General Compliance Question of the Week
Archive
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September 29, 2008
Question:
The Medicare guidelines state that hospitals should not report, as observation
care, services that are part of another Part B service, such as postoperative
monitoring during a standard recovery period (e.g., four to six hours),
which should be billed as recovery room services.
My question is, should that four to six hours be fulfilled before the patient
is placed in observation? Or can a patient be placed in observation sooner
if the physician deems it to be necessary? And if so, is there a time frame
that would be considered reasonable for that determination to be made.
I realize that complications such as bleeding can be recognized fairly
soon, but is there a time frame to determine if the medication has been
successful after administration of an anti-emetic or analgesic?
Answer:
Observation begins when the patient is placed in the bed in which the observation
services will be performed. For example, the patient had surgery and now
is experiencing severe nausea and vomiting. The physician writes the order
for observation, and the patient is transferred out of PACU to the floor
to be observed. When the floor accepts the patient, the observation time
begins. The patient does not have to complete four to six hours of routine
recovery. The key is when the patient is placed in the bed where the observation
is going to happen.
As far as we know, no rules exist about specific time frames after a medication
is administered.
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September 22, 2008
Question:
Can you explain when and how the presence of a HAC will affect inpatient
payments?
Answer:
Effective October 1, 2008, Medicare will no longer assign an inpatient hospital discharge to a higher-paying MS-DRG if a hospital-acquired condition (HAC) was not present on admission (POA). The case will be paid as though the second diagnosis was not present.
More on HACs can be found in the FY 2009 final inpatient PPS rule at http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1390-F.pdf.
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September 15, 2008
Question:
I am in Indiana. We use a physician group and nurse practitioners (NPs)
to provide all physician coverage in our emergency department (ED). The
NPs see patients, provide all treatment and document all care on the T sheet
and order sheet,
including diagnosis. Does the ED physician need to countersign for the NP's
documentation?
Answer:
As incident-to rules do not apply to hospital services, the NPs should be credentialed with the payers and should be billing using their own IDs. This will result in reduced fee schedule allowables in many cases but will ensure compliance.
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September 8, 2008
Question:
Is it appropriate for local medical review policies (LMRP) to require daily
notes to be written for therapy services?
Answer:
According to the Centers for Medicare & Medicaid Services (CMS, treatment
notes are required daily to justify the billing. They must contain the following:
date of treatment, total timed code treatment minutes, total treatment time
including timed and untimed minutes, identification of each intervention/modality
provided, signature and professional identification of the qualified professional
who furnished or supervised, and identification of each person who contributed
to treatment during that encounter. Further documentation to justify the
necessity of the service is required in a progress report, due every 10
treatment days or at least once every 30 calendar days whichever is less.
For details, go to Chapter 15, section 220.3 of the Medicare Benefit
Policy Manual at
http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.
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September 1, 2008
Question:
Are stamped signatures on the medical record allowed by Medicare payers?
Answer:
According to SE0829, issued by the Centers for Medicare & Medicaid Services (CMS), stamped signatures are not acceptable on any medical record. Medicare will accept hand written, electronic signatures or facsimiles of original written or electronic signatures. These requirements are intended to apply all providers/suppliers. For this memo, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0829.pdf.
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August 25, 2008
Question:
Are hospital ED services paid for on the same date as critical care services
when provided by the same physician to the same patient?
Answer:
Here's how it goes according to the Centers for Medicare & Medicaid Services (CMS). When a hospital inpatient evaluation and management (E&M) service was furnished on a day when the patient does not require critical care and then the patient subsequently requires critical care, both critical care services (CPT codes 99291 and 99292) and the previous E&M service may be paid on the same date of service. Physicians and qualified nonphysician practitioners must retain supporting documentation for discretionary contractor review if claims are questioned. For the transmittal describing this policy, go to http://www.cms.hhs.gov/transmittals/downloads/R1545CP.pdf.
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August 18, 2008
Question:
When does Medicare require procedure and device codes to be billed together
on a claim?
Answer:
Procedure-to-device edits require that when a particular procedural HCPCS code is billed, the claim must also contain an appropriate device code. Failure to pass these edits results in the claim being returned to the provider. Device-to-procedure edits require that a claim that contains one of a specified set of device codes be returned to the provider if it fails to contain an appropriate procedure code.
The updated lists of both types of edits can be found under "2008 Device and Procedure Edits" at http://www.cms.hhs.gov/HospitalOutpatientPPS/ .
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August 11, 2008
Question:
Any news yet on how ASCs will be paid for Medicare services in 2009?
Answer:
According to the 2009 proposed rule for the hospital outpatient prospective payment system (OPPS) and the PPS for ambulatory surgical centers (ASCs), this is the second of a four-year transition that aligns ASC rates with the ambulatory payment classification (APC) groups used to pay for services in hospital outpatient departments. In 2009, CMS will continue the transition to the new payment rates, with ASC services paid at a 50/50 blend of their 2007 payments and their 2009 payments. The 2009 payments are 65 percent of the hospital outpatient rate.
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August 4, 2008
Question:
Why does CMS continue to make cuts to Medicare physician payments, which
are then canceled by congressional action?
Answer:
Most of the actions taken by the Centers for Medicare & Medicaid Services (CMS) are a result of some federal law. The physician reimbursement cuts are required by the Medicare sustainable growth rate (SGR) formula, which dictates that once the volume of physician services reaches a certain threshold, payment for each individual service is decreased to remain within a predetermined spending limit. Such reductions impose an arbitrary payment that does not factor in the cost to physicians of providing services.
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July 28, 2008
Question:
What does the hospital prospective payment system (OPPS) cover and not
cover?
Answer:
The OPPS covers the costs of facilities, equipment, supplies, and hospital staff, but do not pay for the services of physicians and nonphysician practitioners who are paid separately under the Medicare physician fee schedule (MPFS).
Beneficiaries share in the cost of services under the OPPS by paying either a 20 percent coinsurance rate or, for certain services, a copayment (as required under the Medicare law) not to exceed 40 percent of the total payment for the APC.
The statutory copayment is gradually being replaced by the 20 percent coinsurance as payment rates for the APCs increase. CMS estimates that the beneficiary share of the proposed total payments for Medicare-covered outpatient services will be about 23 percent in CY 2009.
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July 21, 2008
Question:
Do you know what kind of changes CMS will make to the ASC payment system
in 2009?
Answer:
For 2009, CMS proposes to add nine surgical procedures to the list of procedures for which Medicare will pay when performed in an ambulatory surgical center (ASC). These include three procedures for which the American Medical Association's CPT Editorial Panel created new codes and descriptors and six procedures that were previously excluded from payment under the ASC payment system.
CMS also proposes to add five procedures to the list of office-based procedures (subject to payment at the lesser of the office practice expense payment to the physician or the standard ASC rate), and to update the list of device-intensive procedures and covered ancillary services and their rates, consistent with proposals in the outpatient prospective payment system (OPPS) update.
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July 14, 2008
Question:
When will the 2009 proposed rules for the Medicare program be issued?
Answer:
The 2009 proposed rules for the hospital outpatient prospective payment system (OPPS) and the Medicare physician fee schedule (MPFS) already have been issued by the Centers for Medicare & Medicaid Services (CMS). For the OPPS proposal, go to http://www.cms.hhs.gov/center/hospital.asp and check under Spotlights. For the MPFS proposed rule, also check under Spotlights at http://www.cms.hhs.gov/center/physician.asp.
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July 7, 2008
Question:
What is the proper way for us (hospital billers) to determine the length
of time that critical care services were provided for an outpatient?
Answer:
According to the Centers for Medicare & Medicaid Services (CMS), the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this face-to-face care, the time involved can only be counted once.
