Knowledge Base Category -

Q:

In ICD-9-CM, hemorrhagic was listed as one of the modifiers for pneumonia so it couldn’t be coded separately; however, it has been removed as a modifier for ICD-10-CM.  Can we now code hemoptysis in addition to a diagnosis of pneumonia?

A:

Yes.  Since hemorrhagic is no longer a non-essential modifier for pneumonia, coders can assign an additional code for it.  Even though hemoptysis is a sign and/or symptom, it may be reported in addition to a code for pneumonia, because it is not routinely associated with the diagnosis.

References:

Coding Clinic, Fourth Quarter 2013: Page 118

Q:

What is the code assignment for a patient with a history of emphysema presenting to the hospital with COPD exacerbation? 

A:

Emphysema, unspecified (J43.9) should be assigned for a patient that has COPD exacerbation with emphysema, as long as the patient does not have chronic bronchitis.  There is an Excludes1 note, found in the alphabetic index under category J44, that excludes coding J44.1 with code J43.9.

J44  Other chronic obstructive pulmonary disease

        Excludes1:  emphysema without chronic bronchitis (J43.-)

There was some confusion of how to capture the acuity for COPD after Coding Clinic, Fourth Quarter, 2017 published the above information; however, advice in Coding Clinic, First Quarter 2019, further clarifies coding emphysema (J43.9) only when a present also has acute exacerbation of COPD.

The Centers for Disease Control and Prevention (CDC)/7National Center for Health Statistics (NCHS), the organization responsible for revisions to ICD-10-CM, is aware of this issue and has agreed to consider a Coordination and Maintenance proposal for possible revisions to the instructional note..

Resources:

ICD-10-CM Official Guidelines for Coding and Reporting

Coding Clinic, Fourth Quarter, 2017

Coding Clinic, First Quarter 2019

Q:

Our facility plans to start giving the new drug, Evenity (romosozumab-aqqg), but we are unable to find a HCPCS code for this newly FDA-approved drug. How should we bill Medicare for it and what can we expect to be paid?

A:

For Medicare, it would be appropriate to report HCPCS code C9399 (unclassified drug or biological). Medicare says this code can be reported for new drugs & biologicals that are approved by the FDA for which there is no HCPCS code that describes the drug.

From the FDA announcement on April 9, 2019, “The U.S. Food and Drug Administration today approved Evenity (romosozumab-aqqg) to treat osteoporosis in postmenopausal women at high risk of breaking a bone (fracture). These are women with a history of osteoporotic fracture or multiple risk factors for fracture, or those who have failed or are intolerant to other osteoporosis therapies.”

Instructions for billing and payment of newly approved drugs that have not yet been assigned a HCPCS code can be found in Chapter 17 of the Medicare Claims Processing Manual, Section 90.3. Beginning January 1, 2004, hospitals can bill for new drugs and biologicals that are approved by the FDA for which a product-specific HCPCS code has not been assigned with HCPCS code C9399 (Unclassified drug or biological).

In addition to reporting C9399, the hospital should enter the National Drug Code (NDC), the quantity of the drug administered, and the date furnished in the Remarks section of the claim. The Medicare Administrative Contractor (MAC) will manually price the drug or biological at 95 percent of Average Wholesale Price (AWP). Medicare pays 80% of this amount and the Medicare beneficiary is liable for the remaining 20%, after their deductible is met.

Q:

Our facility has recently started performing digital mammography, but Medicare is denying all of the charges for HCPCS codes 77063 (screening digital tomosynthesis for mammography) and G0279 (diagnostic digital breast tomosynthesis, unilateral or bilateral). Do you know what could be causing these denials?

A:

There are a couple of reasons why you could be receiving these denials. You should be able to determine the reason from the Claim Adjustment Reason Code (CARC) on your remittance.

Lack of Primary Code

One possibility is that you are reporting these add-on codes without the primary code.

• CPT code 77063 must be reported with CPT 77067 (screening mammography).
• HCPCS code G0279 is to be listed separately in addition to CPT codes 77065 (diagnostic mammogram, unilateral) or 77066 (diagnostic mammogram, bilateral).

The manual wording from the Medicare Claims Processing Manual, chapter 18 , section 20.2.1 indicates CPT code 77063 will be returned to the provider for institutional claims if billed without 77067, but HCPCS code G0279 will be denied if not reported with the appropriate code.

