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Articles that are also published in the Medicare B Hotline Bulletin, our provider newsletter, will remain on this page for two months, or until the bulletin in which it appears is posted on our Web site, whichever is later. To access articles in the Medicare B Hotline Bulletin, visit the "Publications" section of our Web site.
Advisories From the Medical Director
Advisories From the Medical Review Department
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.
Physical Therapy Code 97110 Billed by Occupational Therapists (PT/OT)
Posted March 2, 2006
The Medical Review Department recently conducted a service-specific review (SSR) of procedure code 97110 (Therapeutic procedure, one or more areas, each 15 (fifteen) minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) billed by occupational therapists, specialty 67.
This SSR (initiated in August 2005 and completed in February 2006) involved review of 100 claims (for dates of service January 1 – June 30, 2005) chosen at random by our computer system. Medicare contractors conduct these reviews to identify widespread problems by monitoring usage of procedure codes among the provider community.
The decisions that resulted from this SSR were based on the following publications and resources:
- The Physical Medicine and Rehabilitation local coverage determination (LCD), #PM003E07 (Database ID #L13566) and Coding Guidelines Article (#A21075).
- Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.
- Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, §30, and Chapter 5, §20.
- Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.2(A).
- Centers for Medicare & Medicaid Services (CMS) Therapy Services Part B Billing Scenarios for PTs and OTs.
On completion of SSRs, a provider error rate is calculated. An explanation of how error rates are calculated may be accessed in Pub. 100-08, Program Integrity Manual, Chapter 3, §3.11.1.5.
The SSR resulted in an overall error rate of 48 percent, with a down-coded/denial change rate of 64 percent for services that were either correct-coded or denied. Below is a summary of the various issues and billing problems that were identified:
- Required information to accurately adjudicate a claim decision was not documented in the patient record. Examples of this were:
- Documentation lacked the length of time performing therapy.
- The daily note did not identify the type(s) of therapeutic exercises rendered.
- Not all specific information was carried over to the plan of care (e.g., type, amount, frequency and/or duration of therapy).
- Time was documented, however, time in the chart entry was not consistent with the units of time billed on the claim.
- There was not a physician order or a plan of care furnished.
In less than 10 percent of claims reviewed, the following problems were identified:
- Services were billed under an incorrect rendering Provider Identification Number (PIN).
- Reported services were not documented in the medical record.
- Modifier GP (Service delivered by physical therapist) instead of modifier GO (Service delivered by occupational therapist) was appended.
- Documentation did not support that therapy performed was a separately identifiable service on the same day as an evaluation service.
Occupational therapists are to follow physical therapy guidelines in the Physical Medicine and Rehabilitation local coverage determination (LCD) (#PM003E07), which can be accessed on our Web site at www.umd.nycpic.com/lcdcopy.html. In addition, the applicable Medicare manuals stated at the beginning of this article which are pertinent to physical therapy services may be accessed on the CMS Web site at www.cms.hhs.gov/Manuals/IOM/list.asp.
Due to the multiple problems and billing errors identified as a result of this SSR along with the correct coding/denial error rate of 64 percent, per the Progressive Corrective Action (PCA) process, we have found it necessary to begin random auditing of code 97110 billed by occupational therapists.
Specialty Care Transport – Code A0434 (AMB)
Posted March 1, 2006
The Medical Review Department recently conducted a service-specific review (SSR) of Healthcare Common Procedure Coding System (HCPCS) code A0434 (Specialty care transport).
This SSR (initiated in June 2005 and completed in February 2006) involved review of 100 claims chosen at random by our computer system. Medicare contractors conduct these reviews to identify widespread problems by monitoring usage of procedure codes among the provider community.
The decisions that resulted from this SSR were based on the following resources:
- Pub. 100-02, Medicare Benefit Policy Manual, Chapter 10, §30.1.1(6) – Specialty Care Transport (SCT).
- Emergency Medical Services (EMS) Certification and Education Information from the New York State Department of Health Web site.
On completion of SSRs, a provider error rate is calculated. An explanation of how error rates are calculated may be accessed in Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.11.1.5.
The SSR resulted in an overall error rate of 23.26 percent, with a down-coded/denial rate of 68 percent for services that were either correct-coded or denied, as the correct code was not utilized and another code described the service rendered. Below is a summary of the various issues and billing problems that were identified.
