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Q & A
NewDataReporting
Requirementson
HomeHealth
Prospective
PaymentSystem
Coding & Billing for Prospective Payment Systems
Volume 13, Issue 4 June 25, 2013
Implementation
of CME Ruling
1455-R
July 2013 Update of Hospital OPPS
Page 2
Since 1989 HMI Corporation, a Healthcare
Management Company, a subsidiary of Healthcare
Provider Services, has been assisting acute care,
teaching, critical access, long term care, nursing
home, home health, and skilled nursing facilities, as
well as physician groups, with clinical
reimbursement through accurate coding and
billing for all financial classes as well as maintaining
compliance with Federal payers.
HMI’s consultant specialists perform compliance
reviews, billing, and coding medical reviews, as well
as other revenue improvement services, utilizing the
provider’s chargemaster. HMI also provides
physician education to strengthen the medical
staff's E/M coding for compliance and to improve
reimbursement.
HMI offers a full-service program to assist providers
in positioning themselves to meet federal
compliance guidelines, with an emphasis on PPS
reimbursement. This process also includes inpatient
and outpatient record review, on-going
chargemaster maintenance, remote chargemaster
services, interim chargemaster coordinator
coverage, remote contract coding, and on-site
education/training of clinical staff and physicians.
Our twenty-three year success has been primarily
founded on facilitating quality consulting service,
on-going accountability through management
plan objectives and guaranteed service based on
our ability to deliver results.
155 Franklin Road
Suite 100
Brentwood, TN 37027
Phone: 615-661-5145
Fax: 615-661-5147
Email: info@hmi-corp.com
Website: www.hmi-corp.com
Volume 13, Issue 4 June 25, 2013
Table of Contents:
CPT® Copyright 2012 American Medical Association. All rights re-served.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data con-tained or not contained herein.
CPT is a registered trademark of the American Medical Association.
Coding & Billing for Prospective Payment Systems
Implementation of CME Ruling 1455-R
3
July 2013 Update of the Hospital OPPS
4
Technical Component of Pathology Services Furnished to Hospital Patients
10
Use of a Rubber Stamp for Signature
11
Coding Requirements for Laboratory Specimen Collection
12
Ocular Photodynamic Therapy (OPT) with Verteporfin for Macular Degeneration
13
Ambulance Payment Reduction for Non-Emergency Basic Life Support Transport to and from Renal Dialysis Facilities
14
New Data Reporting Requirements on Home Health Prospective Payment System Claims
15
Quarterly Update of HCPCS Codes for Home Health Consolidated Billing Enforcement
16
July 2013 Update to Medicare Physician Fee Schedule Database
17
Question and Answer 18
Page 3
Implementation of CME Ruling 1455-R (Medicare Program; Part B Billing
in Hospitals)
On June 10, 2013 CMS rescinded Transmittal 1243 and released Transmittal 1247 as a one-time notification regarding Ruling 1455-R. This transmittal sets forth the requirements for contractors to implement CMS Ruling 1455-R “until such time as the operating instructions and necessary system change in CR 8185 can be fully implemented”. All other language contained in the initial transmittal will remain the same and is effective for claims processed after July 1, 2013. To read Transmittal 1247 and MLN Matters MM8277 go to:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8277.pdf
http://www.cms.gov/Regulations-and-Guidance/
Guidance/Transmittals/Downloads/R1247OTN.pdf
Coding & Billing for Prospective Payment Systems
Page 4
Coding & Billing for Prospective Payment Systems
CMS released Transmittal 2718 on June 7, 2013 with the changes to and billing instructions for various payment policies effective July 1, 2013. The following is a summary of those changes.
