services are also being targeted by other Medicare reviewers and entities. For example, Novitas (JH/JL MAC) is looking at cardiovascular nuclear medicine testing, sleep testing is part of the OIG Work Plan, and the Recovery Auditors (RACs) have complex reviews involving the medical necessity/coding of chest x-rays and the medical necessity of transthoracic echocardiography.
One new complex issue recently approved by all of the Recovery Auditors is for the diagnostic test Computed Tomography (CT) Coronary Angiography. The issue details reiterate the documentation reminders discussed above -
“All diagnostic tests, including Computed Tomography (CT) Coronary Angiography, must be ordered by the physician who is treating the beneficiary, for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. The physician who orders the service must maintain documentation of medical necessity in the beneficiary's medical record. Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, as part of a routine physical checkup are excluded from coverage.”
How can hospitals ensure compliance with the signature and medical necessity requirements of diagnostic tests without undue effort? Train hospital personnel who first encounter orders for diagnostic testing to reject or obtain corrected orders when order requirements are not met – unsigned orders, orders not dated, orders lacking diagnoses, non-specific orders, etc. This could be the Scheduling, Registration, or Ancillary departments, for example. Hopefully, the practice of only accepting appropriate orders will encourage your physicians and practitioners to get it right the first time. On the back end, if a Medicare reviewer requests claims for diagnostic tests ensure all the required documentation is sent to the reviewer. The request for records should detail the specific medical record elements the reviewer needs. If required, contact the ordering physician’s office to obtain office progress notes for submission to the Medicare contractor.
With a little effort, denials of diagnostic tests can be eliminated or at least, minimized. Though not always a large financial impact, every penny helps and proactive processes also reduce the costs of additional time and effort.
There are no MAC Medical Review Activity updates for this month.
Another good resource for Providers is the CMS YouTube presentation Provider Minute: The Importance of Proper Documentation at https://www.youtube.com/watch?v=10pmw4czf08.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2
July 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Describes changes to and billing instructions for various payment policies implemented in the July 2019 OPPS update.
OTHER MEDICARE TRANSMITTALS
Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment
Removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit and adds information on E&M code that may be billed with superficial radiation treatment.
New to State Operations Manual (SOM), Appendix X, Survey Protocol and Interpretive Guidelines for Organ Transplant Programs
Adds Appendix X to the SOM to outline the survey process and interpretive guidelines for the Conditions of Participation for organ transplant programs.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R189SOMA.pdf
Updates to Medicare Financial Management Manual Chapter 4, Section 20 and 20.1 Demand Letters
Every demand letter, regardless of the cause of the overpayment or the status of the provider, shall meet certain requirements as to form and content.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R316FM.pdf
MEDICARE SPECIAL EDITION ARTICLES
Chimeric Antigen Receptor (CAR) T-Cell Therapy Revenue Code and HCPCS Setup Revisions
Updated reporting instructions for CAR T-Cell Therapy.
MEDICARE COVERAGE UPDATES
Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430R)
The Centers for Medicare & Medicaid Services (CMS) will cover Transcatheter Aortic Valve Replacement (TAVR) for the treatment of symptomatic aortic valve stenosis through Coverage with Evidence Development (CED).
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=293
MEDICARE PRESS RELEASES
CMS Seeks Public Input on Patients over Paperwork Initiative to Further Reduce Administrative, Regulatory Burden to Lower Healthcare Costs
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Outpatient Rehabilitation Therapy Services: Comply with Medicare Billing Requirements
- Bill Correctly for Device Replacement Procedures
Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements
OTHER MEDICARE UPDATES
April-June 2019 Quarterly Provider Updates
CMS publishes this Update to inform the public about the following:
- Regulations and major policies completed or cancelled.
- New/Revised manual instructions
Kepro BFCC-QIO FAQs for Healthcare Providers
Frequently asked questions (FAQs) related to KEPRO’s services.
School is out for the summer and my youngest grandchild graduated from pre-school, where she learned her ABC’s. There is no summer break from learning in real life and if you work with Medicare outpatient claims, you have to learn your A, C, E1, E2, G, J1, etc. status indicators.