The answer above and other frequently asked questions regarding OPPS visit codes can be found at http://www.cms.hhs.gov/HospitalOutpatientPPS/downloads/OPPS_Q&A.pdf.
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June 30, 2008
Question:
My question relates to billing epotein alfa (EPO) and darbepoetin alfa
(Aranesp) related to an emergency or unscheduled dialysis treatment in the
outpatient hospital setting (bill types 13x and 85x). What codes are used?
Answer:
The Centers for Medicare & Medicaid Services (CMS) addresses the details of this topic in Transmittal 1503 http://www.cms.hhs.gov/Transmittals/Downloads/R1503CP.pdf. It noted that payment for codes Q4081 and J0882 will be made only when code G0257 appears on the same claim. If code G0257 is not on the claim with injection codes Q4081 and J0882, your Medicare fiscal intermediary or Part A/B Medicare administrative contractor (MAC) will return the claim to the hospital. For the provider-information memo on the topic, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6047.pdf.
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June 23, 2008
Question:
What revenue codes must be used for blood and blood products?
Answer:
To ensure correct application of the Medicare blood deductible, providers that incur a cost for blood should use revenue code 381 (packed red cells) to report charges for a whole unit of packed red cells. For charges for a whole unit of whole blood, use revenue code 382 (whole blood). Not reporting the correct revenue code will cause your claim to be returned. (Note: Revenue code 380 is not a valid revenue code for Medicare.)
Providers should bill split units of packed red cells and whole blood using revenue code 389 (other blood) and should not use revenue codes 381 or 382. Providers should bill split units of other blood products using the applicable revenue codes for the blood product type, such as 383 (plasma) or 384 (platelets), rather than 389.
If your facility utilizes the 38X series of revenue codes there is a requirement to distinguish between cost of blood (38X) and storage and processing cost (390). This means that two line items are billed per unit. Each line is reported on the claim with modifier BL appended.
Note that the above instruction is specific to the facility that incurs
a cost for blood rather than storage and processing. In today’s environment,
facilities that pay for blood are a minority. Most arrangements between
a blood supplier / community donor station and the transfusing facility
provide for payment of storage and processing fees rather than the cost
of blood. This means that the majority of hospitals will report blood and
blood products with revenue code 390. In this scenario use of modifier BL
is not indicated.
For more on blood and blood products, see Transmittal 1495 at http://www.cms.hhs.gov/transmittals/downloads/R1495CP.pdf.
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June 16, 2008
Question:
We have had claims rejections due to legacy numbers in the secondary provider
identifier field. Can you tell us what to do?
Answer:
Reimbursement managers should be aware that it is the claim submitter's responsibility to obtain the secondary (ordering, referring, attending, operating, other, service facility, or purchased service) provider's national provider identifier (NPI) on the claim.
Don't despair though-CMS has created a temporary workaround given the trouble billing providers may have obtaining these numbers. If, after reasonable effort, billing providers cannot obtain a secondary provider's NPI, then they may use their own NPIs in the secondary provider fields.
Go to the CMS communication about this at www.cms.hhs.gov/NationalProvIdentStand/02_WhatsNew.asp#TopOfPage.
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June 9, 2008
Question:
Patients are sent by the physician to the hospital for many services (e.g.,
dressing changes and accessing subcut ports for later home health IV therapy)
for which there is no CPT code assigned and no Medicare reimbursement. We
have created a substantial nursing assessment that exceeds those that may
be expected for the procedures for which the patients are presenting. We
currently use the low level clinic visit but would like to know the following.
If we established protocols based on resource usage similar to those created
for the technical evaluation and management (E&M) levels in the emergency
room, would it be appropriate and compliant to charge other clinic E&M
levels based on these protocols?
Answer:
If we understand your question, you want to know if you can report more
than just the low level E&M office visit codes (99201 / 99211) for those
services that cannot be reported with a separate CPT procedure code. Our
answer is yes, if, based upon the E&M level criteria that you have developed
for your facility, the resource utilization justifies assigning a higher
level than just level one. If so, you should report accordingly.
CMS has indicated in previously published outpatient prospective payment
system final rules that it expects facilities that define their criteria
to include all levels of care (usually five levels for the new/ established
codes 99201-99205 and 99211-99215). For the services you mentioned and others
review the CPT codes that have been added and/or changed for 2008, as there
may have been codes created to address some of the reporting that you could
have been using the E&M level codes.
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June 2, 2008
Question:
I know that the HIPAA rule about transactions and code sets requires that
medical data codes that are valid at the time health care is furnished be
used for reporting services. When reporting inpatient hospital or other
extended stay facility services that span a range of dates, what date is
to be used as the date of service to determine valid medical codes?
Answer:
In one of its frequently asked questions, the Centers for Medicare & Medicaid Services state the following. For inpatient claims, the date of discharge is used as the date to determine valid medical codes, and other codes that are dependent upon service date for validity. For outpatient claims, the actual date that the service was rendered is reported with the service item at the line level, and used to determine valid medical codes and other codes that are subject to service date for validity.
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May 26, 2008
Question:
How do you determine whether Medicare is the primary or secondary payer?
Answer:
In most cases, Medicare is primary. According to the Centers for Medicare & Medicaid Services, some of the most common situations where Medicare can pay secondary include: 1) the individual or his/her spouse is currently employed or working and covered under an employer group health plan as a result of current employment, 2) the company has 20 or more employees or participates in a multiple-employer or multi-employer group health plan where at least one employer has 20 or more employees, 3) individual in question is entitled to Medicare as a result of a disability, the company has 100 or more employees, or participates in a multi-employer/multiple-employer group health plan where one employer has 100 or more employees, and/or the individual in question is Medicare entitled due to end-stage renal disease. Medicare is the secondary payer to a group health plan until a 30-month coordination period has ended.
For further explanation on how Medicare pays with other types of insurance, see Medicare Coordination of Benefits, Welcome to the Medicare Secondary Payer and You at http://www.cms.hhs.gov/COBGeneralInformation/.
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May 19, 2008
Question:
What does the HAC initiative got to do with hospitals?
Answer:
Under the hospital-acquired conditions (HAC) initiative, beginning October 1, 2008, Medicare will no longer pay hospitals at a higher rate for the increased costs of care that result when a patient is harmed by one of several conditions they didn’t have when they were first admitted to the hospital and that have been determined to be reasonably preventable by following generally accepted guidelines. CMS is working with the National Quality Forum (NQF) on ways to reduce or eliminate 28 “never events” that are included in the HACs. The agency identifies these as preventable injuries or conditions acquired due to hospital errors that should never occur.
For more on this, see the proposed rule for the fiscal year 2009 inpatient prospective payment sytem at Click here.
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May 12, 2008
Question:
One of our insurers is charging us with "excessive billing" because
on our claims we charge an E&M facility fee along with a procedure charge
when procedures are done in the ED. It says if we want to get paid, we need
to provide proper documentation to support our facility charges. Dictation
is not enough. Can you provide supporting documentation that the facility
fee is appropriate?
Answer:
First you need to explain to this payer that the ED charge strategy is such that your E&M level only covers those costs associated with services provided that are not included in the additional procedure charge that you are submitting. The costs associated with the procedure charge should be separate from the costs associated with the E&M level.
Next, explain that you are required by Medicare rules to report both the level E&M visits and any significant procedures, so you have established your charge strategy to reflect these charges accordingly. Your ED charge strategy should be established to support this concept (and requirement). If it is not, then you have some work ahead of you.
Your charge strategy is self-defined, but you need to be able to defend it with sound data. If you can, there's no reason for the insurer to bully you.
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May 5, 2008
Question:
Where can I find instruction from CMS on HCPCS code to revenue code reporting?