1. Changes to Device Edits for July 2013 To obtain the most current listing for device edits go to: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
HospitalOutpatientPPS/
2. New Service
One new payable service is being implemented effective July 1, 2013 as follows:
July 2013 Update July 2013 Update July 2013 Update July 2013 Update of the Hospital of the Hospital of the Hospital of the Hospital
Outpatient Prospective Outpatient Prospective Outpatient Prospective Outpatient Prospective Payment SystemPayment SystemPayment SystemPayment System
HCPCS Short
Descriptor Long Descriptor SI APC Payment
Minimum
Unadjusted Copayment
C9736 Lap ablate
uteri fibroid rf
Laparoscopy, surgical, radiofrequency, ablation of uterine fibroid(s), including intraoperative guidance and monitoring, when performed
T 0131 $3,487.15 $1,001.89
Page 5
Coding & Billing for Prospective Payment Systems
3. New Long Descriptor for C9734 CMS has added a new long descriptor for HCPCS code C9734 to indicate it must be performed with magnetic resonance (MR) guidance.
4. Deletion of HCPCS Code C1879 Effective June 30, 2013 CME will be deleting temporary HCPCS code C1879 (tissue marker, implantable) as it is described by HCPCS code A4648 (Tissue marker, implantable, any type). Providers should report the use and cost of implantable tissue markers with HCPCS code A4648 only. 5. Category III CPT Codes Effective July 1, 2013 there are six new Category III CPT Codes that are now separately payable under OPPS. The payment rates for these services can be found in Addendum B of the July 2013 OPPS Update that will be posted at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html
HCPCS Short
Descriptor Long Descriptor SI APC Payment
Minimum
Unadjusted Copayment
C9734 U/S trtmt,
not leiomyomata
Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (MR) guidance
S 0067 $3,300.6
4 $660.13
CPT
Code Long Descriptor SI APC
0329T Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral with interpretation and report
E N/A
0330T Tear film imaging, unilateral or bilateral, with interpretation and report
S 0230
0331T Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment;
S 0398
0332T Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic
SPECT S 0398
0333T Visual evoked potential, screening of visual acuity, automated E N/A
0334T
Sacroiliac joint stabilization for arthrodesis, percutaneous or minimally invasive (indirect visualization), includes obtaining and applying autograft or allograft (structural or morselized), when performed, includes image guidance when performed (CT or fluoroscopic)
T 0208
Page 6
Coding & Billing for Prospective Payment Systems
6. Billing for Drugs, Biologicals, and Radiopharmaceuticals
A. Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective July 1, 2013.
The updated payment rates effective July 1, 2013 are found in the July 1, 2013 Addendum A and Addendum B which are not available online at the time of this newsletter. Once CMS updates their files it can be found at the following website: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html B. Drugs and Biologicals with OPPS Pass-Through Status
Effective July 1, 2013 CMS has granted OPPS pass-through status to two drugs and biological effective July 1, 2013. It is noted that HCPCS code C9131 is a new code effective July 1, 2013.
C. Flublok (Influenza virus vaccine) On January 16, 2013 the FDA approved Flublok as an influenza virus vaccine. Effective July 1, 2013 CMS has assigned it to HCPCS Q2033 (Influenza Vaccine, Recombinant Himagglutinin Antigen, for Intramuscular Use (Flublok)) with the OPPS status indicator of “L” (Influenza Vaccine; Pneumococcal Pneumonia Vaccine). For all claims prior to July 1, 2013 it should have been reported with an unlisted CPT/HCPCS vaccine code. D. Fluarix Quadrivalent (Influenza virus vaccine) On December 14, 2012 the FDA approved Fluarix Quadrivalent and is described by CPT code 90686 (Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use), however, due to the timing of this approval CMS was unable to assign CPT code 90686 to a separately payable status. As part of the July 2013 update CMS is revising the status indicator for 90686 to “L” Influenza Vaccine; Pneumococcal Pneumonia Vaccine) with an effective date of January 1, 2013. For all claims prior to January 1, 2013 the appropriate code to report Fluarix Quadrivalent would be an unlisted CPT/HCPCS vaccine code.
HCPCS
Code Long Descriptor APC
Status Indicator
Effective 7/1/13
C9131 Injection, ado-trastuzumab emtansine, 1 mg 9131 G
Q4122 Dermacell, per square centimeter 1419 G
Page 7
Coding & Billing for Prospective Payment Systems
E. New HCPCS Codes Effective July 1, 2013 for Certain Drugs
and Biologicals CMS has created two new HCPCS codes for reporting certain drugs and biological (other than new pass-through drugs and biological as discussed earlier) to be used in the hospital setting effective July 1, 2013.
