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Medicare will cover the administration of the H1N1 flu vaccine in addition to coverage of the regular seasonal influenza vaccine and its administration.  Two new HCPCS codes have been created for the H1N1 influenza vaccine, effective for dates of service on and after September 1, 2009:

• G9141—Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)
• G9142---Influenza A (H1N1) vaccine, any route of administration

HCPCS code G9141 has an OPPS payment rate of $24.89 for CY 2009 and beneficiary co-payment and deductible do not apply.  Providers should report one unit of HCPCS code G9141 for each administration of the H1N1 vaccine using diagnosis code V04.81 and revenue code 771.  Providers who normally roster bill for immunizations may submit H1N1 administration claims using the roster billing format.  The same roster billing information is required as for seasonal influenza roster claims.

Payment will not be made for HCPCS code G9142 (status indicator ‘E’ under OPPS) since the H1N1 vaccine will be supplied to providers at no cost.  Providers do not need to submit G9142 on the claim, but if it appears on the claim, only the line item will deny.

Since the H1N1 vaccine was released earlier than anticipated, the October IOCE contained an effective date for the new HCPCS codes of October 1, 2009.  The effective date will be corrected to September 1, 2009 with the January IOCE update.  Claims for H1N1 vaccine administration in September 2009 will be held until the installation of the January IOCE release.

Additional information on Medicare coverage of H1N1 and seasonal influenza vaccines can be found at MLN Matters Article SE0920 and MLN Matters Article MM6626.

Effective April 6, 2009, CMS expanded the coverage of PET scans for initial treatment (diagnosis and staging) and subsequent treatment (restaging and monitoring response to treatment) for most solid tumors.  FDG PET scans for certain cancers, especially for subsequent treatments, must still be provided under the coverage with evidence development/coverage with study participation (CED/CSP) paradigm.  Please see the table at the end of this article for a summary of coverage by tumor type.  Coverage changes are indicated with an asterisk (*).

On July 17, 2009 CMS released two transmittals manualizing the NCDs and providing billing instructions.  However, these transmittals were rescinded and replaced with Transmittal 1817 and Transmittal 106 released September 18, 2009.  The new transmittals added some CPT codes and removed the specification of a diagnosis code range. 

The transmittals introduce two new modifiers and provide billing instructions for reporting PET scans.  Hospitals are required to begin using the new modifiers October 19, 2009 for claims with date of service on or after April 6, 2009.

PI – Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing.  Short descriptor: PET tumor init tx strat

PS – Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treatment physician determines that the PET study is needed to inform subsequent anti-tumor strategy. Short descriptor: PET tumor subsq tx strategy

Claims for PET Scans for Initial Treatment Strategy for Covered Cancers must include:

• PET/PET/CT CPT code (78608, 78811, 78812, 78813, 78814, 78815,78816) and
• -PI modifier
• Coverage limited to only (1) one time per cancer type

Claims for PET Scans for Subsequent Treatment Strategy for Covered Cancers must include:

•  PET/PET/CT CPT code (78608, 78811, 78812, 78813, 78814, 78815,78816) and
• -PS modifier and
•  ICD-9 cancer diagnosis code

Claims for PET Scans for Initial or Subsequent Strategy under CED must include:

•  PET/PET/CT CPT code (78608, 78811, 78812, 78813, 78814, 78815,78816) and
• –PI modifier or –PS modifier as appropriate and
• ICD-9 cancer diagnosis code and
• Modifier –QO
• Diagnosis code V70.7 and condition code 30 for institutional claims to denote a clinical trial
• National Oncologic PET Registry (NOPR) data collection required

Hospitals need to develop internal processes to:
- determine the reason for an oncologic PET scan when it is ordered – i.e. diagnosis or staging (initial treatment strategy) or restaging or monitoring response to treatment (subsequent treatment strategy)
- ensure the appropriate modifier(s) are present on the claim
- verify an appropriate diagnosis is provided and coded

Appendix A: Effect of Coverage Changes on Oncologic Uses of FDG PET
See NCD Manual for specific coverage language.