Each quarter, CMS issues an update for the Outpatient Prospective Payment System (OPPS). These updates sometimes include policy changes, but generally consist mainly of coding updates, such as new HCPCS codes and revised OPPS status indicator assignments. The status indicators (SI’s) describe how particular HCPCS codes and APCs are paid (or not paid) under OPPS, so it is important for providers to understand what the various status indicators mean. CMS provides a table of the definitions of the status indicators in Addendum D1 of the OPPS Final Rule each year – the 2019 addenda can be found here.
Below are descriptions of the status indicators that appear in the July 2019 OPPS Update.
SI “A” means the service is paid under a fee schedule or payment system other than OPPS. For example, you see this code in the tables below for laboratory services that are paid under the Clinical Laboratory Fee Schedule (CLFS). Another common type of service with this SI is therapy services (PT, OT and SLP services).
SI “C” is an inpatient only procedure. These codes will not be paid when billed on an outpatient claim with limited exceptions. For inpatient only procedures, the patient should be admitted as an inpatient.
SI “E1” are services that are not covered for outpatients and will not be paid when submitted on an outpatient claim. They are services that are not an outpatient benefit, are statutorily excluded, or are not medically necessary for outpatients.
SI “E2” are not paid under OPPS because pricing information and claims data are not yet available.
SI “G” indicates drugs and biologicals that receive pass-through payment.
SI “J1” indicates the primary procedure of a comprehensive APC. The payment for all adjunctive services on the claim with the J1 service is packaged into the payment for the primary J1 service, with only a few exceptions.
SI “K” are drugs and biologicals eligible for separate payment under OPPS because they exceed the per day cost threshold for separately payable drugs.
SI “L” are for flu and pneumonia vaccines. They are paid at reasonable cost and are not subject to deductibles and co-insurance
SI “M” are services that are not billable to the MAC and are not paid under OPPS. Notice in the tables below that these services say “provided by physician” or “interpretation and report” meaning they are professional (physician or other qualified health care professional) services and not to be billed by the hospital.
SI “N” indicates services for which the payment for the service is packaged into the payment of other services. This means there is no separate payment made for this HCPCS code. Even though these services are not paid separately, it is important to report the codes so CMS can know all of the components of a primary service.
SI “Q1” is a conditionally packaged service which means the payment for this service is packaged in certain circumstances. Q1 services are packaged if they appear on the same claim with services with an SI of S, T, or V (visit). If the Q1 service does not meet packaging criteria (no S, T, or V code on the claim), it is separately paid. It defaults to the status indicator of its APC when paid separately.
SI “Q4” is for laboratory services with packaged payment. These lab services are only paid separately if they are the only type of services provided on the claim. Most clinical lab services have been conditionally packaged since 2014 and have this status indicator.
SI “S” are procedures and service paid under OPPS similar to SI “T” but to which a payment reduction for multiple procedures/services does not apply. All S services on a claim are paid at 100% of the OPPS payment rate.
SI “T” are procedures and services paid under OPPS but to which a reduction applies for multiple procedures. The first T procedure on a claim is paid at 100%, but subsequent T procedures on the same claim are paid at 50% of the OPPS payment rate.
Below are tables of the code additions and changes from the July 2019 OPPS Updates. All changes are effective July 1, 2019.
Table A includes some miscellaneous additions and changes such as a temporary new C-code, some status indicator changes, and the reassignment of a skin substitute. Notice the change of 0541T and 0542T from E1 (non-payable) due to FDA approval in March of the device associated with these codes – the codes are now S and M respectively, to reflect the technical payment to the hospital and the professional payment for the physician report.
Although payment for skin substitutes are packaged with an SI of N, a lower and higher payment for the application of the product is made due to the assignment of the skin substitute to the Low Cost Group or High Cost Group based on product cost. The reporting of different application HCPCS codes for the low and high cost groups drives the appropriate payment.
There were numerous new codes, including several for biosimilars, and some code replacements for drugs and biologicals as shown in Table B.
The American Medical Association (AMA) releases new Category III codes twice a year – in January and July to be effective the following July and January respectively. For the July 2019 update, CMS is implementing 20 CPT Category III codes that the AMA released in January 2019 for implementation on July 1, 2019.
