Part B Site LinksMedical Review Frequently Asked Questions
ALL FAQs
There are 115 FAQS for this topic.
- Certified Diabetes Educators and Diabetes Self Management Training (DSMT): How do they bill for this?
DSMT is billed using HCPCS code G0108 and G0109. DSMT can be furnished by anyone who qualifies for direct payment for services done by Medicare and meets the definition of certified provider as stated in CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 15, section 300.2.The services of a certified diabetes educator (CDE) could be billed as part of an accredited DSMT program or if he/she is eligible for direct payment from Medicare (for example, a nurse practitioner who is also a certified diabetes instructor). A CDE that is not able to directly bill Medicare could not do DSMT as an "incident to" service to a physician billed either as DSMT or as an E&M visit (i.e. either service billed under the physician's number). If ancillary staff provides Diabetes training in the course of an office visit, it is considered bundled into a medically necessary E&M visit provided by the billing physician that same date. If the only reason for the encounter was Diabetes training by the ancillary staff in an office setting, then the only code billable for this would be 99211. We have seen errors such as providers billing, e.g., the highest level office visit, CPT code 99215, for visits only between the patient and a CDE on staff and billed under the physician's number
Additional information on this service (including eligible beneficiaries, individual training, etc.) can be found in sections 300-300.501 in the same cite above. Also, CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 18, beginning with section 120 details coding, payment and frequency.
Date Posted: 10/1/2007 - Fracture care in the Emergency Room: How should ER doctors bill for splinting/casting of patients with fractures that are referred to orthopedists?
If the ER doctor is only applying a cast or strapping to stabilize or protect a fracture, injury, or dislocation and/or to afford comfort to a patient, then the code billed should be from the "Application of Casts and Strapping" section of the CPT Manual including CPT Codes 29000-29590. Furthermore, if the ER physician does not perform any restorative treatment nor plans on providing subsequent fracture care, then the ER physician should bill only the appropriate casting/strapping code and not a code for co-managed fracture care (e.g. CPT code 25600 + modifier 54). The ER physician may also report the appropriate level of E/M with the -25 modifier appended if the key components for the Evaluation and Management (E/M) service is met. The orthopedist should then be able to bill the fracture care code globally.
Date Posted: 10/1/2007 - Robotic assisted surgery: Does Medicare pay for robotic assistance?
No additional payment would be made beyond reimbursement for the CPT surgery code. For example, we would not pay any differently for an oophorectomy w/robotic assistance as compared to an open or laparoscopic oophorectomy.
Date Posted: 10/1/2007 - Outsourcing of radiology services outside the United States: Can Medicare be billed for these circumstances?
Medicare cannot be billed in this case. CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 16, section 60 states:
"Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside of the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India ".
There is also a Medicare Learning Network Matters article published this year by the Center for Medicare and Medicaid Services.
Date Posted: 10/1/2007 - Guidelines for X-Stop Device: What are the criteria for coverage of this procedure?
This procedure is covered for patients ages 50 and above who have a diagnosis of lumbar stenosis and have undergone six months' of nonoperative treatment without improvement. The first level would be billed for using CPT code 0171T. If medically necessary for the individual patient, one additional level may be paid using code 0172T. These claims are carrier-priced; and therefore, each claim is considered on a case-by-case basis. Therefore, if on initial claim submission, if the patient has met the age and diagnosis criteria, providers will be sent a request for documentation to determine if the other criteria have been met.
Date Posted: 6/27/2007 - Guidelines for physician supervised weight loss prior to Bariatric Surgery: What documentation is required to be in the chart of patients undergoing weight loss surgery to show they have participated in a supervised weight loss program?
We would expect that the medical record reflect at least three failed attempts to lose weight on a supervised non-surgical weight loss program of which one of these attempts having been a physician directed program for at least 6 consecutive months (with corresponding monthly notes that included the assessments as follows and as itemized in the each state's local coverage decision):- Vital signs to include weight
- Current dietary program
- Physical activity/exercise program
- Behavioral interventions
- Consideration of or use of pharmacotherapy with FDA-approved medication, if appropriate
We'd expect that the physician directed program would have recently preceded (i.e. no more than 12-18 months before) the referral to surgical treatment. Please closely review the policy for all requirements:
Date Posted: 6/27/2007 - Therapy recertification & MD visits: Does the patient have to see the doctor every 30 days in order to continue therapy?
CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 15, Section 220.1.3, subsection C, addresses this question under "Physician/NPP options for Certification." It states:(via this link: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf)
"Physicians/NPPs (non-physician practitioners) may require that the patient make a visit for an examination if, in the professional's judgment, the visit is needed prior to certifying the plan. Physicians/NPPs should indicate their requirement for visits, preferably on an order preceding the treatment, or on the plan of care. Physicians/NPPs should not sign a certification if they require a visit and a visit was not made. However, Medicare does not require a visit unless the National Coverage Determination (NCD) for a particular treatment requires it (e.g., see Pub. 100-03, §270.1 - Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds)."
Date Posted: 6/27/2007 - Update on Shingles Vaccination (previously published 092906): Does Medicare cover Zostavax and its administration?
Effective January 1, 2007, physicians administering a Part D vaccine should bill to their Part B carrier HCPCS code G0377. Medicare will not pay for the vaccine itself. If the beneficiary is enrolled in Part D, payment for the Part D covered vaccine is made solely by the participating Prescription Drug Plan.As of January 1, 2008, HCPCS code G0377 can no longer be billed to Part B. At that time, providers will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to the Part D plan for reimbursement.
For additional information see the attached CMS articles:
- http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5486.pdf
- http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0723.pdf
Previous FAQ (question #1 September 2007 issue):
Date Posted: 6/27/2007 - Update on sodium hyaluronates (previously published 060106): Does Medicare cover viscosupplementation treatment of the knee?
The following link is to an article from January 12, 2007 publishing the most recent guidelines for these services:Four interim Q codes are in effect for these products as of January 1, 2007, i.e. Q4083 (Hyalgan/supartz injection per does), Q4084 (Synvisc injection per dose), Q4085 (Euflexxa injection per dose), and Q4086 (Orthovisc injection per dose). These replace HCPCS codes J7317 and J7320 referenced in the June 2006 issue of "Frequently Asked Questions." The remainder of the 011207 article details covered diagnoses, guidelines for repeat use, and guidelines for billing an evaluation and management service the same date as the joint injection of one of these drugs.
For additional information see the attached CMS article:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5459.pdf
Previous FAQ (question #6 June 2006 issue):
http://www.cignamedicare.com/articles/June06/cope4333C.html
Date Posted: 6/27/2007 - Optometry Visits in a Nursing Facility: Can optometrists bill subsequent nursing facility CPT codes 99307-99310?
Optometrists may bill these codes if they are able to meet the individual code requirements. This type of evaluation and management visit requires that two of the three key components be met in order to bill the code. Being able to meet the requirements for the higher level codes within this series would be unlikely for optometrists considering their scope of practice, i.e. what they can assess, diagnose and treat. Rather than billing evaluation and management visits, the services optometrists render may be best represented by the codes under "General Ophthalmological Services" such as CPT codes 92012 or 92014.
Related to this question is the expectation that if a beneficiary in a nursing facility requires the services of an optometrist, the attending physician is first notified to evaluate the need and give the order for the service before it is rendered. Additionally, optometrists should not bill E&M visits for routine screening exams or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, or procedures performed (during the course of any eye examination) to determine the refractive state of the eyes as these are noncovered by Medicare as stated in the Social Security Act 1862 (a)(7).
Date Posted: 3/29/2007 - Removal of Excess Skin after Bariatric Surgery: Will Medicare cover lipectomies after bariatric surgery?
Medicare does not pay for cosmetic surgery as it is excluded from coverage under §l862(a)(l0) of the Social Security Act. After bariatric surgery weight loss, some patients may develop skin breakdown under excess skin. If this skin breakdown has not responded to conservative measures and is significant enough to merit surgery, Medicare may cover what would otherwise consider cosmetic; but the medical record documentation would need to clearly support the medical necessity including the progression to surgical treatment. Otherwise, lipectomies to shape or contour the body would be considered cosmetic and not covered by Medicare.
Date Posted: 3/29/2007 - Post-operative Pain Management: Can a pain management specialist visit a patient post-operatively?
Post-operative pain management is considered part of the global surgery package paid to the operating surgeon. We would expect the medical necessity of a pain management specialist beyond the operating surgeon’s global care to be rare. Additionally, the medical record would need to demonstrate the services of the pain management specialist did not merely replace the expected post-operative pain management by the operating surgeon. Please see the 11-21-07 article for additional information.
Date Posted: 3/29/2007
Date Revised: 12/31/2007 - Anticoagulant Management: Will Medicare cover the codes for monitoring and management of anticoagulant therapy?
CPT codes 99363 and 99364 are new for 2007, but they are currently not separately paid. These are considered bundled into payment for other services the same date of service. See question #4 under the April 2004 "Frequently Asked Questions" via the following link for guidelines on billing CPT 99211 in relation to patient visits for anticoagulation management:
http://www.cignagovernmentservices.com/partb/help/faqs/mr/04_04.html
Please see the 09-20-07 article for additional information.
