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Q:

Sometimes a physician may dilate more than one stricture during an endoscopy procedure. Should we code the dilation of each stricture?

A:

The answer depends on the patient’s insurance because CPT and the NCCI manual provide different coding instructions.

Effective January 2015, CPT guidance allows the reporting of each stricture dilated utilizing modifier 59. Parenthetical notes for CPT codes 43213, 45340, and 45386 state, “For transendoscopic balloon dilation of multiple strictures during the same session, report ‘code’ (43213, 45340, or 45386) with modifier 59 for each additional stricture dilated.”

The National Correct Coding Initiative (NCCI) Policy manual guidance applies to coding and billing for Medicare and Medicaid claims. The 2015 NCCI manual update includes this instruction concerning dilation of multiple strictures:

“Gastrointestinal endoscopy CPT codes describing dilation of stricture(s) (e.g., CPT codes 43213, 45340, 45386) include dilation of all strictures dilated during the endoscopic procedure. These codes should not be reported with more than one (1) unit of service if more than one stricture is dilated.”

Other insurers may choose to follow some of the NCCI coding guidance. Check with the payer to determine their policy regarding these instructions.

We may not know if the testing method for drug screening is classified as moderate or high complexity without looking it up, but I bet everyone will agree that the process of selecting the correct CPT/HCPCS codes for drug screen billing is highly complex.

CPT made a lot of changes to drug assays, specifically drug screening and definitive testing of non-therapeutic drugs, for 2015. And to complicate things even further, Medicare is not accepting the new CPT codes and has established some new HCPCS codes for drug identifications. Medical Management Plus will be covering the drug assay code changes in our coding webinar on December 4, 2014 in more detail, but here is a summary of the major changes.

Instead of classifying drug assays by qualitative versus quantitative, CPT now has three types of drug assays:

1. Presumptive drug assays to detect the possible presence of a drug by simpler testing methods,
2. Definitive drug assays that provide specific identification of individual drugs using complex testing methods, and
3. Therapeutic drug assays to monitor clinical response to a known, prescribed medication.

The assignment of CPT codes for presumptive drug assays are based on the drug classification into one of two drug class lists developed by CPT and the complexity of the testing methods. Drug class list A includes drugs generally considered drugs of abuse and identified by simpler testing methods such as optical observation and chemistry analyzer immunoassay or enzyme assay. Drug class list B includes drugs such as acetaminophen, salicylates, etc. and involves most complex immunoassay analyzer or chromatography methods. The CPT codes for drug screening are:

• CPT 80300 - Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (eg immunoassay) capable of being read by direct optical observation, including instrumented-assisted when performed (eg, dipsticks, cups, cards, cartridges), per date of service
• CPT 80301 - Drug screen, any number of drug classes from Drug Class List A; single drug class method, by instrument test systems (eg, discrete multichannel chemistry analyzers utilizing immunoassay or enzyme assay), per date of service
• CPT 80302 - Drug screen, presumptive, single drug class from Drug Class List B, by immunoassay (eg, ELISA) or non-TLC chromatography without mass spectrometry (eg, GC, HPLC), each procedure
• CPT 80303 - Drug screen, any number of drug classes, presumptive, single or multiple drug class method; thin layer chromatography procedure(s) (TLC) (eg, acid, neutral, alkaloid plate), per date of service
• CPT 80304 - Drug screen, any number of drug classes, presumptive, single or multiple drug class method; not otherwise specified presumptive procedure (eg, TOF, MALDI, LDTD, DESI, DART), each procedure

For Medicare, drug screening codes are the same as last year. Although the description for high complexity lists immunoassay and enzyme assay, most immunoassay and enzyme assay methods are actually moderate complexity tests. Test complexity is determined by the FDA and is listed on their website. Laboratory personnel can help in determining the complexity of drug screen tests that your hospital performs. Medicare’s HCPCS code definitions are:

• HCPCS G0431 - Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter
• HCPCS G0434 - Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter

Both CPT and Medicare developed new codes for individual non-therapeutic drug assays. The new CPT codes are CPT codes 80320 – 80377. CPT clarifies that these codes are to be used for complex definitive methods such as those involving mass spectrometry and specifically excludes immunoassay and enzyme assay testing methods. The new HCPCS codes describing individual drug assays accepted by Medicare for 2015 are HCPCS codes G6030 – G6058. So far Medicare has not provided any guidance on the use of these codes, such as if they are limited to particular testing methodologies.