Proprietary Laboratory Analyses (PLA) codes are CPT codes for labs or manufacturers to more specifically identify their test. Tests with PLA codes must be performed on human specimens and must be requested by the clinical laboratory or the manufacturer that offers the test. For July 1, 2019, one PLA code was deleted and 21 new codes were added.
School is never out in the real world, so study the Medicare OPPS status indicator alphabet to know if and how your hospital will be paid for outpatient services.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
Notice of New Interest Rate for Medicare Overpayments and Underpayments -3rd Qtr Notification for FY 2019
The Medicare contractors shall implement an interest rate of 10.375 percent effective April 17, 2019 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R313FM.pdf
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)
A maintenance update of International Classification of Diseases, 10th Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Claim Status Category and Claim Status Codes Update
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update
Updates the HCPCS code set for codes related to drugs and biologicals.
OTHER MEDICARE TRANSMITTALS
Implementation to Exchange the List of Enrollment in Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System
Introduces the enrollment process for the providers who intend to get their Additional Documentation Request (ADR) letters electronically (as eMDR) through their registered Health Information Handler.
Re-implementation of the AMCC Lab Panel Claims Payment System Logic
Because CMS no longer has payment logic to roll up panel pricing for organ or disease-oriented panels (also known as Automated Multi-Channel Chemistry or AMCC tests), laboratories must report the HCPCS code for the AMCC panel test where appropriate and not report separately the tests that make up that panel.
Documentation of Evaluation and Management Services of Teaching Physicians
A change in policy of documentation for teaching physicians providing evaluation and management (E/M) services.
Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
Effectuates changes to the SNF Prospective Payment System (PPS) that are required for the PDPM. These changes were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162). SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X, (subject to SNF PPS) will be subject to these requirements.
Reporting the HCPCS Level II Modifiers of the Patient Relationship Categories and Codes
Provides educational information regarding reporting of the HCPCS Level II code modifiers for the Patient Relationship Categories and Codes (PRC).
Additional Processing Instructions to Update the Standard Paper Remit (SPR)
Effective October 1, 2019, MACs will mask the Patient Control Number field (also named the Patient CNTRL Number) or the Patient Account Number (ACNT) field on any print file used to create an SPR for mailing if it contains a HICN or SSN in accordance with the Social Security Number (SSN) Fraud Prevention Act of 2017.
MEDICARE SPECIAL EDITION ARTICLES
Proper Use of Modifier 59
Clarifies existing policy on the proper use of Modifier 59. Revised article to correct updated CPT code.
MEDICARE COVERAGE UPDATES
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
CMS covers diagnostic laboratory tests using next generation sequencing when performed in a CLIA-certified laboratory when ordered by a treating physician and when specific requirements are met.
Delay in Final Chimeric Antigen Receptor (CAR) T-cell therapy National Coverage Determination
CMS will not be issuing a final National Coverage Determination on CAR T-cell therapy for cancer today (5-17-19), but a decision is forthcoming.
MEDICARE PRESS RELEASES
CMS outlines comprehensive strategy to foster innovation for transformative medical technologies
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
OTHER MEDICARE UPDATES
2020 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule
https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-08330.pdf
Fact Sheet for Proposed Rule - https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute
BFCC-QIO Contract Awarded for 12th Scope of Work to Start July 2019
The 11th Scope of Work is coming to an end. On April 30th KEPRO and LIVANTA were again awarded the BFCC-QIO contracts for the 12th Scope of Work (SOW) that will run from 2019 – 2023
Temporary Pause of BFCC-QIO Short Stay and HWDRG Reviews
CMS has temporarily paused the performance of both Short Stay reviews and Higher Weighted Diagnosis-Related Group (HWDRG) reviews by the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs). CMS took this action to procure a new BFCC-QIO contractor. Going forward, Short Stay reviews and HWDRG reviews will resume with a single organization performing reviews on a national basis. CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019.
https://qioprogram.org/qionews/articles/temporary-pause-bfcc-qio-short-stay-and-hwdrg-reviews
Local Coverage Determination (LCD) Process Modernization Qs & As
Describes recent changes to the LCD process.
https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/LCD_QsAs.pdf
System Edits Will Be Activated for OPPS Providers with Multiple Service Locations
On July 1, 2019, CMS will begin enforcing edit requirements for Outpatient Prospective Payment System (OPPS) providers with multiple service locations submitting claims to Medicare.