Answer:
Generally, CMS does not instruct hospitals on the assignment of HCPCS codes to revenue codes for services provided under OPPS since hospitals' assignments of costs vary. Where explicit instructions are not provided, providers should report their charges under the revenue code that will result in the charges being assigned to the same cost center to which the cost of those services are assigned in the cost report.
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April 28, 2008
Question:
What exactly is the purpose of the Medicare integrity program?
Answer:
According to the Centers for Medicare & Medicaid Services (CMS), the point of the Medicare integrity program (MIP) is to pay claims correctly. In order to meet that goal, program contactors must they pay the right amount for covered and correctly coded services that legitimate providers render to eligible beneficiaries. CMS follows four parallel strategies in meeting this goal: 1) preventing fraud through detection, effective enrollment, and education of providers and beneficiaries, 2) early detection through medical review and data analysis, 3) close coordination with partners and law enforcement agencies, and 4) fair and firm enforcement policies.
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April 21, 2008
Question:
Can you tell me where I can find information on the type of changes the
recent SCHIP legislation make to the long-term care hospital PPS?
Answer:
Information about the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted on December 29, 2007, can be found in Transmittal 1474 http://www.cms.hhs.gov/transmittals/downloads/R1474CP.pdf. As explained in that memo, the legislation postponed implementation of a portion of the short-stay outlier payment adjustment formula effective upon enactment for a period of three years. It also revised the federal rate for 2008, applicable to discharges occurring on or after April 1, 2008, by providing that the federal base rate is the same as the base rate for discharges for the hospital occurring during the rate year ending in 2007.
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April 14, 2008
Question:
What is the current CCI version that applies to hospitals?
Answer:
CMS issues a new version every three months. Each edition contains the
latest billing information as authorized by CMS. At the moment, here are
versions for the following dates:
- October 1 to December 31, 2007, use Version 13.2
- January 1 to March 31, 2008, use Version 13.3
- April 1 to June 30, 2008, use Version 14.0
More on CCI edits for hospitals (and for physicians) can be found at http://www.cms.hhs.gov/NationalCorrectCodInitEd/.
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April 7, 2008
Question:
Does Medicare cover nutrition therapy?
Answer:
Medicare provides coverage of medical nutrition therapy (MNT) for beneficiaries diagnosed with diabetes and/or renal disease (except for those receiving dialysis) when provided by a registered dietitian or nutrition professional who meets the provider qualification requirements. The beneficiary's treating physician must provide a referral and indicate a diagnosis of diabetes or renal disease. Medicare provides coverage for three hours of MNT in the first year and two hours in subsequent years. Additional hours may be covered in certain situations.
NOTE: For the purpose of this benefit, renal disease means chronic renal insufficiency or the medical condition of a beneficiary who has been discharged from the hospital after a successful renal transplant for up to 36 months post transplant. Chronic renal insufficiency means a reduction in renal function not severe enough to require dialysis or transplantation [glomerular filtration rate (GFR) 13-50 ml/min/1.73m2].
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March 31, 2008
Question:
I know that modifiers must be used to differentiate between routine and
investigational clinical services but I am not clear on which modifiers
should be used for which services. Can you provide?
Answer:
As of December 31, 2007, CMS has discontinued three HCPCS modifiers: QA (Food & Drug Administration [FDA] investigational device exemption), QR (item or service provided in a Medicare-specified study), and QV (item or service provided as routine care in a Medicare-qualifying clinical trial).
In their places, it created the two modifiers below, which took effect
on January 1, 2008. Physicians, providers, and suppliers who bill Medicare
contractors (carriers, fiscal intermediaries (FIs), Part A/B Medicare administrative
contractors (MACs), etc.) will use these to differentiate between routine
and investigational clinical services.
Q0 - Investigational clinical service provided in a clinical research
study that is in an approved clinical research study. Q0 replaces QA and
QR.
Q1 - Routine clinical service provided in a clinical research study
that is in an approved clinical research study (Q1 replaces QV.)
In Transmittal 1418 at http://www.cms.hhs.gov/Transmittals/downloads/R1118CP.pdf and provider-information memo MM5805 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5805.pdf, CMS defined the difference between these services and provided billing guidelines.
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March 24, 2008
Question:
What is the deadline for reporting the POA indicator?
Answer:
By April 1, 2008, hospitals that do not report a valid present-on-admission (POA) indicator for each diagnosis will have their inpatient claims returned. CMS provided the official guidelines of this policy in Transmittal 1240 at http://www.cms.hhs.gov/Transmittals/downloads/R1240CP.pdf and in Transmittal 289 at http://www.cms.hhs.gov/Transmittals/downloads/R289OTN.pdf. Hospitals have had to report a valid POA code for each diagnosis since January 1, 2008, but if they did not, the claims continued to process. When April 1 rolls around, that will no longer be the case.
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March 17, 2008
Question:
Can you provide any information about the Medicare edits that relate to
the preadmission payment window policy?
Answer:
In just a few months, the Centers for Medicare & Medicaid Services (CMS) will change its longstanding payment window policy. According to this policy, the operating costs of inpatient services under the prospective payment system (PPS) include certain preadmission services furnished by the admitting hospital (or by an entity wholly owned or operated by the admitting hospital or by another entity under arrangements with the admitting hospital).
Currently and until July 1, 2008-the effective date of the policy change, the common working file (CWF) reviews the "statement-covers-through" date of the outpatient claim to determine what services fall within the payment window relative to an inpatient stay. On July 1, CMS will modify the diagnostic and therapeutic payment window edits in the CWF to review the line item date of service (LIDOS) of the outpatient bill instead.
Claims will be rejected for payment when the outpatient service's LIDOS falls on the admission date or any of the three days immediately prior to a Medicare beneficiary's admission to an inpatient prospective payment system (IPPS) or Maryland-waiver hospital. For hospitals excluded from the IPPS, such as rehabilitation or an inpatient psychiatric facility, claim rejections will occur on the day of admission or one day prior to that admission.
CMS describes the above and provides implementation instructions to Medicare fiscal intermediaries (FIs) and Part A/B Medicare administrative contractors (MACS) in Transmittal 1429 (February 1, change request 5880) at http://www.cms.hhs.gov/transmittals/downloads/R1405CP.pdf.
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March 10, 2008
Question:
My question relates to discharge status codes. How would we report a transfer
to a facility that is not defined in the UB-04 manual code list?
Answer:
For discharges on or after April 1, 2008, the National Uniform Billing
Committee (NUBC) redefined the patient discharge status code 05 and added
new patient discharge status code 70 to allow providers to indicate discharges
and transfers to another type of healthcare institution not defined elsewhere
in the UB-04 (CMS-1450) manual code list. CMS expects providers to use these
codes in field locator (FL) 17 of the UB-04 and its electronic equivalent
for discharges on or after April 1, 2008.
- Patient discharge status code 05-Discharge/transfer to a designated cancer
center or children's hospital
- Patient discharge status code 70-Discharge/transfer to another type of
healthcare institution not defined elsewhere in the code list
Note that the post-acute transfer payment policy will not apply to claims
that contain patient discharge status code 70 in the case of inpatient prospective
payment system (IPPS) hospitals. Transmittal 1361, available at www.cms.hhs.gov/Transmittals/downloads/R1361CP.pdf,
contains information on these discharge code revisions in addition to a
list and description of the other discharge codes.
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March 3, 2008
Question:
What code should be used to report outpatient rehab? Can you also provide
billing guidelines?
Answer:
Effective January 1, 2008, the following code may be used to report outpatient
rehabilitation therapy services on Medicare claims.
96125 Standard cognitive performance testing (e.g., Ross information processing
assessment) per hour of a qualified healthcare professional's time, both
face-to-face with the patient and time interpreting test results and preparing
the report.