Because of differences in the basis of the code descriptions, it will not be easy to cross-walk the CPT codes and the Medicare HCPCS codes. We also will have to wait and see if Medicare issues any guidance, particularly for the use of the individual drug codes. The chart below provides some suggestions on cross-walking the drug screening codes.

As high complexity is a determining factor in drug testing, it also appropriately describes the process of determining which codes to use for billing. This year, it just seems to become even more complex and even worse, Medicare is packaging the payment for all drug screening codes. All of this work and brain drain for no reward!!

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Some people may not get their gift from Santa this Christmas. When I was a child, I was always told that Santa Claus would not come until I went to sleep. If the number of people having sleep study testing is any indication, a lot of people in the US are having trouble sleeping. An OIG audit reported that from 2005 to 2011, Medicare spending for polysomnography services rose from $407 million to $565 million, an increase of 39 percent.

Because of this dramatic increase in the volume of sleep studies, several Medicare review contractors have sleep studies and polysomnography as one of their review topics. Two such contractors are the Comprehensive Error Rate Testing (CERT) reviewers and the Supplemental Medical Review Contractors (SMRC). (see the SMRC Polysomnography Project )

Medicare covers diagnostic testing of sleep disorders when the patient has symptoms or complaints of narcolepsy, sleep apnea, impotence or parasomnia. Polysomnography for chronic insomnia is not covered. (See Medicare Benefit Policy Manual, Chapter 15 section 70) There is also a National Coverage Determination (NCD 240.4.1) and several Local Coverage Determinations (LCDs) concerning the coverage requirements for sleep studies.

All reasonable and necessary diagnostic tests for the conditions listed above are covered when the following criteria are met:

• The clinic is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic testing routinely performed in disorder clinics may be covered even in the absence of direct supervision by a physician;
• Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physician’s order; and
• The need for diagnostic testing is confirmed by medical evidence, e.g. physician examination and laboratory tests.

Based on the findings from CERT reviews, discussed in the October 2014 Medicare Quarterly Compliance Newsletter, 97% of improper payments are due to insufficient documentation. So what do providers need to do to ensure they receive payment for their polysomnography services? Make sure the documentation in the medical record for sleep studies includes:

• A valid physician’s order for the diagnostic study or documentation to support the intent to order study (if there is no order, evidence of the intent to order PSG documented in the medical record can be accepted)
• A physician’s signature on the procedure note; and
• Clinical documentation to support the reason/need for the diagnostic study (e.g. documentation to support the fact that the beneficiary had symptoms and signs of sleep apnea).

You have to be good (and asleep) to get your presents from Santa, but you have to have complete and appropriate documentation to get your present (payment) from Medicare for sleep testing.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Having undergone back surgery at the age of twenty-seven, I would tell you that yes I needed that back surgery. Whether or not my chart demonstrated that need or not, who knows. That was then and this is now and in the current Medical Review Contractor environment, if the documentation in a medical record does not support the medical necessity of the procedure, claims submitted by hospitals and in some instances the surgeon can and are being denied.

There are countless types of back surgeries but for this article the focus is on documentation required to support the medical necessity of lumbar spinal fusions that code to DRGs 459 (Spinal Fusion Except Cervical with Major Co-morbidity or Complication) and DRG 460 (Spinal Fusion Except Cervical without Major Co-Morbidity or Complication).

Who is Looking?

The CMS Inpatient Hospital Reviews webpage indicates that despite the current Medicare Administrative Contractor (MAC) Probe & Educate Program, “MACs, Recovery Auditors and the Supplemental Medical Review Contractors will continue other types of inpatient hospital reviews” including “reviews for the medical necessity of a surgical procedure provided to a hospitalized beneficiary.”