 “Effective for claims with dates of service January 1, 2018 and later A/B MACs (A) and (B) must assure that claims containing code G0279 also contain HCPCS code 77065 or 77066. A/B MACs (A) or (B) deny claims containing code G0279 that do not also contain HCPCS code 77065 or 77066 with an explanation that payment for code G0279 cannot be made when billed alone.”

Lack of Appropriate FDA Certification Status

We have seen denials of the two codes (77063 and G0279) on claims with a CARC of 171- “Payment is denied when performed/billed by this type of provider in this type of facility.” We believe this is related to lack of appropriate FDA certification. See CMS Transmittal R1387CP or section 20.1 of the Medicare Claims Processing Manual, chapter 18.

All facilities providing screening and diagnostic mammography services (except VA facilities) must be certified by the Food and Drug Administration (FDA). The FDA maintains this data in the Mammography Quality Standard Act (MQSA) file and shares the file with CMS and their contractors weekly. The MQSA indicates whether a facility if certified to perform film or digital mammography.

CMS contractors rely on the FDA certification data contained in the MQSA file to know whether the mammography facility is certified to perform digital mammography. Contractors will deny a claim for a mammography service if the nature of the billed HCPCS code (i.e., film or digital) does not correspond to the FDA certification status listed on the MQSA file for the billing mammography facility.  This means if the FDA MQSA file does not indicate a facility is certified to perform digital mammography, the Medicare contractor will deny the HCPCS codes for these digital mammography services, i.e. HCPCS codes 77063 and G0279.

Q:

In our Cancer Center, we are giving the drug Rasburicase (Elitek) by infusion. Should we charge this as a chemotherapy infusion or as a therapeutic infusion?

A:

Rasburicase is classified as an antihyperuricemic drug, so you should report the infusion as a therapeutic infusion – not as a chemotherapy infusion.

Q:

Our claims for FDG PET scans are being denied when reported with a personal history diagnosis code, Z85.XXX. Why is this happening?

A:

CMS Transmittal 2200 (CR 10859) added the following note concerning PET scans for oncologic conditions (NCD 220.6.17) when reported with a personal history diagnosis:

“Note: Whenever a personal history diagnosis code (Z85.XXX) is on a claim, the claim must also contain a diagnosis code from the list of covered C, D or R diagnosis codes.”

The transmittal referenced above includes a link to the NCD spreadsheet updates for the PET Scan diagnosis codes. You can find the updated list of covered diagnosis codes for PET scans and all other NCD ICD-10 code updates at the Medicare coverage ICD-10 webpage.

Q:

In ICD-9, there were several Coding Clinics that instructed us to sequence Acute Renal Failure as the principal diagnosis when a patient is admitted with Acute Renal Failure due to Dehydration. Has this advice changed in ICD-10?

A:

Yes, this advice has changed per Coding Clinic, First Quarter 2019, page 12.  Effective with discharges March 20, 2019, either Dehydration or Acute Kidney Injury could be sequenced as the principal diagnosis based on the reason for admission. Querying the physician is advised when the reason for admission is unclear. Coding Clinic has specified, “There is no rule that acute kidney injury should always be sequenced first.”

The MACs have begun selecting Acute Renal Failure DRGs for review.  Please review your cases with this Coding Clinic in mind.

Reference:

Coding Clinic, First Quarter 2019, page 12. 

Q:

We are being told that it is Alabama Medicaid Policy that we can obtain a physician order for inpatient admission after discharge on a Medicaid patient that has emergency room charges, observation charges and surgery charges. Is this true?

A:

Chapter 19 of the Alabama Medicaid Provider Billing Manual is specific for hospitals and includes the following regarding patient status orders:

Medicaid will utilize Alabama Medicaid and Pediatric Inpatient Care Criteria (SI/IS) for utilization review, billing and reimbursement purposes.

• It is the hospital’s responsibility to utilize its own physician advisor.
• The attending physician and/or resident may change an order up to 30 days after discharge, as long as the patient met criteria for inpatient or observation charges.”