CMS considers this code "always therapy" no matter who performs the service. Code 96125 requires one of the following therapy modifiers: GN (speech-language pathology), GO (occupational therapy), or GP (physical therapy).
The above information plus a complete list of current rehabilitation therapy codes appears in Transmittal 1377, available at www.cms.hhs.gov/transmittals/downloads/R1377CP.pdf.
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February 25, 2008
Question:
I know that CMS requires that all outpatient claims contain a line item
date of service for each revenue code billed on the claim. What I don't
know is what are the benefits of line-item billing?
Answer:
According to the Centers for Medicare & Medicaid Services (CMS), the benefits include the following:
- More accurate and timely claim payments to providers;
- Less staff time needed to research dates of services performed by other
providers;
- Clinical data will no longer need to be rolled up to accommodate the claims
processing systems and, therefore, will more closely match the claim record;
- More detailed claim data could be used to assist the CMS in future refinements
to improve the accuracy and equity of ESRD payments; and
- HIPAA compliance for submitting the appropriate line item date of service
for both the CMS and its providers is ensured.
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February 18, 2008
Question:
I have question about the payment adjustments or credits that providers
receive from device manufacturers. What claims submitting procedure should
be followed when we don't know the amount of the rebate to be given by the
manufacturer?
Answer:
The Centers for Medicare & Medicaid Services (CMS) stated that it recognizes
that hospitals may not know the amount of the manufacturer's credit for
the device when the replacement procedure occurs, and gives hospitals the
following billing options.
- Submit the claim for the device procedure to your Medicare contractor
immediately without the FC modifier and then submit a claim adjustment with
the FC modifier when the manufacturer makes a credit determination. Note,
however, that this payment is conditional and subject to later adjustment.
- Hold the claim until the manufacturer makes a determination on the partial
credit amount and submit the claim with the FC modifier if the partial credit
is 50 percent or more of the cost of the replacement device.
For a clear understanding of this policy, be sure to read Transmittal 1383 at www.cms.hhs.gov/transmittals/downloads/R1383CP.pdf.
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February 11, 2008
Question:
I am looking for information about the changes made to the 2008 hospital
outpatient prospective payment system. Where can I find this?
Answer:
On January 18, 2008, the Centers for Medicare & Medicaid SErviecs (CMS) issued Transmittal 1417 (change request 5912), which includes this information. For this transmittal, go to http://www.cms.hhs.gov/transmittals/downloads/R1417CP.pdf. Provider-information memo MM5912 can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5912.pdf.
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February 4, 2008
Question:
Where can we find information about whether a MAC has replaced our Medicare
fiscal intermediary?
Answer:
To identify your assigned jurisdiction and monitor the status of the MAC contract assignment for your region, refer to the service area map located at http://www.cms.hhs.gov/MedicareContractingReform/Downloads/PrimaryABMACJurisdictionFactSheets.pdf. Other information regarding Medicare contracting reform can be found at http://www.cms.hhs.gov/MedicareContractingReform/.
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January 28, 2008
Question:
Does CMS plan to phase in its new value based purchasing program?
Answer:
Yes, CMS recommends a phased approach for implementing the VBP program,
and the agency presented the following timeline to Congress:
- Year 1: Incentive payment based 100 percent on pay-for-reporting for all
VBP measures.
- Year 2: Incentive based 50 percent on reporting and 50 percent on performance
- Year 3: Incentive based 100 percent on performance.
More on this program can be found in "Report to Congress: Plan to Implement a Medicare Hospital Value-Based Purchasing Program," available at www.cms.hhs.gov/AcuteInpatientPPS/downloads/HospitalVBPPlanRTCFINALSUBMITTED2007.pdf.
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January 21, 2008
Question:
What is the difference between the current project for hospitals to report
quality data and a new program called value based purchasing (VBP)?
Answer:
The currently used Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program bases the annual Medicare payment update on submission of quality measures. Hospitals will soon say goodbye to RHQDAPU as Medicare replaces it with a new program-value-based purchasing (VBP)-mandated by the Deficit Reduction Act of 2005.
The key difference between the two is that the VBP program will base a portion of a hospital's update payment on its actual performance on specified measures, not merely the reporting of measures as in the RHQDAPU program. The good news is that the VBP program builds on RHQDAPU, so hospitals will not have to go back to square one in their data-collection and reporting efforts.
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January 14, 2008
Question:
What is the difference in payment for reporting, or not reporting, hospital
inpatient quality measures to Medicare?
Answer:
Under the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program, inpatient prospective payment system (IPPS) hospitals that voluntarily submitted data on 27 quality measures in 2007 will receive the full market basket update of 3.3 percent in 2008. However, as specified by law, Medicare payments for inpatient services will be cut by 2 percent (i.e., only a 1.2 percent update in 2008) if hospitals fail to report this quality information.
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January 7, 2008
Question:
Where can I find a list of the 2008 Level II codes?
Answer:
The Centers for Medicare & Medicaid Services (CMS) recently issued the modifications to the Healthcare Common Procedure Coding System (HCPCS) code set. These changes have been posted to the "Alpha-Numeric HCPCS" list at http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp. All changes are effective January 1, 2008, unless otherwise indicated in the effective date column.
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December 31, 2007
Question:
Can providers submit legacy numbers after the national provider identifier
takes effect?
Answer:
Hospitals and other health care providers are required to use a national provider identifier (NPI) when billing Medicare contractors at the start of 2008. Contractors will return claims containing only a legacy provider identifier in their primary fields. However, providers may include both the legacy identifier and the NPI through April 2008. Also, the agency recommends that hospitals submit at least some claims with only an NPI to assure claims process correctly when just the NPI is required on May 1, 2008.
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December 24, 2007
Question:
Are physicians required to document any differently under the new MS-DRGs?
Answer:
Although comprehensive documentation always has been important, it is even more so now. Physician buy-in for better documentation continues to be paramount. One industry consultant recommends that hospitals implement a clinical documentation improvement program that educates medical staff about the importance of documenting and reporting illness severity using ICD-9-CM terminology. As always, medical staff should be reminded to provide documentation that is clear, consistent, legible, and complete. Having data of the highest quality ensures that coders have a fighting change of doing the best job.
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December 17, 2007
Question:
In a previous Q&A, you mentioned that, under the new MS-DRG system,
more time will be required for accurate coding. Do you have any guidelines
for improving productivity and reducing this time allotment?
Answer:
Managers should ensure that coding staff do the following.
- Consult and comply with the fiscal year 2008 ICD-9-CM Official Guidelines
for Coding and Reporting.
- Refine their diagnosis coding skills to ensure that their final code assignments
are as accurate as possible. A comprehensive understanding of all codes
is essential, including V codes and others less frequently used in the past.
- Increase their clinical knowledge so they can dig deeper into the documentation.
This is especially important in regard to the facility's top-volume procedures.
- Query physicians and practitioners for more specific information (such
as complications) when documentation is incomplete so that all appropriate
codes may be assigned.
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December 10, 2007
Question:
We perform a procedure where we replace a patient's existing suprapubic
tube with a multipurpose catheter. We code a 51710 for the tube change and
C1729 for the multipurpose tube. Device edits are requiring a code of C2627
for the tube. Which device code should we assign on the claim?
Answer:
Medicare Transmittal A-02-050 (June 17, 2002), describes device codes (C-codes)
C1729 and C2627 as follows.
- Catheter, suprapubic/cystoscopic (C2627)
- Drainage catheter (C1729) - Intended to be used for percutaneous drainage
of fluids. (Note: This category does NOT include Foley catheters or suprapubic
catheters. Refer to category C2627 to report suprapubic catheters.)