Date Posted: 3/29/2007
Date Revised: 12/31/2007 - Nerve Conduction Testing: Can a family practitioner bill for CPT codes 95903 & 95904?
These codes represent nerve conduction studies (NCS). Generally, a provider can bill any code for services he or she is qualified to perform. That being said there has been increasing utilization of these highly specialized tests due to the availability of equipment that would allow in-office testing generating immediate results. These devices and tests do not conform to the current descriptors of existing CPT codes and should not be billed with 95900, 95903 or 95904. If performed and billed to Medicare, they should be billed with the non-specific CPT code 95999. Regardless of this facilitated testing, it remains that there is a local coverage policy for nerve conduction studies indicating the following:
"Training in the performance of electrodiagnostic procedures, in isolation without awareness and ability to diagnose and manage neuromuscular diseases, is not always adequate for electrodiagnostic consultation. Recognition and experience in the management of disparate diseases that produce common electrodiagnostic findings may be necessary…Without awareness of the disease spectrum, diagnosis solely by EMG-NCV findings may be either wrong or detrimental to the patient.
Additionally, an appropriate provider would not only be one who could use the information from these tests in the diagnosis and management of these patients but is also able to determine in the first place if the patient is appropriate for this type of testing.
Therefore, we do not generally expect billing for nerve conduction studies to be done by non-specialists. Charges for NCS will be monitored and probed if necessary to determine if performed in compliance with local policy. Providers are cautioned to not to bill for these services based solely on having acquired this equipment.
Date Posted: 12/21/2006 - How are providers supposed to bill for bilateral knee replacements?
Bilateral knee replacement surgery during the same encounter is considered a procedure subject to bilateral pricing per CMS. Many times the bilateral knee replacements are accomplished by two surgeons who each replace a distinct knee. Even though each surgeon is doing a separate knee, the two surgeons are actually operating as co-surgeons for bilateral knee replacement and should each bill their part with CPT code 27447 with modifiers 50 and 62.
Additionally, according to the Medicare Physicians' Fee Schedule Database, co-surgery for bilateral knee replacement is covered if medically necessary. It is expected the medical records will support the medical necessity for bilateral knee replacement.
Date Posted: 12/21/2006 - My provider billed a claim for 76075 and 76076 the same date of service, and the 76076 was denied. Why?
CPT codes 76075 and 76076 are both bone density studies. These codes are used to report services prior to 010107. For services done 010107 and after, CPT codes 76075 and 76076 are to be reported using CPT codes 77080 and 77081 respectively.The bone density testing represented by codes 76075/77080 is for the measurement of an axial skeleton site whereas 76076/77081 is measurement of a peripheral or appendicular skeleton site. The national coverage for measurement of bone density on qualified individuals is one test every 2 years. We are seeing providers doing both of these studies on the same date which amounts to the every 2 year benefit being exceeded on a single day. In many cases, we have seen providers cite the same diagnosis for both tests which raises further questions as to whether both tests done the same date of service are medically necessary. In the rare incidence that a second bone density test is needed the same date of service due to another having been inconclusive, providers could present these reasons on an appeal basis.
Date Posted: 12/21/2006
Date Revised: 2/22/2007 - Is Intervertebral Differential Dynamics covered? How do I bill for it?
At this time, Intervertebral Differential Decompression or Intervertebral Differential Dynamics (IDD) is not covered by Part B Medicare. This service is accomplished using equipment such as the Accu-Spina device/DRS,DRX 9000, etc. Providers rendering this service say this procedure is represented by HCPCS code S9090. This code per its description is for "vertebral axial decompression (VAD)." This code though is not valid for billing Medicare. Some providers have asked if this service can be billed with CPT code 97012. CPT code 97012 is an active, i.e. payable, code for Medicare and is used for application of mechanical traction. Other forms of traction are payable by Medicare using this CPT code, but vertebral axial decompression (i.e. IDD) is not. Therefore, when performing VAD/IDD, providers should use CPT Code 97012 + modifier GY. Modifier GY represents a service that is statutorily noncovered, and this is appropriate based on the attached national coverage determination established by the Centers for Medicare and Medicaid Services dealing with this issue/treatment.
Since this service will be denied investigational and become a beneficiary responsibility for payment, we would advise you to clearly inform the patient of this prior to the service.
Date Posted: 12/21/2006 - How do you bill for flushing of a port when this is the only service during the patient encounter?
Previously, per an article from the April/May 1997 Medicare Bulletin, we advised providers to bill for a port flush using CPT code 99211. Effective 2006, there is a new code, CPT code 96523, that should be used instead of billing 99211. You would not bill CPT code 96523 if there is a visit or other injection or infusion provided on the same day the port flush would be considered component to these other services. See CMS Manual 100-4, the Medicare Claims Processing Manual, Chapter 12, Section 30.5, subsection E via the following link for this advice:
http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf
Date Posted: 12/21/2006 - How often can foot care be done?
Generally, routine foot care is excluded from Medicare coverage unless the patient has a systemic condition that prompts for the skills of a professional to safely perform the routine foot care or the patient has mycotic nails that limit his/her ambulation, results in pain or causes secondary infection. (See CMS Publication 100-2, The Medicare Benefit Policy Manual, Chapter 15, section 290 for the specific guidelines on coverage of foot care).
The Code of Federal Regulations is the basis for excluding routine foot care from Medicare coverage. The exceptions to this are also detailed here - specifically 42 CFR 411.15 that states exceptions to routine foot care exclusion as follows:
"Treatment of mycotic toenails may be covered if it is furnished no more often than every 60 days or the billing physician documents the need for more frequent treatment"
Therefore, routine foot care more frequently than every 60 days may be subject to medical review to determine if the patient qualifies for coverage and if the frequency of the foot care performed is medically necessary.
Date Posted: 12/21/2006 - Shingles Vaccination: Does Medicare cover Zostavax and its administration?
The vaccine for varicella-zoster was approved by the FDA in May 2006, but Medicare Part B will not be paying for this code under CPT code 90736 (or any other code) or for the associated administration fee. Likewise, providers should not bill an evaluation and management service when the patient is only receiving this injection. Providers may be able to be reimbursed by a patient’s Medicare Part D plan, but this would be subject to each individual plan’s guidelines and, again, is not a Part B paid service at this time.
Date Posted: 9/29/2006 - Moderate Sedation Codes: Does Medicare cover CPT codes 99143-99150 new for 2006?
Based on medical necessity for each individual patient’s circumstances and as documented in the medical record, CPT codes 99148-99150 (moderate sedation services provided by a physician other than the one performing the diagnostic or therapeutic service that the sedation supports, first 30 minutes and each additional 15 minutes) may be paid. In contrast, the codes for moderate sedation provided by the physician performing the diagnostic or therapeutic procedure will not be paid by Medicare Part B. Based on CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, Section 50. A, separate payment for anesthesia performed by the physician who also furnished the medical or surgical service is not allowed as it is considered component to/included in the payment for the medical or surgical service.
Date Posted: 9/29/2006 - What are the coverage guidelines for B-12 injections?
CIGNA Government Services retired the Idaho, Tennessee, and North Carolina local coverage determinations for B-12 effective 090106. The Centers for Medicaid and Medicare Services still state in CMS Publication 100-2, the Medicare Benefit Manual, Chapter 15, section 50 that the use of a drug or biological is "reasonable and necessary for the diagnosis or treatment of the illness or injury for which they are administered according to accepted standards of medical practice." Also, in the same chapter under section 50.4.3, it states "Medications given for a purpose other than the treatment of a particular condition, illness, or injury are not covered (except for certain immunizations). Charges for medications, e.g., vitamins, given simply for the general good and welfare of the patient and not as accepted therapies for a particular illness are excluded from coverage." An example of accepted standard of practice and covered B-12 therapy would be the maintenance treatment of pernicious anemia via a monthly injection. The medical record would also need to support the diagnosis the drug administration and code for B-12 would be referenced to, and an evaluation and management visit would not be indicated unless it was necessary according to the patient’s need for the provider to perform a separately identifiable service beyond the assessment related to and customarily performed with the B-12 administration. See the above information through the following link:
http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf
Date Posted: 9/29/2006 - Why do some critical care visits deny?
If critical care is billed the same date of service as a procedure, the services represented by the critical care charges must go above and beyond any evaluation and management efforts normally included in the surgical procedure. When critical care exceeds the work included in the surgery and the patient is critically ill requiring the constant attendance of the physician, providers bill the critical care code(s) with modifier 25. Additionally, the Centers for Medicaid and Medicare Services specifically require for critical care to have a diagnosis different from the diagnosis for a procedure done the same date. Therefore, without an appropriate modifier and different diagnosis reported on the initial claim submission, critical care charges the same date as a procedure will edit to deny. Coverage for critical care and a procedure sharing the same diagnosis might be allowed at the Appeals/Redeterminations level with appropriate documentation submitted.