Both the Alabama Medicaid and Pediatric Inpatient Care Criteria and a link to Chapter 19 can be accessed on the Alabama Medicaid Hospital Services webpage at http://www.medicaid.alabama.gov/content/4.0_Programs/4.4_Medical_Facilities/4.4.1_Hospital_Services.aspx

Q:

A Colonoscopy was performed to identify the source of GI bleeding in a patient.  The physician diagnosed arteriovenous malformation (AVM) of the large intestine.  However, this condition is assigned to a congenital code, Arteriovenous Malformation of Digestive System Vessel (Q27.33), which is not specifically documented in the record.  In prior ICD-9-CM Coding Clinics, we did not use the congenital codes and were instructed to code AVM to Angiodysplasia.  Is this still the case in ICD-10-CM?

A:

Yes, assign a code for Angiodysplasia of Colon with Hemorrhage (55.21) for the bleeding AVM of the large intestine.  These codes are not assigned to a congenital code as they are believed to be degenerative in nature.

Vascular Ectasias, also known as Angiodysplasias and Arteriovenous Malformations are dilated vessels that develop in the cecum and ascending colon.  They occur in people >60 years of age and are the most common cause of lower GI bleeding.  They appear as bright red, can be flat or raised and covered by thin tissue.

References:

Coding Clinic:

                3rd Quarter 2018, page 21

                4th Quarter 1990, page 4

                3rd Quarter 1996, page 9-10

Vascular GI Lesions – Gastrointestinal Disorders Merck Manual 

Q:

Our hospital has had Implantable Cardiac Defibrillator (ICD) claims denied by our Medicare Administrative Contractor (MAC) for what appears to be a missing Q0 modifier. The Q0 modifier was required for ICDs implanted for primary prevention to attest the patient was in a clinical trial or the data was reported to a qualifying data registry. We thought this requirement went away with the update to the ICD National Coverage Determination (NCD) which was effective for dates of service on and after February 15, 2018. Why are our claims being denied and is there anything we can do about it?

A:

You are correct that the updated NCD removed this requirement. Here are two statements from MLN Matters Article MM10865 which addressed the updated ICD NCD:

“Effective February 15, 2018, coverage policy is no longer contingent on participation in a trial/study/registry. Therefore, claims with a Date of Service (DOS) on an after February 15, 2018, no longer require any trial-related coding.”

The reason you have had claim denials for this requirement after it was no longer effective is due to the implementation date of the NCD. Once a new or revised NCD is announced, it takes Medicare contractors a while to implement the business requirements, including revising any claims processing system edits they have in place. That is why the transmittals announcing the changes include both an effective date and an implementation date. For a more thorough discussion of decision memos and NCD effective and implementation dates, see our prior Wednesday@One article, Effective Dates of New ICD NCD Rules.

A provider’s options when new NCD rules are released are to:

• Continue to follow the guidelines of the old NCD for claim submission until the implementation date,
• Follow the new NCD guidelines, but hold your claims until the implementation date for submission, or
• Submit your claims following the new NCD guidelines, but realize they may be denied under the old NCD requirements and you will have to appeal these claims to obtain proper payment.

Since your claims have been denied, you will have to appeal the denial or you may be able to resubmit the claim. Palmetto GBA, the MAC for jurisdictions J and M, recently released the following instructions.

Clinical Trial Implantable Defibrillator Claims

Issue Identified: 3/22/2019

Current Status

Claims reporting Implantable Cardiac Defibrillators (ICDs) related to National Coverage Determination (NCD) 20.4, with dates of service on or after February 15, 2018, previously rejected due to absence of clinical trial/study/registry codes may be submitted after March 26, 2019. Please refer to Palmetto GBA Medical Policy Article A56343   regarding applicable billing/coding changes.

Situation
CMS revised Change Request (CR): 10865   (PDF, 113 KB),

"National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs)". The implementation date for Medicare Administrative Contractor (MAC) local edits is to March 26, 2019. Effective February 15, 2018, NCD 20.4 is no longer contingent on participation in a clinical trial/study/registry. Therefore, claims with dates of service on an after February 15, 2018, no longer require any trial-related coding.”

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BAHQ6T4283?opendocument

If you are in another MAC Jurisdiction and have received denials for lack of reporting the Q0 modifier on ICD claims with dates of service on and after February 15, 2018, check with your MAC to see if you can resubmit those claims after March 26, 2019 (the implementation date).  If you have to go the appeal route and send in your medical records, be sure the ICD procedure meets all the requirements of this complex NCD and that your medical record contains the appropriate supporting documentation. Hopefully, this is something for which you already have processes in place and will not be an issue. The ICD procedure has a significant Medicare payment, so whatever you do, be persistent with your MAC in obtaining your proper payment.