MACs

Jurisdiction-N (J-N): First Coast Services Options, Inc.

First Coast is the MAC for Florida and in the absence of a National Coverage Determination (NCD) they were the first and to date the only MAC to have a Local Coverage Determination (LCD) for Spinal Fusions. LCD L32074: Lumber Spinal Fusion for Instability and Degenerative Disc Conditions had an original effective date for services performed on or after October 16, 2011.

Key LCD Guidance

• It is “when conservative therapy (non-surgical medical management) is unsuccessful after at least 3 to 12 months, depending on the diagnosis, lumbar spinal fusion may be considered for certain conditions.”
• “The hospital records are the primary source of information for the audit of hospital/procedure services. Therefore, any historical data supporting the medical necessity of the fusion (for example, duration and outcome of physiotherapy, injection therapy, anatomic factors influencing the decision for surgery, etc.) must be included in the inpatient medical record as noted in the history and physical examination, operative note and/or copies of office notes. For example, fusion of iatrogenic instability (i.e., surgical resection of facet as essential portion of the required decompression rendering an unstable segment) should be documented in a pre-operative note and/or an operative note.”
• “To meet Medicare’s reasonable and necessary (R&N) threshold for coverage of a procedure, the physician’s documentation for the case should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need and is at least as beneficial as existing alternatives & the procedure is furnished with accepted standards of medical practice in a setting appropriate for the patient’s medical needs and condition). Lacking compelling arguments for an exception in the supporting documentation, the hospital (FISS claim) and physician services (MCS claim) can be denied.”
• Physician documentation must support the need for surgery and “must include the following:
• Office notes/hospital record, including history and physical by the attending/treating physician
• Documentation of the history and duration of unsuccessful conservative therapy (non-surgical medical management) when applicable. Failure of non-surgical medical management can be historical and does not have to be under the direction of the operating surgeon.
• Interpretation and reports for X-rays, MRI’s, CT’s, etc.,
• Medical clearance reports (as applicable)
• Documentation of smoking history, and that the patient has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation if accepted (if applicable)
• Complete operative report outlining operative approach used and all the components of the spine surgery

Medical record documentation must be made available to Medicare upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act.”

Jurisdiction-11 (J-11) Palmetto GBA

Palmetto, the MAC for North Carolina, South Carolina, Virginia and West Virginia posted the YouTube Presentation Clinical Updates: DRG 459, 406earlier this year on August 11th. The most common reason cited by Palmetto for denials was a lack of information in the medical record about the conservative care provided prior to the surgical intervention.

Palmetto goes on to list documentation examples of conservative treatment that when clearly documented may help support payment for spinal fusion-related hospital care. Physical therapy, joint injections, neurologic deficits and upper and lower extremity strength are just a few of the examples provided.

Cahaba GBA, the MAC for Alabama, Georgia and Tennessee, has on more than one occasion indicated that simply documenting “failed outpatient therapy” for a total joint replacement is not sufficient to support the surgery. Similarly, Palmetto notes in this presentation that “failed outpatient therapy, admit for spinal fusion” is not sufficient evidence of Medical Necessity for a spinal fusion.

Supplemental Medicare Review Contractor (SMRC)

Transmittal 508 had an Effective and Implementation date of April 8, 2014 and added the Supplemental Medicare Review Contractor (SMRC) to the already long list of “Review Contractors” (MACs, CERT, RAC, PSCs, and ZPICs) performing medical review activities.

Strategic Health Solutions, LLC was awarded the SMRC Contract and they have been busy this year fulfilling one of their primary tasks of “conducting medical review based on the analysis of national claims data versus data that is limited to a specific jurisdiction as performed by Medicare Administrative Contractors (MACs).”