A patient’s medical records should support the different diagnoses used for critical care and a procedure done on the same date of service.
See CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, Section 40.2, subsection A, #9 via the following link for the information cited above:
http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf
For critical care occurring postoperatively in the global period of a procedure, the same requirements apply except for the modifier to be used would be modifier 24.
Date Posted: 9/29/2006 - Cyberknife: Does Medicare cover this service?
Medicare does cover treatment by cyberknife if medically necessary and within accepted standard of practice. Codes 0082T and 0083T (for services prior to 010107) and 77373 and 77435 (for services 010107 and after) were established to describe daily stereotactic body radiation delivery and treatment of localized tumors or lesions anywhere in the body. Code 0082T is reported for daily treatment delivery and 0083T is reported for daily treatment management. Code 77373 is for treatment delivery per fraction to one or more lesions including image guidance and entire course not to exceed 5 fractions whereas 77435 is for treatment management per treatment course to one of more lesions including image guidance and entire course not to exceed 5 fractions. Stereotactic body radiation management will require additional and different work of the physician to evaluate and personally manage patients undergoing SBRT. This work includes the evaluating of the patient set-up, checking calculations against treatment plans, and managing the patient's general condition before, during, and after SBRT.
Date Posted: 9/29/2006
Date Revised: 12/31/2007 - Are cosignatures by physical therapists required on each treatment note written by a physical therapy assistant?
No, notes written by the physical therapy assistant would not have to be cosigned by the physical therapist. Requirements for treatment encounter notes can be found in CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 15, section 220.3.5, subsection B.
See the above via the following link: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf
Date Posted: 9/29/2006 - Can nurse practitioners and physician assistants perform and bill for consultations, initial visits, and critical care?
Technically, these practitioners could perform these types of services if:
- allowed by the institution (e.g. some hospitals do not allow nonphysician practitioners admitting privileges) and
- provided the NPPs are also within the scope of their state licensure and training
The latter point should prompt caution in billing among nonphysician practitioners in that they must have the background training and education to support the high-complexity work and medical decision-making included in codes such as critical care and the higher levels of consultations and initial visits. See question #2 of this same issue for further related discussion especially regarding consultations.
Date Posted: 6/1/2006 - Can non-physician practitioners such as nurse practitioners and physician assistants perform consultations?
According to CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, Section 30.6.10, subsections A (see attached link), "qualified nonphysician practitioners (NPP) may perform consultation services within the scope of practice and licensure requirements for NPPs in the state in which he or she practices." In subsection E of the same section, CMS defines a "qualified" consultant as a practitioner that has expertise in a specific medical area beyond the requesting professional's knowledge. We have seen instances when patients are referred to a specialty practice for consultations that are then done by NPPs (i.e. physician assistants or nurse practitioners) who then refer the patient to a physician in the same group for a therapeutic procedure. Subsequently, the physician then also performs a "pre-procedural" consultation which raises the issue why multiple consults were necessary. As a consultation may include the initiation of diagnostic and/or therapeutic services, it would seem appropriate that the consult be done by a practitioner who has the expertise to do this-- which further raises the question if the NPP who did the initial consult was truly "qualified" for performing consultations. In other words, it does not appear the NPP made a decision beyond what was already determined by the original ordering provider. CMS does state in subsection E of this same chapter that "a consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting." We would apply this guideline in the above example and deny the NPP consult as lacking medical necessity. It is expected that if an ordering physician asks for a consult by another physician then the service would actually be fulfilled by a physician.
Date Posted: 6/1/2006 - Can a nurse practitioner or physician assistant do any part of a new patient office visit or consultation and still bill under the physician's billing number?
The Evaluation and Management guidelines established by CMS would allow a physician's ancillary staff (which may include NPPs) to document a limited portion of the patient's history (specifically, a patient's review of systems and/or past, family, social history**). No other parts of an initial visit or consultation (i.e. the other key components-exam, medical decision-making or the chief complaint of the patient's history) could be done by these practitioners and the service still be billed under the physician's billing number. CMS guidelines stipulate that consults, whether office or inpatient, cannot be split/shared. Furthermore, split/sharing other office visits (such as new patient visits) cannot be done because the "incident to" criteria must be satisfied. For the "incident to" criteria to be fulfilled, the physician would have had to seen the patient before which is not the case in a new patient visit, and thus precludes this type of visit from being split/shared between the physician and NPP. For example, in an office setting, if the NPP performs a portion of the new patient visit (beyond the allowed limits described above) and the physician completes the E&M service, the service would still have to be billed using the NPP's billing number.
See CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, Section 30.6.1, Subsection B for split/share guidelines:
http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf
See either page 5 of the 1995 or page 8 of the 1997 CMS Evaluation and Management guidelines via the following link:
http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp
**The documentation guidelines state specifically "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others."
Date Posted: 6/1/2006 - Can an initial hospital visit be split/shared?
Hospital evaluation and management visits are reported according the level of work done per day. Therefore, only one visit would be reported per date of service by any given provider, but the level of visit billed may actually be comprised of the work done by a nonphysician practitioner and a physician from the same group practice done on separate encounters the same date of service. Typically, this is seen in the performance of a subsequent hospital visit billed and paid under the physician rate of reimbursement which is acceptable provided these encounters were:
- medically necessary (i.e. the physician's portion of the work done was from an actual medically necessary face to face encounter with the patient)
- performed separately and
- were documented separately.
In the performance of an initial hospital visit, if the patient is an established patient in the group practice, we would allow this visit if split/shared; but if the patient is new to the group practice, the expectation would be that the physician provides the entire encounter and its required components to the patient (and could not be split/shared with a nonphysician practitioner).
Date Posted: 6/1/2006 - Which CPT code for drug administration should be used for the subcutaneous injection of xolair- 90772 or 96401?
Xolair (Omalizumab) is a monoclonal antibody given as a subcutaneous injection for the treatment of asthma. Based on the route of administration, the administration of this code should be billed using CPT code 90772, Therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular. It would be incorrect to bill for administration of Xolair under CPT code 96401, Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic" as Xolair is not an anti-neoplastic as is required in this code. CIGNA Government Services has Local Coverage Decisions specifying coverage details for this drug in each of the states it oversees (see the attached links). Additionally, please see the CPT Manual 2006/Professional Edition which states "Report 90772 for non-antineoplastic hormonal therapy injections" and "Report 96401 for anti-neoplastic non-hormonal injection therapy."
Idaho: http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=15599&lcd_version=3&show=all
North Carolina:
http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=15643&lcd_version=3&basket=lcd%3A15643%3A3%3AOmalizumab+%28Xolair%AE%29%3ACarrier%3ACIGNA+Government+Services+%2805535%29%3A
Tennessee:
http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=15329&lcd_version=3&basket=lcd%3A15329%3A3%3AOmalizumab+%28Xolair%AE%29%3ACarrier%3ACIGNA+Government+Services+%2805440%29%3A
Date Posted: 6/1/2006 - Does Medicare cover viscosupplementation treatment of the knee?
CIGNA Government Services does not have a local coverage decision for this treatment, but the following article addressing this issue has been previously published in our Medicare bulletin and details the guidelines still applied presently:
http://www.cignamedicare.com/partb/bltin/all/99bltin/99_4/forall/Intraarticular%20knee%20injections.html
In summary, sodium hyaluronates and hyaluronic acid derivatives approved by the FDA for the treatment of osteoarthritis of the knee joints are covered for patients who have failed to respond or had inadequate response to other treatments. Presently, there are five available drugs (Euflexxa, Hyalgan, Supartz, Orthovisc and Synvisc) that may be billed under the appropriate/corresponding HCPCS code of which there are two available:
J7317, SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA-ARTICULAR INJECTION (use for the Euflexxa, Hyalgan, Supartz and Orthosvisc)
J7320, HYLAN G-F 20, 16 MG, FOR INTRA-ARTICULAR INJECTION (use for Synvisc)
Note that each of the above drugs is prepared in a different concentration and has different recommended treatment cycles. For example, Euflexxa comes prepared as 10mg per mL, and the recommended dose is 2 mL via intra-articular injection at weekly intervals for 3 weeks for a total of 20 mg at each of the 3 injections. Each weekly dose is therefore equal to (1) number of service of J7317 (since this code is per 20 to 25 mg dose) even though 2mL is given. The total number of services for the initial series of Euflexxa would then be three (3). Synvisc is also based on a total of 3 injections whereas Hyalgan and Supartz are based on 5 injections per treatment cycle, and Orthovisc is based on a cycle of 3 or 4 weekly injections.
The only approved indication for this type of treatment is osteoarthritis of the knee as supported by one of the following ICD-9 codes that should submitted of the claim for this service:
715.16 Osteoarthrosis, localized, primary, lower leg
715.26 Osteoarthrosis, localized, secondary, lower leg
715.36 Osteoarthrosis, localized, not specified whether primary or secondary, lower leg
715.96 Osteoarthrosis, unspecified whether generalized or localized, lower leg
Please note the above article linked to details the requirements that must be present in the medical record for the diagnosis of osteoarthritis (i.e. via xray) and required preceding treatments that failed (i.e. knee aspiration of clear viscous fluid followed by instillation of a steroid product that resulted in either unsatisfactory relief or relief that lasted less than three months).