MEDICARE TRANSMITTALS – RECURRING UPDATES
July 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2019
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.2 Effective July 1, 2019
OTHER MEDICARE TRANSMITTALS
Billing for Hospital Part B Inpatient Services
Provides billing instructions for hospital Part B inpatient services.
Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment – REVISED
Revised to clarify that providers need to bill the 25 modifier when performing E/M services with CPT code 77401.
Pub. 100-04, Chapter 29 – Appeals of Claims Decisions – Revisions
Incorporates the following policy updates to the Medicare Claims Processing Manual:
- The policy on use of electronic signatures
- Timing of signatures on transfer of appeal rights and the appointment of representative forms
- Tolling an adjudication timeframe when trying to cure a defective appointment form
- Limiting scope of redetermination review in certain instances
- Application of good cause for late filing involving beneficiary accessibility
- Application of good cause where there is a declared disaster
New Waived Tests
Informs MACs of new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
MEDICARE SPECIAL EDITION ARTICLES
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations
Claim information for Outpatient Prospective Payment System (OPPS) providers that have multiple service locations.
MEDICARE COVERAGE UPDATES
CMS Proposes Updates to Coverage Policy for Transcatheter Aortic Valve Replacement (TAVR)
CMS is updating the coverage criteria for hospitals and physicians to begin or maintain a TAVR program.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing
- Provider Minute Video: The Importance of Proper Documentation
OTHER MEDICARE UPDATES
April 2019 Patients Over Paperwork Newsletter
Updates on ongoing work to reduce administrative burden and improve the customer experience for hospitals.
GAO Report for Medicare and Medicaid:
CMS Should Assess Documentation Necessary to Identify Improper Payments
GAO examined: (1) Medicare and Medicaid documentation requirements and factors that contribute to improper payments due to insufficient documentation; and (2) the extent to which Medicaid reviews provide states with actionable information.
April is National Occupational Therapy Month. The American Occupational Therapy Association (AOTA) states on their website, “Occupational therapy practitioners enable people of all ages to live life to its fullest by helping them promote health, and prevent—or live better with—injury, illness, or disability.” In honor of OT month (and also with a nod to physical therapists and speech language pathologists) today’s article will address the issue of the correct reporting of therapy units.
Although the reporting of timed therapy codes would seem to be more difficult than untimed codes, this April’s Medicare Quarterly Provider Compliance Newsletter addresses errors identified by the Recovery Auditors for the reporting of untimed therapy codes. To cover all our bases, let’s review both.
A number of CPT codes, such as constant attendance modalities and most therapeutic procedures, specify a time frame of 15 minutes as the direct one-on-one time spent providing the therapy service to the patient. These are referred to as “timed” therapy procedure codes.
When a therapy service is not defined by a specific timeframe, it is an “untimed” therapy procedure (CPT or HCPCS) code. Untimed codes are billed with a unit of one (1) per date of service. The unit for untimed codes is one regardless of how long the evaluation or service took. Providers should enter a 1 in the ‘units bill’ column per date of service. Below is a table of the untimed therapy codes. There may be exceptions to a unit of one if a patient has more than one encounter on the same day.
Timed therapy codes include in their CPT description the time frame of “each 15 minutes” and units are calculated based on the total time of all “timed” code services. Per the Medicare Claims Processing Manual, chapter 5, section 20.2, “Providers report these “timed” procedure codes for services delivered on any single calendar day using CPT codes and the appropriate number of 15 minute units of service.” The total number of units billed for “timed” services are based on the total time of the “timed” services according to the following chart. If more than one “timed” service is provided, add the minutes of all “timed” services together and get the total number of “timed” units to be billed. These are then divided appropriately among the various “timed” services provided. Although Medicare requires providers to report the total treatment time (timed and untimed services), do not add the minutes of “untimed” codes when calculating the units of “timed” services.
