Forget about digging through the latest Medicare Physician Fee Schedule and calculating the conversion factor when it comes to determining your Part B reimbursement rate for flu shots. CMS has come out with a handy MLN Matters article explaining this i…
Get ready for another year of nail-biting to find out if your Medicare payments will be slashed. “The calendar year 2011 Physician Fee Schedule conversion factor is $25.5217,” notes the 2011 Medicare Physician Fee Schedule Final Rule, printed in th…
The National Correct Coding Initiative (CCI) version 16.3 instructions align MTWA and stress tests coding manual guidelines with version 16.2 edit deletions.
Update Chapter 11 of Your CCI Manual
The CCI version effective July 1 deleted the edits that barred reporting cardiovascular stress test codes 93015-93017 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress …) with MTWA code 93025 (Microvolt T-wave alternans for assessment of ventricular arrhythmias).
The manual in effect at that time, however, stated you couldn’t report 93015-93017 on the same date as 93025. The previous wording said, “If a physician performs an MTWA with submaximal stress test followed by a traditional stress test on the same date of service, CMS payment policy allows separate payment of MTWA (CPT code 93025) and the interpretation and report for the traditional stress test (CPT code 93018). The practice expense component of the traditional stress test is not separately payable, and a physician should not report CPT codes 93015-93017 on the same date of service as CPT code 93025.”
CCI’s updates present in the current manual, version 16.3, reflect the CCI edit deletion that allows you to report both an MTWA with submaximal stress test and a traditional stress test, acknowledging that the tests are different. The current wording says, “Microvolt T-wave alternans (MTWA) (CPT code 93025) testing requires a submaximal stress test that differs from the traditional exercise stress test (CPT codes 93015-93018) which utilizes a standard exercise protocol. CPT codes 93015-93018 should not be reported separately for the submaximal stress test integral to MTWA testing. If a physician performs an MTWA with submaximal stress test followed by a period of rest and then a traditional stress test on the same date of service, both the MTWA and traditional…
Only report primary procedure – except for 99455 edits.
The latest version of the National Correct Coding Initiative (CCI) edits went into effect October 1, and introduced a slew of pairings involving two new Category III “T” codes for transforaminal epidural injections:
Explanation: “The new Category III codes 0228T-0231T have added the addition of ultrasound guidance to transforaminal epidural injections,” says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, CEO of Healthcare Consulting and Coding Education in Boardman, Ohio. “That will eliminate the need to code the ultrasound independently.” The existing, Category I codes for transforaminal epidural injections of anesthetic and/or steroids (64479-64484) include only the injection itself.
Even Simple Procedures Rule With NME Edits
CCI classifies the bulk of edits involving 0228T and 0230T as non-mutually exclusive.
No breakage: The rationale behind the new bundling edits falls to “standards of medical/surgical practice.” Most edits carry a modifier indicator of “0,” which means you cannot break the edit with a modifier and report both codes during a single encounter.
Examples of common procedures that override the accompanying 0228T or 0230T codes include:
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CMS clears up flu shot coding confusion.
You’ve heard the advantages of participating in CMS’s Electronic Health Record (EHR) Incentive Program (including $44,000 per-physician bonus incentives over a five-year period), but you may not be sure how to enroll.
CMS staffers cleared up that confusion during an Oct. 5 open door forum, where CMS’s Rachel Maisler indicated that you must register on CMS’s EHR incentive program’s Web site, which will open in January 2011 for the Medicare program.
In addition, you must be enrolled in CMS’s PECOS system and have an NPI, and you must use certified EHR technology. You can find details on how to determine which EHR systems are certified on www.healthit.hhs.gov.
Key dates: During the call, CMS reps also announced important dates involved in EHR participation. “Attestation, which is how you will report the objectives and measures for meaningful use and clinical quality measures, will begin in April of 2011, and we expect the first payments will be made in May of 2011,” Maisler said.
