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On January 26th, Health and Human Services Secretary Sylvia M. Burwell “announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.” According to the CMS Press Release, “this is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.”

This call to action by Secretary Burwell brings to mind the Institute for Health Improvement’s (IHI) Plan-Do-Study-Act (PDSA) cycle that involves planning a test or observation, trying out the test on a small scale, analyzing data and studying the results and finally, refining the change based on what was learned.

Plan-Do-Study

Long before the Affordable Care Act, it was obvious that the current state of healthcare in the United States was more reactive than proactive and that the current Prospective Payment System was not financially sustainable.

In a related Fact Sheet to the January 26th announcement, CMS indicated that “the Affordable Care Act offers many tools to improve the way providers are paid to reward for quality and value instead of quantity, to strengthen care delivery by better integrating and coordinating care for patients, and to make information more readily available to consumer and providers. Doing so will improve coordination and integration of health care, engage patients more deeply in decision-making and improve the health of patients – with a priority on prevention and wellness.”

While not an all-inclusive list, specific examples of progress attributed to the Affordable Care Act by CMS include:

• Years 2011, 2012 and 2013 saw the slowest growth in real per capita national healthcare expenditures on record in part due to slow growth in per-beneficiary spending across Medicare, Medicaid, and the private insurance beneficiary population.
• “Looking forward, due primarily to the persistent slowdown in health care costs, the Congressional Budget Office now estimated that Federal spending on Medicare and Medicaid in 2020 will be $188 billion below what it projected as recently as August 2010.”
• The Partnership for Patients has been instrumental in “patient harm falling by 17%, saving 50,000 lives and billions of dollars.”
• The Affordable Care Act tied Medicare payment for hospitals to readmission rates. Since 2012 the efforts made by hospitals “translates into an 8 percent reduction in the rate and an estimated 150,000 fewer hospital readmissions among Medicare beneficiaries between January 2012 and December 2013.”
• Providers are engaged as evidenced by the fact that currently “there are 424 organizations currently participating in Medicare ACOs, serving over 7.8 million Medicare beneficiaries” and the “ACOs participating in the Shared Savings Program and the Pioneer ACO Model combined generated over $417 million in savings for Medicare.”
• The three mandated quality programs for hospitals (Hospital Value-Based Purchasing Program, Hospital Readmissions Reduction Program and Hospital-Acquired Condition Reduction Program) reward hospitals for the quality of care they provide to patients.
• Improvement in the availability of information to guide the beneficiary in their decision-making has been made available through Physician Compare, updates to Hospital Compare, and the May 2013 release of Charge Data for Hospital and Physician Services by CMS.

Act

Again, Secretary Burwell made the HHS call to action by setting explicit alternative payment model goals and value based payment goals to “help drive the health care system towards greater value-based purchasing – rather than continuing to reward volume regardless of quality of care delivered.”

Alternative Payment Models Goal

By the end of 2016 have 30 percent of Medicare payments in alternative payment models.

By the end of 2018 have 50 percent of Medicare payments in alternative payment models.

The Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organizations (ACOs), the Bundled Payment for Care Initiative, and the Comprehensive Primary Care Initiative are examples of current Alternative Payment Models. “HHS is working with private payers, including health plans in the Health Insurance Marketplace and Medicare Advantage plans, as well as state Medicaid programs to move in the same direction toward alternative payment models and value-based payment to providers and to meet or exceed the goals outlined above wherever possible.”

Value Based Payments Goal

By 2016 have 85 percent of Medicare fee-for-service payments tied to quality of value.

By 2018 have 90 percent of Medicare fee-for-service payments tied to quality of value.

The Hospital Value Based Purchasing Program, Hospital Readmission Reduction Program and the Hospital-Acquired Condition Program are the three Affordable Care Act Mandated Quality Programs that have begun to tie a hospitals payment to quality of value.

