Medical Review Frequently Asked Questions - October 2004
Website posting October 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. Providers may submit questions to the website at http://www.cignamedicare.com/customer_service/disclaimer.html.
- Denials for Hospital Observation
Q: Why would observation services deny when rendered in a hospital?
A: Denials may be due to the place of service reported. Observation services should be reported as place of service 22, outpatient hospital, and not place of service 21, inpatient hospital. This is supported by CMS Publication 100-4, The Medicare Claims Processing Manual, Chapter 12, Section 30.6.8 that you can access through the following link:
http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf
Visits by other physicians while the patient is in observation status should be billed using the office and other outpatient service codes or outpatient consultation codes as appropriate. In the rare circumstance when a patient is held in observation status for more than two calendar dates, the physician must bill subsequent services furnished before the date of discharge using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.Please see the December 2007 article for additional information.
- Team Conferences in a Rehab Hospital
Q: Can a subsequent hospital visit be billed for team conferences in a rehabilitation hospital?
A:No as the subsequent hospital visits codes, 99231-99233, require a face-to-face encounter with the patient and two of the three key components performed (i.e. history of present illness, an exam and medical decision-making). See CMS Publication 100-4, The Medicare Claims Processing Manual, Chapter 12, Section 30.6.16, Subsection A that addresses team conferences that may also be billed with CPT codes 99361-99362 * (which are bundled/not separately payable codes):
http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdfNote: CPT codes 99361-99362 were deleted and replace with 99366-99368 effective 010108 but remain bundled and not separately payable
- E&M Services for pronouncement of death?
Q: Can CPT codes 99238-99239 be billed for pronouncement of death?
A: Reasonable and necessary medical services rendered up to and including pronouncement of death by a physician are covered diagnostic or therapeutic services. [CMS Manual System, Pub 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 70.4 ( http://www.cms.hhs.gov/manuals)]. The above codes may be billed for this reason as long as the provisions of the code descriptor are met as documented in the medical record. Please see the following article published on our website 0323.4:
http://www.cignamedicare.com/articles/march04/cope766.html. - Aranesp for Non-ESRD Use
Q: Why doesn't the local coverage decision for Aranesp/Darbepoetin include anemia due to End Stage Renal Disease?
A: CMS addresses coverage of Aranesp on patients with ESRD (both on and not yet on dialysis) in CMS Publication 100-2, The Medicare Benefit Policy Manual, Chapter 11, Section 90: http://www.cms.hhs.gov/manuals/102_policy/bp102c11.pdf
Each state's LCD is written to address those indications outside of ESRD use.