Pattern continues…
Do not report any units if total minutes of timed therapy services is less than 8 minutes
See Section 20.2 of Chapter 5 of the Claims Processing Manual for examples of the billing of timed codes. Here is a straight forward example from the Manual:
“Example 1 –
- 24 minutes of neuromuscular reeducation, code 97112,
- 23 minutes of therapeutic exercise, code 97110,
- Total timed code treatment time was 47 minutes.
See the chart above. The 47 minutes falls within the range for 3 units = 38 to 52 minutes.
Appropriate billing for 47 minutes is only 3 timed units. Each of the codes is performed for more than 15 minutes, so each shall be billed for at least 1 unit. The correct coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service that took the most time.”
Other examples in the Manual address trickier situations, such as the division of an odd number of units if both services are the same length, division of units if the number of different services exceeds the number of units, and the counting of services lasting less than 8 minutes.
One of the most common time errors I see when reviewing therapy records is the inclusion of the time of “untimed” codes in the time used to calculate code minutes. Remember, untimed codes are billed with 1 unit per day of service and “untimed” code minutes do not affect the overall units of codes.
- For example, a patient receives 25 minutes of therapeutic exercise (CPT 97110) and 10 minutes of unattended e-stim (HCPCS G0283).
- Do not add the 10 minutes of unattended e-stim to the 25 minutes of ther ex for a total of 35 minutes, limiting your total units to 2.
- In this situation, 35 minutes is the total treatment time, but the total “timed” code minutes is 25 for 2 units of ther ex (97110). The unattended e-stim, as an untimed code, is reported with units of 1.
Separate your “timed” and “untimed” minutes when determining units – untimed codes = units of one (1); timed codes = units based on total minutes of “timed” codes only.
Therapy providers should know their “timed” versus “untimed” code and keep them separate for calculating units. Again, we at MMP wish a timely Happy OT Month to all the dedicated and hard-working Occupational Therapists who help their patients “live life to its fullest.”
Debbie Rubio
When I was growing up, there were lots of television commercials about cigarettes (remember the Marlboro man?), but none about prescription drugs. Things change. Today television commercials featuring tobacco products are banned, but the airwaves are inundated with advertisements for prescription medications. I am not sure that is any wiser choice than the cigarette commercials, but that is the way it is. You may also notice that the generic name of a large number of the medicines advertised end with the letters “mab.” This means the drug is a monoclonal antibody. Even if there had been television advertisements for drugs when I was growing up, they would not have been MABs, because those drugs were not even developed back then. I am sure there are a lot of things that can be said about monoclonal antibodies, but two such statements could be - first, they offer new hope to many with certain conditions and second, “cha-ching!” meaning of course they are expensive drugs.
As a payor of healthcare services, specifically drugs in this case, Medicare wants to ensure the drugs they are paying for are appropriate (medically necessary), administered to the patient, and follow Medicare and evidence-based guidelines. Add this to the high costs of some of these drugs and it is not surprising that a number of Medicare Administrative Contractors (MACs) are auditing certain drugs under their Targeted Probe and Educate (TPE) audits. Specifically, Palmetto GBA (Jurisdictions J and M) and Novitas (Jurisdictions H and L) include the review of several drugs in their TPE Medical Reviews. As the name indicates, TPE reviews focus on individualized provider education. The MACs also offer educational resources that are available to all through their websites. Palmetto has recently added the following “checklists” for drugs to their website as well as an article about Prolia (Denosumab).
These checklists include the basic requirements for the billing of any drug administered to outpatients –
- A signed and dated physician’s order that includes the dosage, frequency, and route of administration
- Documentation supporting the need for the drug and the patient’s diagnosis – this may require the hospital to obtain the physician’s office notes discussing the patient’s condition and treatment
- The units billed, the units ordered, and the units administered to the patient must all match
- A protocol was followed as specified in the package insert (FDA approved) or in accepted drug compendia for off-label uses
- Medicare and MAC-specific coverage requirements for the drug are met
- The medical record includes documentation of the administration of the drug with date, time, route, dose, and patient response
Some drugs require additional documentation such as the patient’s weight or body surface area to calculate dosage or other documentation based on coverage requirements. For example, the drug Prolia (denosumab) requires documentation the patient is taking calcium and vitamin D supplements or the reasons why not and documentation the patient has had an x-ray or DEXA scan.