How to Reach the Goals

Secretary Burwell also announced the creation of a Health Care Payment Learning and Action Network. This Network “will accelerate the transition to more advanced payment models by fostering collaboration between HHS, private payers, large employers, providers, consumers, and state and federal partners. Working together, Learning and Action Network partners will:

• Serve as a convening body to facilitate joint implementation and expansion of new models of payment and care delivery
• Identify areas of agreement around movement toward alternative payment models and define how best to report on these new payment models
• Collaborate to generate evidence, share approaches, and remove barriers
• Develop common approaches to core issues such as beneficiary attribution, financial models, benchmarking, and risk adjustment
• Create implementation guides for payers and purchasers

Alignment between HHS, private sector payers, employers, providers, and consumers will help health care payments transition more quickly from pure fee-for-service to alternative payment models – a critical step toward better care, smarter spending, and healthier people.” The first Network meeting is set for March 2015.

As health care in this country is propelled towards new payment models and payment for quality instead of quantity, there are a couple of valuable resources that hospitals should be familiar with.

First is the CMS Innovation Center. Per the Affordable Care Act, “the purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished to individuals under such titles.” I encourage you to visit their website to find out where and what Innovation is Happening in your state and while there check out the November 10, 2014 CMS Innovation Center Update Webinar that featured Dr. Patrick Conway, CMS Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer.

A second resource is the Health Care Transformation Task Force. On January 28, 2015, just two days after the CMS announcement, this group “whose members include six of the nation’s top 15 health systems and four of the top 25 health insurers, challenged other providers and payers to join its commitment to put 75 percent of their business into value-based arrangements that focus on the Triple Aim of better health, better care and lower costs by 2020.”

Resources:

Fact Sheet: Better Care, Smarter Spending, Healthier People: Why It Matters: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-2.html

Fact Sheet: Better Care, Smarter Spending, Healthier People: Paying Providers for Value, Not Volume: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

Fact Sheet: Better Care, Smarter Spending, Healthier People: Improving Out Health Care Delivery System: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26.html 

American Hospital Association Response to January 26th Announcement:

http://www.aha.org/presscenter/pressrel/2015/150126-pr-medicare.shtml

American Medical Association Response to January 26th Announcement: http://www.ama-assn.org/ama/pub/news/news/2015/2015-01-26-hhs-shifting-medicare-reimbursements-volume-value.page

 

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!

 

Yes, it is true that in this age of electronic health records (EHRs) that most Physician notes are no longer written with a pen. However, in the January 2015 release of the Medicare Quarterly Compliance Newsletter, there are two Comprehensive Error Rate Testing (CERT) review findings that share the denial commonality of “the physician’s failure to document a reasonable expectation that the beneficiary would require a hospital stay that would cross 2 or more midnights.” So hand written or electronic, it is a fact that the denials were due to the Physician’s pen.

First, for those that may still be unfamiliar with this newsletter, it is a resource provided by the CMS to serve as an “educational product, to help providers understand the major findings identified by MACs, Recovery Auditors, Program Safety Contractors, Zone Program Integrity Contractors, the Comprehensive Error Rate Testing (CERT) review contractor and other governmental organizations, such as the Office of Inspector General.” If you are interested in viewing past issues, the CMS maintains a Newsletter Archive of all of the newsletters to date.

The January edition of the newsletter includes findings from the Office of Inspector General (OIG), Recovery Auditor and CERT. This article focuses on two of the CERT findings.

Surgical Procedures Related to Hemodialysis being billed as an Inpatient
Provider Types Affected: Physicians and Hospitals

 

Background

Placement of an arteriovenous fistula (AVF) is the best option for beneficiaries requiring hemodialysis for end-stage renal disease (ESRD). The procedure is typically an outpatient procedure. “Inpatient hospital admission is appropriate when the beneficiary has some other acute problem requiring inpatient care or when a serious post-operative complication arises.”

Medicare payment to a hospital for surgical procedures includes the procedure itself and all normal post-op recovery and monitoring even if the monitoring extends overnight. Also, hemodialysis and a beneficiary’s need for chronic hemodialysis “does not justify an inpatient hospital admission for a vascular access-related procedure.”

Review Finding

Most improper payments identified by the CERT were due to the hospital inappropriately billing Medicare for the surgery and post-op care as an inpatient hospital admission.