- In 62 of 100 claims reviewed, documentation did not support payment of specialty care transport for various reasons:
- Documentation of 30 claims did not support that the beneficiary was critically ill or injured and/or did not support personnel requirements for specialty care transport. Therefore, the claims were correct-coded to the appropriate ambulance transport.
- Documentation of 32 claims determined that the patient was not critically ill or injured. Therefore, the claims were correct-coded to the appropriate ambulance transport.
- In 2 of 100 claims, the beneficiary was an inpatient at the time of transport and the service should have been billed as a Part A service. Therefore, the services were denied and money paid was recouped.
- In 2 of 100 claims, documentation supported a paramedic intercept service that had already been billed and allowed on another claim. Therefore, the services were denied and money paid was recouped.
- In 2 of 100 claims, the provider told Medicare that the service had been billed in error and returned the paid amount to Medicare.
Pub. 100-02, Medicare Benefit Policy Manual, Chapter 10, §30, defines specialty care transport as “transportation of a critically ill or injured beneficiary by a ground ambulance vehicle (including the provision of medically necessary supplies and services) at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training.”
“The EMT-Paramedic level of care is set by each State. Care above that level that is medically necessary and that is furnished at a level of service above the EMT-Paramedic level of care is considered SCT. That is to say, if EMT-Paramedics – without specialty care certification or qualification – are permitted to furnish a given service in a State, then that service does not qualify for SCT. The phrase “EMT-Paramedic with additional training” recognizes that a State may permit a person who is not only certified as an EMT-Paramedic, but who also has successfully completed additional education as determined by the State in furnishing higher level medical services required by critically ill or critically injured patients, to furnish a level of service that otherwise would require a health professional in an appropriate specialty care area (for example, a nurse) to provide. “Additional training” means the specific additional training that a State requires a paramedic to complete in order to qualify to
furnish specialty care to a critically ill or injured patient during an SCT.”
The Health Emergency Medical Services (EMS) Certification and Information page of the New York State Department Web site at www.health.state.ny.us/ identifies the five EMS levels recognized by New York State to become certified as an EMS provider. The Upstate Medicare Division (UMD) has determined that EMS personnel who have attained a New York State level 4 and level 5 certifications are qualified to furnish specialty care transport. Those levels are:
- Level 4 – Emergency Medical Technician – Critical Care (AEMT-CC).
- Level 5 – Emergency Medical Technician – Paramedic (AEMT-P).
Documentation of EMS personnel who render specialty care transport should identify the full title of the EMS provider (e.g., AEMT-CC, AEMT-P) and signature.
In circumstances where documentation indicates specialty care transport is furnished by hospital personnel (such as a nurse, respiratory therapist, etc.), Medicare will not reimburse for the service, because the individual is on hospital duty at the time specialty care transport is being rendered. Therefore, their service is already covered under Part A.
Due to the multiple problems and billing errors identified as a result of this SSR, along with the correct coding/denial error rate of 68 percent, per the Progressive Corrective Action (PCA) process, we have found it necessary to begin auditing for specialty care transport.
Reminder to Podiatrists: New 2006 Initial Nursing Facility Care Codes (99304-99306) – Not Covered when Billed by a Podiatrist (GEN)
Posted February 28, 2006
Effective January 1, 2006, comprehensive nursing facility assessment codes 99301 through 99303 were deleted and were replaced by initial nursing facility care codes 99304 through 99306. A complete description of each of these procedure codes may be found in the 2006 Current Procedural Terminology (CPT) Manual.
Medicare guidelines for nursing facility services can be found in Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §30.6.13. These guidelines state:
“The initial visit is defined as the initial comprehensive assessment visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident.”
Based on the above Medicare guidelines, the Upstate Medicare Division (UMD) will deny claims for codes 99304-99306, when billed by a podiatrist (specialty 48).
Per Change Request (CR) 4246 and Medlearn Matters article MM4246, the Centers for Medicare & Medicaid Services (CMS) has instructed that this section of the Medicare Claims Processing Manual includes the new 2006 CPT codes along with guidelines for utilization.
Before billing Medicare for service(s) rendered to a beneficiary in a skilled nursing facility or nursing facility, a podiatrist should first determine what was performed. Podiatry providers are reminded to report the specific CPT code most accurately describing the service(s) rendered. When reporting an evaluation and management (E/M) service alone in the absence of a surgical podiatry procedure, podiatrists are limited to utilize and bill the subsequent nursing facility care E/M codes 99311-99313 through December 31, 2005, and new 2006 subsequent nursing facility care E/M codes 99307-99310, effective January 2006.
