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The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Affordability Act (the Reconciliation Act) made many changes to healthcare that will affect hospitals.  One little publicized requirement requires hospitals to make their charges public.  This requirement is buried in a section of the law that deals primarily with insurance companies and bringing down the cost of health care coverage. 

A paragraph in Section 2718 states:

“(e) STANDARD HOSPITAL CHARGES.—Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital‘s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act.” 

Specific guidelines on the implementation of this requirement have not been published and it is unclear as to the effective date of this section.  MMP, Inc. will forward information concerning this requirement as it becomes available.

Question:

How do you change a patient’s status from inpatient to observation?

Answer:

First, CMS has made clear that observation is a service and not a status.  Therefore, an inpatient would be changed to an outpatient status.  Per recent Medicare FAQs and Cahaba education, there must be involvement of the Utilization Review (UR) committee to change a patient’s status from inpatient to outpatient.  A physician’s order to revise a patient’s status from inpatient to outpatient, in and of itself, is not sufficient to change a patient’s status from inpatient to outpatient.  
Inpatient to outpatient status changes must meet all the requirements of Condition Code 44.  These include:

• Change in patient status is made prior to discharge or release;
• Hospital has not submitted an inpatient claim to Medicare;
• A physician concurs with the UR committee’s decision; and
• Physician concurrence with the UR committee’s decision is documented in the patient’s medical record.

For Condition Code 44 decisions, one physician member of the UR committee may make the determination for the committee that the inpatient admission is not medically necessary.  This physician member of the UR committee must be a different person from the concurring physician for Condition Code 44 use, who is the physician responsible for the care of the patient.  The medical record should contain documentation of these interactions including the concurrence of the treating physician.  For more information, see the Medicare Claims Processing Manual (Pub. 100-04), Chapter 1, Section 50.3.2.

Changes in patient status must be fully documented in the medical record, complete with orders and notes that indicate the following:

• Why the change was made;
• The care that was furnished to the beneficiary; and
• The participants making the decision to change the patient’s status.

If the patient requires medically necessary observation services after the change to outpatient status, the attending/treating physician should write an order for the observation services.  Cahaba GBA strongly encourages providers to document a separate order for observation when it is applicable, in addition to the order to revise the patient’s status from inpatient to outpatient, subsequent to Condition Code 44 guidelines.  It is important to note that the hospital may not bill for observation prior to the time of a physician order for observation.  The hospital should begin billing for observation services at the time documented in the patient's medical record that observation services are initiated in accordance with a physician's order for observation services. 

If an inpatient does not meet inpatient medical necessity criteria and the hospital is unable to follow the CC 44 criteria for a status change, the hospital may submit a Type of Bill 12X for covered “Part B Only” furnished services.  See the Medicare Benefits Policy Manual (Pub. 100-02), Chapter 6, Section 10.

With the recent changes and focus on the hospital inpatient three-day payment window, it is important to review the basic tenets of the original rule, such as the definition of an entity that is “wholly owned or operated” by the hospital.

The Payment for Preadmission Services Final Rule (Federal Register, Vol. 63, No. 28, February 11, 1998, page 6864) addressed this definition.  The notice gives the following definition: “In general, if a hospital has direct ownership or control over another entity’s operations, then services provided by that other entity are subject to the 3-day window.  However, if a third organization owns or operates both the hospital and the entity, then the window provision does not apply.” 

The notice goes on to give several examples.  Key points of the examples are:

• A hospital-owned or hospital-operated physician clinic or practice is subject to the payment window provision.  The technical portion of preadmission diagnostic services performed by the physician clinic or practice must be included in the inpatient bill and may not be billed separately. A physician’s professional service is not subject to the window.
• If Hospital A owns Hospital B which owns Hospital C, then CMS would consider Hospital A as owning both Hospitals B and C and the payment window would apply.
• The payment window does not apply to situations in which both the admitting hospital and the entity that furnishes the preadmission services are owned or operated by a third entity. The payment window includes only those situations in which the entity furnishing the preadmission services is wholly owned or operated by the admitting hospital itself.
• The payment window does not apply to situations in which the admitting hospital is not the sole owner or operator of the entity performing the preadmission testing (such as independent laboratories that perform testing and bill Medicare directly for the testing).
• The admitting hospital must be the sole owner or operator of the entity performing the preadmission testing for the payment window to apply.  If the hospital is only part owner of the entity, the payment window would not apply.

The Federal Register notice can be viewed at FR Payment for Preadmission Services Final Rule.