*HCPCS code J9002 (Injection, Doxorubicin Hydrochloride, Liposomal, Doxil, 10 mg.) will be replaced with HCPCS code Q2050 effective July 1, 2013, The status indicator for HCPCS code J9002 will change to E, “Not payable by Medicare”, effective July 1, 2013. ** HCPCS code J3487 (Injection, Zoledronic Acid (Zometa), 1 mg) and
HCPCS code J3488 (Injection, Zoledronic Acid (Reclast), 1 mg) will be
replaced with HCPCS code Q2051 effective July 1, 2013. The status
indicators for HCPCS codes J3487 and J3488 will change to E, “Not
Payable by Medicare”, effective July 1, 2013.
F. Revised Status Indicator for HCPCS Codes Q4126 and Q4134
Effective July 1, 2013 CMS is changing the status indicator for HCPCS code Q4126 (Memoderm, dermaspan, tranzgraft or integuply, per sq. cm) and HCPCS code Q4134 (Hmatrix, per sq. cm) from “E” (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type)) to “K” (Paid under OPPS; separate APC payment) effective with dates of service on or after July 1, 2013. The prices for these codes will be updated quarterly. G. Updated Payment Rates for Certain HCPCS Codes Effective
April 1, 2013 through June 30, 2013. CMS has indicated that the payment rates for two HCPCS codes were incorrectly entered during the April 2013 OPPS Pricer update. The corrected payment rates have been installed in the July 2013 OPPS Pricer and is effective for services provided on April 1, 2013 through June 30, 2013.
HCPCS
Code Long Descriptor APC
Status
Indicator
Effective
7/1/13
Q2050* Injection, Doxorubicin Hydrochloride, Liposomal, Not Otherwise Specified, 10 mg
7046 K
Q2051** Injection, Zoledronic Acid, Not Otherwise Specified, 1 mg
1356 K
Page 8
Coding & Billing for Prospective Payment Systems
H. Updated Guidance; Billing and Payment for New Drugs,
Biologicals, or Radiopharmaceuticals Approved by the FDA but Before Assignment of a Product-Specific HCPCS Code
Hospital outpatient departments are allowed to bill for new drugs, biologicals, and therapeutic radiopharmaceuticals that are approved by the FDA on or after January 1, 2004 for which pass-through status has not been approved and a C-code and APC payment have not been assigned using the “unclassified” drug/biological HCPCS code C9399 (Unclassified drugs or biological). Drugs, biologicals, and therapeutic radiopharmaceuticals that are assigned to HCPCS code C9399 are contractor priced at 95 percent of AWP. Diagnostic radiopharmaceuticals and contrast agents are policy packaged under the OPPS unless they have been granted pass-through status. Therefore, new diagnostic radiopharmaceuticals and contrast agents are an exception to the above policy and should not be billed with C9399 prior to the approval of pass-through status but, instead, should be billed with the appropriate “A” NOC code as follows: 1. Diagnostic Radiopharmaceuticals – All new diagnostic radiopharmaceuticals are assigned HCPCS code A4641 (Radiopharmaceutical, diagnostic, not otherwise classified). HCPCS code A4641 should be used to bill a new diagnostic radiopharmaceutical until the new diagnostic radiopharmaceutical has been granted pass-through status and a C-code has been assigned. HCPCS code A4641 is assigned status indicator “N” and, therefore, the payment for a diagnostic radiopharmaceutical assigned to HCPCS code A4641 is packaged into the payment for the associated service.