C1729 is a percutaneous drainage catheter, which is a general device used
for a multitude of drainage procedures. Currently, the CPT code 51710 (change
of cystostomy tube, complicated) maps to device code C2627 (according to
the CMS, July 2007, Procedure to Device Edit file). Confirm with
your Medicare intermediary the appropriateness of this edit when other than
51710 is reported (such as 51705--change of cystostomy tube, simple.
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December 3, 2007
Question:
We have a question about chemotherapy infusion. When you use the base code
96413 for your first hour of chemo infusion and then the patient has an
additional three hours, which of the following should be on the bill: 96413
and 96415 as one line item with three units OR 96413 and 96415 as three
separate line items?
Answer:
The appropriate way to bill for this service is 96413 (1 unit) and 96415 (3 units). If this is how you are billing and are getting rejections you would need to determine if this is payer specific and if they have a directive to bill each line item and not use units.
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November 26, 2007
Question:
I know that Medicare does not cover lumbar artificial disc replacement
(LADR) for beneficiaries over 60. But I do not know how to bill when this
situation occurs. Can you help?
Answer:
The Centers for Medicare & Medicaid Services published details of Medicare
fiscal intermediary (FI) and carrier billing requirements in Transmittal
1340, September 21 at (http://www.cms.hhs.gov/transmittals/downloads/R1340CP.pdf).
To avoid denials, says CMS, do not submit claims with:
- Category III Codes 22857 and 0163T for Medicare beneficiaries over 60
years of age, (i.e., on or after a beneficiary's 61st birthday).
- ICD-9-CM procedure code 84.65 for Medicare beneficiaries over 60 years
of age
Also included in the transmittal is information on the use of the advanced
beneficiary notice (ABN) and hospital-issued notice of non-coverage.
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November 19, 2007
Question:
What is the purpose of the medically unlikely edits (MUEs)?
Answer:
According to the Centers for Medicare & Medicaid Services (CMS), these edits will lower the Medicare fee-for-service paid claims error rate. It defines an MUE as an edit that tests claim lines for the same beneficiary, HCPCS code, date of service, and billing provider against a criteria number of units of service. Medicare contractors will deny the entire claim line when the units of service are in excess of MUE criteria and/or return claims to providers that contains units of service that exceed MUE criteria.
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November 12, 2007
Question:
Should modifier 59 be used when a CT scan with contrast is done and a separate
injection/infusion is given, specifically one for an emergency department
(ED) visit?
Answer:
Providing an IV infusion in the ED may prompt a CCI (correct coding initiative) edit for the contrast. If this occurs, you would append the code for the infusion procedure with modifier 59 to indicate a separate and distinct medical procedure.
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November 5, 2007
Question:
Should CPT code 19102 be charged per lesion or per breast? The situation
we had was the patient had three lesions in the same breast, all of which
were biopsied. Some coding resources say one charge per breast and others
say one charge per lesion.
Answer:
Each separate lesion that is individually biopsied, whether in the same breast or in different breasts, should be separately coded. Modifier assignment will be based upon state-specific payer requirements. In addition to the surgical code (19102 or 19103) , imaging guidance (when used and documented) should also be separately coded (see codes 76942, 77012, 77021, 77031 or 77032). Also, if a localization clip/device is also used during this procedure, see code 19295 as well.
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October 29, 2007
Question:
Can you tell me how the Centers for Medicare & Medicaid Services (CMS)
defines "mass immunizer" as well as a source for becoming one?
Answer:
According to CMS, a mass immunizer is a provider or supplier who enrolls in the Medicare program to offer the influenza vaccination to a large number of individuals. Enrollment for mass immunizers is ongoing. Mass immunizers who operate as centralized billers are those entities that operate in at least three different payment localities and have received permission from CMS to bill a single Medicare contractor for payment. An annual June 1 application deadline applies only to mass immunizers who are applying for participation as a mass immunizer centralized biller.
The following provider-information memo provides further clarification on the topic: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5511.pdf. Similar information can be found at http://www.cms.hhs.gov/Transmittals/Downloads/R1278CP.pdf.
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October 22, 2007
Question:
What effects will the new MS-DRG system have on hospital coders?
Answer:
More time will be required for accurate coding, which means that coder productivity may decline initially. In addition, say some health information management (HIM) experts, inadequate coding could result in missed revenue and a decline in case-mix index. Estimates of the productivity decline range from 20 to 30 percent.
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October 15, 2007
Question:
I only bill on paper, do I need a national provider identifier (NPI)?
Answer:
If you are a health care provider who conducts no standard transactions adopted under the Health Insurance Portability and Accountability Act of 1996 or HIPAA (that is, you conduct claims, eligibility inquiries, claims status inquiries, prior authorizations/referrals on paper, fax machine, or telephone only), then you are not required by law to obtain an NPI because you are not a covered health care provider.
However, CMS encourages all health care providers to apply for NPIs. It says that, although not required by law, some health plans, including Medicare, are requiring health care providers to use NPIs on paper transactions (such as paper claims). Many health plans do tend to follow Medicare policies so it is very likely that other health plans will require that paper claims be submitted with an NPI. You should check with your health plan to determine its policy.
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October 8, 2007
Question:
How will Medicare contracting reform affect Medicare providers?
Answer:
Here's what the Centers for Medicare & Medicaid Services (CMS) has to say about that. Through the competitive process, CMS will establish Medicare administrative contractors (MACs) that will provide improved service and performance to all providers in their jurisdictions. The MAC will serve as the single point of contact for providers and suppliers for all claims-related business. In addition to processing claims, the MAC will be able to assist providers and suppliers with obtaining information on behalf of patients about items or services received from another provider or supplier that could affect claims payment.
Medicare contracting reform also will bring some potential benefits to providers, including improved provider education and training for small providers or suppliers as well as a role in contractor evaluation via surveys. CMS will manage the MAC transitions to ensure continuity, accuracy and timeliness in claims processing and payment for providers.
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October 1, 2007
Question:
When we do IV drug therapy can we charge for the fluids?
Answer:
According to the American Medical Association, the incidental saline that is used in administration of another drug becomes part of that service. It is not separately billable.
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September 24, 2007
Question:
If an antibiotic was infused over 85 minutes with a 10 minute flush at
the end, can we bill one initial hour and then one additional hour? Or do
we get credit only for the antibiotic?
Answer:
The timing for your service is based on the actual infusion of the drug or the substance that is the medically necessary procedure. So, you would have 85 minutes of infusion of the antibiotic, code 90765-intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour. But you have not met the 91-minute requirement for the additional hour code 90766-each additional hour (List separately in addition to code for primary procedure) and cannot use the time to flush the line as part of the total calculation.
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September 17, 2007
Question:
Does Medicare cover LADR?
Answer:
Lumbar artificial disc replacement (LADR) is not reasonable and necessary for the Medicare population over 60, according to the Centers for Medicare & Medicaid Services (CMS). CMS has amended Section 150.10 of the Medicare NCD Manual to reflect the change from non-coverage for LADR with a specific implant to non-coverage for the LADR procedure for the Medicare population over 60 years of age. For Medicare beneficiaries 60 and under, there is no NCD so determinations will be made on a local basis. For this final decision, go to http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=197.
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September 10, 2007
Question:
I heard that Medicare now has something called a dispute reason code. What
is this, and is there any action providers must take in relation to it?
Answer:
When claims crossed over by Medicare to a supplemental payer are rejected or disputed by that insurer, Medicare adds (as of July 1, 2007) a standardized message to the provider's notification saying "claim rejected by other insurer." This message will be accompanied by one of 10 "dispute reason codes" listed in Medicare memo SE0728 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0728.pdf. This memo also provides additional background on the coordination of benefits agreement detailed error report notification process.
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September 3, 2007
Question:
How does Medicare determine the length of time that a hospital provided
critical care services?