One such Project was a review of Medicare Part A Inpatient Services for Spinal Fusions. As part of the Project Background they noted that “analysis of Medicare claims data for calendar years 2012 and 2013 indicated a significant increase in billing and payment in Inpatient Hospitals Stays of Diagnosis-Related Group (DRG) Codes 459 (Spinal Fusion, except cervical spine, with major complications or comorbidities) and 460 (Spinal Fusion, except cervical spine, without major complications or comorbidities).”

The purpose of this project was to determine if claims had been appropriately adjudicated according to Medicare regulations and guidelines. At the end of the project 986 claims had been reviewed. Of those claims 589 were denied due to no response from the hospital and 374 claims were denied after review with a resultant overall Error Rate of 49%.

Project findings also included Specific Denial Reasons and Ways to Prevent Denials.

Denial Reasons

• Providers not responding to Additional Documentation Request (ADR) within the 45 day time frame
• Lack of documentation supporting the medical necessity of the procedure.
• Lack of documentation showing that conservative treatment was done prior to the surgical intervention.

Ways to Prevent Denials

• “Responding timely to SMRC ADR letters,
• Submit all documentation related to the services billed which support the medical necessity of services billed.”

Moving forward, hospitals need to be aware of NCD and LCD requirements to ensure records support the medical necessity of a procedure, be mindful of all of the Review Contractors that could be requesting records and submit requested information within the allowed time frame.

“The ABC’s of …” refers to the basic facts of a topic. This article looks at the basic facts of the rehabilitative therapy updates for 2015, which involve C’s (caps and codes), D’s (documentation), E’s (exceptions and extensions), and F’s (functional reporting). So the ABC’s of the CDEF’s of therapy are…

There are not a lot of changes for rehabilitative therapy for 2015 like there have been the past few years. But all of the changes from previous years remain in place, at least for now. So let’s look at what is new and review some of the ongoing requirements for therapy services.

Therapy Caps

• The 2015 therapy cap for physical therapy and speech-language pathology combined is $1,940
• The cap for occupational therapy is $1,940 for 2015
• There is an exception process for therapy services beyond the cap limit if services are reasonable and necessary
• Use KX modifier on therapy services to request exception to therapy caps
• KX modifier - therapist is attesting that the services above the therapy caps are reasonable and necessary and that there is documentation of medical necessity for the services in the beneficiary’s medical record
• See MLN Matters Article MM8970

Therapy Code List

• Two new codes created to describe negative pressure wound therapy with the use of a disposable system
• CPT Code 97607 – Negative pressure wound therapy utilizing disposable, non-durable medical equipment …, total wound(s) surface are less than or equal to 50 square cm
• CPT Code 97608 – Negative pressure wound therapy utilizing disposable, non-durable medical equipment …, total wound(s) surface are greater than 50 square cm
• CPT codes 97607 and 97608 designated as “Sometimes Therapy”
• Negative pressure wound therapy CPT codes 97605 and 97606 revised to specify the use of durable medical equipment
• G-codes (G0456 and G0457) that described negative pressure wound therapy using disposable device are being deleted
• See MLN Matters Article MM8985

Extension of Therapy Provisions

The Protecting Access to Medicare Act of 2014 (PAMA) extended the following provisions through March 31, 2015:

• The exceptions process for outpatient therapy caps
• The manual medical review process for therapy services exceeding threshold of $3,700 (one threshold for PT/SLP combined; one for OT)
• The application of the therapy caps and related provisions to services furnished in hospital outpatient departments
• The patient’s performance on the Berg Balance Scale (score 46 out of 56) indicates that she is a low fall risk according to the interpretive guidance provided. However, the patient is a moderate fall risk due to the added contribution of lower extremity muscle weakness and reduced vision. The patient classifies as between 20%-40% impaired (CJ). Due to ongoing visual impairment, the patient is expected to obtain a goal of 1-20% impairment (CI) with the recommended therapy plan of care.

