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Search the FAQs - Search our current and archived FAQs.
The Upstate Medicare Division (UMD) is currently in the process of reorganizing the frequently asked questions (FAQs) archive. To help you find FAQs that are relevant to your needs, we will begin archiving FAQs by topic rather than by date.
New questions will continue to be posted on the main page of the FAQs section (as seen below). After one month, these questions will be moved to the most relevant topic archive page.
April 2008
1. In a situation where the patient presents in the office and then requires critical care services (in the office), and then is transferred to the hospital and admitted, how can the provider be reimbursed for both the office service and the hospital admission? (Last Reviewed: April 25, 2008)
2. Explain the billing of a consultation vs. an admission. (Last Reviewed: April 25, 2008)
3. How can we obtain Correct Coding Initiative (CCI) bundled code information? (Last Reviewed: April 25, 2008)
4. How do I bill for a Fecal Occult Blood Test for a patient who is under the age of 50? (Last Reviewed: April 25, 2008)
5. Under what circumstances would Medicare reimburse for anesthesia services furnished by the same physician providing the medical and surgical service? (Last Reviewed: April 25, 2008)
6. What are the three basic requirements for Medicare to cover routine costs in a clinical trial setting? (Last Reviewed: April 25, 2008)
7. Under what conditions will Medicare cover mammography as a diagnostic service? (Last Reviewed: April 25, 2008)
8. If an internist writes an order for an x-ray, but the oncologist at the testing facility thinks the patient should have a bone scan instead, does the oncologist need to write a new order? (Last Reviewed: April 25, 2008)
1. In a situation where the patient presents in the office and then requires critical care services (in the office), and then is transferred to the hospital and admitted, how can the provider be reimbursed for both the office service and the hospital admission? (Last Reviewed: April 25, 2008)
The office visit may not be paid in addition to the hospital admission on the same day. Per Pub. 100-04, Chapter 12, §30.6.9.1 - Initial Hospital Care, "When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician's office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission."
2. Explain the billing of a consultation vs. an admission. (Last Reviewed: April 25, 2008)
The intent of a consultation service is that a physician or qualified nonphysician practitioner (NPP) or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc., in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional's knowledge.
If the physician has been called in to give his/her opinion, and is giving his/her opinion back to the primary physician, then this would constitute a consultation.
Physicians use the initial hospital care codes (codes 99221-99223) to report the first hospital inpatient encounter with the patient when he or she is the admitting physician. Carriers consider only one M.D. or D.O. to be the admitting physician and permit only the admitting physician to use the initial hospital care codes. Physicians that participate in the care of a patient but are not the admitting physician of record should bill the inpatient evaluation and management services codes that describe their participation in the patient's care (i.e., subsequent hospital visit or inpatient consultation). Please refer to Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §§30.6.9.1 and 30.6.10.
3. How can we obtain Correct Coding Initiative (CCI) bundled code information? (Last Reviewed: April 25, 2008)
Information regarding CCI is available on the Centers for Medicare & Medicaid Service (CMS) Web site at www.cms.hhs.gov/NationalCorrectCodInitEd/.
4. How do I bill for a Fecal Occult Blood Test for a patient who is under the age of 50? (Last Reviewed: April 25, 2008)
Per the Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report, you would want to bill using Healthcare Common Procedure Coding System (HCPCS) code G0394. HCPCS code G0394, (Blood occult test (e.g., guaiac), feces, for single determination for colorectal neoplasm (e.g., patient was provided three cards or single triple card for consecutive collection)) became effective for dates of service on or after April 1, 2007. The NCD is Fecal Occult Blood Test (FOBT) (190.34) and can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at www.cms.hhs.gov/mcd/index_section.asp?from2=index_section.asp&ncd_sections=40&. MLN Matters article MM5514, "Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2007," is an additional reference and can be accessed by visiting the CMS Web site at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5514.pdf.
5. Under what circumstances would Medicare reimburse for anesthesia services furnished by the same physician providing the medical and surgical service? (Last Reviewed: April 25, 2008)
If the physician performing the procedure also provides moderate sedation for the procedure, then payment may be made for conscious sedation consistent with CPT guidelines; however, if the physician performing the procedure provides local or minimal sedation for the procedure, then no separate payment is made for the local or minimal sedation service. See MLN Matters article MM5618, "Anesthesia Services Furnished by the Same Physician Providing the Medical and Surgical Service," on the CMS Web site at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5618.pdf.
6. What are the three basic requirements for Medicare to cover routine costs in a clinical trial setting? (Last Reviewed: April 25, 2008)
Per Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, under §310 - Clinical Trials, §310.1(A) - Requirements for Medicare Coverage of Routine Costs, any clinical trial receiving Medicare coverage of routine costs must meet the following three requirements: (1) The subject or purpose of the trial must be the evaluation of an item or service that falls within a Medicare benefit category (e.g., physicians' service, durable medical equipment, diagnostic test) and is not statutorily excluded from coverage (e.g., cosmetic surgery, hearing aids). (2) The trial must not be designed exclusively to test toxicity or disease pathophysiology. It must have therapeutic intent. (3) Trials of therapeutic interventions must enroll patients with diagnosed disease rather than healthy volunteers. Trials of diagnostic interventions may enroll healthy patients in order to have a proper control group.
7. Under what conditions will Medicare cover mammography as a diagnostic service? (Last Reviewed: April 25, 2008)
Per the Breast Imaging local coverage determination (LCD), #RD001E08 (Database #L3761), which can be referenced on our Web site at www.umd.nycpic.com/lcdcopy.html, diagnostic mammogram is indicated when: (1) When there are signs or symptoms suggestive of malignancy (e.g., a mass, some types of spontaneous nipple discharge, skin changes, unilateral breast pain, or unilateral axillary lymph nodes); (2) There are radiographic abnormalities detected on screening mammogram; (3) There is short interval follow-up (at six months intervals, for two years) necessary for unresolved clinical/radiographic concerns; or diagnostic breast evaluation may be indicated in cases of a personal history of malignancy and in cases of benign biopsy-proven breast disease; (4) Once clinical stability has been established, the routine use of diagnostic mammogram over screening mammogram is not warranted; (5) Performed in a patient with metastatic disease of undetermined etiology, in whom the source is suspected to be breast; (6) Performed in a patient with axillary lymphadenopathy of undetermined etiology.
8. If an internist writes an order for an x-ray, but the oncologist at the testing facility thinks the patient should have a bone scan instead, does the oncologist need to write a new order? (Last Reviewed: April 25, 2008)
No. When an interpreting physician (e.g., radiologist, cardiologist, family practitioner, general internist, neurologist, obstetrician, gynecologist, ophthalmologist, thoracic surgeon, vascular surgeon) at a testing facility determines that an ordered diagnostic radiology test is clinically inappropriate or suboptimal, and that a different diagnostic test should be performed (e.g., an MRI should be performed instead of a CT scan because of the clinical indication), the interpreting physician and/or testing facility may not perform the unordered test until a new order from the treating physician and/or practitioner has been received. Similarly, if the result of an ordered diagnostic test is normal and the interpreting physician believes that another diagnostic test should be performed (e.g., a renal sonogram was normal and based on the clinical indication, the interpreting physician believes an MRI will reveal the diagnosis), an order from the treating physician must be received prior to performing the unordered diagnostic test. (Reference: Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §§80.6.2 and 80.6.3.)
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