The benefit of these checklists is that if you use them and make sure you submit all of the required documentation upon request for records for Medicare review, your chances of being paid by Medicare are much better than if you didn’t follow a checklist. Is this a Medicare contractor being nice to providers?!? Well, things change.
Debbie Rubio
CMS released MLN Matters Article MM11181 titled “Billing for Part B Hospital Inpatient Services” on March 22, 2019. This is not a new rule at all, but has been around since 2013. In the 2014 Inpatient Prospective Payment System (IPPS) Final Rule CMS-1599-R, effective October 1, 2013, CMS first allowed the billing of certain Part B services when an inpatient hospital admission is determined to not be reasonable and necessary for payment under Medicare Part A. Prior to this rule change, the billing of Part B inpatient services on a 12x type of bill (TOB) was limited to those occasions when the Medicare beneficiary did not have Part A coverage or the Part A benefits were exhausted.
The new policy specifically stated, “Medicare will allow payment under Part B of all hospital services that were furnished and would have been reasonable and necessary if the patient had been treated as a hospital outpatient, rather than admitted to the hospital as an inpatient.” The determination that the patient did not meet inpatient criteria could have been from 1) a denial by Medicare or 2) the result of a hospital “self-audit” after the patient was discharged. There are rules for the hospital self-audit.
- It must follow Medicare Conditions of Participation UR guidelines (42 CFR 428.30);
- It must be made by a physician member of the UR committee if the attending physician concurs, or by 2 physician members of the UR committee if the attending does not concur;
- The attending physician must be consulted; and
- The patient must be notified of the decision in writing within 2 days.
CMS also expanded what could be billed on a 12x TOB under Part B for these “reasonable and necessary inpatient admission denials” to include surgeries, drugs and therapeutic services such as coronary and peripheral interventions. Services requiring an outpatient status such as observation services and ED visits, and routine inpatient services cannot be billed under Part B inpatient billing. Note that the routine inpatient services include drug administrations, blood transfusions, and nebulizer treatments provided by floor nurses and should not be reported on a Part B inpatient claim. CMS provides a list of revenue codes that should not be submitted on a “reasonable and necessary inpatient denial” 12x TOB in section 240.1 of chapter 4 of the Medicare Claims Processing Manual. When a revenue code can be sometimes covered and sometimes not covered, providers should use Medicare guidance and the HCPCS code to determine if the service is covered.
If the “reasonable and necessary inpatient denials” Part B rebilling rule is six years old, what was the purpose of this latest MLN article? Again, CMS did not really change any rules, but added verbiage to the Claims Processing Manual clarifying the need for a Part A claim prior to submitting the Part B claim. In order to submit a Part B 12x claim after a hospital self-audit, the hospital must:
- Submit a Part A claim indicating that the provider is liable under section 1879 of the Act for the cost of the Part A services. This is a no-pay inpatient claim, type of bill 110. If the hospital has already submitted a regular inpatient claim (111 TOB), it must adjust the Part A claim to make the provider liable.
- The Part B 12x type of bill may be submitted for these “reasonable and necessary inpatient denials” only after the Part A claim is denied or a no-pay claim is submitted.
Also, the Part B inpatient claim is subject to the timely filing requirements described in the Medicare Claims Processing Manual, Chapter 1, Section 70.
This new MLN Matters Article (MM11181) also makes some modifications to the list of revenue codes that are not allowed on a 12x TOB for “other circumstances.” These circumstances would be for Medicare patients who are not entitled to benefits under Part A, have exhausted their Part A benefits, or receive services not covered under Part A. Part B inpatient claims for these circumstances restrict the types of services that can be billed much more than the “reasonable and necessary inpatient denials” Part B rebilling.
For more information about Part B Inpatient billing, see sections 240.1 and 240.2 of Chapter 4 of the Medicare Claims Processing Manual and sections 10.1 and 10.2 of Chapter6 of the Medicare Benefits Policy Manual. And remember for Part B rebillling, it is always A before B.
Debbie Rubio
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