Functional Limitation Reporting

Reporting of the functional limitation G-codes and severity modifiers is now a requirement for rehabilitative therapy claims to allow Medicare to gather data on therapy usage and outcomes to assist in reforming the Medicare payment system for outpatient therapy services. From therapy reviews performed by Medical Management Plus, it appears providers are generally reporting these correctly. The one issue that needs improvement is the documentation of the rationale for selection of the severity modifiers. The Medicare manual states – “Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.”

Documentation should clearly indicate the measures and reasons the therapist selected a particular degree of impairment. Some examples of documentation that meets these requirements are:

• The patient’s performance on the Berg Balance Scale (score 46 out of 56) indicates that she is a low fall risk according to the interpretive guidance provided. However, the patient is a moderate fall risk due to the added contribution of lower extremity muscle weakness and reduced vision. The patient classifies as between 20%-40% impaired (CJ). Due to ongoing visual impairment, the patient is expected to obtain a goal of 1-20% impairment (CI) with the recommended therapy plan of care.
  (Paraphrased from APTA Functional Limitation Reporting Toolkit at the following link: http://www.apta.org/Payment/Medicare/CodingBilling/FunctionalLimitation/)

• Patient’s goal for PT is to be able to walk in her house and around the community (G8978) with minimal to no assist. Her current impairment is 80% (CM) based on her OPITMAL, Berg Balance, and 10 meter walk scores. She is expected to be able to walk with minimal assistance with around 30% (G8979 CJ) impairment after 6 weeks of therapy.

Therapists definitely need to know their alphabet for billing, coding and documentation.

November is Lung Cancer Awareness Month and annually the American Cancer Society has designated the third Thursday of November as the Great American Smokeout “by encouraging smokers to use the date to make a plan to quit, or to plan in advance and quit smoking that day.” We at MMP would also like to use this date to encourage our readers to make a plan and be prepared for the documentation changes for smoking in ICD-10.

In record reviews I have seen doctors note a patient has never smoked, is a smoker, is a reformed smoker, patient has cut back to 2-3 cigarettes a day. While all of this is interesting, currently in ICD-9 physicians simply need to document when a patient smokes or uses tobacco.

However, in ICD-10, physicians will need to provide more detailed documentation. Physicians will need to document the following additional information for the coder to most accurately report a patient’s tobacco use:

• The physician should document the type of tobacco a person uses (e.g. cigarettes, chewing tobacco, pipe, and/or gum).

• To further specify the type of tobacco dependence that a patient has, the physician will need to document the frequency of use.
• The patient uses nicotine, or
• The patient abuses nicotine, or
• The patient has a nicotine dependence or
• The patient is in remission from nicotine.

• Also, when it is applicable, the physician should document the type of second hand smoke experienced by the patient (e.g. from parent, at work, perinatal, etc.).

Take a look at what your physicians are currently documenting about tobacco use and begin to educate your physicians on what needs to be documented for the accurate reporting of tobacco use.

Everyone knows that in medical record documentation you have to be sure to “say what you did.” But don’t forget that it also has to be authenticated, dated, legible, timely, and include documentation to not only support the service provided, but the clinical indications for why it was provided. Sort of an extended version of “who, what, when, where, and why…”

Our focus this month is the medical review of claims containing CPT code 33249 (Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber). There has been a lot of concern about appropriate billing of AICDs; in fact over the last few years the Department of Justice has investigated these claims to determine if they meet the requirements of the National Coverage Determination (NCD). All of this attention on AICDs is due to high-dollar reimbursement and a long and complex NCD. The Medicare Quarterly Compliance Newsletter for October 2014 discusses the findings of a special study of CPT 33249 by the Comprehensive Error Rate Testing (CERT) program. The CERT review found that many improper payments were made due to insufficient documentation and medical necessity errors.

I will not address all of the requirements for AICDs in this article, but will concentrate on the deficiencies sighted in the Compliance newsletter. For complete information on AICD coverage, please see the NCD for Implantable Automatic Defibrillators (20.4).

The CERT study found that approximately 85 percent of the improper payments were due to insufficient documentation, meaning the required information was missing from the medical record or was inadequate to support payment. Services that were not medically necessary, based on Medicare coverage policies, accounted for approximately 12% of the improper payments.