 * Formerly “diagnosis” and “staging”
** Formerly “restaging” and “monitoring response to treatment when a change in treatment is anticipated”
N/C = noncover

(1) Cervix: Covered for the detection of pre-treatment metastases (i.e., staging) in newly diagnosed cervical cancer subsequent to conventional imaging that is negative for extra-pelvic metastasis. All other uses are CED.
(2) Breast: Noncovered for diagnosis and/or initial staging of axillary lymph nodes. Covered for initial staging of metastatic disease.
(3) Melanoma: Noncovered for initial staging of regional lymph nodes. All other uses for initial staging are covered.
(4) Thyroid: Covered for subsequent treatment strategy of recurrent or residual thyroid cancer of follicular cell origin previously treated by thyroidectomy and radioiodine ablation and have a serum thyroglobulin >10ng/ml and have a negative I-131 whole body scan. All other uses for subsequent treatment strategy are CED.

On July 31, 2009, CMS released Transmittal 526 (CR 6518) concerning the correct coding of facet joint injections, especially relating to bilateral injections.  Please see the following excerpts from the MLN Matters Article .

“The primary codes, 64470 and 64475, are used for a single injection in the cervical/thoracic or lumbar/sacral area of the spine, respectively. Each primary code has an associated add-on code for use when injections are provided at multiple spinal levels. The add-on codes are 64472 (cervical/thoracic) and 64476 (lumbar/sacral).

Bilateral injections are performed on the right and left sides of one joint level. The Centers for Medicare & Medicaid Services (CMS) requires physicians to indicate a bilateral injection by using billing modifier 50 and the appropriate CPT code. If a physician performs multiple bilateral injections, modifier 50 should accompany each facet joint injection CPT code.

To summarize, when facet joint injections are performed on both the right and left sides of a level of the spine, physicians must use modifier 50 and the appropriate primary CPT code. When facet joint injections are performed at more than one level, physicians must use add-on codes 64472 or 64476 to represent additional levels of the spine injected.”

This is the fourth in a series of information from government entities concerning the coding and billing of facet joint injections.  Previous information includes: an OIG report that found errors in the billing of facet joint injections; a CMS transmittal that instructed Medicare contractors to strengthen program safeguards to prevent improper payments for facet joint injections; and Cahaba GBA probe review findings that reported issues with missing modifiers and incomplete documentation.  Although some of these articles stress physician billing and coding practices, hospitals should also take necessary actions to ensure they are documenting, coding and billing these services appropriately.

CMS Transmittal 1775 (CR 6478) released July 24, 2009 adds two new point of origin (formerly source of admission) codes for use in Field Locator 15 on the UB-04 (CMS 1450).  Field Locator 15 of the UB-04 and its electronic equivalence is a required field on all institutional inpatient claims and outpatient registrations for diagnostic testing services.  The new codes will be accepted by Medicare’s claims processing systems as of January 4, 2010.

The new codes are:

 E – Transfer from Ambulatory Surgical Center:
- Inpatient: This patient was admitted to this facility as a transfer from an ambulatory surgery center.
- Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services from an ambulatory surgery center.

 F – Transfer from Hospice and is Under a Hospice Plan of Care or Enrolled in a Hospice Program:
- Inpatient: The patient was admitted to this facility as a transfer from hospice.
- Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services from a hospice.

Please share this information with the Registration/Admission and Quality Abstraction departments in your hospital.

For more information, you can view the CMS Transmittal 1775 or the MLN Matters Article.

On January 15, 2009, the Centers for Medicare & Medicaid Services (CMS) finalized National Coverage Determinations (NCDs) for non-coverage of three surgical “never events.”  Per the NCDs, Medicare will not cover a particular surgery or invasive procedure if:

1. the wrong procedure is performed on a patient,
2.  the procedure is performed on the wrong body part, or 
3.  the procedure is performed on the wrong patient. 

On June 12, 2009, CMS released two transmittals that manualize the determinations, further define related non-covered services, and provide billing instructions. 

The effective date of the transmittals is for discharges and services on or after January 15, 2009, but the implementation date, including availability of the new HCPCS modifiers is July 6, 2009 for Part B claims and October 5, 2009 for Part A claims.  Contractors will not go back and search for erroneously processed claims prior to the implementation dates but will adjust any claims brought to their attention.

