Medical Review Frequently Asked Questions - April 2005
Web site posting April 2005
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. Providers may submit questions to the Web site at http://www.cignamedicare.com/customer_service/disclaimer.html.
- Electronic Claims for Services requiring additional documentation?
- G0351
- Onsite Supervision for "Incident To" Services
- Miscellaneous Screening Services
- Supervising Provider for Incident To Services
Q: If the supervising provider is different from the ordering provider, which provider number is used to report "incident to" services?
A: "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
Q: 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?
A: 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.
Q: 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?
A: 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
Q: What does CIGNA consider as "on-site" supervision for "incident to" services?
A: 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
Q: 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?
A: 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
