Knowledge Base Category -

Q:

How do I determine which devices, APCs, and DRGs are subject to Medicare’s device credit policy?

A:

Medicare publishes the list of APCs subject to the device credit policy in the annual Outpatient Prospective System (OPPS) Final Rule.  For 2016, Medicare is proposing to apply the device credit to all device-intensive APCs listed in Table 38 of the Proposed Rule (see page 70 of the 2016 OPPS Proposed Rule).  In previous years, CMS also included a separate list of the devices subject to the device credit policy.  For CY 2016 and beyond, they are proposing to no longer specify a list of devices, but “apply the APC payment adjustment to all replaced devices furnished in conjunction with a procedure assigned to a device-intensive APC when the hospital receives a credit for a replaced specified device that is 50 percent or greater than the cost of the device.”

In MLN Matters Article MM9121, CMS updated the list of MS-DRGs subject to the device credit policy.  Due to changes to MS-DRGs for 2015 and 2016, Medicare deleted two expired DRGs from the list and added seven DRGs.  The complete list of MS-DRGs, including the existing MS-

DRGs and the new MS-DRGs subject to the policy for replaced devices offered without cost or with a credit, is displayed in the table attached to CR9121.

For more information about Medicare’s Device Credit Policy, see the article Learning More about Medicare’s Device Credit Policy in this week's Wednesday@One which can also be accessed through the Knowledge Base section of our website or listen to our On-Demand Webinar on Understanding and Managing Device Credits which can be purchased in the Classes section of our website.

MMP Knowledge Base Webpage: http://www.mmplusinc.com/knowledge-base

MMP Classes Webpage: http://www.mmplusinc.com/earn-ceus

Q:

At the August 18th Hospital Open Door Forum, the CMS representative who answered questions about the “PO” modifier stated that the modifier applied to all outpatient services “paid under OPPS.” The instructions for the “PO” modifier from the July 2015 OPPS Update state that, “This modifier is to be reported with every HCPCS code for all outpatient hospital items and services furnished in an off-campus provider-based department of a hospital.” From reading of the 2015 OPPS Final Rule it appears the intent of this modifier is mainly to gather information on off-campus physician offices and clinics operating as hospital provider-based departments.

Based on differences in the above descriptions of the use of the “PO” modifier, to which types of outpatient services provided in off-campus provider-based departments (PBDs) should the PO modifier be appended?

A:

Medical Management Plus posed this question to CMS through the Hospital Open Door Forum email. The answer we received from Tiffany Swygert with CMS is that, “It applies to all services paid under the OPPS that are furnished in an off-campus provider based department of a hospital except for remote locations, satellite facilities and EDs. If the specific services are not paid under the OPPS, then no modifier is required under this policy.”

Ms. Swygert went on to clarify specifically that rehabilitative therapy services (PT, OT and Speech therapy) paid under the Medicare Physician’s Fee Schedule in accordance with an OPPS Status Indicator of “A” do not require a PO modifier when furnished in an off-campus PBD since they are not paid under the OPPS. Another common outpatient service not paid under OPPS is laboratory services when they are non-patient services or the only outpatient services performed. In this situation, most clinical lab services are paid under the Clinical Laboratory Fee Schedule (CLFS) and based on the same logic would not require a PO modifier. However, lab services furnished with other outpatient services are packaged services which means they are “paid under OPPS” although there is no separate payment. Therefore these lab services would require a PO modifier.

The use of the PO modifier is voluntary for 2015, but will be required on claims for off-campus provider-based departments beginning in 2016.

Hospitals should refer to the OPPS Addendum B to find a service’s status indicator and to Addendum D1 for the descriptions of the status indicators to determine which services are paid under OPPS and which are not.

Everyone loves a bargain, a special, or a deal. Package deals involve a discounted price when multiple services are bundled together. These have been especially popular with telecommunication companies lately and a lot of households have a “bundle” that includes cable or satellite television service, internet service and telephone service. Medicare, charged with efficient use of our tax dollars for healthcare services, loves a package deal also. So it is no surprise that we are seeing more and more service bundles for Medicare services.

Injections during cataract and other ocular surgeries are becoming more common, replacing the previous application of drugs via eye drops after the surgery. This technique may be referred to as “dropless cataract surgery.” In the 2015 Outpatient Prospective Payment System (OPPS) October Update, CMS reminds providers of correct coding conventions for injections provided during ocular surgery. The National Correct Coding Initiative clearly states that injection of a drug during a cataract extraction procedure or other ophthalmic procedure is not separately reportable – it is a packaged service. The CPT/ HCPCS code used to report the ocular procedure includes any injections performed during the surgery.

