Medical Review Frequently Asked Questions - July 2005
Web site posting July 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.
- Low Osmolar Contrast
Q: How are providers supposed to bill with the new low osmolar contrast codes?
A: 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.
- Nursing Home Visits
Q: 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?
A: 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.
- Nursing Home Visits
Q: 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?
A: 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.
- Internal Medicine and Family Practice Visits Same Date
Q: 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?
A: 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.
- "Incident To"
Q: 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?
A: 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.
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Drug Adminstration Codes
Q: With the new drug administration codes, how do you bill if more than one infusion is performed?
A: 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
- New Patient Visits
Q: 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?
A: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.
- Radiologists
Q: Can a radiologist order additional tests if medically necessary as long as they document the medical necessity and write an order?
A: 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
- Corrections in the Medical Record
Q: What is acceptable for correcting medical records/documentation and what is the time period allowed?
A: 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.