CMS Transmittal 734 (CR 7080) clarifies the new Medicare timely filing limits regarding line item span dates and leap years.  The Affordable Care Act (ACA) changed the timely filing limit to 1 calendar year after the date of service (DOS) for services furnished on or after January 1, 2010.  Claims for services furnished prior to January 1, 2010 must be filed no later than December 31, 2010.

For institutional claims that include span dates of service (i.e., a “From” and “Through” date span on the claim), the “Through” date on the claim will be used to determine the date of service for claims filing timeliness.  Timeliness will be determined by the “From” date for professional claims (CMS-1500 Form and 837P).

Claims with a date of service of February 29th must be filed by February 28th of the following year to be considered as timely filed.  Claims received on or after March 1st of the following year will be denied for having failed the timely filing limit.

For more information, see the Transmittal at the link above or MLN Matters Article M7080.

Question:

How do we bill for the administration of fresh frozen plasma (FFP)? 

Answer:

You would bill the appropriate HCPCS code for the FFP product (such as P9017) with units equal the number of units infused, and the blood administration CPT code 36430 with a unit of 1. If this is a Medicare claim, and if the blood product was fresh frozen plasma, you cannot charge 86927 which is the “thawing” fee.  Medicare says that if the blood product has the word “frozen” in the HCPCS code description, thawing the product before you give it is inherent and should not be billed in addition.  There is not a CCI edit for this, so if you charge FFP and thawing, the claim will not edit out, and you will get paid for both.  But, this is a Medicare rule. We suggest setting up an internal edit for Medicare outpatient claims to catch these and prevent overpayment.

On May 21, 2010, CMS released two transmittals that manualize the requirements for Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) services.  Following is a summary of some of the key points of those transmittals.  However, MMP, Inc. strongly encourages providers to carefully review the manual content contained in these transmittals for a complete understanding of coverage and billing requirements.  Transmittal 126 updates the Medicare Benefits Policy Manual and Transmittal 1974  updates the Medicare Claims Processing Manual.  Both transmittals are effective January 1, 2010 for claims processed on or after October 4, 2010.

“Effective January 1, 2010, Medicare Part B pays for CR/ICR programs and related items/services if specific criteria is met by the Medicare beneficiary, the CR/ICR program itself, the setting in which it is administered, and the physician administering the program, as outlined below:”

Beneficiary Requirements:
Medicare covers CR/ICR items and services for patients with:

• Acute myocardial infarction within the preceding 12 months
• Coronary artery bypass surgery
• Current stable angina pectoris
• Heart valve repair or replacement
• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting
• Heart of heart-lung transplant

Program Components:

• Physician-prescribed exercise.  Aerobic exercise combined with other types of exercise as determined appropriate by a physician.
• Cardiac risk factor modification including education, counseling, and behavioral intervention.
• Psychosocial assessment.  A written evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation.
• Outcomes assessment conducted by the physician minimally at the start and end of the program, including objective clinical measures of exercise performance and self-reported measures of exertion and behavior.
• An individualized treatment plan that includes a description of the individual’s diagnosis; the type, amount, frequency, and duration of CR/ICR items and services; and the patient’s goals.
• The plan must be established, reviewed, and signed by a physician every 30 days. 

Setting Requirements:

CR/ICR must be furnished in a physician’s office or a hospital outpatient setting.

A physician must be immediately available and accessible for consultation and emergencies; for hospital outpatient services, this means the physician must be present on the campus for on-campus services and in the provider-based department for off-campus services.

Physician Requirements:

The medical director and the supervising physician must meet the following requirements:

• Expertise in the management of individuals with cardiac pathophysiology
• Licensed to practice medicine in the state in which the CR/ICR program is offered
• Cardiopulmonary training in basic life support or advanced cardiac life support

The medical director, in consultation with staff, is involved in directing the progress of individuals in the program.

ICR Programs

• Must be approved through the NCD process
• A list of approved ICR programs will be posted to the CMS Web site and listed in the Federal Register.
• Hospital outpatient settings must provide ICR using an approved ICR program

Billing Requirements:

Services should be billed with the following HCPCS codes:

• 93797 for CR services without continuous monitoring
• 93978 for CR services with continuous monitoring
• G0422 for ICR services with exercise
• G0423 for ICR services without exercise

Only 13X and 85X types of bill (TOB) are acceptable.  All other TOBs shall be denied.

Use revenue code 0943 for CR/ICR services.

Frequency:

Sessions are limited to a maximum of 2 1-hour sessions per day for CR and a maximum of 6 1-hour sessions per day for ICR.  Claims will be denied if units exceed the maximum units on the same date of service.