Additionally, the article also details that if the first series of hyaluronates does not prove beneficial then there would be no medical necessity to repeat the therapy. If the initial treatment is beneficial, it is expected it would not be repeated within six months.
Finally, the article gives instructions on claim filing. Please note the article makes reference to code J7315 for Synvisc that is no longer an effective code. The active/payable codes for these drugs are as listed above.
Date Posted: 6/1/2006 - Can "physician extenders" such as nurse practitioners, physician assistants, certified nurse midwives, or RN's perform subsequent hospital visits or discharges from the hospital?
"Nonphysician practitioners" such as nurse practitioners, physician assistants, etc. could perform subsequent hospital visits and discharge visits provided these were billed under their own performing provider number. They could not perform the work then bill these services under a physician's performing provider number as this would be "incident to", and "incident to" is not allowed in the hospital setting.
There are no services that could be performed by a registered nurse (i.e. as an employee of the billing provider) that could be billed to Medicare.
Non-physician practitioners (NPP) may perform subsequent hospital and discharge visits as "split/shared" services (i.e. billed under the physician's provider number) if the NPP visits are medically necessary according to the individual patient's circumstances and performed and documented independent of the physician's visit. The physician's visit must be a separate, medically necessary face-to-face encounter with the patient. The physician's visit cannot simply be for signing off behind the NPP's note/visit.
Date Posted: 2/22/2006 - Can an established patient visit and ear lavage be paid the same dos?
Ear lavage to remove ear wax would be considered part of an evaluation and management visit. Ear lavage may be done by either the physician or his/her staff. If a patient had impacted cerumen removed by the physician (e.g. via curettes) then CPT code 69210 could be billed. (Removing wax that is not impacted does not warrant the reporting of CPT code 69210)
As far as billing an E&M visit in addition to removal of impacted cerumen, visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to irrigating the ears if, for example, a neurological assessment was medically necessary - i.e. done because the patient exhibited symptoms beyond those attributable to impacted cerumen: but, billing for a visit would not be appropriate if the physician only identified the need to remove the impacted cerumen. (See CMS Publication 100-4, the Claims Processing Manual, Chapter 12, section 40.1, subsection C via the attached link: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf
).
Date Posted: 2/22/2006 - Can a consultation be "split/shared"?
No, a consult visit cannot be "split/shared" as asserted in attached Medlearn Matters article as published by CMS. Other services that cannot be "split/shared" include critical care procedures, and E&M services in nursing facilities and skilled nursing facilities.
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4215.pdf
Date Posted: 2/22/2006 - Can a pharmacist bill "incident to" when providing medication counseling in a physician's office?
No, because there is no benefit category under Medicare for pharmacists so the only level they might qualify for billing under the physician's number (provided all "incident to" requirements were met) would be CPT code 99211 (the lowest level established patient office visit); and pharmacists may not "split/share" visits with physicians/non-physician practitioners.
Date Posted: 2/22/2006 - Can CPT codes 90867 and 90847 be billed for marriage counseling?
No, marriage counseling is not family psychotherapy as represented by CPT codes 90846 and 90847. Family psychotherapy is covered by when the primary purpose of such counseling is the treatment of the patient's condition. For example, two situations where FAMILY counseling services would be appropriate are as follows:
- where there is a need to observe the patient's interaction with FAMILY members; and/or
- where there is a need to assess the capability of and assist the FAMILY members in aiding in the management of the patient.
See CMS Publication 100-3, the National Coverage Determinations Manual, Chapter 1, Section 70.1 via the following link:
Date Posted: 2/22/2006 - How should multiple level bilateral paravertebral facet joint injections be billed?
Providers may have received denials for bilateral paravertebral facet injections when more than one add-on level was billed without a modifier 59 or an electronic notepad indicating the add-on levels were distinctly different. For example, if a provider treats bilaterally three thoracic levels (such as T7-8, 8-9, and 9-10), the provider should bill 64470-50 for the first level then 64472-50 for each of the two additional levels except the last level should include a modifier 59 or a notepad explaining the three different levels treated.
Date Posted: 11/14/2005 - How should electrical stimulation HCPCS codes G0281 and G0283 be billed?
These codes are not timed codes but do specify (treatment to) "one or more areas." Therefore, these codes should be billed by encounter and not by site.
Date Posted: 11/14/2005 - How should physician bill for supervision and interpretation of stress test done in an outpatient facility?
CPT code 93015, could not be billed by the physician as this is a global code including both technical and professional components; and, since the stress test in this example is being done outside of the office setting, then the physician is not due the technical component. Providers should note that there are a series of codes for cardiovascular stress test. CPT code 93016, is for physician supervision only without interpretation and report whereas 93017 is for the stress test tracing (also without interpretation and report). Finally, 93018 is the last of this code series and is for stress testing interpretation and report. In the scenario where a provider provides supervision for the stress test done outside of the office setting and also interprets the report, the provider may bill 93016 and 93018 but not 93015 and 93017.
Date Posted: 11/14/2005 - Can an initial hospital visit be billed on a patient admitted for a procedure?
If the patient was admitted for a planned procedure, then an initial visit would be considered part of the global package and should not be billed with a modifier prompting separate payment.
If a patient was admitted to the hospital and during that initial visit the circumstances led to the decision was made to perform a major surgery that day or the very next day, then the initial hospital visit would need to be billed with modifier 57 in order to be separately paid. Likewise, if during an initial hospital visit the decision was made to perform a minor procedure (i.e. "minor" only as defined by the number of global days being "0" or "10") then a provider may bill the initial hospital visit with modifier 25 appended only as long as the patient's condition required an evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed.
Take for example the stenting of a coronary artery. This is a very serious and complex procedure (CPT code 92980); but, per the Medicare Physicians' Fee Schedule database, this is a minor procedure in terms of global days (i.e. CPT code 92980has "0" global days). If the stent procedure was planned prior to admission to the hospital, then the physician should not bill an initial hospital visit (CPT code 99221-99223) unless there existed a medically necessary reason for that specific patient beyond the normal or expected pre-operative work that is included in the global reimbursement for the stent procedure.
Date Posted: 11/14/2005 - How are providers supposed to bill with the new low osmolar contrast codes?
Previously, there were local coverage decisions on low osmolar contrast for Tennessee and North Carolina but these have since been retired (see attached).
http://www.cignagovernmentservices.com/partb/lmrp_lcd/tn/archive/96-03-04.html
http://www.cignagovernmentservices.com/partb/lmrp_lcd/nc/archive/92-02.html
CIGNA Government Services published an article 041505 reflecting the change in the codes as directed by CMS. Attached is that article we published in addition to the CMS Medlearn Matters article explaining the change:
http://www.cignamedicare.com/articles/April05/cope2347.html
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3748.pdf
These articles direct:
Effective with April 1, 2005 (date of service):
- HCPCS codes Q9945 - Q9951 will replace codes A4644 - A4646; except that
- Hospital outpatient departments shall continue to bill codes A4644 - A4646 (Change Request 3748: http://www.cms.hhs.gov/manuals/pm_trans/R502CP.pdf).
As there are specific codes with corresponding prices, providers do not need to submit invoice information. We do suggest providers include in the notepad of their claim the total dosage given to the patient . Pricing per number of service for each code is available on the CIGNA Government services website via the following link:
http://www.cignagovernmentservices.com/partb/fsch/2005/Q2/ASP.html
All of the new codes pay per milliliter (except for Q9954 which is per 100 mlof oral magnetic resonance contrast agent). The number of services you should bill is equal to the number of milliliters given to the patient of the specific low osmolar contrast concentration/preparation you gave the patient (except for Q9954 as explained above). For example, Q9945 is for products with a concentration of iodine up to 149mg/ml whereas Q9946 is for products containing an iodine concentration of 150-199mg per milliliter (150-199mg/ml). So, you have to know which product/preparation/concentration of drug you are using and how many milliliters were given to the patient in order to bill the right number of services and get the right payment.
Date Posted: 7/28/2005 - How often can a nursing home patient be seen if the physician is just managing the care. I know that the patient can be seen at any time if there is a new problem for the physician to address but for managing the care does it have to be every 30 days?
Attached is a link to CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, Section 30.6.13, Subsection A and B:
http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf
It addresses coverage and frequency of visits. Please note it says:
Payment is made for visits required to monitor and evaluate residents at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. These visits and all other medically necessary visits for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are covered under Medicare Part B.
Please note this section is in reference to visits required by "Federal Regulations." Please note these are not state regulations.
Additionally, please see CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, Section 30.6.13 via the following link:
http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf
It states:
The required initial comprehensive visit in a skilled nursing facility (SNF) and nursing facility (NF) is the initial visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the resident. This must take place no later than 30 days after admission.
Date Posted: 7/28/2005 - Can a nursing home code and a hospital discharge code be billed the same date if the physician only sees the patient in the hospital and does not go to the nursing home?