Related Services

Medicare will not cover hospitalizations and other services related to these non-covered procedures as defined in the Medicare Benefit Policy Manual, Chapter 1 , Sections 10 and 120 and Chapter 16, Section 180. 

• Related services do not include performance of the correct procedure
• All services provided in the operating room when an error occurs are considered related and therefore not covered
• All providers in the operating room when the error occurs, who could bill individually for their services, are not eligible for payment
• All related services provided during the same hospitalization in which the error occurred are not covered
• Following hospital discharge, any reasonable and necessary services are covered regardless of whether they are or are not related to the surgical error.

Billing Instructions – Inpatient Admission

If covered services were provided during the same hospitalization in which a surgical error occurred, the hospital should submit two separate claims: one claim with covered services and procedures unrelated to the erroneous surgery on a Type of Bill (TOB) 11X (except not 110) and another claim with the non-covered services and procedures related to the error on a TOB 110 (no-pay claim).  On the claim for the non-covered services (TOB 110), hospitals should enter one of the following 2-digit surgical error codes in the Remarks field.

• MX: wrong surgery on patient
• MY: surgery on wrong body part
• MZ: surgery on wrong patient

Claims submitted on a TOB 110 with one of the surgical error codes will be denied for payment.

Billing Instructions – Hospital Outpatient

On hospital outpatient claims for services where one of the non-covered surgical events occurred, the hospital should append one of the following applicable HCPCS modifiers to all lines related to the surgical error.

• PA: surgery on wrong body part
• PB: surgery on wrong patient
• PC: wrong surgery on patient

All line-items with one of the above HCPCS modifiers will be denied for payment.

CMS cannot envision a scenario in which HINNs or ABNs could be validly delivered in these NCD cases.  Medicare contractors will maintain a list of surgical error occurrences and will review beneficiary history for other claims potentially related to the surgical error.  If the contractor determines that related services should not have been covered, they will deny payment for the related services and recover overpayments when appropriate. 

Links to the CMS transmittals:
http://www.cms.hhs.gov/transmittals/downloads/R1755CP.pdf
http://www.cms.hhs.gov/transmittals/downloads/R101NCD.pdf

There have been questions regarding whether it is appropriate to bill CPT codes for IV push injection when given in conjunction with a blood transfusion - particularly since the IV push injection requires a 59 modifier when billed on the same outpatient date of service as the blood transfusion, CPT code 36415, representing a separate and distinct service.

We contacted National Correct Coding Initiative and received confirmation that it is appropriate to bill IV push injections in this scenario for the administration of drugs administered in conjunction with the blood transfusion, including but not limited to Benadryl, Lasix, Solumedrol. the drugs must be ordered by the physician and medically necessary.

It is also appropriate to assign modifier 59 to the IV push injections to verify the codes are not being reported for the actual administration of the blood.

CMS provides clear guidance on billing for frozen/thawed blood products.  Providers should bill the most specific HCPCS code that describes the blood product in addition to the CPT code for the transfusion.  If the blood product HCPCS code description includes “frozen” in the description, it would not be appropriate to also bill additional CPT codes for freezing and/or thawing since charges for freezing and thawing should be included in the charge for the product.  If there is not a specific HCPCS code for the frozen blood product, then the provider should bill the appropriate HCPCS code for the blood product plus the CPT codes for freezing and/or thawing.  Also, if a product is frozen and/or thawed in preparation for a transfusion, but the patient does not receive the transfusion, the provider may bill for the freezing and/or thawing services provided.  Please note that for frozen plasma HCPCS codes P9017, P9023, P9059 and P9060; cryoprecipitate HCPCS codes P9012 and P9044; and frozen blood/RBC HCPCS codes P9039, P9054, and P9057 freezing and thawing codes are not separately billable.

This information can be found in Chapter 4 of the Medicare Claims Processing Manual, section 231.6 including a detailed list of all blood/blood product codes with freezing/thawing billing instructions. Link to the Claims Processing Manual Chapter 4:
http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf

The same billing guidelines apply to blood and blood products regarding irradiation of blood (§231.5) and autologous processing (§231.3).