Treatment must last at least 31 minutes to report a unit of 1 session.  Additional sessions of CR/ICR services beyond the first session may only be reported in the same day if the duration of treatment is 31 minutes or greater beyond the hour increment.  The minutes of service of several shorter periods of CR/ICR must be added together for reporting in 1-hour session increments.

Duration:

Medicare covers up to 36 CR sessions over a period of up to 36 weeks, with the option for an additional 36 sessions if medically necessary.  Providers must append modifier –KX to medically necessary CR sessions beyond 36.

Medicare covers up to 72 ICR sessions over a period of up to 18 weeks.  Medicare will pay ICR claims which exceed 72 sessions within 126 days (18 weeks) from the date of the first session when the KX modifier is included on the claims. 

The CWF will display the remaining CR and ICR sessions on all CWF provider query screens.

Also see MLN Matters Article MM6850 for a summary of information on Cardiac and Intensive Cardiac Rehabilitation services.

Some of MMP, Inc.’s clients have reported to us that Medicare has changed how they are handling line items that exceed the MUE limit.  Previously, claims were returned to the provider (RTP’d) indicating the particular line item(s) that exceeded the limit.  This allowed the provider to verify the units and adjust the claim appropriately.  The proper way to submit medically necessary services that exceed the MUE limit is to list the service on one line with a quantity that equals the MUE limit and then submit the rest of the services on additional lines (each line quantity up to the MUE limit) with an applicable modifier (such as modifier 59) to bypass the MUE edit.  

Medicare is now denying line items that exceed the MUE limit, instead of RTP’ing the claim.  This means the provider will have to appeal the claim in order to receive appropriate reimbursement for services exceeding the MUE limit.  The best course of action is to submit line items that exceed the MUE limits appropriately on the initial claim.  This can be accomplished by having front-end edits in place to halt claims with services exceeding the MUE limits.  However, this solution is compromised because CMS does not publish all MUE limits.  Certain MUEs are confidential and not available to providers or vendors.  For these services, it will be a trial and error process to determine acceptable MUE limits.  The published MUE list can be viewed on the CMS website at CMS MUE Edits Page.

In April 2010, a hospital CCI edit was introduced involving CPT codes representing MRI and MRA procedure for the same anatomic location. The effective date was retroactive to January.

We sent an inquiry to NCCI asking for clarification. We did not receive a reply, but a reply to the same question was published by codelist.net as follows:

Thank you for your inquiry regarding National Correct Coding Initiative (NCCI) edits that bundle magnetic resonance imaging (MRI) with magnetic resonance angiography (MRA) services.

These NCCI were implemented on January 1, 2010. The edits bundle MRI procedures with MRA procedures for the same anatomic location. The higher paying code is the column one code for each edit pair. The edits are based on the principle that both codes of an edit pair should not be reported together for a single study. A provider should not perform a single study, generate images for separate MRI procedure and MRA procedure reports, and report separate MRI and MRA common procedural terminology (CPT) codes. The Centers for Medicare & Medicaid Services(CMS) allows the use of NCCI-associated modifiers (e.g., modifier 59) for situations where two separate and distinct studies corresponding to an edit pair are performed on the same date of service.

This information will be added in the 2010 annual update to the National Correct Coding Initiative Policy Manual for Medicare Services this summer which will be posted on CMS' website on October 1, 2010.

On May 7, 2010, CMS released two transmittals that manualize the requirements for Pulmonary Rehabilitation (PR) services.  Following is a summary of some of the key points of those transmittals.  However, MMP, Inc. strongly encourages providers to carefully review the manual content contained in these transmittals for a complete understanding of coverage and billing requirements.  Transmittal 124 updates the Medicare Benefits Policy Manual and Transmittal 1966 updates the Medicare Claims Processing Manual.  Both transmittals are effective January 1, 2010 for claims processed on or after October 4, 2010.

“A pulmonary rehabilitation (PR) program is typically a physician-supervised, multidisciplinary program individually tailored and designed to optimize physical and social performance and autonomy of care for patients with chronic respiratory impairment. The main goal is to empower the individuals’ ability to exercise independently.”

• Medicare covers PR items and services for patients with moderate to very severe chronic obstructive pulmonary disease (COPD) (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease.
• Program components must include:
Physician-prescribed exercise.  Some aerobic exercise must be included in each session.

Education or training closely and clearly related to the individual’s care and treatment which is tailored to the individual’s needs, including information on respiratory problem management and, if appropriate, brief smoking cessation counseling.