The physician cannot bill for both codes unless the physician has a face-to-face visit with the patient at both places of service. If a physician prepares nursing home admit orders as part of the discharge from the hospital but does not see the patient at the nursing home that date, then the nursing home orders would be considered part of the discharge services. Furthermore, the discharge visit requires a final examination of the patient at the hospital, but the nursing home codes specifically require all three key components be performed (at the nursing facility place of service) and billed at the level medically necessary for that patient and as supported (met/exceeded) by the documentation in the medical record.
Date Posted: 7/28/2005 - If an internist and a family practitioner of the same group saw the same patient on the same date of service, would both be reimbursed?
This is addressed in CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, section 30.6.5 via the following link:
http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf
Please note it states:
Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.
Please note it should be medically necessary for the patient to have both a family practitioner and internist seeing the same patient. Each doctor would need to be managing different aspects of the patient's care.
Please also see CMS Publication 100-4, Chapter 12, Section 30.6.9, Subsections B and C via the following link:
http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf
It says:
B - Two Hospital Visits Same Day
Carriers pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase "per day" which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.
C - Hospital Visits Same Day But by Different Physicians
In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, carriers do not pay physician B for the second visit. The hospital visit descriptors include the phrase "per day" meaning care for the day.
If the physicians are each responsible for a different aspect of the patient's care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty.
Date Posted: 7/28/2005 - When a patient is being seen incident to the physician by a non-physician practitioner, is there a requirement the physician sees the patient every 3rd visit?
There is guidance in the CMS Manuals stating the physician should see the patient receiving "incident to" services at a frequency to stay current of the patient's status: " where the physician performs an initial service and subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment. (However, the direct supervision requirement must still be met with respect to every nonphysician service)."
See CMS Publication 100-2, the Medicare Benefits Policy Manual, Chapter 15, Section 50.1 for the above.
Previously, an article published in the July-August 2001 issue of the Medicare Bulletin advised that if the qualified employee performing "incident to" services is " not a nurse practitioner, a physician assistant, a clinical nurse specialist, a certified nurse midwife, or a certified registered nurse anesthetist, the physician/practitioner must perform the initial service and they should perform subsequent services at a frequency of one out of every three."
http://www.cignagovernmentservices.com/partb/bltin/all/01bltin/01_4/forall/b0104b07b.html
This "one in three" rule is no longer required by CIGNA, but the ancillary personnel referred to in this excerpt (i.e. those that do not have a benefit category under the Medicare program such as nurses, medical assistants, etc.) cannot bill "incident to" at anything other than the 99211 CPT code level.
Date Posted: 7/28/2005 - With the new drug administration codes, how do you bill if more than one infusion is performed?
If a combination of chemotherapy drugs, nonchemotherapy drugs, and/or hydration is administered by infusion, the initial code that best describes the primary or major service at that encounter should always be billed irrespective of the orderin which the infusions occur. The initial code is the code that best describes the primary or major service the patient is receiving and the additional codes are secondary to the initial code. Only one initial drug administration service code should be reported per patient per day, unless protocol requires that two separate IV sites must be utilized. The initial infusion codes for chemotherapy, nonchemotherapy and hydration are G0359, G0347 and G0345 respectively.
Providers can view the following resource on the CMS website regarding the 2005 drug administration coding revisions and the chemotherapy demonstration project:
http://www.cms.hhs.gov/medlearn/cmsinit.asp
Medlearn Matters article MM3818 can be viewed using the link below. This article advises on other important revisions to the 2005 Drug Administration codes effective 051605.
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3818.pdf
Date Posted: 7/28/2005 - Regarding a patient seen in a multispecialty practice, if a patient is seen by a specialist such as a neurologist for the first time at this group, then the same patient is seen by an internist at the same group several days later, can each physician bill a new patient visit?
Historically, CMS has defined a new patient as one not having received services from a physician or another physician of the same specialty within the same group practice in the past three years; and CIGNA Government Services would observe the same on claim reviews.
Therefore, in your example, both physicians could bill a new patient visit.
Date Posted: 7/28/2005 - Can a radiologist order additional tests if medically necessary as long as they document the medical necessity and write an order?
It is our interpretation that an order for additional tests can be given only by the treating physician. NOTE: A radiologist performing a therapeutic interventional procedure is considered a treating physician. A radiologist performing a diagnostic interventional or diagnostic procedure is not considered a treating physician.)
The specific regulatory language from the Code of Federal Regulations (42 CFR 410.32(a)) states as follows: All diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a 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.
CMS does allow for the following exception for screening mammograms (see CMS Publication100-4, the Medicare Claims Processing Manual, Chapter 18, Section 20.6B:
http://www.cms.hhs.gov/manuals/104_claims/clm104c18.pdf
It states:
A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the screening exam. When a radiologist's interpretation results in additional films, Medicare will pay for both the screening and diagnostic mammogram.
Carrier Claims
For carrier claims, providers submitting a claim for a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier "-GG" to the diagnostic mammography. A modifier "-GG" is appended to the claim for the diagnostic mammogram for tracking and data collection purposes. Medicare will reimburse both the screening mammography and the diagnostic mammography.
See also CIGNA Government Services website for the Radiology Provider Specialty Manual:
http://www.cignagovernmentservices.com/partb/specman/pdf/Radiology.pdf
Date Posted: 7/28/2005 - What is acceptable for correcting medical records/documentation and what is the time period allowed?
See via the attached link a previously published article regarding delayed entries and (from the July/August 2001 issue of the Medicare Bulletin):
http://www.cignamedicare.com/partb/bltin/all/01bltin/01_4/forall/b0104b08b.html
These are not Medicare regulations but would be our expectations on claim reviews.
Please note these references state:
- Medicare expects the documentation to be generated during the time of service or shortly thereafter.
- Delayed entries within a reasonable time frame (24-48 hrs.) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.
- The medical record cannot be altered. Errors must be legibly corrected so that the reviewer can draw an inference as to their origin. These corrections or additions must be dated, preferably timed, and legibly signed or initialed.
- Every note stands alone, i.e., the performed services must be documented at the outset.
- Delayed written explanations will be considered for purposes of clarification only. They cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary.
- All entries must be legible to another reader to a degree that a meaningful review can be conducted.
- All notes should be dated, preferably timed, and signed by the author.
- In the office setting, initials are acceptable as long as they clearly identify the author.
- If the signature is not legible and does not identify the author, a printed version should be also recorded.
Date Posted: 7/28/2005 - With enforcement of electronic claim filing going into effect this summer, how are providers supposed to file claims for modifier 22, unlisted codes, cosurgery, etc. that usually require additional information?
Providers should include a description for the service in the electronic equivalent of field 19 of the claim form. For example, if the provider is requesting additional reimbursement via use of modifier 22, then a description should be entered in the electronic notepad describing why the procedure was extraordinary meriting additional pay. The same guidelines can be used for those claims where providers must substantiate the medical necessity for an assistant at surgery or co-surgeon before Medicare can pay. For example, the notepad could say what/how the other provided assisted or served as a cosurgeon. Finally, in the case of unlisted codes, if there is no specific/listed code for a procedure performed, providers should bill an unlisted code. The procedure can be described in the electronic notepad. In all of these scenarios, the electronic notepad will be reviewed to determine if the information is sufficient to allow payment. If that is not the case, Medicare will develop for the additional information necessary. The amount of space available on the electronic notepad is limited, but we have encountered providers with even less space available per their electronic claim vendor. Providers may need to consult with their vendors to expand their notepads to match the space the contractor allows.
Date Posted: 4/28/2005 - If a patient requires more than one G0351 (therapeutic or diagnostic SQ/IM injection per encounter, how would you file the claim for these? Can an E&M be billed the same date of service as G0351?
If the injections are given for the same diagnosis, then the injections could be reported using G0351 on one line with multiple numbers of services equal to the number given. If the injections are for different indications, then providers should bill G0351 on the same claim but separate lines (using modifier 59 on each line after the first G0351) with each line referenced to the appropriate corresponding diagnosis.
If a significant separately identifiable evaluation and management (E & M) service is performed, the appropriate E & M service code should be reported utilizing modifier 25 in addition to codes G0347-G0354.
See also MedLearn Matters article via http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3631.pdf
Date Posted: 4/28/2005 - What does CIGNA consider as "on-site" supervision for "incident to" services?
Per CMS Publication 100-, the Medicare Claims Processing Manual, Chapter 15 , Section 60.1, Subsection B, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the auxiliary personnel is performing services. CIGNA Government Services would interpret this as in the same office suite which should furthermore be the same floor/building.
See CMS Internet Only Manuals http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf
Date Posted: 4/28/2005 - Does Medicare cover screening services such as ones for abdominal aortic aneurysms, fundus photography for diabetic retinopathy, or CT of chest/coronary arteries for calcium scoring of coronary arteries?