Answer:
The time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once. This relates to the outpatient prospective payment system.
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August 27, 2007
Question:
Which HCPCS codes are used by provider-based outpatient hospitals to report
Type A and Type B hospital emergency department (ED) visits? Which HCPCS
codes are used for reporting hospital outpatient clinic visits?
Answer:
Under the outpatient prospective payment system (OPPS), hospitals report Type A ED visits using HCPCS codes 99281-99285. Hospitals report Type B emergency department visits using HCPCS codes G0380-G0384. Hospitals report hospital outpatient clinic visits using HCPCS codes 99201-99215 and 99241-99245.
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August 20, 2007
Question:
Could a facility choose to set up criteria for evaluation and management
(E&M) selection in the emergency room (ER), but for clinic services
choose to not set up criteria, but rather default to the lowest level for
every clinic visit?
Answer:
No, your E&M level coding for clinic facility charges should be resource intense, based on acuity and reflective of those resources utilized.
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August 13, 2007
Question:
Does Medicare have a medical necessity requirement for infusions and injections?
Answer:
Medical necessity is required for ANY service that is billed to Medicare.
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August 6, 2007
Question:
Has the hospital outpatient prospective payment system proposed rule for
2008 been issued yet? If so, where can it be found?
Answer:
Yes, the Centers for Medicare & Medicaid Services (CMS) issued the proposed OPPS rule for 2008 on August 2. It can be found at the following address: http://www.access.gpo.gov/su_docs/fedreg/a070802c.html. Scroll down to Centers for Medicare & Medicaid Services, Proposed Rules, Medicare.
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July 30, 2007
Question:
Why is CMS beginning to base DRG weights on estimated hospital costs instead
of hospital charges?
Answer:
Studies by the Medicare Payment Advisory Commission have indicated that hospitals charge significantly more than their costs for some types of services, such as medical supplies and radiology. As a result, certain services are relatively more profitable, potentially contributing to the development of specialty hospitals which focus on high margin conditions. By basing DRG weights on estimated costs, rather than hospital charges, hospital payments will be more closely aligned with the actual costs of patient care, and the incentive for hospitals to take higher margin cases will be reduced. In October 2006, CMS began to phase in the new cost-based weights. The phase-in will take three years.
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July 23, 2007
Question:
Last week you provided information about the present-on-admission (POA)
indicator. What action will the Medicare payer take if this indicator is
not on claims?
Answer:
In regard to the implementation of the POA indicator, there are several
important dates that providers should be aware.
- Beginning with discharges on or after January 1, 2008, if hospitals do
not report a valid POA code for each diagnosis on the claim, the claim will
continue to process. However, hospitals will be provided with a remark code
on their remittance advice advising them that they did not correctly submit
the POA code.
- Beginning April 1, 2008, if hospitals do not report a valid POA code for
each diagnosis, the claim will be returned for correct submission.
- For discharges on or after October 1, 2008, the presence of these diagnosis
codes on claims could allow the assignment of a higher paying DRG, when
they are present at the time of discharge, but not at the time of admission.
The DRG that must be assigned to the claim will be the one that does not
result in the higher payment.
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July 16, 2007
Question:
What is a present-on-admission (POA) indicator? I have heard that this
will be required on Medicare claims sometime in the near future.
Answer:
On January 1, 2008, the Centers for Medicare & Medicaid Services (CMS) will require the completion of a POA indicator for every diagnosis on inpatient acute care hospital claims. The UB-04 Data Specifications Manual defines POA as "present at the time the order for inpatient admission occurs-conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission." Critical access hospitals, Maryland waiver hospitals, long-term-care hospitals, cancer hospitals, and children's inpatient facilities are exempt from this requirement.
A section of the Deficit Reduction Act of 2005 requires hospitals to begin reporting the secondary diagnoses that are POA. In order to be able to group these diagnoses into the proper DRG, CMS needs to capture a POA indicator for all claims involving inpatient admissions.
For more information, go to Transmittal 1240 at http://www.cms.hhs. gov/Transmittals/downloads/R1240CP.pdf.
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July 9, 2007
Question:
Are roster bills subject to billing edits re: frequency?
Answer:
According to Transmittal 273 (April 27), roster bills will not be subject
to frequency-of-billing edits. Currently, only the following vaccine/administration
code pairs are allowed to be roster billed:
- Influenza: 90656 with G0008, 90658 with G0008, and 90660 with G0008
- Pneumococcal pneumonia: 90732 with G0009
Go to http://www.cms.hhs.gov/transmittals/downloads/R273OTN.pdf
for this information.
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July 2, 2007
Question:
How do small critical access hospitals (CAHs) get paid for lab tests?
Answer:
After July 1, 2007, CAHs with fewer than 50 beds in qualified rural areas will continue to receive reasonable-cost payments for outpatient clinical laboratory tests. The Tax Relief and Health Care Act of 2006 extended the reasonable-cost payment from a two-year period to a three-year period. Reasonable-cost payments will be made to those CAHs with cost-reporting periods that began between July 1, 2004 and July 1, 2007. To determine reasonable costs, the ratio of costs to charges for the laboratory cost center is used. This amount is then multiplied by the provider statistical and reimbursement report's (PS&R's) billed charges for outpatient laboratory services. See Transmittal 1180 at http://www.cms.hhs.gov/transmittals/downloads/R1180CP.pdf, which contains more on this policy change.
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June 25, 2007
Question:
Will the public have access to national provider identifier (NPI) data?
Answer:
A Federal Register notice includes information on how CMS will share NPI data with the public. This action is required by the Freedom of Information Act (FOIA), and covered entities under the Health Insurance Portability and Accountability Act (HIPAA) and others need this data to process claims for payment.
CMS addresses who may have access to, or receive data from, the system;
the processes for requesting and receiving data; and the conditions under
which data may be disclosed. The NPI data will be available on the Internet
on June 28, and, initially,
will be updated monthly. Providers with NPIs should review their data at
this time and make any necessary updates or corrections before that date
to ensure that the NPI data being disclosed is accurate. You may delete
data that was not required to obtain an NPI before June 28 by submitting
a request to the CMS FOIA Office either in writing or by fax machine.
The Federal Register notice is available at http://www.access.gpo.gov/su_docs/fedreg/a070530c.html.
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June 18, 2007
Question:
What is the correct way to code hemophilia clotting factors?
Answer:
Transmittal 1234 (April 17) states that CMS has terminated HCPCS code J7188 effective December 31, 2006 and new HCPCS code J7187 took effect for claims dated January 1, 2007, and after. Although system changes won't be implemented until October 2007, CMS instructs providers to use code J7187 (injection, vonWillebrand factor complex, human, ristocetin cofactor, per IU VWF:RCO) rather than terminated code J7188 (vonWillebrand factor complex, human, per IU). The transmittal, which can be found at http://www cms.hhs.gov/transmittals/downloads/R1234CP.pdf, includes the procedures that will be followed between the effective date and implementation date.
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June 11, 2007
Question:
Our claims for bariatric surgery are being denied. Can you provide a source
where we can check on coverage requirements?
Answer:
On April 28, 2006, the Centers for Medicare & Medicaid Services (CMS) announced that it would cover certain bariatric surgical procedures. It subsequently came to the agency's attention that the national coverage determination (NCD) for this policy is not being implemented uniformly. Specifically, some claims not involving bariatric surgery are being denied in error while some covered bariatric surgery claims were being held rather than paid. To clarify last year's claims processing instructions, CMS issued Transmittal 1233 on April 27 2007. It is available at http://www.cms.hhs.gov/transmittals/downloads/R1233CP.pdf.
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June 4, 2007
Question:
Would you please provide a quick overview of the severity-adjusted DRGs
that CMS proposed for the 2008 inpatient PPS?