Also please remember, to report an E/M service on the same day as a surgical podiatry procedure, documentation should substantiate a separately identifiable E/M service above and beyond the surgical service performed and modifier 25 should be appended to the E/M service. Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §40.1-C – Minor Surgeries and Endoscopies, provides that the physician’s visit on the same day as a minor surgery is included in the payment for the procedure.
The Medicare Claims Processing Manual can be accessed on the Centers for Medicare & Medicaid Services Web (CMS) site at www.cms.hhs.gov/Manuals/IOM/list.asp. Medlearn Matters articles may be accessed on the CMS Web site at www.cms.hhs.gov/MedlearnMattersArticles. Also, podiatry providers are to follow requirements stated in the following local coverage determinations, which can be accessed on our Web site at www.umd.nycpic.com/lcdcopy.html.
- Nursing Home Services (#M-96-5 (3A)).
- Routine Foot Care (#FC001E06).
- Debridement of Mycotic Nails (#FC002E01).
Billing for Medications Used in Conjunction with Drug or Biological Infused Through DME and/or an Implanted Infusion Pump (GEN)
Posted February 28, 2006
We have noted that multiple claims for medication refills of an implanted infusion pump are being incorrectly billed without the KD modifier. The KD modifier denotes “Drug or biological infused through DME.” When you bill a drug code that represents medications for refill to be infused through durable medical equipment (DME), you must append the KD modifier to ensure correct payment of services. This is not solely for implanted intrathecal infusion pumps.
The Upstate Medicare Division (UMD) published two articles on the proper use of the KD modifier. Please refer to the March 2004 and December 2004 Medicare B Hotline Bulletins for further information. The March 2004 bulletin article, Medlearn Matters article MM3105, titled, “MMA Pricing File Clarification,” references Change Request (CR) 3105, which was effective January 30, 2004. CR 3105 is available at www.cms.hhs.gov/transmittals/Downloads/R75CP.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.
Furthermore, we have also noted incorrect billing when drugs being refilled are compounded drugs. The Coding Guidelines article for the Implanted Catheter/Pump for Drug Infusion via Intrathecal or Epidural Drug Delivery System local coverage determination (LCD) (#SU031E00), states:
“To bill for the compound drugs used for the opioid infusion with the implantable pump or reservoir (CPT code 95990 and 95991), report code J3490 and attach a copy of the invoice from the pharmacy specific to that patient. The invoice should list the NDC number, name and quantity of the drug/drugs used and the total cost (which may include a compounding fee in addition to the cost of each component drug to the compounding pharmacist). For electronic claims, the notepad must include the invoice information (specific to that patient) plus the pharmacy name and address.”
This LCD can be accessed on our Web site at www.umd.nycpic.com/lcdcopy.html.
We further clarified the term “compounded drugs” with CMS Central Office. Whether there is one drug or more than one drug, if the process of compounding the drug(s) is used to supply the medication(s) for refill of the implanted infusion pump, you would bill code J3490 with the KD modifier and submit an invoice, as stated above.
Velcade - New Coverage
Effective for dates of service May 13, 2003, and after, Velcade (J9999) is covered for patients with multiple myeloma, ICD-9-CM 203.00, which has failed two other types of chemotherapy.
Mental Health Policy Clarification
As of September 2002, Upstate Medicare Division providers are no longer required to append the AH and AJ modifiers for psychological services performed by a clinical psychologist or clinical social worker.
Preventive Services
There are still questions and concerns in relation to the use of the preventive medicine codes, 99381 through 99387 (New patient) and 99391 through 99397 (Established patient). The problem directed evaluation and management (E&M) series 99201 through 99350 may be used for those portions of a preventive medicine examination for which there are signs and symptoms and are not applicable to the preventive medicine codes. One can file for the portion of the examination which represents a problem-directed service. There should be identifiable history, examination, and plan of management (3 of 3 or 2 of 3 components) for that problem-directed service.
