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 medical review policy issues. Providers may submit questions to the website at http://www.cignagovernmentservices.com/customer_service/disclaimer.html.

1. Nonphysician Practitioners (NPPs) Performing Initial Visits, Consults & Critical Care

Q: Can nurse practitioners and physician assistants perform and bill for consultations, initial visits, and critical care?

A: 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.

2. Non-physician Practitioner Consult followed by Physician Consult

Q: Can non-physician practitioners such as nurse practitioners and physician assistants perform consultations?

A: 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.

3. Use of NonphysicianPractitioners (NPPs) in New Patient Visits or Consultations

Q: 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?

A: 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."

4. Split/share Initial Hospital Visits

Q: Can an initial hospital visit be split/shared?

A: 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).

5. Appropriate Drug Adminstration Code for Xolair

Q: Which CPT code for drug administration should be used for the subcutaneous injection of xolair— 90772 or 96401?

A: 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
• North Carolina
• Tennessee

6. Coverage of Intra-articular Hyaluronates

NOTE: Please see the June 2007 Medical Review FAQ for updates to this topic.

Q: Does Medicare cover viscosupplementation treatment of the knee?

A: 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.

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.