HCPCS
CODE Status
Indicator APC Short Descriptor
Corrected
Payment
Rate
Corrected
Minimum
Unadjusted
Copayment
C9297 G 9297 Omacetaxine mepesuccinate $2.53 $0.51
C9298 G 9298 Injection, ocriplasmin $1,046.75 $209.35
Page 9
Coding & Billing for Prospective Payment Systems
2. Contrast Agents – All new contrast agents are assigned HCPCS code A9698 (Non-radioactive contrast imaging material, not otherwise classified, per study) or A9700 (Supply of injectable contrast material for use in echocardiography, per study). HCPCS code A9698 or A9700 should be used to bill a new contrast agent until the new contrast agent has been granted pass-through status and a C-code has been assigned. HCPCS code A9698 is assigned status indicator “N” and, therefore, the payment for a drug assigned to HCPCS code A9698 is packaged into the payment for the associated service. The status indicator for A9700 will change from SI=B (Not paid under OPPS) to SI=N (Payment is packaged into payment for other services) and, therefore, the payment for a drug assigned to HCPCS code A9700 is packaged into the payment for the associated service.
To read Transmittal 2718 go to: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2718CP.pdf
To read MLN Matters MM8338 go to: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8338.pdf
To read Transmittal 2717 for the ASC July Payment update to go: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2717CP.pdf
To read MLN Matters MM8328 for the ASC July Payment update go to: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8328.pdf
Page 10
On May 24, 2013 CMS issued Transmittal 2714 to indicate changes to Chapters 12 and 16 of the Medicare Claims Processing Manual to revise instructions regarding the Technical Component (TC) of pathology services furnished to hospital patients. This change request was issued to communicate the changes made in each section so that they contain the up-to-date instruction for the billing of the technical component of physician pathology services furnished to hospital patients. It is noted that effective July 1, 2012 an independent laboratory may not bill for the TC of a physician pathology service furnished to a hospital inpatient or outpatient.
It further clarifies that payment will be made under the physician fee schedule for TC services furnished in institutional settings such as Ambulatory Surgery Centers where the TC service is not bundled into the facility payment. To read transmittal 2714 go to: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2714CP.pdf
TechnicalComponent
(TC)ofPathology
ServicesFurnishedto
HospitalPatients
Coding & Billing for Prospective Payment Systems
Page 11
On May 17, 2013 CMS issued Transmittal 465 effective June 18, 2013, to clarify the use of a rubber stamp for signature to be in accordance with the Rehabilitation Act of 1973. Please note below the new language that has been added to 3.3.2.4 – Signature Requirements, of the Program Integrity Manual.
EXCEPTION 4: CMS would permit use of a rubber stamp for signature in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document.
To read Transmittal 465 go to: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R465PI.pdf
To read MLN Matters MM8219 go to: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8219.pdf
Use of a
Rubber Stamp
for Signature
Coding & Billing for Prospective Payment Systems
Page 12
CMS released Transmittal 2730 on
June 20, 2013 to update the coding
requirements for Laboratory
Specimen collections in The
Medicare Claims Processing Manual
Chapter 16, Section 60.1.4. Effective
July 16, 2013, the following HCPCS
codes and terminology must be used:
• 36415 – Collection of venous
blood by venipuncture
• P9615 – Catheterization for
collection of specimen(s).
This update is being released to
address questions CMS has received
from the laboratory industry. The
allowed amount for specimen
collection in each of the above
circumstances is included in the
laboratory fee schedule.