Denial due to the Physician’s Pen

The CERT asserted that the most common denial for an inpatient hospitalization spanning less than 2 midnights “is the physician’s failure to document a reasonable expectation that the beneficiary would require a hospital stay that would cross 2 or more midnights.”

What You Should Know

“Physicians do not need to include a separate attestation of the expected length of stay; rather, this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes. Expectation of time and the determination of the underlying need for medical care at the hospital are supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event, which are expected to be documented in the physician’s assessment and plan of care.”

The 2 Midnight Rule and Elective Procedures
Provider Types Affected: Physicians Facilities and Hospitals

Background

The 2014 IPPS Final Rule (CMS-1599-F) 2-Midnight Rule provision maintains that an inpatient admission and payment under Medicare Part A is generally appropriate when the physician:

1. “Expects the beneficiary to require a stay that crossed at least two midnights; and
2. Admits the beneficiary to the hospital based upon that expectation.”

Medicare Administrative Contractors (MACs) have been performing reviews under the Probe and Educate Program that began with admissions on or after October 1, 2013 and is currently set to end on March 31, 2015.

This review focuses on the review findings “as they pertain to admissions for elective procedures.”

Exception to the 2 Midnight Rule and Unforeseen Circumstances

When the Expected Length of Stay was Less Than 2 Midnights

It would not be appropriate to admit a beneficiary as an inpatient when they present for an elective surgical procedure that is not designated as Inpatient Only by Medicare and the physician does not expect to keep the patient in the hospital beyond 2 midnights.

Contractors will deny this type of claim unless there is documentation in the record of an approved exception. Currently the only approved exception is “newly initiated mechanical ventilation (excluding anticipated intubations related to minor surgical procedures or other treatment).”

When the Expected Length of Stay was 2 or More Midnights

There are times when a physician expects a beneficiary to require a 2 midnight or longer hospitalization but due to unforeseen circumstance the stay is less than 2 midnights. CMS approved examples of unforeseen circumstances includes “unexpected death, transfer to another hospital, departure against medical advice, clinical improvement, and election of hospice care in lieu of continued treatment in the hospital.”

Denial due to the Physician’s Pen

The CERT again asserted in this review that the most common denial for an inpatient hospitalization spanning less than 2 midnights “is the physician’s failure to document a reasonable expectation that the beneficiary would require a hospital stay that would cross 2 or more midnights.”

Two examples of Medicare Part A Inpatient Denied Claims provided in this review include a vascular procedure where the documentation did not support the inpatient admission and a urologic procedure where there was no inpatient order and the documentation did not support a 2 midnight expectation.

What You Should Know

Just as in the first CERT review findings, this article asserts that what you should know is that “Physicians do not need to include a separate attestation of the expected length of stay; rather, this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes. Expectation of time and the determination of the underlying need for medical care at the hospital are supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event, which are expected to be documented in the physician’s assessment and plan of care.”

I encourage you to take the time to read this entire newsletter as it provides the issues, what you should know as well as valuable links to resources to find more information about each review type.

 

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.

Updated January 29, 2015

Motivational speakers like catchy words and phrases – remember such terms as “synergy” and “apples to apples”. Sometimes we hear these terms so much that they become irritating, but with this year’s code changes, providers have to be careful or they will be trying to correlate things that don’t go together – it’s like “apples to oranges”. Here are just a few examples.

Radiation Oncology – CPT Codes for Hospitals; HCPCS Codes for Physicians

The CPT code changes for radiation oncology for 2015 represent significant changes in how radiation therapy services and associated image guidance are reported. Since CMS decided not to pursue proposed cuts to physician radiation oncology payments, CMS created new HCPCS codes for physicians to use in reporting services for 2015 that crosswalk from the 2014 CPT codes. These codes are not for hospital reporting. The HCPCS codes G6001-G6017 are assigned a status indicator of B for OPPS. Hospitals are to report the new CPT codes for radiation oncology services.