Answer:
By far the most significant part of the rule is the creation of 745 new Medicare-severity DRGs (MS-DRGs) to replace the current 538 DRGs. The goal is to account more fully for the severity of each patient's condition. Payments to specific hospitals may increase more or less depending on the patients they serve. For instance, urban hospitals generally treat more severely ill patients and could receive a 3.5 percent payment increase, instead of the average 3.3 percent mentioned above.
CMS took its initial steps toward implementing the new system when it created new DRGs for cardiac procedures performed in fiscal year (FY) 2006. An additional set of DRGs reflecting severity of illness was introduced for discharges in FY 2007. At least one goal of the new MS-DRGs is to further reduce incentives for hospitals to "cherry pick"-the practice of treating only the healthiest and most profitable patients.
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May 28, 2007
Question:
In regard to the Medicare pay-for-performance initiative, will payments
to lower- performing hospitals be reduced?
Answer:
By the end of the demonstration, participating hospitals are expected to show improvement from baseline performance in year one. In year three, hospitals will receive lower DRG payments if they score below performance baselines set in the first year. The demonstration baseline will be clinical thresholds set at the year one cut-off scores for the lower 9th and 10th decile hospitals. Those hospitals that do not perform above these established baselines will receive lower payments for measured clinical conditions. Hospitals will receive 1 percent lower DRG payment for performance below the 9th decile baseline level and 2 percent less if they score below the 10th decile baseline level. There will be no reduction in payments to any hospitals in years one or two of the demonstration.
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May 21, 2007
Question:
Why is the Centers for Medicare & Medicaid Services paying a bonus
for high-quality inpatient care? Shouldn't hospitals provide quality care
without a bonus?
Answer:
CMS acknowledges that hospitals already try to provide high-quality care to their patients, and evidence shows that some hospitals follow clinical guidelines to improve the quality of care better than others. One obstacle is that developing and implementing quality systems costs money, which competes for the scarce resources for all of the other things that hospitals must do. By providing financial incentives for higher performance on certain measures of quality care, CMS provides the financial incentive to push hospitals to follow the clinical guidelines to better align the incentives between quality and profits. Also, for those hospitals that will get incentive payments, those incentives will help to pay for the cost of the quality measurement and improvement system.
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May 14, 2007
Question:
Is line-item billing required for ESRD claims?
Answer:
Any provider who bills Medicare FIs for end-stage renal disease (ESRD) services will want to read Transmittal 1084, October 27, 2006. It contains detailed informationabout the now-required line-item billing requirements for ESRD claims (type of bill 72X) with dates of service on or after April 1, 2007. Renal dialysis facilities are then required to bill all services with line item date-of-service detail, except supplies and epoetin alfa (EPO). In addition to reviewing the benefits of line-item billing, CMS addresses coding adequacy for hemodialysis and home dialysis under method one in this transmittal, which can be found at http://www.cms.hhs.gov/transmittals/downloads/R1084CP.pdf.
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May 7, 2007
Question:
Does Medicare reimburse a physician for filling an implantable pump?
Answer:
Physicians and other practitioners may be paid for filling or refilling an implantable pump or reservoir when the service is medically necessary. Determining this is up to Medicare contractors as is allowing payment for drugs furnished incident to the professional service.
If a physician (or other practitioner) is prescribing medication for a
patient with an implantable pump, a nurse may refill the pump if the following
is true:
- The medication administered is accepted as a safe and effective treatment
of the patient's illness or injury
- There is a medical reason that the medication cannot be taken orally
- The skills of the nurse are needed to infuse the medication safely and
effectively,
For other details about this payment, go to Transmittal 1204 (March 16) at http://www.cms.hhs.gov/transmittals/downloads/R1204CP.pdf.
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April 30, 2007
Question:
Can nonphysician practitioners bill Medicare?
Answer:
Beginning April 26, 2007, nurse practitioners (NPs) and certified nurse
specialists (CNSs) may bill Medicare carriers directly for their professional
services under their billing numbers when furnished to hospital inpatients
and outpatients. In addition to not billing for NPs and CNSs, hospitals
should not bill for a physician assistant's (PA) professional services unless
the PA is a hospital employee. Rather, employers of the PAs must bill carriers
for professional services when furnished to hospital patients.
Hospitals may bill the carrier for the NP's or CNSs' professional services
when payment for the hospital services has been reassigned to the hospital
and when the hospital bills for these services under the NP's or CNS's identification
number.
For more on this policy, go to Transmittal 1168 at http://www.cms.hhs.gov/transmittals/downloads/R1168CP.pdf.
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April 23, 2007
Question:
What is a provider's liability for claims denied as a result of the medically
unlikely edits (MUEs)?
Answer:
In all cases, providers are liable for denials, and they may not bill beneficiaries for excess charges due to units of service greater than the MUE. In other words, this charge cannot be waived or subject to an advance beneficiary notice. A CMS spokesperson called this issue insignificant because most errors will end up being typographical in nature and can be handled by simply resubmitting.
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April 16, 2007
Question:
In regard to MUEs, how does the claim-adjudication process work?
Answer:
The process for carriers, fiscal intermediaries (FIs), and Part A/B Medicare administrative contractors (MACs) differs as outlined below.
Carriers auto-deny a line if units of service billed exceed the number of units established for the service. Providers may appeal carrier denials. Those that win on appeal will receive appropriate Medicare payments.
FIs and A/B MACs return claims containing units for any line in excess of the criteria number. Providers may resubmit these claims electronically, but, at this time, they do not have appeal rights. In an industry audioconference, a CMS representative said the agency is "trying to address this system glitch." The glitch may cause a problem with reimbursement, but CMS believes that the risk has been mitigated to ensure most services would be covered within the MUE limits.
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April 9, 2007
Question:
How will the medically unlikey edits (MUEs) recently implemented affect
Medicare payments?
Answer:
According to the Centers for Medicare & Medicaid Services (CMS(, MUEs are not meant to establish payment policy but to lower the Medicare fee-for-service paid claims' error rate and detect implausible claims submissions. (Apparently, CMS has been accused of setting limits on the units of service in an attempt to reduce payments.) Further, MUEs do not require Medicare contractors to perform manual review or suspend claims.
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April 2, 2007
Question:
We have a question about code J2912, which was deleted effective for 2007.
The only code I can find as a replacement is A4216, which my finance department
tells me Medicare will not reimburse. We are billing as an outpatient hospital
infusion service for that code. Would you know of another J-code we could
use for the Saline flush (sodium chloride 0.9%, non-infusion) charge?
Answer:
There is no replacement code. The saline should be reported with no HCPCS code and a revenue code of 250.
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March 26, 2007
Question:
Did hospitals benefit from participating in the HQID project?
Answer:
According to a report from CMS, the hospitals participating in the initial Premier Hospital Quality Incentive Demonstration (HQID)--a value-based purchasing project-- reported process and outcome measures in five clinical areas: acute myocardial infarction (AMI), heart failure, coronary artery bypass graft (CABG), pneumonia, and hip and knee replacement. They received incentive payments for providing high quality care. During the first three years of the project, only top-performing hospitals have been eligible for incentive payments.
As the Q&A stated last week, CMS has extended the project for another three years. The extension will test the effectiveness of offering incentive payments to hospitals achieving a defined level of quality (i.e., quality threshold) and to hospitals achieving the greatest improvement in quality that also achieve the quality threshold. The extension will continue to track hospital performance in the five identified clinical focus areas, with flexibility to add quality measures and clinical conditions in the fifth and sixth years. For more on this topic, go to http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp?listpage=3.
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March 19, 2007
Question:
Why is CMS extending the hospital QI demonstration?