To read Transmittal 2730 go to:
http://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/
Downloads/R2730CP.pdf
Coding Requirements for Laboratory Specimen Collection Update
Coding & Billing for Prospective Payment Systems
Page 13
Coding & Billing for Prospective Payment Systems
Effective April 3, 2013 with an implementation date of July 16, 2013, CMS will expand coverage of OPT with verteprofin for “wet” AMD. They are also revising the requirements for testing to permit either optical coherence tomography (OCT) or FA to assess response to treatment. These changes are being made to The Medicare Claims Processing Manual, Chapter 32 – Billing Requirements for Special Services. To read Transmittal 2728 to go: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2728CP.pdf
To read MLN Matters MM8292 go to: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8292.pdf
Ocular Photodynamic
Therapy (OPT) with
Verteporfin for Macular
Degeneration
Page 14
Ambulance Payment Reduction
for Non-Emergency Basic Life
Support (BLS) Transports to and
from Renal Dialysis Facilities Transmittal 2703 was released by CMS on May 10, 2013 to update changes as required by Section 637 of the American Taxpayer Relief Act of 2012. Effective with transports occurring on and after October 1, 2013 there will be a 10% reduction in fee schedule payments for the non-emergency transport of individuals with ESRD to and from renal dialysis. This includes transports to and from both hospital based and freestanding dialysis treatment facilities. These changes are noted in The Medicare Claims
Processing Manual Chapter 15 – Ambulance Section 20.6. To read Transmittal 2703 go to: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2703CP.pdf
To read MLN Matters MM8269 go to: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8269.pdf
Coding & Billing for Prospective Payment Systems
Page 15
Coding & Billing for Prospective Payment Systems
Effective with Home Health episodes beginning on or after July 1, 2013, home health agencies must report new codes indicating the location of where the services were provided and indicate if the services were added to the home health care plan by a physician that did not certify the plan of care. The HCPCS codes for the location of services are:
To read Transmittal 2680 go to: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2680CP.pdf
To read MLN Matters MM8136 go to: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8136.pdf
New Data Reporting Requirements on Home
Health Prospective Payment System (HHPPS) Claims
HCPCS CODE
Definition
Q5001 Hospice or home health care provided in patient’s home/residence
Q5002 Hospice or home health care provided in assisted living facility
Q5009 Hospice or home health care provided in place not otherwise specified (NO)
Page 16
Quarterly Update of
HCPCS Codes Used for
Home Health Consolidated
Billing Enforcement
Effective July 1, 2013 the following HCPCS codes will be added to the Home Health consolidated billing therapy code list: To read Transmittal 2672 to go: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2672CP.pdf
To read MLN Matters MM8246 go to: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8246.pdf
Coding & Billing for Prospective Payment Systems
HCPCS CODE
DEFINITION
G0456
Negative pressure wound therapy, (e.g., vacuum assisted draining collection) using a me-chanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session, total wound(s) surface area less than or equal to 50 square centimeters
G0457
Negative pressure wound therapy, (e.g., vacuum assisted draining collection) using a me-chanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session, total wound(s) surface area greater than 50 sq. cm.
Page 17
Reporting End Stage Renal Disease (ESRD) Drugs Administered Through the Dialysate
Effective July 1, 2013 ESRD facilities will be required to append the JE (Administered via Dialysate) modifier to all ESRD claims where drugs and biological are furnished to ESRD beneficiaries via the dialysate solution. To read Transmittal 2688 go to: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2688CP.pdf
To read MLN Matters MM8256 go to: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8256.pdf
Coding & Billing for Prospective Payment Systems
Page 18
155 Franklin Road Suite 100
Brentwood, TN 37027 Phone: 615-661-5145
Fax: 615-661-5147 E-mail: info@hmi-corp.com
www.hmi-corp.com Website: www.hmi-corp.com
CPT® Copyright 2012 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indi-rectly practice medicine or dispense medical services. The AMA as-sumes no liability for data contained or not contained herein.
CPT is a registered trademark of the American Medical Association.
Q: We have several clients that are inquiring into the proper way in which to bill for 77417 –
Therapeutic radiology port film(s).
A: Per the Medicare Claims Processing Manual Chapter 13, Section 70.3 carriers pay for this
TC service on a weekly (five fractions) basis for radiation treatment delivery. Upon additional research with the various carriers it is concluded that this service cannot be billed in multiple units. We have included the links to the Medicare Claims Processing Manual, Noridian Medicare, and Novitas for authoritative guidance. While not an authoritative source, we are also including the link to the American Society for Radiation Oncology (ASTRO) for their opinion regarding the coding and billing of Therapeutic Radiology Port Films. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c13.pdf https://www.noridianmedicare.com/provider/updates/docs/radiation_oncology_workshop_QA_0411.pdf https://www.novitas-solutions.com/policy/mac-ab/l27515-r15.html https://www.astro.org/Practice-Management/Radiation-Oncology-Coding/Coding-Guidance/IGRT.aspx
Coding & Billing for Prospective Payment Systems
Volume 13, Issue 4 June 25, 2013
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