Medical Review Frequently Asked Questions - April 2004
Website posting April 2004 - Revised 12.31.07
The following represent a variety of questions the Medical Review department has received. CIGNA Government Services will address at least quarterly "Frequently Asked Questions" related to coverage and local coverage determination issues. The previous issue was published in the December 2003 website bulletin. New issues of FAQ's are, generally, first posted on the website "What's New" section and list served to registered providers. Providers may submit questions to the website at http://www.cignamedicare.com/customer_service/disclaimer.html. Providers may register for list serve announcements at the following website: http://www.cignamedicare.com/mailer/subscribe.asp.
- Unna Boots
Q: When are Unna boots separately payable? Can an evaluation and management visit with modifier 25 also be billed?
A: :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.
- ASC
Q: 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.
A: 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.
- ASC
Q: How do ambulatory surgical centers get paid for procedures not on the approved list?
A: 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
- 99211
Q: 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?
A: 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.
- Billing Technical and Professional Components of Diagnostic
Tests
Q: 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?
A: 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.
- Chiropractor Services
Q: Can a chiropractor refer a patient for diagnostic tests?
A: 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.
- ESRD
Q: 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?
A: 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.