The injections during ocular surgery may be combined or compounded drugs such as triamcinolone and moxifloxacin with or without vancomycin. Effective June 30, 2015, the manner of reporting compounded drugs to Medicare changed. Modifier JF (Compounded drug) was discontinued and replaced with HCPCS code Q9977 (Compounded Drug, Not Otherwise Classified) effective July 1, 2015. HCPCS code Q9977 should be used to report compounded drug combinations, including the compounded drug combinations use for ocular surgeries. These drugs will be packaged as surgical supplies and separate payment will not be made for the drugs. Providers should be sure to report these drug combinations in accordance with these instructions. Providers should not:

• Report these drugs and drugs combinations with HCPCS code C9399
• Try to shift the financial liability to the patient for the drugs or injections using an Advance Beneficiary Notice (ABN) because both are a covered part of the surgical procedure
• Circumvent packaged payment by having patients purchase and bring the drugs with them to the facility for administration.

Other updates from the July OPPS update include the following:

Q:

How will the coding of blood transfusions change in ICD-10-PCS?

A:

Answer: Under I-9, the coder would search for, Transfusion in the Alphabetic Index and then look for the specific blood product to be transfused.

Example: Transfusion of PRBCs - 99.04

In I-10, much more clinical information will be required to arrive at the correct code. We will have to know the specific blood vessel that will receive the blood product and the approach/technique used to reach that blood vessel. Also, we will have to know whether the blood is Autologous (taken from the patient; auto-transfusion) or Non-Autologous (obtained from another person).

Example: Transfusion of Nonautologous Red Blood Cells into Peripheral Artery, Percutaneous Approach – 30253N1

To obtain more specific documentation from the clinician, it would be beneficial to list all of the physical locations in the hospital where the patient would have the opportunity to receive blood products, such as, at bedside, Operating Room, or Emergency Room. Inform the appropriate personnel in these areas of the documentation needed for code assignment. Or, simply request that this specific documentation be added to your hospital’s blood transfusion sheets.

Q:

CPT guidance indicates it is acceptable to report CPT code 31624, Bronchoscopy with bronchial alveolar lavage, with a bilateral modifier when this procedure is performed bilaterally. However, a comment on a recent MMP HIQUP report stated this was not appropriate. We are confused – could you please explain?

A:

This is one of those examples where the CPT guidelines differ from Medicare guidelines. Very similar to the guidelines for billing modifier 50 for certain cystoscopy procedures, but Medicare says modifier 50 should not be used.

To our understanding, when Medicare processes a hospital claim, they apply the bilateral surgery indicators from the Physician fee schedule RVU file, and that is the basis for the edit you see in the HIQUP Report. For the code range 31623 – 31656, the bilateral surgery indicator is a zero, which means “Do not submit these procedures with modifier 50”. The RVU Explanation for Bilateral Indicator “0” states: “The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.”

The good news is - - if you submit modifier 50, Medicare ignores it and pays the code as quantity of 1, so this should not result in an overpayment. We think this is a very low risk for recoupment since overpayment does not occur, but it is “possible” RAC could cite inappropriate billing and try to recoup your correct payment. We say this based on other RAC targets where the correct code was billed, correct payment was received, but there was some other technicality cited as incorrect billing (wrong revenue code, modifier RT/LT).

And don’t try billing this code with modifiers RT and LT . . . since the MUE for these codes is 1 – that would result in no payment at all for the procedure due to exceeding the MUE. 

Q:

During a procedure when only one or two lymph nodes are removed; would the correct “Root Operation” be “Resection” or “Excision”?

A:

Lymph nodes are known to form together in clusters, better known as a “chain of nodes”. There are generally numerous amounts of lymph nodes within a chain of nodes. It can be difficult to know for sure whether all nodes were removed or not during any one particular procedure. One example of this would be when a patient is extremely obese.

Assign root operation “Resection”:

• When all nodes in a chain are removed.
• When total removal of lymph nodes is the physician’s intent but difficult to determine if they have actually all been removed.

Assign root operation “Excision”:

• When only a partial amount of lymph nodes are removed from the chain.

Assign root operation “Excision”:

• Sampling of nodes removed – example would be Sentinel Nodes

The operative report should be read carefully to determine the exact intent for the lymph node removal.

References Coding Clinic 3rd Quarter 2014 (ICD-10-CM/PCS) pages 9 and 10

Q:

What should we do when Acute Respiratory Failure is documented but the clinical signs and symptoms describing the patient do not reflect the severity of the diagnosis?