Another area where this may be applicable is in relation to the gynecologic service carried out annual, or bi-annually. Code G0101, Cervical or vaginal cancer screening; pelvic and clinical breast examination, is a covered procedure annually for women who have high risk factors for cervical and vaginal cancer, indicated by ICD-9-CM code V15.89 to indicate high risk, or every two years for women with ICD-9-CM code V76.2 to indicate low risk. Use V76.49, Special screening for malignant neoplasm, other sites (to indicate other low risk for a patient who does not have a uterus or cervix), effective January 1, 2001, and after. Code Q0091, Screening papanicolaou smear, obtaining, preparing, and conveyance of cervical or vaginal smear to the laboratory, is also an associated code. The payment for the G0101 and the Q0091 would be subtracted from the charge for the portion of the examination which qualifies for preventive exam. The patient would be responsible for that determined difference. No advance beneficiary notice (ABN) is needed for noncovered services, such as a preventive exam. It is advisable to discuss these payment components with the patient so they understand their payment obligations. There are a number of related bulletin articles available on our Web site: February 1998, page 10; December 1998, page 23; April 1999, page 1; and December 1999, page 2. The Pap Smear of the Cervical or Vaginal Mucosa and Screening Pelvic Examinations policy is also in the Medical Policies section for review.
Evaluation & Management (E&M) Coding
It is important to realize that merely meeting the definition of an evaluation and management (E&M) code is not sufficient to justify payment. The level of code which is used must be reasonable and necessary to the presenting complaint(s). A voluminous note does not justify a high level charge for a relatively minor problem. The documentation which is recorded establishes what level E&M service is appropriate and establishes the extent of component services in the history, examination, and plan of management.
There have been recurrent questions in relation to shared E&M services between a physician and a nonphysician practitioner (NPP) in the same group practice. This is addressed in the Medicare Carriers Manual, Section 15501, revised. In the office or clinic setting, when a physician performs an E&M service, the service must be reported using the physician’s UPIN/PIN. When an E&M service is a shared/split encounter between a physician and an NPP (NP, PA, CNS, or CNM), the service is considered to be performed "incident to," if the requirements for "incident to" are met and the patient is an established patient. If "incident to" requirements are not met for the shared/split E&M service, the services must be billed under the NPP’s UPIN/PIN and the payment will be made at the appropriate physician fee schedule payment. In the hospital inpatient/outpatient/emergency department setting, when hospital inpatient/hospital outpatient, or emergency department E&M is shared between the physician and an NPP of the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed either under the physician’s or the NPP’s UPIN/PIN number. However, if there is no face-to-face encounter between the patient and the physician (even if the physician participated in the service by only reviewing the patient’s medical record), then the service may only be billed under the NPP’s UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate, based on the UPIN/PIN entered on the claim. The full presentation regarding the above may be found in Transmittal #1776, dated October 25, 2002, at www.cms.hhs.gov/manuals.
Request for Pre-Approvals
It is recognized that it is standard practice for health maintenance organizations (HMOs) to grant pre-approval of proposed treatments, procedures, etc. Medicare does not provide for pre-approval. This action has been advanced by organized medicine for approval on the federal level. To date, it has not happened. You are free to peruse our Web site or the Centers for Medicare & Medicaid Services (CMS) Web site, www.cms.hhs.gov, for information on coverage concerns which you may have. We, also, can advise on the apparent reasonableness and likelihood of coverage, based on national and local medical review policy.
In the Medicare program, the final determination of whether a payment is correct is determined by the documentation which establishes the reasonable and necessary nature of that accomplished service or procedure in relation to national or local Medicare policy. If you have been advised that it is not likely to be covered, you can use an advance beneficiary notice (ABN). If the patient refuses to sign the ABN, that is to be recorded and witnessed in the patient’s medical record. If the service is a noncovered service, i.e., acupuncture or cosmetic surgery, then no ABN is necessary. It is important to note the difference between "never" or "noncovered" by Medicare services and services which may or may not be covered as determined by Medicare policy.
Medicare policy is based on Title XVIII of the Social Security Act. The Program Integrity Manual states, "the primary authority for all coverage provisions and subsequent policies is the Social Security Act (the Act). Contractors use Medicare policies in the form of regulations, NCDs, coverage provisions and interpretive manuals, and LMRPs to apply the provisions of the Act." When adequate guidance is lacking from these sources, the carrier may obtain guidance from CMS Regional Office or Central Office, or the Contractor Medical Director may consult with other sources or authorities to render a decision.
Adjudication of Claims for Global Surgeries - Modifiers 58, 78, and 79
Medicare does not allow separate payment for additional procedure(s) with a global fee period if furnished during the postoperative period of a prior procedure by the same provider and if billed without modifier 58, 78, or 79. These services will be denied.
