Plus: You can now download a list of all practitioners who can order/refer.
If you’ve been confused about how to report low-level hospital visits now that consult codes are gone, you aren’t alone. CMS intends to tackle this problem by issuing more specific guidance on the topic in the near future.
That’s according to a Feb. 2 CMS-sponsored Physicians, Nurses, and Allied Health Professionals Open Door Forum, where one practice asked the CMS reps when the agency plans to issue instructions on how to report initial hospital visits when the documentation doesn’t meet the criteria for the lowest level visit, a 99221.
CMS is currently working with the medical community to create such guidance, which will “hopefully be out shortly,” noted CMS’s Whitney May during the call.
One caller indicated that her MAC (WPS Medicare) instructed her to use the unlisted E/M code 99499 when the visit doesn’t meet the criteria of 99221 — but the MAC also said …
it would be inappropriate to report a subsequent care code prior to an initial care code.
That interpretation basically says “that if you don’t meet the initial care code, you have to bill unlisted, but the next day if you don’t meet the initial care code you still can’t bill a subsequent visit because you haven’t billed an initial hospital care code, so you have to bill another 99499,” the caller said. “I understand you’re working on creating guidance on this issue, but what do we do today?”
A CMS rep. advised the caller to follow local contractor guidance until CMS is able to issue a more detailed update. “We’ve been working closely with the medical community to try to develop very clear instructions for how to address this particular situation as well as some other questions that have come to us, and we are very close to having that information completed,” the CMS representative said. “We want to be very sure when we’re putting out information that we’re putting it out only one time and that it’s understood by everyone – so that should be coming out very soon.”
When asked whether the guidance would be issued in “days, weeks, or months,” the CMS rep responded only that CMS is doing its best “to get it out as soon as possible.”
Look for NPI List on CMS Site
CMS also addressed the fact that it had previously committed to sharing a list of all physicians and non-physician practitioners who are eligible to order and refer, and that list is now available on the Medicare provider enrollment web page at www.cms.hhs.gov/MedicareProviderSupEnroll, said said Patricia Peyton from CMS’s provider supplier enrollment office, during the call.
Once on the Web site, click on “ordering and referring report.” The .pdf file includes about 800,000 practitioners, their NPI numbers, and their last and first names.
Phase two of the ordering and referring edit starts on April 5, “and what happens then is every claim for an ordered or referred service, when it goes to be processed, if that ordering or referring provider does not pass the two edits, which are to have a current enrollment record and to be of the type that can order and refer,” then that claim will be rejected, Peyton said.
If you review the file and you don’t find your name but think you should be there, “contact your Medicare enrollment contractor,” she indicated.
One caller said that their organization submitted an application for a new provider, but was concerned that any services the provider orders during that period (such as diagnostic lab, radiology, or DME items) will be denied while CMS is waiting to process the certification application.
“We know that the applications can’t be processed overnight,” Peyton said. Once the physician is in PECOS, that supplier can resubmit the claim. “The supplier is not going to look at the date the provider enrolled, as long as the provider’s on the PECOS file that the claims processors use, and everything else is ok with the claim, the claim will then be paid.”
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