Look for Combined Flu Shot
Flu vaccine: Now that the H1N1 immunization is part of the regular flu vaccine, a caller asked the CMS officials whether a new code will be developed to describe the combined flu shot, but CMS officials noted that no such code will be issued.
“We’re continuing to use the same codes as last year, and my understanding is the H1N1 is part of the regular flu vaccine this year, so you’d bill what the appropriate flu vaccine code is,” said CMS’s Amy Bassano, during the call. High-dose flu vaccine code 90662 (Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use) has been added to the roster of codes that can be billed to Medicare, Bassano confirmed.
RACs: Another caller…
Make sure your postop office visit documentation measures up.
The OIG has once again set its sights on several new targets to go with the upcoming new year, and this time the feds will be double- and triple-checking your E/M documentation.
On Oct. 1, the OIG published its 2011 Work Plan, which outlines the areas that the Office of Audit Services, Office of Evaluations and Inspections, Office of Investigations, Office of Counsel to the Inspector General, Office of Management and Policy, and Immediate Office of the Inspector General will address during the 2011 fiscal year. When the OIG targets an issue in its Work Plan, you can expect the agency to carefully review and audit sample claims of those services.
The Work Plan “describes the specific audits and evaluations that we have underway or plan to initiate in the year ahead considering our discretionary and statutorily mandated resources,” the document indicates.
On the agenda for next year, the OIG has indicated that its investigators will “review the extent of potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations.” The OIG also plans to hone in on whether payments for E/M services performed during the global periods of other procedures were appropriate.
In addition, the OIG will scrutinize Medicare payments for Part B imaging services, outpatient physical therapy services, sleep testing, diagnostic tests, and claims with modifier GY on them (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, it is not a contract benefit).
The OIG also intends to “review Medicare payments for observation services provided during outpatient visits in hospitals” to assess whether hospitals’ use of observation services affects Medicare beneficiaries’ care.
Keep your compliance plan up to date with tips from Part B Insider,…
Medically unlikely edits ignorance could be causing you medical coding claim denials.
Ensure you’re not letting medically unlikely edits (MUEs) wreak havoc on your urology practice’s coding and reimbursement by uncovering the truth about four aspects of these edits.
Myth 1: MUE Edits Don’t Affect Your Practice
Some practices feel that they don’t need to worry about MUEs.
Reality: “They limit the frequency a CPT code can be used,” says Chandra L. Hines, business office manager at Capital Urological Associates in Raleigh, N.C. “With our specialty of urology, we need to become aware of the denials and not let every denial go because the insurance company said it was an MUE. We should all be aware of MUEs as they occur, and we cannot always control whether or not we will receive payment.”
The MUE list includes specific CPT or HCPCS codes, followed by the number of units that CMS will pay. CMS developed the MUEs to reduce paid claims error rates in the Medicare Program. The first edits were implemented in January 2007, although some of the edits themselves became public in October 2008.
Some MUEs deal with anatomical impossibilities while others edit automatically the number of units of service you can bill for a service in any 24-hour period. Still others limit codes according to CMS policy. For example, excision of a hydrocele, bilateral (55041) has a bilateral indicator of “2,” so you should never bill two or more units of this code. Additional edits focus on the nature of the equipment for testing, the study or procedure, or pathology specimen.
Anatomical example: The MUEs edit out and deny an erroneously coded claim for a circumcision (54161, Circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age) for a patient…
BC/BS UHC, tell coder to halt 96110-59 denials with 96110-79.
If you’re ready to bill 96110 and 96110-59, think again.
One office was billing 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) with modifier 59 (Distinct procedural service). BlueCross/BlueShield (BC/BS), UnitedHealthcare (UHC), and other insurers were denying the 96110-59s. “I called BC/BS on 8-19-2010 and was told that we should be using a 76 (Repeat procedure or service by the same physician) modifier instead,” reports Bonnie Palmer, with Lawrenceville Pediatrics in Georgia. “I also called UHC and was told the same thing.”