We have seen some providers billing for fundus photography as a screening tool for diabetic retinopathy which is not covered. Fundus photography may be reimbursable only when utilized by qualified providers (ophthalmologists and optometrists) for documenting a baseline in diagnosed retinopathy and follow up examinations as a part of an ophthalmologic evaluation. Other screening services beyond those specifically identified as Medicare benefits in the Medicare manuals are not covered by Medicare. That would include screening aortic aneurysm for beneficiary with history of smoking or family history of aortic aneurysm. CIGNA Government Services previously address calcium scoring of coronary arteries in a bulletin article attached via the following link:
http://www.cignamedicare.com/partb/bltin/all/02bltin/02_5/base_septoct.html#004
Currently, this test is not considered a covered screening benefit by Medicare.
See CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 18 and CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 15, Sections 280-280.4 for detail on screening services covered by Medicare (see respective links below).
http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp
http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf
Date Posted: 4/28/2005 - If the supervising provider is different from the ordering provider, which provider number is used to report "incident to" services?
"Incident to" services should be billed under the supervising physician who would be covering for the patient's normal physician and would be a member of the same group with the patient's physician. If the supervising physician had no relationship with ordering physician, then "incident to" criteria would not be satisfied as supervising physician would have not had an initial service with the patient.
See also MedLearn Matters article via http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3138.pdf
Date Posted: 4/28/2005 - Use of Mesh in Laparoscopic Ventral Hernia Repairs: How does a provider bill and get paid for this?
We can accept the mesh code, 49568, billed in addition to the unlisted laparoscopic procedure code for laparoscopic ventral/hernia repair. Please note in the exceptional circumstance when another hernia repair is done in addition to a laparoscopic or open ventral hernia repair, for example 49505-initial inguinal hernia repair, the mesh code will rebundle. In that scenario, you'd have to bill the unlisted lap procedure with a modifier 22 to receive reimbursement for the mesh.
Date Posted: 1/31/2005 - Frequency of Bone Mineral Density Testing: Long term use of certain medications is a covered indication for more frequent bone mineral density testing. What drugs would this include?
First of all, only for qualified individuals is bone mineral density testing a Medicare benefit. CMS defines this as:- A woman who has been determined by the physician or a qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings;
- An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture;
- An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 7.5 mg of prednisone, or greater, per day, for more than three months;
- An individual with primary hyperparathyroidism; or
- An individual being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy.
See also:
NC LCD: http://www.cignamedicare.com/partb/lmrp_lcd/nc/cms_fu/2003-004.html
TN LCD: http://www.cignamedicare.com/partb/lmrp_lcd/tn/cms_fu/97-31-07.html
CMS Publication 100-4, The Medicare Claims Processing Manual, Chapter 13, Section 140:
http://www.cms.hhs.gov/manuals/104_claims/clm104c13.pdf
Date Posted: 1/31/2005 - Hospice Claims: Why would these claims be denied?
The reason for any denial might be specific to the particular patient; but in general, the lack of modifiers on hospice claims may be the reason the services are being denied.
When a Medicare beneficiary elects hospice coverage he/she may designate an attending physician, who may be a nurse practitioner, not employed by the hospice, in addition to receiving care from hospice-employed physicians. The professional services of a nonhospice affiliated attending physician for the treatment and management of a hospice patient's terminal illness are not considered "hospice services." These attending physician services are billed to the carrier, provided they were not furnished under a payment arrangement with the hospice. The attending physician codes services with the GV modifier "Attending physician not employed or paid under agreement by the patient's hospice provider" when billing his/her professional services furnished for the treatment and management of a hospice patient's terminal condition.
Any covered Medicare services not related to the treatment of the terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be billed by the rendering provider to the FI or carrier for non-hospice Medicare payment. These services are coded with the GW modifier "service not related to the hospice patient's terminal condition."
If another physician covers for a hospice patient's designated attending physician, the services of the substituting physician are billed by the designated attending physician under the reciprocal or locum tenens billing instructions. In such instances, the attending physician bills using the GV modifier in conjunction with either the Q5 or Q6 modifier.
See also:
CMS Manual System, Pub 100-4, Chapter 11, Medicare Claims Processing Manual, Sections 10; 40; 50:
http://www.cms.hhs.gov/manuals/104_claims/clm104c11.pdf
Date Posted: 1/31/2005 - What codes are to be used for laser or radiofrequency ablation of varicose veins?
Patients must first qualify for coverage by satisfying the criteria outlined in the following Local Coverage Decisions and documented in the patients' medical record. For services prior to 01.01.05, the unlisted CPT code 37799 should be used. Providers may also bill CPT code 76986* for intraoperative ultrasound. Claim reviews have revealed providers incorrectly billing CPT codes 36011(select catheterization of first order vein) and 75894(embolization radiologic supervision and interpretation) also being billed although the medical records do not support these services. There is neither introduction of a catheter into a first order vein as the code 36011 describes, nor is there embolization of vein being performed as represented by CPT code 75894. For any remaining 2004 endoluminal ablation of varicose veins claims, providers should bill the unlisted code as advised. For any charges of CPT codes 36011 or 75894 billed in error along with treatment of varicose veins, providers should refund these overpayments. Effective 01.01.05, providers may use CPT codes 36475-36476 and 36478-36479 for radiofrequency or laser ablation respectively. These new codes include all imaging guidance and monitoring which renders billing code 76986 no longer necessary for intraoperative ultrasound. Likewise, please note other imaging codes such as 75894 or 76942 rebundle into this service. Finally, the new 2005 codes also include any catheter introduction or establishing vascular access for these procedures.*Note: CPT code 76986 was deleted and replaced with code 76998 effective 010107. All imaging guidance including intraoperative ultrasound remains component to the procedure codes 36475-36479.
Date Posted: 1/31/2005
Date Revised: 12/31/2007 - What CPT codes are to be used for kyphoplasty of vertebral compression fractures? Can bone biopsies be billed in addition kyphoplasty?
Prior to 010106, providers were to submit claims with CPT code 22899 (unlisted procedure, spine) and state "Kyphoplasty" in Item 19 of Form CMS-1500 form or in its electronic equivalent. For dates of service 010106 and forward, providers should submit the appropriate code(s) from CPT code series 22523-22525. Radiological supervision and interpretation may be billed as applicable with CPT codes 76012 - 76013 (for dates of service before 010107) or 72291-72292 (for dates of service 010107 forward). CPT codes 22325-22327 (Open treatment and or reduction of vertebral fractures and/or dislocations) are not appropriate to bill for this service and exceed the work performed in a kyphoplasty. Providers should not use these codes for billing kyphoplasty.
Casting or the removal of bone to create a cavity for the insertion of the tamp, sometimes submitted as a bone biopsy (i.e. CPT codes 20225-20251), are not separately billable. Bone biopsy would be considered a payable service if the medical record supported a separate effort and indication beyond the kyphoplasty procedure for osteoporotic compression fractures.
See also:
"Kyphoplasty Update" Web site/bulletin article http://www.cignagovernmentservices.com/partb/pubs/news/2003/1003/cope173.html
Date Posted: 1/31/2005
Date Revised: 12/31/2007 - Why would observation services deny when rendered in a hospital?
Denials may be due to the place of service reported. Observation services should be reported as place of service 22, outpatient hospital, and not place of service 21, inpatient hospital. This is supported by CMS Publication 100-4, The Medicare Claims Processing Manual, Chapter 12, Section 30.6.8 that you can access through the following link:
http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf
Visits by other physicians while the patient is in observation status should be billed using the office and other outpatient service codes or outpatient consultation codes as appropriate. In the rare circumstance when a patient is held in observation status for more than two calendar dates, the physician must bill subsequent services furnished before the date of discharge using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.Please see the December 2007 article for additional information.
Date Posted: 10/29/2004
Date Revised: 12/31/2007 - Can a subsequent hospital visit be billed for team conferences in a rehabilitation hospital?
No as the subsequent hospital visits codes, 99231-99233, require a face-to-face encounter with the patient and two of the three key components performed (i.e. history of present illness, an exam and medical decision-making). See CMS Publication 100-4, The Medicare Claims Processing Manual, Chapter 12, Section 30.6.16, Subsection A that addresses team conferences that may also be billed with CPT codes 99361-99362* (which are bundled/not separately payable codes):
http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf*Note: CPT codes 99361-99362 were deleted and replace with 99366/99368 effective 010108 but remain bundled and not separately payable
Date Posted: 10/29/2004
Date Revised: 12/31/2007 - E&M Services for pronouncement of death: Can CPT codes 99238-99239 be billed for pronouncement of death?
Reasonable and necessary medical services rendered up to and including pronouncement of death by a physician are covered diagnostic or therapeutic services. [CMS Manual System, Pub 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 70.4 ( http://www.cms.hhs.gov/manuals)]. The above codes may be billed for this reason as long as the provisions of the code descriptor are met as documented in the medical record. Please see the following article published on our website 0323.4:
http://www.cignamedicare.com/articles/march04/cope766.html.
Date Posted: 10/29/2004 - Why doesn't the local coverage decision for Aranesp/Darbepoetin include anemia due to End Stage Renal Disease?