Psychosocial assessment.  A written evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehab or respiratory condition.

Outcomes assessment conducted by the physician at the start and end of the program, including objective clinical measures of the effectiveness of the program.

An individualized treatment plan that includes the type, amount, frequency, and duration of PR items and services.  It must also include measurable and expected outcomes and estimated timetables to achieve these outcomes. 

The plan must be established, reviewed, and signed by a physician every 30 days.  It may initially be developed by the referring physician or the PR physician.  If the plan is developed by the referring physician who is not the PR physician, the PR physician must also review and sign the plan prior to the start of the PR services.

 

• Must be furnished in a physician’s office or a hospital outpatient setting.
• The setting must have the necessary cardio-pulmonary, emergency, diagnostic, and therapeutic life-saving equipment to treat chronic respiratory disease.  
• A physician must be immediately available and accessible for consultation and emergencies; for hospital outpatient services, this means the physician must be present on the campus for on-campus services and in the provider-based department for off-campus services.
• The supervising physician must meet the following requirements:
Expertise in the management of individuals with respiratory pathophysiology

Licensed to practice medicine in the state in which the PR program is offered

Responsible and accountable for the PR program

Involved substantially, in consultation with staff, in directing the progress of the individual in the PR program.

 

• Services should be billed with HCPCS code G0424 – Pulmonary rehabilitation, including exercise (includes monitoring), per hour, per session.
• Only 13X and 85X types of bill (TOB) are acceptable.  All other TOBs shall be denied.
• Use revenue code 0948.
• Sessions are limited to a maximum of 2 1-hour sessions per day.  Claims will be denied if units exceed 2 on the same date of service.
• Treatment must last at least 31 minutes to report a unit of 1 session.  Two sessions may only be reported on the same day if the duration of treatment is at least 91 minutes.  The minutes of service of several shorter periods of PR must be added together for reporting in 1-hour session increments.  See CPM transmittal for examples.
• Medicare covers up to 36 sessions, with the option for an additional 36 sessions if medically necessary.  Providers must append modifier –KX to medically necessary sessions beyond 36 (sessions 37-72).  Claims that exceed 36 PR sessions without a KX modifier will be denied.  Claims that exceed 72 PR sessions (with or without a KX modifier) will be denied.  The CWF will display the remaining PR sessions on all CWF provider query screens.

Colorectal screening services may be covered for inpatients under Part B, even though the patient has Part A coverage for the hospital stay, if applicable conditions of coverage are met and the patient has not exceeded frequency limitations.  CMS Transmittal 1953 (CR 6760) requires providers to submit claims for colorectal screening services provided to hospital inpatients on a 12X Type of Bill (TOB), in place of 13X TOB effective for dates of service October 1, 2010 and later.  Providers should use the discharge date of the hospital stay for the 12X TOB. This applies to the following services when provided to hospital inpatients under Part B, or when Part A benefits have been exhausted: Fecal Occult Blood Test (CPT 82270), Flexible Sigmoidoscopy (G0104), Colonoscopy (G0105 or G0121), Barium Enema as an alternative to other screening tests (G0106, G0120, G0122, or G0328).  Continue to use appropriate TOBs for colorectal screening services provided to patients in settings other than hospital inpatient (13X, 14X, 22X, 23X, 83X, and 85X).  See the transmittal at the link above or MLN Matters Article MM6760 for more information.

Effective October 1, 2010, providers are no longer required to submit value codes to report the total number of therapy visits when billing for therapy services.  CMS Transmittal 1951 (CR 6899) removes the requirement to report the total number of therapy visits using value codes 50 – physical therapy, 51 – occupational therapy, 52 – speech therapy, and 53 – cardiac rehab.  See the transmittal at the link above or MLN Matters Article MM6899 for more information.

HCPCS code L8509 describes a trachea-esophageal voice prosthesis inserted in a physician’s office or other outpatient setting by a licensed health care provider.  CMS Transmittal 686 (CR  6743) states that effective for dates of service on or after October 1, 2010, claims for HCPCS code L8509 must be submitted to the A/B MAC or Part B carrier, instead of the DME MAC.  The A/B MACs and Part B carriers will cover claims for HCPCS code L8509 as a prosthetic device; payment amount will be the lower of the actual charge or the fee schedule amount.  Claims for these types of prostheses changed by the patient/caregiver in the home setting (HCPCS code L8507) will continue to be submitted to the DME MACs. See the transmittal at the link above or MLN Matters Article MM6743 for more information.