A:

Coders in this day and time have to know and be aware of more clinical factors than ever before. Look at the patient’s clinical presentation and what tests are performed. Below is a listing of just a few basic things MMP suggests looking for:

1.Documented signs / symptoms

• SOB (shortness of breath) / Respiratory distress
• Delirium and/or anxiety
• Pursed lips
• Syncope
• Use of accessory muscles
• Tachycardia
• Tachypnea
• Confusion
• Sleepiness
• Depressed consciousness
• Cyanosis (bluish color to skin, lips and/or fingernails)

2.Per Coding Clinic, Acute Respiratory Failure is supported as a diagnosis when at least 2 of the following critical values (ABG’s) are met.

• pH < 7.35
• PO2 < 60
• PCO2 > 50

Note: The above ABG levels may not apply to the patient with chronic lung disease (e.g., COPD). If a baseline PO2 is known, a decrease by 10mmHg or more indicates acute Hypoxic Respiratory Failure.

3.Type of oxygen treatment, i.e., oxygen via mask, Bipap, nasal cannula or vent?

4.Generally, patients are placed in ICU for close monitoring.

MMP recommends coding Acute Respiratory Failure if there are sufficient clinical indications and the physician has documented the diagnosis. Most importantly, if you don’t see sufficient clinical signs/symptoms/indicators documented, the physician should be queried for clarification. It is recommended that all clinical indications in the record and the type of treatment the patient received, be documented in the physician query.

Q:

Have the Medicare coverage requirements for pneumococcal vaccinations changed?

A:

Yes, the Advisory Committee on Immunization Practices (ACIP) has issued new recommendations for pneumococcal vaccinations and Medicare has modified their coverage requirements in response to the new recommendations.

As announced in MLN Matters Article MM9051, effective for dates of service on and after September 19, 2014, Medicare will cover the administration of two different pneumococcal vaccinations.

• An initial pneumococcal vaccine to all Medicare beneficiaries who have not previously received a vaccine (based on ACIP recommendations a 13-valent pneumococcal conjugate vaccine – PCV13 should be administered first)
• Followed by a second, different vaccine a year later (23-valent pneumococcal polysaccharide vaccine – PPSV23)

Patients, age 65 and older, who have already received the PPSV23 vaccine, should receive the PCV13 vaccine a year or more after the date of their last PPSV23 vaccine.

These new guidelines differ from the previous coverage of pneumococcal vaccine which was only for individuals at high risk of serious pneumococcal disease (age 65 and older, risk from chronic disease, or immune-compromised patients) with a repeat vaccine after five years for only patients at highest risk (May 1, 1981- September 18, 2014).

Note that a physician’s order is not required for patients to obtain a pneumococcal vaccine.

Q:

How should laceration repairs by steri-strips or dermabond be coded?

A:

According to the CPT manual a wound closure/repair with adhesive strips as the sole repair material are not reported with a separate CPT code but as part of the evaluation and management (E/M service). This means that laceration repairs performed in the Emergency Department using only steri-strips would be included as part of the determination of the ED visit level.

For tissue adhesives, which would include dermabond, you can report a CPT code from the repair section.

This guidance is in the first paragraph under the ‘Repair (Closure)’ section in the CPT book. The complete paragraph reads:

“Use the codes in this section [CPT codes 12001-13160] to designate wound closure utilizing sutures, staples, or tissue adhesives (eg, 2-cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips. Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code.”

Q:

Sometimes a physician may dilate more than one stricture during an endoscopy procedure. Should we code the dilation of each stricture?

A:

The answer depends on the patient’s insurance because CPT and the NCCI manual provide different coding instructions.

Effective January 2015, CPT guidance allows the reporting of each stricture dilated utilizing modifier 59. Parenthetical notes for CPT codes 43213, 45340, and 45386 state, “For transendoscopic balloon dilation of multiple strictures during the same session, report ‘code’ (43213, 45340, or 45386) with modifier 59 for each additional stricture dilated.”

The National Correct Coding Initiative (NCCI) Policy manual guidance applies to coding and billing for Medicare and Medicaid claims. The 2015 NCCI manual update includes this instruction concerning dilation of multiple strictures:

“Gastrointestinal endoscopy CPT codes describing dilation of stricture(s) (e.g., CPT codes 43213, 45340, 45386) include dilation of all strictures dilated during the endoscopic procedure. These codes should not be reported with more than one (1) unit of service if more than one stricture is dilated.”

Other insurers may choose to follow some of the NCCI coding guidance. Check with the payer to determine their policy regarding these instructions.