Signature Issues:

• The procedure note was not signed by the physician.
• There was not a signature log or attestation for cases in which the physician’s signature was illegible.
• There was a lack of policies for electronic signature process in electronic health records, when applicable.
• Clinical records supporting the patient’s history of heart disease were not authenticated.
• A second copy of a previously unsigned post-operative history and physical examination note was submitted to which a signature had been added without a signature date. Providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead should make use of the signature authentication process.

Date of Service:

• There was a lack of records for the specified date of service.
• An operative report showed that the patient had an AICD implanted; however, the date on the report did not match the billed date of service. Medicare payment rules do not allow reviewers to accept documents with dates that are significantly different from the billed date of service.

Clinical Indication:

• Documentation did not support the clinical indication for the procedure.
• Clinical documentation did not support a previous Myocardial Infarction (MI). MIs must be documented and defined according to the consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction

Clinical Trial:

• There was a lack of records to support the patient was enrolled in a clinical trial/study. Patients receiving defibrillator implantation for primary prevention must be enrolled in either:
• A Food and Drug Administration (FDA) approved category B investigational Device Exemption (IDE) clinical trial;
• A trial under the CMS Clinical Trial Policy; or
• A qualifying data collection system including approved clinical trials and registries.
• Documentation of enrollment in a clinical trial/study is required to support the use of the Q0 (Q zero) modifier.

Lack of Medical Necessity:

• For all AICDs, the beneficiary must not have irreversible brain damage from preexisting cerebral disease.
• For primary prevention of sudden cardiac death, criteria include that the beneficiary must not have:
• Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm;
• Had a Cardiopulmonary Artery Bypass Graft (CABG) surgery or Percutaneous Transluminal Coronary Angioplasty (PTCA) within the past 3 months;
• Had an acute Myocardial Infarction (MI) within the past 40 days;
• Clinical symptoms or findings that would make them a candidate for coronary revascularization; or
• Any disease, other than cardiac disease (e.g., cancer, uremia, liver failure), associated with a likelihood of survival less than 1 year.

Amendments, Corrections and Delayed Entries:

• Medical record amendments, corrections and delayed entries must comply with the widely accepted Recordkeeping Principles described in the Medicare Program Integrity Manual, Chapter 3 (Section 3.3.2.5 (Amendments, Corrections and Delayed Entries in Medical Documentation), Section B (Recordkeeping Principles) to be considered for review determinations.
• Medicare Reviewers do not consider any entries that do not comply with the principles listed in Section B, even if such exclusion would lead to a claim denial.
• For example, undated or unsigned entries handwritten in the margin of a document are excluded from consideration.

So be sure your medical records contain sufficient information to support your Medicare billing. But be especially mindful of those AICD records – that’s a lot of money!!

One other note about Medicare Administrative Contractor (MAC) medical reviews – CMS now requires that MACs post their review topics to their public websites (see Transmittal 527). This requirement was effective September 5, 2014. You will notice on this month’s MAC Review table that First Coast (Jurisdiction N MAC) has added numerous current review topics. These may have been noted on their website previously, but this is the first time I have been able to locate this information.  

In billing Medicare, the details are important. And the details are complicated! Is the status inpatient or outpatient? Is there additional reimbursement? Are the services provided on or off campus? And with an inpatient only list, packaging of services, and provider-based vs. satellite vs. remote locations, how is a provider to figure it out? It takes lots of reading, interpreting, head-banging and gnashing of teeth. And as if the sheer complexity isn’t enough, the rules change constantly or at least once a year - as is the case with the 2015 Outpatient Prospective Payment System Final Rule (OPPS FR).

The other two articles in this week’s Wednesday@One address some of the major changes from the 2015 OPPS FR, specifically the new packaging rules including Comprehensive APCs and the changes to the physician certification requirements for inpatient admissions. In keeping with the theme, this article will address some of the other outpatient changes found in the final rule.

