Idaho Ask-the-Contractor Teleconferences (ACT)
CIGNA Government Services is hosting a quarterly "Ask-the-Contractor" teleconference. This call will give us an opportunity to highlight a few new Medicare topics for you and will offer you an open forum for asking questions and sharing your ideas on any Medicare topic. The next call is not yet scheduled scheduled.
Schedule:
TBD
Minutes:
To learn more about the discussion topics at ACT meetings, access recent ACT minutes here:
Questions and Answers:
March 15, 2006
- Scenario #1: 66 year old presents to the ED after an auto accident with blunt abdominal trauma. He appears stable, and is worked-up and observed appropriately. The initial evaluation supported, let’s say a 99284. The patient continued to be observed for an hour or so after the initial evaluation. Then, as the ED was awaiting further labs and studies the patient arrested and critical care was provided by 35 minutes.
Scenario #2: ED E/M and Critical Care Question: The ED received a 65 year old Medicare patient following an auto accident. Comprehensive history, exam and MDM were made. The patient was not critical when he presented to ED. Over a two-hour stay (awaiting patient studies and observation), the patient "crashed" requiring 30 minutes of critical care by same ED doctor. I believe both should be reimbursed and am aware of MCM documentation which addresses how the patient "presents." Patty did a great job attempting to answer this - I suspect my question was not clear. Key comment - the patient did not PRESENT needing critical care, and patient actually had two different services by ED physician.
The Questions: Is it appropriate to code both the ED-25 and CC? I have asked the question of CIGNA Medicare and received a no answer with the attached citation of the MCM. I am not convinced the actual answer is “No.” It may simply be a matter of the way the information was published. In other words, I know what it says but I am not sure it means what it says. (MCM Citation saved as PDF file.)
Answer from CIGNA Government Services Medical Review staff: It is possible to bill both an ED encounter and a critical care encounter on the same day, but the scenarios described do not appear to meet criteria to do so. Each service must be completed to bill for it, and in the above examples, the ED visit does not seem to be a complete service, as the patient is awaiting return of labs and studies and still in the ED awaiting some disposition when the “crash” occurs, so further treatment would be merely a continuation of the ED service. (Note: Because the ED services have never had “average” times as part of their descriptor, prolonged service codes cannot be used with ED services.) In the situations described, the provider could bill for a high level ED visit, OR a Critical Care visit, but not both.
Had the patient been admitted, and experienced the “crash” shortly after arriving in the admission location, and the ED physician was called to see the patient and done the critical care, then both could have been billed.
- Why aren't claims crossing over to Blue Cross of ID (and a few other 2nd insurances) for my patients? What can I do to facilitate this? I've never gotten a straight answer on this from Medicare customer service.
Answer from CIGNA Government Services: Providers should check with the secondary insurance to ensure that the patient’s Health Insurance Claim Number was sent to CIGNA Government Services on the crossover tape so claims will accurately cross to the secondary.
- A. Who can we contact to check on our Corrected Claims still being worked on since
May 2005?Answer from CIGNA Government Services Customer Service: Jan Patterson will work with Doris to review the status of these claims.
B. Who reviews Category III codes 0001T - new 2004 - I have claim for a patient that got denied in error for C0-17 - It is now denying for timely filing but issue was incorrect denial originally - Without local help and Wendy Collins in Nashville helping - our claims did not process on this code. 3. Unlisted codes - 22 modifiers - who has been reviewing these claims for payment when document sent in with claim? I have two claims I have not been able to get paid. Would like to discuss. Who will be reviewing once we send electronically w/o documentation?
Answer from CIGNA Government Services Medical Review: Medical Review will review these codes and if needed, will develop the claim for additional medical necessity.
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Do the Therapy Caps apply to a patient who is in a SNF bed, but not a skilled level of care patient? Can this be billed as Hospital outpatient PT?
Answer from CIGNA Government Services Medical Review department: In the situation provided above, no, this service cannot be billed as Hospital Outpatient PT. Physical Therapy services rendered in the outpatient hospital setting are not subjected to the therapy caps.
September 7, 2005
- How does an Ambulatory Surgery Center, get implants other than IOL's paid for by Medicare?
- Response: Penny Morton from CGS stated to remove the SG modifier and include manufactures invoice along with the claim.
- Lisa Fix with CGS also mentioned that there is a web page within CMS’ Web site dedicated only to ASC – www.cms.hhs.gov/suppliers/asc/default.asp
- We have been unable to receive payment for the drug Macugen. We have received several different answers as to how to su mit the NDC # and name and dosage however every time it is changed and resubmitted it is still incorrect. We have over 100 of these at $1000 (our cost). Any ideas?
- Response: Jo Ann Yardley with CGS stated that there is a required diagnosis 362.52 for this drug, Macugen. This instruction was part of the drug update that was released on CGS’ Web site.
- IS THERE STILL A LINE SPECIFIC FOR TELEPHONE REVIEWS? IF SO, WHAT IS THE NUMBER AND WHAT TYPES OF DENIAL CODES CAN BE BE REVIEWED BY PHONE?
There has been a correction made since the call…the correction is in bold below.
Response: Lisa Fix with CGS stated The Idaho telephone review # is 1.866.520.4021 and the lines are open from 8:30 until 11:30 CT and closed for lunch and re-opened at 12:30 until 3:30 CT daily. Effective December 31,2005, CMS is eliminating the telephone review process and all appeals will need to be sent in as written appeals.