Answer:
The Centers for Medicare & Medicaid Services (CMS) has approved a three-year extension of the Premier Hospital Quality Incentive Demonstration (HQID), a value-based purchasing project involving more than 250 hospitals across the country. The recently released second-year results of the demonstration show substantial improvement in quality of care across five clinical focus areas, with total gains over the first two years of 11.8 percentage points. CMS will use the three-year extension to test new incentive models and develop new ways to measure quality.
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March 12, 2007
Question:
Where will the new NPI go on the CMS-1500 claim form?
Answer:
The CMS-1500 has been revised to accommodate the reporting of the national provider identifier (NPI). The revised form is designated as Form CMS-1500 (8/05). The revisions include additional items for the reporting of the NPI. More on this can be found in Transmittal 1187 at http://www.cms.hhs.gov/transmittals/downloads/R1187CP.pdf.
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March 5, 2007
Question:
I am looking for ICD-9-CM guidelines for assigning codes for therapeutic services. Can you help?
Answer:
Here's one item on that topic included in the ICD-9-CM Official Guidelines for Coding and Reporting that took effect on November 15, 2006. Section IV.M. states the following.
For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy, radiation therapy, or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.
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February 26, 2007
Question:
Can you provide more information about the new hospital discharge notices that you mentioned in last week's Q&A?
Answer:
Currently, beneficiaries or their representatives are required to sign the Important Message from Medicare (IM) to indicate that they did indeed receive and comprehend it. Hospitals must deliver the advance written notice at or near admission, but no later than two calendar days after the beneficiary's hospital admission. Hospitals will be expected to review the notices with beneficiaries or their representatives, answer any questions and, if necessary, help them to request a review of a discharge decision by a quality improvement organization (QIO).
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February 19, 2007
Question:
When must hospitals comply with the new hospital discharge notices?
Answer:
On July 1, 2007, new regulations take effect related to discharges. From
that point on, hospitals must issue the "Important Message from Medicare
(IM)" notice within two days of a Medicare patient's admission. They
also must get the patient's signature or the signature of his or her representative.
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February 12, 2007
Question:
Where can I find the latest ICD-9-CM guidelines?
Answer:
Each year CMS and the National Center for Health Statistics release updated
guidelines for coding and reporting clinical diagnoses and procedures using
the ICD-9-CM coding system. The American Hospital Association, American
Health Information Management Association, CMS and NCHS approved the guidelines,
which took effect November 15, 2006. Providers are legally required by the
Health Insurance Portability and Accountability Act to follow the guidelines.
The reason is HIPAA officially adopted the ICD-9-CM procedure codes for
inpatient procedures reported by hospitals and the ICD-9-CM diagnosis codes
for all health care settings. For the guidelines, go to http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm#guidelines.
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February 5, 2007
Question:
I know that the new conditions of participation for hospitals address postanesthesia
evaluation. What requirement is addressed, and where can I find the COPs?
Answer:
This requirement permits the postanesthesia evaluation for inpatients to
be completed and documented by any individual qualified to administer anesthesia
instead of only the individual who administered the anesthesia. The final
rule issued by CMS ensures that requirements are consistent with current
standards of practice, to provide hospitals and practitioners greater flexibility
in meeting the needs of patients, and to reduce unnecessary regulatory burden
for hospitals.To view the final rule, go to http://www.cms.hhs.gov/quarterlyproviderupdates/downloads/cms3122f.pdf.
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January 29 , 2007
Question:
I need guidelines related to verbal orders. Do you know the Medicare policy,
and, if so, where can I find that information?
Answer:
On November 27, 2006, the Centers for Medicare & Medicaid Services (CMS)
published a final rule revising requirements in the hospital conditions
of participation (CoPs) for several topics, including authentication of
verbal orders. You can find the rule at http://www.cms.hhs.gov/quarterlyproviderupdates/downloads/cms3122f.pdf.
For a five-year period beginning with the date of publication of the final rule, the regulation requires that all orders, including verbal orders, must be dated, timed, and authenticated promptly by the prescribing practitioner or another practitioner responsible for the patient's care, even if the order did not originate with him or her.
In the absence of a state law specifying the timeframe for authentication of verbal orders, verbal orders need to be authenticated within 48 hours. For the five-year period, verbal orders no longer need to be signed by the prescribing practitioner but can be authenticated by another practitioner responsible for the patient's care.
Finally, this requirement clarifies and reinforces current regulations
regarding minimizing the use of verbal orders, persons who may accept verbal
orders, authentication of all orders for drugs and biologicals, and authentication
of medical record entries.
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January 22, 2007
Question:
Will observation services receive better payment in 2007?
Answer:
Yes and no, according to the hospital outpatient prospective payment system
final rule. Observation services reported using HCPCS code G0378 (hospital
observation services, per hour) that are eligible for separate payment map
to APC 0339 (observation). The 2006 payment rate for that APC was $425.08.
In 2007, the pay rate is $442.16.
Direct admission to observation (HCPCS code G0379), when separately payable,
was assigned to APC 0600 (low level clinic visit) in 2006 with a payment
rate of $52.37. For 2007, CMS proposed to assign direct admission to observation,
when separately payable, to APC 0604 (low level clinic visit) with a median
cost of $49.93.
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January 15, 2007
Question:
Does the Centers for Medicare & Medicaid Services ever audit Medicaid
claims?
Answer:
For the first time since the beginning of the Medicaid program 41 years
ago, CMS has instituted a comprehensive national plan to combat Medicaid
fraud and abuse. The plan is called the Medicaid Integrity Program (MIP),
and it aims to identify, recover, and prevent inappropriate payments.
CMS’s blueprint for the MIP is contained in the “Comprehensive Medicaid Integrity Plan.” a document that the agency is required by law to update annually. This plan outlines two broad operations.
- Reviewing the actions of Medicaid service providers
- Providing support and assistance to the states to fight fraud and abuse
The “Comprehensive Medicaid Integrity Plan, FY 2006–2010”
is available at http://www.cms.hhs.gov/DeficitReductionAct/Downloads/CMIP%20Initial%20July%202006.pdf.
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January 8, 2007
Question:
Are the Medicare quality-reporting requirements the same for 2007?
Answer:
No, the quality-reporting requirements for hospital inpatient services have
been expanded. For the first time, hospitals will be required to report
consistent measures on patient satisfaction with hospital care to receive
a full inpatient prospective payment system (IPPS) payment update.
The survey instrument, called HCAHPS® (Hospital Consumer Assessment of Healthcare Providers and Systems), was developed jointly by the Agency for Healthcare Research and Quality and CMS. It is designed to gather information about patient perspectives on the care that they have received during an inpatient stay.
Also for the first time, hospitals will report risk-adjusted outcome measures to receive the full payment update, including 30-day mortality measures for patients hospitalized with an acute myocardial infarction, or heart failure. Three new measures related to the process of care for beneficiaries undergoing surgical procedures have been added from the Surgical Care Improvement Project.
Beginning in 2009, the final rule will tie outpatient prospective payment
system (OPPS) rate increases to the reporting of quality measures. CMS plans
to develop additional outpatient-specific quality measures.
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January 1, 2007
Question:
Has Medicare implemented the 5 percent reduction to the conversion factor
(CF) for 2007?
Answer:
The Medicare physician fee schedule (MPSF) conversion factor (CF) will remain
the same as it was in 2006 (37.8975)-thanks to a last minute decision by
Congress. In the 2007 MPFS, the Centers for Medicare & Medicaid Services
(CMS) did (as required by law) reduce the 2007 CF by 5 percent, and announced
that the CF would be 35.9848. However, on December 9, Congress passed legislation
freezing the CF to the previous rate. President Bush signed this into law,
and it took effect on January 1, 2007.