CMS addresses coverage of Aranesp on patients with ESRD (both on and not yet on dialysis) in CMS Publication 100-2, The Medicare Benefit Policy Manual, Chapter 11, Section 90: http://www.cms.hhs.gov/manuals/102_policy/bp102c11.pdf
Each state's LCD is written to address those indications outside of ESRD use.
Date Posted: 10/29/2004 - Diversified Chiropractic Adjustive Techniques: Can chiropractors no longer bill massages that manipulate the spine?
In the April 2004 (043004) website posting of Part B Medical Review Frequently Asked Questions, the following statement was included under question #6:
Furthermore, massages (including hydromassages) or any other "diversified adjustive technique" do not meet the definition of manual manipulation and should not be billed using CPT codes 98940-98943.
To clarify, coverage of chiropractor services extends only to treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is legal in the State where performed. In addition, in performing manual manipulation of the spine, some chiropractors use manual devices that are hand-held with the thrust of the force of the device being controlled manually. While such manual manipulation may be covered, there is no separate payment permitted for use of this device. All other services ordered or furnished by chiropractors (e.g. massages that do not manipulate a spinal subluxation) are not covered.
See CMS Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, Section 30.5: http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf
Date Posted: 7/26/2004 - What is the status of Medicare coverage of Enteryx for treatment of gastroesophageal reflux disease?
Based on the evaluation of peer reviewed literature and technology assessments, this is considered an investigational service at this present time. Any time providers bill for a service that is statutorily excluded or does not meet the definition of any Medicare benefit, they may append modifier GY. When billing for Enteryx, an unspecified code should be used (as there is no designated code).
Date Posted: 7/26/2004 - What diagnoses would be accepted for medical necessity of renal angiography performed during cardiac catheterization?
There is no predefined set of covered diagnoses for selective or nonselective renal angiography when performed during cardiac catheterization. As for all services reimbursed by Medicare, medical reasonableness and necessity by Medicare's criteria must be present and documented in the medical record. The close proximity of the catheter to the renal arteries and the relative ease with which renal arteriograms could be accomplished is not sufficient, even if the patient suffers from a condition that under certain circumstances may require evaluation with renal arteriography. As an example, the mere presence of hypertension does not justify this study, unless the provider has reason to believe and documents in the medical record that the hypertension is renovascular (accelerated course, resistance to treatment, renal artery bruits, and other features of renovascular hypertension). Furthermore, renal angiography is typically not a first-line diagnostic modality.
Providers should code the diagnosis confirmed by the test; and, if no diagnosis is confirmed by the study, then the symptoms and findings the patient demonstrated necessitating the renal angiography should be coded. Therefore, the medical record would need to support the necessity of the test based on the patient's pertinent findings and how it (i.e. renal angiography) will impact the patient's treatment.
The report must be in keeping with the accepted standard of practice. This usually includes an indication, the description of the methodology, a detailed description of the findings, and an opinion.
Additionally, unless the patient's situation during the cardiac catheterization acutely necessitates the performance of a renal arteriogram, it is Medicare's expectation that this test is ordered specifically by the referring physician (if other than the performing cardiologist).
Please see the December 2003 issue of "Frequently Asked Questions" for additional information on renal angiography: http://www.cignamedicare.com/partb/faq/dec03.html
Date Posted: 7/26/2004 - Can providers bill for services denied due to National Correct Coding Initiative (NCCI) edits?
Providers CANNOT bill beneficiaries for services denied based on NCCI edits. These denials are coding denials. They are NOT denials based on statutory exclusions for which a provider may elect to use an NEMB. They are also NOT medical necessity denials for which a provider may use an ABN (Advanced Beneficiary Notice).
Date Posted: 7/26/2004 - The Use of Locum Tenens for Short Term Coverage: Could a practice hire a locum tenens physician to cover for the regular physician on their weekly days off?
This situation does not match the locum tenens provision. The locum tenens arrangement is distinct from a temporary coverage situation, when one physician fills in for another for brief periods of time, such as after hours, weekends, vacations, and the like. Generally, the locum tenens physician has temporary contractor status. The arrangement cannot be a permanent employment situation in which the substitute "rotates" by covering for physicians on their weekly days off. This, in effect would constitute permanent employment and the application of the locum tenens rules in scenarios for which they were not designed. Whereas a provider's days off are a regularly recurring event without limit, the need for a "fill-in" physician exceeds the 60 day limit inherent to locum tenens. Therefore, a practice could not hire a "fill-in" physician to cover other doctors' days off and bill the services under the locum tenens provision.
See CMS Publication 100-4, Chapter One, Section 30.2.10-11 for specifics on locum tenens through the following link: http://www.cms.hhs.gov/manuals/104_claims/clm104c01.pdf
Date Posted: 7/26/2004 - Sensory Nerve Conduction Threshold Tests (SNCT) and Nerve Conduction Studies: In regards to the 033104 "What's New" article and May 2004 bulletin article, what CPT codes does this apply to?
The unique code for current perception threshold/sensory nerve testing (SNCT) is G0255. The noncoverage is included in the link to the national coverage determination below: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=160.23&ncd_version=2&basket=ncd%3A160%2E23%3A2%3ASensory+Nerve+Conduction+Threshold+Tests+%28sNCTs%29
Please note it states "...this procedure is different and distinct from assessment of nerve conduction velocity, amplitude and latency. It is also different from short-latency somatosensory evoked potentials. Codes designated for eliciting nerve conduction velocity, latency or amplitude, and those designed for short latency evoked potentials are not to be used for SNCT."
This was also published in the May 2004 bulletin:
http://www.cignamedicare.com/partb/bltin/all/04bltin/04_05/base_may05.html
And in Medlearn Matters:
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3339.pdf
What's New Article publication 033104:
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM2988.pdf
Date Posted: 7/26/2004 - What is the status of Medicare coverage of virtual colonoscopy?
At this point and time the Medicare colon cancer screening benefit consists of fecal occult blood testing (FOBT), sigmoidoscopy, colonoscopy, and barium enema, as applicable. Virtual colonoscopy is not included. Also, based on the evaluation of peer reviewed literature and technology assessments, this is currently considered an investigational service. Any time providers bill for a service that is statutorily excluded or does not meet the definition of any Medicare benefit, they may append modifier GY. When billing for a virtual colonoscopy, an unspecified code should be used (as there is no designated code).
Date Posted: 7/26/2004 - When are Unna boots separately payable? Can an evaluation and management visit with modifier 25 also be billed?
Per the NCCI rebundling table, the code for Unna boots ( CPT code 29580) is component to many other comprehensive surgeries (e.g. tendon sheath injections, joint aspiration/injection, etc.) unless a modifier is appended to reflect the Unna boot was used in a distinct, separate service. Unna boots applied as dressings would not be considered a separately reimbursable service apart from surgical procedure as payment for surgical dressings applied by the physician during his/her encounter with the patient is included in the fee schedule payment for the physician's service. For medically necessary Unna boots not applied as post operative dressings, CPT code 29580 may be billed; but an evaluation and management visit should not be billed unless there is a distinct, separately identifiable reason for the E&M service. It would be inappropriate to bill an E&M service for the assessment related to Unna boot application. The assessment would be considered part of the pre-procedural evaluation that is component to the procedure/service. This is reflected in the following link to CMS Publication 100-4, The Medicare Claims Processing, Chapter 12, and Section 30.6.6. It explains that each procedure includes a pre-procedural evaluation that should not be separately billed as a distinct, separately payable E&M visit.
http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf
Date Posted: 4/30/2004 - Does Medicare reimburse ASC facilities for a covered procedure rate and implant cost? Many orthopedic cases involve implants that are substantially more in cost than the group rate fee that is paid.
According to CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 14, Section 10.4, prosthetic devices, other than intraocular lenses (IOLs), whether implanted, inserted, or otherwise applied by covered surgical procedures, are covered; but these are not included in the ASC facility payment amount. These items may be filed separately from the surgery using the appropriate HCPCS code; and if there is no specific code for the implant or prosthesis, providers should use an unlisted HCPCS code. In the latter case, these services would be reviewed to determine whether they fall under Part B or DMERC jurisdiction, if they should be separately paid from the surgery, and if separately paid then how much. Our interpretation for separately payable implants are those that can be set apart from items usually needed to perform the surgery (e.g. wires, screws, clips, tapes, etc.), and we use resources such as the AMA's Relative Value Update Committee notes in making such determinations.
http://www.cms.hhs.gov/manuals/104_claims/clm104c14.pdf
Date Posted: 4/30/2004 - How do ambulatory surgical centers get paid for procedures not on the approved list?