This carrier has opted to ask for the surgical report(s) in order to review the billed surgeries for the addition of the above-mentioned modifiers. It would behoove the provider community to bill the surgeries in sequence and to append the correct modifier in order to prevent delays in reimbursement.
The intent of this article is to educate the provider community in the correct use of modifiers 58, 78, and 79 when surgery(s) within the global period is billed by the same provider. The definitions of the modifiers can be found in the Current Procedural Terminology (CPT) manual.
58 Modifier
The 58 modifier is used for staged or related procedures or services by the same physician during the postoperative period. The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure.
An example of a staged procedure is procedure code 57155, insertion of uterine tandems and/or vaginal ovoids for clinical brachytherapy. The operative report documentation states "placement of uterine tandem (1st of 2 implants)." The dates of service are June 26, 2002, and July 10, 2002. The procedure codes should be billed in sequence with procedure code 57155 and 57155 58, respectively.
78 Modifier
The 78 modifier is used to indicate a return to the operating room for a related procedure during the postoperative period. The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier 78 to the related procedure.
An example of the correct use of the 78 modifier is procedure code 36831, thrombectomy, open arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft, when the procedure is done more than once within the global period for the same dialysis graft on the same or different date of service. The procedure(s) should be billed in sequence with procedure code 36831 and 36831 78. If you bill out of sequence, and bill the subsequent surgery first, the subsequent surgery will pay in full. Then, when you bill the initial procedure after the subsequent procedure, the claim will suspend because you have already been paid for the subsequent procedure in full. Medicare will ask for both operative reports in order to substantiate the services and to determine if the 78 or 79 modifier is applicable. If procedure code 36831 is performed on the same graft, it is a related procedure and the 78 modifier is correct. The provider will be reimbursed with the intraoperative allowed amount. If the subsequent procedure is billed first, the initial procedure will be prorated to allow for the pricing difference in the allowed amount when the 78 modifier is the correct modifier and should have been added to the subsequent service. If the patient has two dialysis grafts in different areas of the body, and procedure code 36831 is done on each of the grafts, then modifier 79 is the correct modifier to use and the provider will be reimbursed without any adjustment in payment, unless multiple surgeries are performed on the same date of service. The multiple surgery rules would apply for all the applicable surgeries on that date of service.
When a CPT code billed with modifier 78 describes services involving a return trip to the operating room to deal with complications from the original surgery, the provider will be reimbursed with the intraoperative allowed amount of the code(s) that describe the treatment of the complication. The multiple surgery reduction does not apply to treatment for complications resulting from the initial surgery that require a return trip to the operating room, even when multiple procedures are required to treat the complication. However, the multiple surgery reduction does apply when modifier 78 indicates a related procedure only.
An example of the use of modifier 78 to treat a complication from the initial surgery is cardiac hemorrhage following cardiac surgery that requires a return trip to the operating room. All procedures to treat the hemorrhage are reimbursed at the intraoperative allowed amount. The multiple surgery rules would not apply. If, however, a service that is related to the initial procedure is rendered during the same returned session to the operating room that does not treat the complication from the original procedure, the multiple surgery rules would apply to those services.
If additional procedures are performed during the same operative session as the original surgery to treat complications which occurred during the original surgery, the provider is reimbursed with the multiple surgery rules for applicable services. Only surgeries that require a return to the operating room are paid under the complications rule.
If the patient is returned to the operating room after the initial operative session, but on the same day as the original surgery for one or more additional procedures as a result of complications from the original surgery, the complications rules apply to each procedure required to treat the complications from the original surgery. The multiple surgery rules would not also apply.
If the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for multiple procedures that are required as a result of complications from the original surgery, the complications rules would apply. The multiple surgery rules would not also apply.
79 Modifier
The 79 modifier is used for an unrelated procedure or service during the postoperative period rendered by the same physician. The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. An example of the correct use of the 79 modifier for unrelated procedures would be the performance of a colectomy as the initial procedure and a subsequent cholecystectomy rendered during the postoperative period of the initial procedure.
The provider can avoid delays in reimbursement and the necessity of record submission, unless a problem is identified by Medicare, by understanding and using the modifiers, 78, 79, and 58 correctly. The provider must bill the surgeries in chronological order to be reimbursed correctly for services rendered. Please refer to the Medicare Carriers Manual (MCM), section 4824, Adjudication of Claims for Global Surgeries, for further reference and clarification. The MCM can be accessed on the Centers for Medicare & Medicaid Services (CMS) Web site at www.cms.hhs.gov/manuals. |
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