Inpatient Only Procedures

CMS did not make a lot of changes to the Inpatient Only list for this year but some of the changes were significant in terms of hospital operation.

They added an Osteotomy code –

• CPT code 22222 (Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic)

They removed two codes for additional spinal levels of laminotomy –

• CPT code 63044 (Laminotomy … each additional lumbar interspace)
• CPT code 63043 (Laminotomy … each additional cervical interspace)

The removal of these codes seems extremely reasonable since the primary codes (CPT 63040 and 63042) representing the first and single interspace for these additional-level procedures were already not listed as inpatient only procedures. Since these are add-on codes, there will not be additional reimbursement for the additional levels, but at least these can now be performed as outpatient services.

Payment for Drugs and Biologicals

Medicare is continuing to pay for both pass-through drugs and separately payable drugs, biologicals, and therapeutic radiopharmaceuticals without pass-through status at ASP + 6%. The packaging threshold for separately payable drugs for CY2015 increased to $95. The packaging threshold (average per day cost) began at $50 in 2005 and has steadily increased from year to year; for example it was $90 for 2014. Drugs with a per day cost equal to or below this threshold (by Medicare calculations) are not separately paid, but are packaged into other services.

Off-campus Provider-Based Departments

Medicare and other governmental agencies have recently expressed concerns about the trend of hospitals acquiring physician practices. Outpatient hospital services are paid at a higher reimbursement rate than services provided in a physician’s office or free-standing clinic. In order to collect data on the amount and types of services being provided in hospital off-campus provider-based departments (PBDs), CMS will be requiring the addition of a modifier to services furnished in an off-campus provider-based department on facility claims and a new place of service (POS) code on the physician claims. This proposal was finalized in the 2015 OPPS Final Rule with the following details:

• The addition of the modifier for hospital services in an off-campus provider-based department is not required until 2016. The modifier may be voluntarily added beginning in 2015.
• The new HCPCS modifier is “PO” (Services, procedures and/or surgeries furnished at off-campus provider-based outpatient departments) and is to be appended on the hospital claim to all services furnished in the off-campus PBD.
• CMS defines “campus” as the physical area immediately adjacent to the provider’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider’s campus.
• The modifier is not to be reported for services furnished in:
• Remote locations of a hospital as defined at 42 CFR 412.65,
• Satellite facilities of a hospital as defined at 42 CFR 412.22(h), or
• Services furnished in an emergency department.
• CMS will be deleting POS code 22 (outpatient hospital department) and replacing it with two new codes, one of which will identify services furnished in a hospital off-campus PBD for physician reporting.

CMS indicates that additional instructions and provider education will be forthcoming in sub-regulatory guidance.

These are some more of the most recent changes – until the next changes come along. Hospitals need to adjust their processes to address the above new regulations and watch for any clarifying guidance. Don’t bang your head too hard!

The 2014 IPPS Final Rule placed a significant burden on hospitals by requiring that a Physician Certification be completed on ALL Medicare inpatient admissions. In their effort to achieve “policy goals with the minimum administrative requirement necessary,” CMS finalized the 2015 OPPS proposed changes to the physician certification process that only requires physician certification for long-stay and outlier cases.

Implications for Hospitals:

• The physician certification change does not change the fact that there must be a signed inpatient order prior to a beneficiary being discharged as a hospital Condition of Participation (CoP) & a requirement for payment for Medicare Part A Services.
• Physician documentation in the medical record (e.g., History & Physical, MD Progress Notes and Physician Orders) still must support the medical necessity for hospital care that is expected to span at least two midnights.

• For Medicare beneficiaries that reach a 20 day length of stay it will be important to make sure that the “physician certifies or recertifies the following:

1. (1)The reasons for either –
2. (i)Continued hospitalization of the patient for medical treatment or medically required diagnostic study; or
3. (ii)Special or unusual services for cost outlier cases (under the prospective payment system set forth in subpart F or part 412 of this chapter).
4. (2)The estimated time the patient will need to remain in the hospital.
5. (3)The plans for posthospital care, if appropriate.’