Generally, for CPT codes not on the ASC reimbursable list and that do have facility and non-facility prices, the physician gets reimbursed at a nonfacility level. There may be an arrangement between the physician and ASC where the physician might forward some of the differential amount to the ASC. For CPT codes that have identical reimbursements in and outside a facility, this may or may not be feasible and depends on the arrangement and ownership relationship that the physician and ASC might have. It may not be feasible to perform this procedure in an ASC, but this is not within our judgment and jurisdiction. The carrier does not determine when there is a facility/non-facility fee for a given procedure or what procedures are on the approved list. We receive these instructions from CMS. This list can be seen on the CMS website through the following link under "Ambulatory Surgical Center (ASC) Base Eligibility File":
http://www.cms.hhs.gov/providers/pufdownload/default.asp?#asc
Date Posted: 4/30/2004 - 99211: Can this code be billed at the same time an injection is given or a protime or urinalysis is collected? Can it be billed for assessment of vital signs?
CPT code 99211 cannot be billed solely for the purpose of administering an injection or collecting a specimen for a diagnostic test. Furthermore, it should not be billed for routine vital signs that would not impact the patient's care. Checking a patient's vital signs as part of a drug administration encounter would be component to the drug administration codes as would observing the patient for a response to an injection. For services furnished on or after January 1, 2004, CMS will not allow CPT code 99211 to be billed on the same day as a drug administration code that has a work relative value unit. The law defines drug administration services as those services classified as of October 1, 2003, within any of the following groups: therapeutic or diagnostic infusions (excluding chemotherapy); chemotherapy administration services; and therapeutic, prophylactic, or diagnostic injections. Effective January 1st, the work RVU's for 99211 have been added to CPT drug administration codes 90780-90781, 90782-90788, 96400, 96408-96425, 96520 and 96530. For example, this means that CPT code 99211, with or without modifier -25, is not separately payable on the same day as a chemotherapy administration service (such as 99211 could not be billed for assessment of fitness for chemotherapy). If other office visits are billed the same date of service as drug administration codes, there must be documentation in the medical record of a separately identifiable reason for the E&M service, in which case modifier -25 would apply. Also, please note that the MPFSDB Status Code indicator for CPT codes 90782 - 90788 has not changed. It remains "T" with the following definition: "There are RVU's for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed under the same date by the same provider, these services are bundled into the service(s) for which payment is made." In other words, when an E/M service is billed with a code of the series 90782 - 90788, the latter will deny.
It would be difficult to discuss here every possible correct and incorrect use of 99211, but CPT code 99211 does require a documented face to face evaluation and management service that has an impact on the patient's care. If a patient comes in for lab, leaves and a telephone call is later made to give pt instructions, 99211 should not be billed as face-to-face E&M service as required in the code was not met. Merely assessing the patient's vital signs in addition to the labwork would not substantiate separately billing 99211. There should be documentation in the medical record such as the patient/clinician exchanging medically significant and necessary information, and there is management of patient's care via medical decision making e.g. change in a med regimen. 99211 should not be used though just for writing of new or renewal prescriptions if no other E&M service is rendered. Finally, even though the code does not require the presence of the physician in the patient's room or a face to face encounter with the physician, the service would be done face to face with the physician's staff and "incident to" a physician's service. In other words, the physician must be in the office suite and immediately available.
Please see the 09-20-07 article for additional information.
Date Posted: 4/30/2004
Date Revised: 12/31/2007 - Billing Technical and Professional Components of Diagnostic Tests: When placing a Holter monitor on a heart patient that will be worn by the patient for 24 hours or a cardiac event monitor that will be worn for 30 days, what dates do you bill for the technical component for the hook-up and what date do you bill for the date of the physician's interpretation, since these dates are different?
Generally, the Medicare rule is that services (or their components if applicable) must be billed for the date of service on which they were performed. For example, tests with professional and technical components/codes, each component (per its corresponding code) would be billed on the date when it was performed. For global tests only, e.g. Holter monitor that is billed with the global code only (for example, CPT code 93224), the date of service would be when the test was completed (i.e. interpreted).
Whether a 24 hour Holter or 30 day cardiac event monitor, the date of service to report would be equal to the date the service as described by the code was completed. Therefore, the technical component for recording as in 93225 or 93270 (Holter monitor and cardiac event recorder, respectively) would likely be one date whereas the date of the physician's interpretation ( CPT codes 93227 or 93272) would be another. As another example, code 93224 would be reported the date the interpretation was completed even though the code also includes hook-up which would have been done on another/earlier date of service.
Date Posted: 4/30/2004 - Can a chiropractor refer a patient for diagnostic tests?
According to CMS Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, Section 30.5, coverage of chiropractor services is a follows:
Coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is legal in the State where performed. All other services furnished or ordered by chiropractors are not covered. If a chiropractor orders, takes, or interprets an x-ray or other diagnostic procedure to demonstrate a subluxation of the spine, the x-ray can be used for documentation. However, there is no coverage or payment for these services or for any other diagnostic or therapeutic service ordered or furnished by the chiropractor.
Furthermore, massages (including hydromassages) or any other "diversified adjustive technique" do not meet the definition of manual manipulation and should not be billed using CPT codes 98940-98943.
Date Posted: 4/30/2004 - How do you bill for ESRD services for at home dialysis patients that die within the month? Are there any other common billing problems with the new ESRD codes?
The new HCPCS codes G0320-G0323 are for home dialysis patients. These codes are defined "per full month." When a patient expires, do not span the dates of the service you are billing past the beneficiary's date of death. Also, we have noted an error when providers try to bill for monthly capitation using "30" for the number of service. This should be reported as only "1" number of service. Also, when home dialysis patients are hospitalized sometime during the month, daily management ( HCPCS codes G0324-G0327) must be reported for the days the patient is not in the hospital; and monthly management should not be billed. Furthermore, the number of services billed for the daily code should equal the number of days the patient is not in the hospital, and the dates of service for these must not coincide with the hospital dates.
Date Posted: 4/30/2004 - Credentialed Facilities and Staff for Noninvasive Vascular Tests: Have there been changes in the coverage of noninvasive vascular tests?
Each state's local medical review policy requires the facility and staff performing noninvasive vascular testing to be credentialed. This guideline was effective for North Carolina on January 1, 2002 and January 1, 2004 for Tennessee and Idaho. (See links to the current lmrps below).
We have received a variety of questions with the carrier's responses summarized as follows:
- "Incident to" guidelines do not apply to technologists. Therefore, a noncredentialed technologist cannot perform these tests under the supervision of a credentialed technologist.
- Physician supervision at the appropriate level (as directed by the MFSDB physician supervision indicator--see attached link) would still be required for credentialed technologists
Medicare Physician Fee Schedule Database:ÿ http://www.cms.hhs.gov/physicians/mpfsapp/step1.asp
NC LMRP: http://www.cignamedicare.com/partb/lmrp/nc/cms_fu/2000-008-08.htm
ID LMRP: http://www.cignamedicare.com/partb/lmrp/id/cms_fu/2003-04.html
TN LMRP: http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/96-07-05.html
Date Posted: 1/27/2004 - How often can lipid testing be done? What about measuring the direct LDL?
Previously, there were local medical review policies for lipid testing, but these were retired in deference to the implementation of a national coverage determination by CMS that can be viewed at the following link:
http://cms.gov/mcd/viewncd.asp?ncd_id=40-12&ncd_version=7&show=all
The above addresses indications for performing and frequency of testing. Deviating from these guidelines would need to be supported by clinical indication(s) as documented in the medical record.ÿ Providers have inquired about separately billing for a direct LDL beyond the calculated LDL included in a lipid profile (as the latter can be an inaccurate value if the triglycerides are high).ÿ If the patient's treatment will be impacted by these results (i.e. by additional dietary or pharmacological therapy) then it is acceptable to separately bill a direct LDL with modifier 59 in addition to the lipid panel. There is no set guideline for a triglyceride level that should be followed with a direct LDL measurement.ÿ Testing should be driven by medical reasonableness and necessity rather than an institutional protocol level for triglycerides.
Date Posted: 1/27/2004 - PA's and NP's Performing "Incident To" in SNF/NF: How does CIGNA audit records for evaluation and management visits in nursing facilities (skilled or otherwise)?
CMS stipulates that "incident to" is not covered in an inpatient setting. Therefore, if claims reviewed find that nonphysician practitioners (i.e. physician assistants, nurse practitioners, etc.) perform these visits and not the physician whose provider number the service is being billed under, the service will be denied. The nonphysician practitioners should bill their inpatient visits under their own provider numbers.
Date Posted: 1/27/2004 - What is the status of codes G0289 and 29877 in relation to other arthroscopic knee procedures?
CPT code 29877 is arthroscopic debridement/shaving of articular cartilage (chondroplasty) which is a component of more comprehensive procedures such as 29881 (arthroscopic medial or lateral meniscectomy) and 29883 (arthroscopic repair of medial and lateral meniscus). This code has been through multiple revisions as far as NCCI rebundling edits. Furthermore, there has been the addition of the HCPCS code G0289 (arthroscopy of knee for removal of loose or foreign body, chondroplasty at the time of other surgical knee arthroscopy in a different compartment of the same knee).ÿeffective 030103. Presently, code 29877 may be separately billed if performed in a different compartment of the same knee (as also being treated with, for example 29881 or 29883) or in the contralateral knee for dates of service prior to 030103. For dates of service after 030103, providers should use G0289; but providers should not use 2987