October 1, 2007
Medical Review Frequently Asked Questions
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 through our Online Inquiry System.
Certified Diabetes Educators and Diabetes Self Management Training (DSMT)
Question: How do they bill for this?
Answer: DSMT is billed using HCPCS code G0108 and G0109. DSMT can be furnished by anyone who qualifies for direct payment for services done by Medicare and meets the definition of certified provider as stated in CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 15, section 300.2.
The services of a certified diabetes educator (CDE) could be billed as part of an accredited DSMT program or if he/she is eligible for direct payment from Medicare (for example, a nurse practitioner who is also a certified diabetes instructor). A CDE that is not able to directly bill Medicare could not do DSMT as an "incident to" service to a physician billed either as DSMT or as an E&M visit (i.e. either service billed under the physician's number). If ancillary staff provides Diabetes training in the course of an office visit, it is considered bundled into a medically necessary E&M visit provided by the billing physician that same date. If the only reason for the encounter was Diabetes training by the ancillary staff in an office setting, then the only code billable for this would be 99211. We have seen errors such as providers billing, e.g., the highest level office visit, CPT code 99215, for visits only between the patient and a CDE on staff and billed under the physician's number
Additional information on this service (including eligible beneficiaries, individual training, etc.) can be found in sections 300-300.501 in the same cite above. Also, CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 18, beginning with section 120 details coding, payment and frequency.
Fracture care in the Emergency Room
Question: How should ER doctors bill for splinting/casting of patients with fractures that are referred to orthopedists?
Answer: If the ER doctor is only applying a cast or strapping to stabilize or protect a fracture, injury, or dislocation and/or to afford comfort to a patient, then the code billed should be from the "Application of Casts and Strapping" section of the CPT Manual including CPT Codes 29000-29590. Furthermore, if the ER physician does not perform any restorative treatment nor plans on providing subsequent fracture care, then the ER physician should bill only the appropriate casting/strapping code and not a code for co-managed fracture care (e.g. CPT code 25600 + modifier 54). The ER physician may also report the appropriate level of E/M with the -25 modifier appended if the key components for the Evaluation and Management (E/M) service is met. The orthopedist should then be able to bill the fracture care code globally.
Robotic assisted surgery
Question: Does Medicare pay for robotic assistance?
Answer: No additional payment would be made beyond reimbursement for the CPT surgery code. For example, we would not pay any differently for an oophorectomy w/robotic assistance as compared to an open or laparoscopic oophorectomy.
Outsourcing of radiology services outside the United States
Question: Can Medicare be billed for these circumstances?
Answer: Medicare cannot be billed in this case. CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 16, section 60 states:
"Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside of the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India ".
There is also a Medicare Learning Network Matters article published this year by the Center for Medicare and Medicaid Services.