• The physician certification continues to be a requirement until January 1, 2015 and must include the following:
• Authentication of the Practitioner order prior to the beneficiary being discharged,
• The reason for inpatient services,
• The estimated time that the patient will require as an inpatient; and
• The plans for hospital care.

Final Rule Comments and Responses

• Comment: CMS indicates that several commenters “continued to disagree that CMS has the statutory authority to require signed admission orders for all inpatient cases.”
  
  Commenters further “argued that the continued requirement for admission orders is essentially the same as the certification requirement and stated that section 1814(a)(2) of the Act is explicit in requiring physician certification only for services “furnished over a period of time” and not for all services.”
  
  Response: Not surprising, CMS disagrees noting that, “While the inpatient admission order was a required component of the physician certification under our previous policy, the order and the physician certification do not serve identical policy goals under our proposal, which we are now finalizing. For all cases, a properly authorized and documented admission order is necessary because the admission order is integral to a clear regulatory definition of when and how a beneficiary becomes an inpatient.”

• Comment: There were also several commenters that requested that the timing of a signed admission order be by the time of billing as is permitted for Critical Access Hospitals (CAHs).
  
  Response: Again, not surprising, CMS disagrees and indicates that “we believe that, in most cases, matters relating to the determination of patient status should be resolved before discharge, due to the consequences that flow from such a determination. For example, whether services are billed under Medicare Part A or Part B can have a significant impact on a beneficiary’s financial liability. Therefore, we do not believe it is appropriate to change our existing policy which requires that inpatient orders be signed prior to discharge by a practitioner familiar with the case and authorized by the hospital to admit inpatients.”

• Comment: Several commenters also requested additional guidance around the required content and format of the physician certification statement.
  
  Response: CMS reiterates in the Final Rule that “the physician certification requirements at § 424.13 generally may be satisfied by elements routinely found in a patient’s medical record, such as progress notes. CMS does not require that a physician certification comply with a specific standard or format--only that it ensures that the conditions at § 424.13(a) were met. If the medical record adequately describes the reasons for continued hospitalization, the estimated time the patient is expected to require inpatient care, and discharge planning (where appropriate), and the medical record is signed by a physician involved with and responsible for the patient’s care, this would satisfy certification requirements.”

Final Rule

“We are finalizing the policy as proposed in the CY 2015 OPPS/ASC proposed rule, which limits the requirement for physician certification to long-stay (20 days or longer) and outlier cases”

“We are also are finalizing our proposed revision of paragraph (b) of § 424.13, without modification, to specify that certifications for long-stay cases must be furnished no later than 20 days into the hospital stay.”

For those interested, the Revision of the Requirements for Physician Certification of Hospital Inpatient Services Other Than Psychiatric Inpatient Services can be found on pages 901-912 of the Display Copy of the Final Rule.

Link to the Display Copy of the Final Rule: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1613-FC.html?DLPage=1&DLSort=2&DLSortDir=descending

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Q:
What does Medicare expect from providers concerning limiting drug wastage? For example, if a chemo drug comes in two sizes of single-dose vials, 100 mg and 160 mg and the patient’s dose is 237 mg, could we use three 100mg vials with a wastage of 63 mg, or must we use one 100mg and one 160mg vial for the least amount of wastage (23mg)? 

A:

The Medicare Claims Processing Manual, Chapter 17, section 40 states, “The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.”

Medicare is generally not concerned if you have to jump through extra hoops in order to comply with their guidelines.

Since…

• This drug is separately reimbursed by Medicare
• Medicare has done targeted reviews of some of the other chemo drugs specific to waste issues
• Medicare has instructed hospitals how to report drug waste

 ……MMP recommends you try to minimize waste, even if it involves extra steps.

If you have only the 100 MG dose vials available, then you use what you have. In this case, you are allowed to bill the waste as long as there is not another patient getting the same drug for which the unused portion could have been used.

If you are reviewed by a Medicare reviewer, and they question your billing, you might have to provide invoices, or other documentation proving why you billed as you did.