Drug Screening Codes – HCPCS Codes for Medicare; CPT Codes for Non-Medicare Payers

Another area with major CPT code changes for 2015 is the Laboratory Drug Screening Codes. CPT deleted old codes and developed new codes based mainly on the testing methods used for analysis. Since Medicare’s HCPCS codes for drug screen tests were already based on the complexity of the laboratory testing methods, you would think these would match. Unfortunately, a direct crosswalk from CPT codes to HCPCS codes is not possible. CPT is based on the type of method (optical observation, immuno- or enzyme assay, or more complex methods). Medicare’s G codes (G0431 and G0434) are based on the testing complexity assigned by the FDA to the testing kit or analyzer – methods may fit into different complexities depending on the type of analyzer. Most hospitals are finding that selecting the new codes takes both clinical and coding expertise for correct assignment.

New Modifiers – Continue to Use 59 Modifier or Use New Modifiers

Due to concerns about the overuse and misuse of modifier 59, CMS developed new more specific modifiers available for use beginning January 1, 2015. These new X {ESPU} modifiers are a subset of modifier 59 with more specific descriptions:

• XE –separate encounter
• XS – separate structure
• XP – different practitioner
• XU – Unusual, non-overlapping service

The confusion here is whether to go ahead and use the new modifiers now or wait for further CMS guidance. There have been conflicting statements from CMS concerning this:

• “As a default, at this time CMS will initially accept either a -59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.” (MLN MM8863)
• Beginning on January 1, 2015, providers canuse the X modifiers if they are currently using modifier59 for a reason within the published definition of the X modifiers. Providers also have the option to continue using modifier59 until CMS issues examples of circumstances in which the X modifiers are or are not appropriate.” (October 23rd Provider Connects eNews)

There are probably many more examples in the world of Medicare coding and billing of “apples to oranges” comparisons. If you think of some good examples, please share them with MMP at info@mmplusinc.com .

The human race continues to make amazing strides in technology that are wondrous and change the very ways we live and even how long we may live. There are devices that monitor how many steps we take in a day, that allow us to control our home electrical systems from our smart phones and that track our “global positioning” wherever we go. And in the medical realm, there is a new FDA-approved device to clip mitral valve leaflets together and potentially prevent the heart failure that could result from mitral regurgitation. This device is inserted via a Transcatheter Mitral Valve Repair (TMVR) procedure.

A National Coverage Determination (NCD) for coverage of TMVR was announced in MLN Matters Article MM9002 effective for dates of service on and after August 7, 2014. Medicare will cover TMVR for treatment of Mitral Regurgitation (MR) when furnished under Coverage with Evidence Development (CED). This means that patients receiving this procedure must be entered into a national qualified registry or part of a FDA-approved, randomized clinical trial.

Some of the requirements for coverage of TMVR for mitral regurgitation include:

• The TMVR procedure must be performed by an interventional cardiologist and/or cardiac surgeon
• For treatment of significant, symptomatic, degenerative mitral regurgitation for FDA-approved indication or for non-listed indications for MR within context of approved clinical trial
• Face-to-face examination and evaluation of patient prior to TMVR by cardiac surgeon and cardiologist experienced in mitral valve surgery with documentation of their decision and rationale
• Performed in a hospital with appropriate infrastructure and with a surgical program, interventional cardiology program, and heart team that meets certain specific requirements. There are numerous and very detailed requirements that the hospital must meet – refer to the NCD for the specifics of these requirements.

TMVR is non-covered for the treatment of MR when not furnished under CED according to the NCD criteria. TMVR used for the treatment of any non-MR indications are non-covered by Medicare.

Hospital Claim Requirements

This is an inpatient-only procedure. Hospital inpatient claims (11x type of bill) must contain:

• ICD-9 Procedure Code - 35.97 - Percutaneous mitral valve repair with implant
• ICD-9 Diagnosis Code for TMVR for MR Claims is - 424.0 – Mitral valve disorder
• Secondary ICD-9 diagnosis code V70.7
• Condition Code 30
• An 8-digit National Clinical Trial Number

For complete information, including instructions for physician claims, see the MLN Matters article referenced above.

This month’s coverage updates include a number of retired LCDs from the MACs within our client regions and Palmetto finalized the LCD on Wound Debridements. Please refer to our coverage article from July 2014 for more information about the various wound care/debridement local coverage policies.

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.

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.

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.