96110 x 2 or 96110-59 Is Technically Correct
Modifier 59 rather than 76 more appropriately describes two distinct 96110s. When you’re reporting two 96110s, you’re doing so to represent two different tests, not a repeat second test as modifier 76 represents. That being said, the American Academy of Pediatrics prefers that you report multiple 96110s using units rather than any modifier.
Two 96110s indicate that the second developmental test is a separate test. Staff administered — or the parent completed — two different tests, such as the Ages and Stages Questionnaire (ASQ) and the Modified Checklist for Autism in Toddlers (MCHAT) — and that the physician interpreted and documented the tests’ interpretation.
Before Using Repeat Method, Obtain Proof
Modifier 76 instead indicates that the second test was repeated. The modifier appropriately describes cases in which staff has to readminister the same test and the physician has to reinterpret the results.
In practice, the old adage is best to follow: Get the policy in writing. If you obtain a modifier directive from an insurer to use modifier 76 for multiple 96110s – either from the payer’s Web site or an email confirmation, save the documentation – and then adhere…
Agencies will have little control over new physician-related payment condition. Home health agencies are hoping for some big changes to one troublesome provision in the 2011 proposed payment rule – the face-to-face physician encounter requirement.
The mandate for the face-to-face encounter was in the Patient Protection and Affordable Care Act health care reform law enacted earlier this year. But the CMS version of the requirement is even stricter than the law requires.
Example: The proposed rule also requires that the encounter be for the primary reason home care services are required and that physicians furnish “unprecedented” physician documentation about the encounter and why the patient meets homebound criteria. “We believe that CMS has gone beyond statutory intent” in those two provisions, says the National Association for Home Care & Hospice.
The proposed face-to-face encounter requirement is riddled with problems for HHAs, industry experts say. To begin with, agencies have little influence over whether their patients make it to the doctor for a visit.
“It is absolutely ridiculous to place a requirement on home health providers for which they have absolutely no control,” protests consultant Pam Warmack with Clinic Connections in Ruston, La. “How in the world is the staff of the home health provider supposed to ensure that the patient visits the physician and that the physician documents appropriately in his/her office records?” Warmack asks.
“We can make appointments for patients, but we can’t ensure they keep them, that their transportation is reliable, that they feel well enough to make the trip, etc.,” Warmack continues. “There are so, so many reasons that patients fail to see the physician despite the best efforts of the home care staff to make it happen.”
The requirement will be “a particular burden on home health patients who are homebound and have difficulty leaving home,” notes…
Don’t let nurses do the doctor’s work, or risk downcoded E/Ms upon audit.
The only parts of the E/M visit that an RN can document independently are the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs, according to a June 4, 2010 Frequently Asked Questions (FAQ) answer from Palmetto GBA, Part B carrier for Ohio. The physician or mid-level provider must review those three areas and write a statement that the documentation is correct or add to it.
Only the physician or non-physician practitioner who conducts the E/M service can perform the History of Present Illness (HPI), Palmetto says.
Exception: In some cases, an office or Emergency Department triage nurse can document “pertinent information” regarding the Chief Complaint or HPI, Palmetto says. But you should treat those notes as “preliminary information.” The doctor providing the E/M service must “document that he or she explored the HPI in more detail,” Palmetto explains.
Other payers have expanded on Palmetto’s announcement, letting physicians know that they cannot simply initial the nurse’s documentation. For example, Noridian Medicare publishes a policy that states, “Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be ‘I have reviewed the HPI and agree with above.’”
Good news: Thanks to this clarification, your doctor won’t have to repeat the triage nurse’s work. Right now, if the nurse writes “knee pain x 4 days,” at the top of the note, some auditors might insist that your doctor needs to write “knee pain x 4 days” in his/her own handwriting underneath. But that requirement is a thing of the past if your carrier echoes Palmetto’s requirement.
Bad news: Now this carrier has made it…